SPINE DISORDERS

(For Med Students)

Andhika Yudistira
Spine Division
Orthopaedic Department
Faculty of Medicine Brawijaya University
1ST Spinal Instrumentation
Workshop in Malang
 Introduction :
Functions of Spine
Functions of Spine
1. Protect of the spinal cord,
nerve roots, and internal
organs

2. Provide structural support

and balance to maintain an
upright posture

3. Enable flexible motion

 Regions of Spine
Cervical Spine (C1 – C7)  mobile

Thoracic Spine (T1 – T12)  semi rigid

Lumbar Spine (L1 – L5)  rigid

Sacrum / Sacral Spine (S1 – S5) : spine-hip connector.

Together with illiac bone forms Pelvic Girdle.  rigid

Coccyx (tailbone) : 4 fused bones and provide

attachment of ligaments and muscles of pelvic floor

 Cervical : Supports weight of the head (10

pounds); Hast the most range of motion. C1 as
atlas, C2 as axis.

 Thoracic : Holding rib cage and protect heart

and lungs. ROM is limited

 Lumbar : Bearing weight of the body. Larger

size to absorb stress of lifting and carry objects
Natural Curvatures of Spine
• Natural curvature in sagital
plane (alignment)
• Cervical lordosis - average of 25o
(concave bacwards)
• Thoracic kyphosis -average of
40o (20o-50o concave forwards)
• Lumbar lordosis - average of 60o
(40 o -80 o concave bacwards)
 Special Characteristics
of Cervical Spine
 Atlas (C1)

• Bony ring consisting an

anterior & posterior arch
which are connected by two
lateral masses
• No body & no spinous process

 The weakest point is at the

narrowed areas where the
anterior and posterior arches
connect to the lateral masses
 Axis (C2)
• The most distinctive
characteristic is the
vertically projecting
odontoid process  a
pivotal restraint againts
horizontal
displacements of the
Atlas
• Provides a bearing
surface on which the
Atlas may rotate 7
Regional Characteristics of Vertebrae Thoracic
 Body

Larger than cervical,heart shaped,bears two costal

demifacets

 Spinous process

Long, sharp, projects inferiorly

 Vertebral foramen

Circular

 Transverse processes

Bear facets for ribs (Except T11&T12)

 Superior & inferior articulating processes

Superior facets directed posteriorly

Inferior facets directed anteriorly

 Movement allowed

Rotation, lateral flexion possible but limited by ribs,

flexion & extension prevented
 Regional Characteristics of Vertebrae Lumbar
• Body

Massive, kidney shaped

• Spinous process

Short, blunt, projects posteriorly

• Vertebral foramen

Triangular

• Transverse processes

Thin & tapered

• Superior & inferior articulating processes

Superior facets directed posteromedially (or

medially)

Inferior facets directed anterolaterally (or

laterally)

• Movement allowed

Flexion & extension ; some lateral flexion,

rotation prevented
 Regional Characteristics of Vertebrae
Sacrum

 Composed of five fused vertebrae that form a

single triangular complex of bone that support
the spine & forms the posterior part of the
pelvis

 Inferior half of the sacrum is not

weightbearing

 Provide strength & stability to the pelvis and

transmits the weight of the body to the pelvic
girdle
Sacral canal contains nerve root of the cauda equina

The sacrum is tilted so that articulates with L5 vertebrae at

the lumbosacral angle which varies from 130-160o

Pelvic surface is smooth & concave

Dorsal surface is rough & convex

Sacral hiatus results from the absence of the laminae &

spinous process of S5 vertebrae
Regional characteristics of Vertebrae Coccyx

• Formed by four rudimentary

vertebrae
• The coccyx contributes no
supportive function to the spine
• It serve as an origin for the gluteus
maximus posteriorly and the
muscles of pelvic diaphragma
anteriorly
• Pelvic surface is concave &
smooth
• Dorsal surface is convex & rough
 Joints of the Spine
• Atlanto-occipital joints
• Atlantoaxial joints
• Costovertebral joints
• Joints of the vertebral bodies (intervertebral discs)
• Joints of the vertebral arches (zygapophysial
joints/facet joints)
• Sacroiliac joints
13
 Joints of the Spine
 Atlanto-occipital joints
 Occipital condyles of skull and
superior articulating surface of atlas
 Primarily involved in flexion,
extension & lateral bending
movements
 Atlantoaxial joints
Median Atlantoaxial C1-2

 Dens of axis and anterior arch of

atlas
 Primarily involved in rotation

14
 Joints of the Spine
• Costovertebral joint
 The lateral surface of the vertebral body has both superior and
inferior facet for articulation with adjacent ribs

15
Joints of the vertebral bodies Intervertebral
Disc
• Fibrocartilaginous complex that form articulation between the bodies of the
vertebrae
• Intervertebral disc - comprised of three parts :

• nucleus pulposus

• annulus fibrosus

• hyaline cartilage end plates

( Williams,1989 ; White III & Pamjabi, 1990 ; Holm,1990 ; Willis & Burton,1992)

• Acts as a thick-walled cylinder to distribute load, support stability &

flexibility of the spine
16
 Functional Spinal Unit
Functional Spinal Unit

(Schmorl and Junghanns) :

“Smalllest physiological
motion unit of the spine”

1. Intervertebral Discs.

2. Adjoining ligaments
between 2 vertebrae.

3. Exclude other soft tissues

such as muscles.
 Intervertebral Discs
• A pair of vertebral bodies with the intervening
disc and a pair of facet joints is called
• Motion segment
• Functional Spinal Unit

18
Annulus Fibrosus
• A ring consisting of 15-25 concentric lamellae
of fibrocartilage forming the circumference of
the IV discs.

• The fibers forming each lamella run obliquely

from one vertebra to another

• The major function is to withstand tension

• Collagen : 50 – 70 %

• Proteoglycan : 10 – 20 %  H2O <<

• Outer side : Collagen type I >>

• The collagen fibres of the inner two-thirds of

the AF sweep around into the vertebral
endplate, forming its cartilagineous component.
 Nucleus Pulposus
 More cartilagineous than fibrous and normally highly elastic

 30-50% of IV Disc volume

 Located more posteriorly than centrally because the lamellae of AF are thinner
and less numerous posteriorly than anteriorly or laterally

 Has a high content of water (70-90%) that is maximal at birth and decreases
wiith advancing age

 Acts like a shock absorber for axial forces and like semifluid ball bearing during
flexion, extension, rotation and lateral flexion of the spine

 NP is avascular and receives nourishment by diffusion from blood vessels at the

periphery of AF and vertebral body

 NP having no nerves, so it is insensitive

 Nucleus Pulposus
 Collagen : 15%-25% (Collagen type 2 >>)

 Proteoglycan : 50%  H2O (90%)

 The essential function is to resist & redistribute compressive

force within the spine

21
 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 flexion
• Facet joint capsules are highly
innervated and have been shown to be
a source of LBP
 Sacroiliac Joint
• Connects the sacrum to the ilium
• The stability depends on :

• Joint configuration – L shaped

• Extensive ligamentous support

* Sacroiliac ligaments

* Accessory sacroiliac

ligaments

23
 Ligaments of the Spine
• Connected between adjacent
vertebrae along length of spine

• Act to limit excessive motion

• Ligaments:
• Anterior and posterior longitudinal
ligaments
• Ligamentum flavum
• Inter- and supraspinosus ligaments
• Intertransverse ligaments
• Facet joint capsules

24
 Ligaments of the Spine
Anterior longitudinale ligaments
• covers and connects the anterolateral aspects of
the vertebral bodies and Intervertebral discs
• ultimate load of 340 N
• strongly attached to the the vertebral bodies
but loosely attached to AF
• maintains stability of the joints between the
vertebral bodies and help prevent hyperextension
of the spine

25
 Ligaments of the Spine
Posterior longitudinale ligaments
• runs within the vertebra canal along the posterior
aspects of the vertebral bodies
• ultimate load of 180 N
• strongly attached to the AF and the posterior
edges of the vertebral bodies
• helps prevent hyperflexion of the spine and
posterior protrusion of the discs
26
 Spine Musculature
• Muscle of the spine are part of the trunk musculature
• Muscle injury generally occurs during forcible lengthening
while the muscle is activated (contracting)

27
 Spine Musculature
• The anatomy of the posterior
muscles of the back is divide into
three main layers:

• Superficial layer: Consists of

muscles that attach the upper
extremity to the spine. The trapezius
latissimus dorsi and levator
scapulae muscles overlie the deeper
rhomboid major and minor muscles

• Intermediate layer: serratus

posterior superior and inferior.

28
 Spine Musculature
• Deep layer: Consists of the intrinsic back
muscles, which function in movement of
the spinal column, can be subdivided into
three layers:

1. Splenius capitis and splenius cervicis

2. Sacrospinalis (erector spinae),

subdivided into spinalis, longissimus, and
iliocostalis portions in the thoracic region

3. Semispinalis, multifidi, rotatores,

intertransversari, and interspinales

29
30
 The Spinal Cord
 Runs through the vertebral canal, extends
from foramen magnum to second lumbar
vertebra
 Elongated cylindrical mass of nerve tissue
 occupies the upper 2/3 of the vertebral
canal

 Conus medullaris- tapered inferior end

• Ends between L1 and L2

 Cauda equina - origin of spinal nerves

extending inferiorly from conus medullaris
Segments of the Spinal Cord
 Composed of 31 segments :

8 cervical

12 thoracal

5 lumbalis

5 sacralis

1 coccygeus
 Not uniform in diameter
• Cervical enlargement: supplies upper
limbs
• Lumbar enlargement: supplies lower
limbs
Spinal cord
 Connective tissue membranes
• Dura mater: outermost layer; continuous with
epineurium of the spinal nerves
• Arachnoid mater: thin and wispy
• Pia mater: bound tightly to surface
 Forms the filum terminale
anchors spinal cord to coccyx

 Forms the denticulate ligaments that attach the

spinal cord to the dura

 Spaces
• Epidural: external to the dura
 Fat-fill

• Subdural space: serous fluid

• Subarachnoid: between pia and arachnoid
 Filled with CSF
The Spinal Nerves

34
 Blood Supply

 The vertebral artery is the first

branch of the subclavian artery 
Major blood supply to cervical spinal
cord, nerve roots & vertebrae
 BLOOD SUPPLY
• Anterior & posterior spinal
arteries supply the thoracic
spinal cord.
• Radicular arteries 
intervertebral foramina 
vertebral canal  divided into
anterior & posterior spinal
arteries

Aorta  Intercostal arteries

Radicular arteries
 Blood Supply
• The Radicular arteries of Adamkiewicz is the largest segmental
arteries & is a major blood supply to lower spinal cord

Originates from left side (80%) and usually accompanies the

ventral root of thoracic nerve 9, 10, 11

• Careful dissection near the intervertebral foramen &

costotranverse joint to prevent injury to this vascular supply

37
 Blood Supply
 Lumbar vertebrae is supplied by Lumbar segmental artery, for
L1-L4 arise from Aorta, L5 arise from Iliolumbar artery

 The venous supply of the lumbar region parallels the arterial

supply. It consists of a anterior and posterior ladder-like

configuration of valveless veins that communicate with the

inferior vena cava.

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 The watershed region and critical supply zone of the
thoracic spinal cord
 The limited number of radicular arteries supplying the thoracic spinal
cord results in a less abundant blood supply. Branches of the anterior
median spinal artery supply the ventral two-thirds of the spinal cord,
whereas branches of the posterior spinal arteries supply the dorsal
third of the cord. The region where these two zones meet is relatively
poorly vascularized and is termed the watershed region.

 The zone located between the fourth and ninth thoracic vertebrae has
the least profuse blood supply and is termed the critical vascular
zone of the spinal cord.
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• Batson’s plexus is a system of valveless veins located
within the spinal canal and around the vertebral body. It is
an alternate route for venous drainage to the inferior vena
cava system.
• Because it is a valveless system, any increase in abdominal
pressure (e.g. secondary to positioning during spine
surgery) can cause blood to flow preferentially toward the
spinal canal and surrounding bony structures.
• Batson’s plexus also serves as a preferential pathway for
metastatic tumor and infection spread to the lumbar spine.

40
SPINE PROBLEMS
Most Common in Daily Practice
Most Common Problems
in Malang
(2014 – 2017)

1. Degenerative Lumbar and Cervical Spine

2. Lumbar and Cervical Disc Herniation

3. Trauma (Fracture / Fracture-Dislocation)

4. Spine Infections

5. Spine Deformities (esp. Scoliosis)

6. Spine Metastasis

7. Spinal Cord and Nerve Tumors

8. Ankylosing Spondylitis
 Principles of
Degenerative Spine
 Disc Dysfunction

Deterioration of the mechanical and

chemical properties of the disc, caused
by :
Aging process
Environmental factore

Kirkaldy-Willis and Farfan proposed :

Phase 1 : Disc dysfunction

Phase 2 : Instability

Phase 3 : Stability
Kirkaldy – Willis
Cascade
The Cascade
 Clinical Problems in Degenerative Spine

1. Back Pain / Neck Pain

2. Radicular pain (Pain

radiating through extrimities)

3. Sensory and/ motor power

impairmenr of the extrimities

4. Bladder and bowel

impairment

5. Gait disorders

6. Dysruption of daily activities

 Pain in Degenerative

Pain due to degenerative disc

Pain due to Canal Stenosis
Pain due to Instability
Radiating Pain

Cervical Radiculopathy

Lumbar Radiculopathy
 Spinal Canal Stenosis
 Chronic compression of the nerve structures in

- Spinal Canal (Spinal Cord Compression  Myelopathy / Upper Motor Neuron,

- Cauda Equina  Nerve Root Compression  radiculopathy / Lower Motor

Neuron)

 The canal constriction or enrouchment mechanically affects the nerve structures and
the free flow of CSF around the spinal cord and/ nerve roots.

 Intraneural edema  fibrosis

 Affects nerve conduction  leg symptoms (lumbar), arm symptoms (cervical)

 Imaging for Degenerative
Spine (Spondylosis)
Standard Radiographs (X-Ray)
 AP & Lateral views are useful in diagnosing transitional anomalies
 AP & Lateral views can identify dsc narrowing with endplate sclerosis, and
facet joints OA.
 Flexion / Extension  to view segmental instability (> 4mm)  lateral

MRI  diagnostic choice  cant see alignment

 Investigation of choice !!
 Disc degneration
 Vertebral endplate changes
 Facet Joint OA
Imaging for Degenerative Spine
(Spondylosis)
CT-Scan
 Assessment of fusion status
 Contraindication in performing MRI
 Myelo CT  to provide conclusions on neural compression

Discography
 Provocation test : symptomatic or asymptomatic
 Diagnostic of efficacy is still debatable
 Only if the patient is potential candidate for surgery (Dx test will
influence the strategy)
Imaging Diagnosis
Xray (AP & Lateral)

Osteophyte

Narrowed Disc

Vacuum
phenomenon

Spondylolisthesis

Deformity
Magnetic Resonance Imaging

Compression of Spinal Canal

Discography
 CT & Myelography
Myelograph
y

CT scan
Degenerative Spine Treatment
 Conservative / Non Operative Treatment : Mild –
moderate pain, Acitivity Daily Living remains tolerable.

- Medical pharmacotherapy

- Physical Therapy

- Nerve root / Epidural injections

- Percutaneous Disc Laser Injection

- Intradiscal Electrothermal Therapy

Degenerative Spine Treatment
 Operative Treatment (Based on problems & prognosis)

1. Spinal Canal Stenosis  Decompression of spinal canal

(Central Canal, Foramina, Disc decompression)

2. Instability  Goal : Provides stability & Fusion (spine

arthrodesis )
Gender: Female
Age: 58
Symptom Description: Patient suffers DDD between L5¡ÐS1,
which has caused severe pain with difficulty to move around.
Treatment: the posterior lumbar discectomy, and circumferential
fusion and Instrumentation fusion were performed to relieve the
symptoms.

Before (MRI)   Before After

Minimal Invasive Decompression
 Minimal Invasive
Decompression

 Percutaneous Endoscopic Lumbar / Cervical

Decompression / Discectomy

 Micro Endoscopic Discectomy / Decompression

 Spinal Fusion
 Spinal fusion is defined as a bony union between two
vertebral bodies following surgical manipulation.

 The goal of spinal fusion is to achieve solid arthrodesis

between two or more vertebrae

 Thereby potentially eliminating painful movement,

stabilizing segmental instability, and / or correcting
deformity.
 Types of Spinal Fusion
Cervical Spinal Fusion

 Robinson & Smith  remove

cervical disc and fusion using
horse-shoe shaped graft

 Cloward  drilling holes in

IVD space and adjacent
vertebrae to insert bone dowel

 Plate fixation & Fusion

 Fusion with cages

Thoracolumbar Spinal Fusion (With
or Without Instrumentation):

 Posterolateral Fusion by Watkins

 Posterior Lumbar Interbody Fusion

(PLIF) by Jaslow – Cloward

 Transforaminal Lumbar Interbody

Fusion (TLIF)

 Anterior Lumbar Interbody Fusion by

Capener

 Circumferential Fusion
LUMBAR DISC
HERNIATION
RUPTURE OF DISC
Disc Ruptures (HNP)
 HISTORY :
 ONSET :
 Prodromal back pain for varying lengths of time
 Intermittent
 Acute, followed soon after onset of leg pain
 Direct trauma/sudden weight loading of the spine are not
causal agents of disc rupture, although may aggravate a
preexisting lesion
 Disc Ruptures (HNP)
 HISTORY :
 LOCATION OF PAIN :
 THE BACK
 THE BUTTOCK
 THE THIGH
 THE LEG
 THE FOOT
Disc Ruptures (HNP)
 HISTORY
 AGGRAVATION
 BENDING

 STOOPING

 LIFTING

 COUGHING

 SNEEZING

 STRAINING AT STOOL

 RELIEVED BY REST
Disc Ruptures (HNP)
 PHYSICAL EXAMINATION
 The back :
 Lumbar spine is flattened,
slightly flexed
 Sciatic scoliosis (obvious on
bending forward)
 Standing with the affected hip &
knee slightly flexed
 Limitation of flexion &
extension

 Tenderness & muscle spasm 

in the standing position
Disc Ruptures (HNP)
 PHYSICAL EXAMINATION
 The extremities
 Root tension & irritation

 STRAIGHT LEG RAISING (L3, L4,L5)

 BOWSTRING SIGN
 FLIP TEST
 CROSSOVER PAIN (WELL-LEG RAISING SIGN)
 FEMORAL NERVE STRETCH(L2 , L3)
Disc Ruptures (HNP)
 PHYSICAL EXAMINATION
 THE EXTREMITIES
 ROOT COMPRESSION
 MOTOR WEAKNESS
 CHANGES IN SENSORY APPRECIATION
 CHANGES REFLEX ACTIVITY
 Common Neurological Changes in HNP

Change RootL4 RootL5 RootS1

Motor Knee Ankle Ankle
Weakness extension Dorsiflexion Plantarflexion
EHL FHL

Sensory loss Medial shin to Dorsum of Lateral border

knee foot and of foot and
lateral calf posterior calf

Reflex knee Tibialis Ankle

depresion posterior

Wasting Thigh (no Calf (minimal Calf (minimal

calf) thigh) thigh)
Criteria for the diagnosis of the acute radicular
syndrome (sciatica due to an HNP):

1. Leg pain (including buttock) as the dominant complaint

when compared to back pain
2. neurological symptoms that are spesific (e.g., paresthesia in
typical dermatomal distribution)
3. significant SLR changes (any one or a combination of these)
 SLR less than 50% of normal
 Bowstring discomfort
 Crossover pain

4. neurological signs – weakness, wasting, sensory loss or

reflex alteration (at least 2 of 4)
Cauda Equina Syndrome
 prodromal stage of back pain and some leg symptoms

 dramatic increase in back pain and the occurrence of bilateral

leg pain and perineal numbness

 inability to void; decreased tone in the rectal external sphincter

 numbness to pinprick in the perineal region

 usually caused by a massive midline disc sequestration into the

spinal canal
Double Root
Involvement
 A disc rupture that migrates medially

 Any disc rupture that migrates cephalad and

laterally

 A disc rupture that migrates cephalad and medially

 foraminal L4 disc rupture

 rare double disc herniation.

 conjoined nerve root

Classification
 (a) contained protrusion,

 (b) contained extrusion

(subannular),

 (c) noncontained extrusion

(transannular),

 (d) noncontained
sequestration.
 Differential Diagnosis Sciatica
 interspinal causes :
 proximal to disc : conus & cauda equina
lesions
 disc level :
 herniated nucleus pulposus
 Stenosis
 infection (osteomyelitis, discitis)
 inflammation (arachnoiditis)
 neoplasm (benign/malignant with nerve
root pressure)
 extraspinal causes :
 pelvis
 cardiovascular conditions (peripheral
vascular disease)
 gynecological condition
 orthopaedic condition (osteoarthritis
of hip)
 sacroiliac joint disease
 neoplasm (invading or compressing
lumbosacral plexus)
 peripheral nerve lesions
 neuropathy (diabetic, tumor, alcohol)
 local sciatic nerve condition (trauma,
tumor)
 inflammation (herpes zoster)
Disc Ruptures (HNP)
 Conservative treatment :
 Bed rest
 Exercise
 Medication
 Epidural steroids
 Miscellaneous (traction, manipulation)
Disc Ruptures (HNP)
 Surgery, indications :
 Bladder & bowel involvement & ereksi
 Increasing neurological deficit

 Significant neurological deficit with significant SLR

 Failure of conservative treatment
 Recurrent of sciatica syndrome
 A disc rupture into a stenotic canal
Disc Ruptures (HNP)
 Disc Ruptures (HNP)

 Chemonucleolysis

 Surgery, treatment options

 POSTERIOR APPROACH
 STANDARD LAMINECTOMY
 MICROLAMINECTOMY - POSTERIOR
 MICORLAMINECTOMY – LATERAL
 POSTERIOR LUMBAR INTERBODY FUSION
 ANTERIOR APPROACH
 ANTERIOR LUMBAR INTERBODY FUSION
 PERCUTANEOUS DISCECTOMY APPROACH
 Chemonucleolysis
 Chymopapain, first report of its clinical use in the
treatment of lumbar disc herniations by Smith, 1964

 again released for general use in 1982

Artificial Disc Replacement
 inserts a small prosthetic
(artificial) disc comprising
a polyethylene core that
slides between two metal
end plates. The end plates
are attached to the
vertebral body with
anchoring teeth built along
the rim of the end plates.

 The disc is made of the

same material used in
artificial hips and knees.
Disc Degeneration With Root Irritation,
Lateral Zone : Foraminal HNP
Foraminal HNP
Bony Encroachment in The
Lateral Zone
Female, 51 y.o
PURWANINGSIH/F/51 YO
PURWANINGSIH/F/51 YO
PURWANINGSIH/F/51 YO
THORACOLUMBAR
FRACTURE
Will Be Delivered By :
dr. Syaifullah Asmiragani, SpOT(K)
Spine Infections
Pyogenic Spine Infection
Spine Tuberculosis Infection
 How To Classify
A. Histologic Response of The Host to The Specific
Organisms (According causative organisms)

- Pyogenic Response (Most bacteria)

- Granulomatous Reactions (Mycobacterium, fungi, Brucella, Syphillis

B. Primary Location

- Vertebral Osteomyelitis – Discitis – Epidural Abscess

C. Main Routes

(Haematogenous / Direct Inoculation / Spreading from Contagious Source)

 Spine Tuberculosis
(Introduction)
 1st described by Sir Percival Pott (1779)

 Pott’s disease

 The most common granulomatous spine infection in the world

(followed by fungi, and spirochete)

 The spine is the most common site of skeletal tuberculous, 50% of all
musculoskeletal TB.  thoracal : adamkiewkz

 Tuberculous involvement of the spine has the potential for serious

morbidity, including permanent neurologic deficits and severe
deformity.

 Medical treatment or combined medical and surgical strategies can

control the disease in most patients
 Spine Tuberculosis
(Etiology)
 Mycobacterium tuberculosis

 Aerobic, non-spore forming, non-motile, slow growing

 Die with heat, UV light

 AFB with Ziehl-Neelsen

Musculoskeletal Tuberculosis
 1% - 5% of all patients with TB

 Men affected more than women

 Haematogenous seeding in most cases, or from direct

extension of the disease

 A pre-pus inflammatory reaction with Langerhan’s giant

cells, epitheloid cells, and lymphocytes

 The granulation tissue proliferates, producing thrombosis

of vessels.
 Tissue necrosis and breakdown of inflammatory cells result
in a paraspinal abscess

 The pus may be localized, or it may track along tissue planes

 Progressive necrosis of bone leads to a kyphotic deformity

 Typically, the infection begins in the anterior aspect of the

vertebral body adjacent to the disk

 The infection then spreads to the adjacent vertebral bodies

under the longitudinal ligaments

 Noncontigous (skip lesions) are also seen occasionally.

Tuberculous Spondylitis
Pathophysiology
 Usually secondary to an extraspinal source of infection.
 The basic lesion is a combination of osteomyelitis and arthritis.
 Typically, more than one vertebra is involved. The area usually
affected is the anterior aspect of the vertebral body adjacent to the
subchondral plate. Tuberculosis may spread from that area to
adjacent intervertebral discs. In adults, disc disease is secondary
to the spread of infection from the vertebral body. In children,
because the disc is vascularized, it can be a primary site.
 Pathophysiology Of
Tuberculous Spondylitis
 Progressive bone destruction leads to vertebral collapse
and kyphosis.

 The spinal canal can be narrowed by abscesses,

granulation tissue, or direct dural invasion  spinal
cord compression and neurologic deficits.
 Pathophysiology Of
Tuberculous Spondylitis
 Kyphotic deformity occurs as a consequence of
collapse in the anterior spine. Lesions in the thoracic
spine have a greater tendency for kyphosis than those in
the lumbar spine.
 A cold abscess can occur if the infection extends to
adjacent ligaments and soft tissues.
 Abscesses in the lumbar region may descend down the
sheath of the psoas to the femoral trigone region and
eventually erode into the skin
 Pathophysiology Of
Tuberculous Spondylitis

Vuyst, D. et al. 2003. Imaging features of musculoskeletal tuberculosis.

 Types of Spondylitis TB
1.Paradiscal
2.Central
3.Anterior
4.Appendiceal
 Paradiscal Type
 Most common

 Adjacent to intervertebral
disc leading to narrowing of
disc space

 MRI shows high signal /

destruction of endplate,
narrowing of the disc, and
large paraspinal and
sometimes epidural abscess
 Anterior Type
 Subperiosteal lesion under ALL

 Pus spreads over multiple vertebral

segments, stripping periosteum and
ALL from anterior surface of
vertebral bodies

 Periosteal stripping renders the

vertebrae avascular and susceptible to
infection

 Both pressure and ischaemia combine

to produce anterior scalloping

 More commo in thoracic spine

 MRI shows subligamentous abscess,

preservation of discs.
 Central Lesions
 Centered on the vertebral body

 Disc is not involved

 Infection starts from center of

vertebral body, through Batson’s
venous plexus or through
posterior vertebral artery.

 Vertebral collapse  Vertebra

plana

 MRI shows a signal abnormality

of the vertebral body with
preservation of disc

 DDx : Metastasis or Lymphoma

 Appendiceal Type
 Isolated infection of the
pedicles & laminae (neural
arch), transverse process,
and spinous process

 Uncommon lesion (<5%)

 Occur in isolation or in
conjunction with the
typical paradiscal variant

 Radiographycally, appears
as erosive lesions,
paravertebral shadows,
with intact disc space
Clinical Symptoms
 Fatigue
 Weakness
 Weight loss
 Anorexia
 Low grade fever
 Night sweats
 Productive cough
 Hemoptysis
 Clinical
 History:

 Presentation depends on the following:

 Stage of disease
 Site
 Presence of complications such as neurologic deficits,
abscesses, or sinus tracts

 The reported average duration of symptoms at the time of

diagnosis is 3-4 months.
 Back pain is the earliest and most common symptom.
 Patients have usually had back pain for weeks prior to
presentation.
 Pain can be spinal or radicular.

 Constitutional symptoms include fever and weight loss.

 Neurologic abnormalities occur in 50% of cases and
can include spinal cord compression with paraplegia,
paresis, impaired sensation, nerve root pain, or cauda
equina syndrome
 Cervical spine tuberculosis  a less common presentation
but is potentially more serious  severe neurologic
complications :  myelopathy cervical
 This condition is characterized by pain and stiffness.
 Patients with lower cervical spine disease can present with
dysphagia or stridor.
 Symptoms can also include torticollis, hoarseness, and neurologic
deficits.

 Patients infected with HIV is similar to that of patients who

are HIV negative;
 Physical

 Examination should include the following:

 Careful assessment of spinal alignment
 Inspection of skin, with attention to detection of sinuses
 Abdominal evaluation for subcutaneous flank mass
 Meticulous neurologic examination
 Thoracic spine is frequently reported as the most
common site of involvement  comprise 80-90%
 Spine deformity (kyphosis) of some degree occurs in
almost every patient.
 There may be large cold abscesses of paraspinal tissues
or psoas muscle that protrude under the inguinal
ligament. They may erode into the perineum or gluteal
area.
 Neurologic deficits may occur early in the course of
disease. Signs depend on the level of spinal cord or
nerve root compression.
 Disease involving the upper cervical spine can cause
rapidly progressive symptoms.
 Retropharyngeal abscesses occur in almost all cases.
 Neurologic manifestations occur early and range from a
single nerve palsy to hemiparesis or quadriplegia.
 If no evidence of extraspinal tuberculosis  diagnosis
can be difficult.

 62-90% of patients in reported series present in this

manner.

 Information from imaging studies, microbiology, and

anatomic pathology should help establish the diagnosis.
 Lab Studies
 Tuberculin skin test (purified protein derivative [PPD]) demonstrates a positive finding in
84-95% of patients who are non–HIV-positive. Indicates past or present exposure to
Mycobacterium.
 Erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h). 
Nonspecific
 Microbiology studies to help diagnosis: acid-fast bacilli (AFB) staining
 An absolute diagnosis can be made only biopsy of the spine lesion and isolate organisms
for culture (Histopathology) and susceptibility.
 CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft
tissue structures. These study findings may be positive in only about 50% of the cases.
 Some rapid sensitive detection systems has been established, such as PCR (Polymerase
Chain Reaction) or other molecular detection systems. These systems require great care
in minimizing contaminants in the specimens, and expensive.  ga spesifik + mahal
 Imaging Studies:

 Radiographic changes present relatively late. Plain radiography

demonstrates the following characteristic changes of spinal
tuberculosis:
 Lytic destruction of anterior portion of vertebral body
 Increased anterior wedging
 Collapse of vertebral body
 Reactive sclerosis on a progressive lytic process
 Enlarged psoas shadow (abses) with or without calcification
 Additional findings
 Vertebral end plates are osteoporotic.
 Intervertebral discs may be shrunk or destroyed.
 Vertebral bodies show variable degrees of destruction.
 Fusiform paravertebral shadows suggest abscess
formation.
 Bone lesions may occur at more than one level.
Typical Xray
CT scanning
CT scanning provides much better
bony detail of irregular lytic lesions,
sclerosis, disk collapse, and
disruption of bone circumference.
Low-contrast resolution provides a
better assessment of soft tissue,
particularly in epidural and
paraspinal areas.
It detects early lesions and is more
effective for defining the shape and
calcification of soft tissue abscesses.
In contrast to pyogenic disease,
calcification is common in
tuberculous lesions.
MRI
MRI is the criterion standard for
evaluating disc space infection and
osteomyelitis
 most effective for demonstrating the
extension of disease into soft tissues and
the spread of tuberculous debris under
the anterior and posterior longitudinal
ligaments.
MRI findings useful to differentiate
tuberculous spondylitis from pyogenic
spondylitis include thin and smooth
enhancement of the abscess wall and
well-defined paraspinal abnormal signal,
whereas thick and irregular enhancement
Thus, contrast-enhanced MRI appears to
be important in the differentiation of
these two types of spondylitis.
MRI is most effective for
demonstrating neural compression.
 Other Tests:

 Radionuclide scanning is not useful.

 Gallium and bone scans have a high false-negative rate

of 70% and 35%, respectively..
Histologic Findings:

 exudative granulation tissue with interspersed

abscesses.

 Coalescence of abscesses results in areas of caseating

necrosis
 Tuberculous Spondylitis –
Radiological Findings

Griffith, J. Imaging of Musculoskeletal Tuberculosis: A new look at an old disease. 2002. Clinical orthopedics and related
research.
 Imaging Features that Favor
Spinal TB Rather than Neoplastic
Disease

Griffith, J. Imaging of Musculoskeletal Tuberculosis: A new look at an old disease. 2002. Clinical orthopedics and
related research.
Tuberculous spondylitis
 List of Problems
1. Infection 9. Deformity

2. Poor General Condition 10. Kyphosis Progression by

Growth
3. Pain
11. Socioeconomic
4. Multiple Lesions
12. Psychogenic
5. Cold Abcess  no demam
13. Pulmonary Dysfucntion
6. Pathologic Fracture
14. Cardiac Disability
7. Instability

8. Neurological Deficits
 TREATMENT
Aims of treatment :

 To eradicate the disease

 To prevent or correct deformity

 To prevent paraplegia / neurological deficits or

progression
 Medical therapy
 INH and rifampin should be administered during the whole course of
therapy.
 Additional drugs are administered during the first 2 months of therapy ;
pyrazinamide, ethambutol, and streptomycin. A 3-drug regimen usually
includes INH, rifampin, and pyrazinamide.

 The duration of treatment is somewhat controversial ; some studies

favor a 6- to 9-month course, traditional courses range from 9 months to
longer than 1 year.
 Duration of therapy should be individualized and based on the resolution
of active symptoms and the clinical stability of the patient.
 Drug Category: Antituberculous drugs -- Inhibit growth and proliferation
of causative organism
 Surgical Care:

 Indications
 Neurologic deficit (acute neurologic deterioration,
paraparesis, paraplegia)
 Spinal deformity with instability
 No response to medical therapy
 Nondiagnostic percutaneous needle biopsy sample

 Resources and experience are key factors in the

decision to use a surgical approach.
 Reconstruction depends on the level of vertebral spine
involved and the extent of bony destruction.
 The lesion site, extent of vertebral destruction, and
presence of cord compression or spinal deformity
determine the specific operative approach.
 Vertebral damage is considered significant if more than
50% of the vertebral body is collapsed or destroyed or a
spinal deformity of more than 5° exists.
 The most conventional approaches include anterior
radical focal debridement and posterior stabilization with
instrumentation.
 Contraindications
 Vertebral collapse of a lesser magnitude is not considered an indication for surgery because
with appropriate treatment and therapy compliance, it is less likely to progress to severe
deformity.

 Consultations:
 Orthopedic surgeons
 Pulmonologist
 Rehabilitation teams

 Activity:
 Despite questionable efficacy, prolonged recumbence and the use of frames, plaster beds,
plaster jackets, and braces are still used.
 Cast or brace immobilization was a traditional form of treatment but has generally been
discarded. Patients should be treated with external bracing.
Further Inpatient Care

Once the diagnosis is established and treatment is started, the

duration of hospitalization depends on the need for
surgery and the clinical stability of the patient.
Further Outpatient Care

 Patients should be closely monitored to assess their

response to therapy and compliance with medication.
Directly observed therapy may be required.
 The development or progression of neurologic deficits,
spinal deformity, or intractable pain should be
considered evidence of poor therapeutic response. This
raises the possibility of antimicrobial drug resistance as
well as the necessity for surgery.
 Complications:
 Abscess
 Spine deformities
 Neurologic deficits and paraplegia

 Prognosis:
 Current treatment modalities are highly effective if not complicated by severe
deformity or established neurologic deficit.
 Therapy compliance and drug resistance are additional factors that significantly
affect individual outcomes.
 Paraplegia resulting from the active disease causing cord compression usually
responds well to chemotherapy.
 If medical therapy does not result in rapid improvement, operative decompression
will greatly increase the recovery rate.
 Paraplegia can manifest or persist during healing because of permanent spinal cord
damage.
 Patient Education:

Patients should be instructed on the

importance of therapy compliance.
 Pyogenic
Spondylodiscitis
 Bacteremia due to haematogenous
vertebral osteomyelitis

 UTIs, Soft tissue infections, and

respiratory tract infections

 Predisposing factors : direct

inoculation, Immunodeficiencies.

 S.aureus (55%), E.coli,

Pseudomonas, Proteus.
 Pyogenic
Spondylodiscitis
Idiopathic Scoliosis
Spinal deformity characterized by lateral bending and fixed
rotation of the spine in the absence of any known cause.
Prof.dr. Subroto Sapardan
(1941 – 2011)

 Three-dimensional deformity of the spine with

lateral curvature plus rotation of the vertebral
bodies in sagital coronal and axial plane
 Classification
1.Non structural scoliosis(reversible,no rotation)
 habitual poor posture
 pain and muscle spasm
 lower limb length discrepancy  pincang

2.Structural scoliosis(irreversible,rotate)
 Idiopathic  selain yang dibawah
 Osteopathic
 Neuropathic
 myopathic
 Etiology
 Unknown  ongoing research.

 Factors.
 Genetic Factors  incidence families.
 CNS.
 Collagen, muscle, platelet defects.
 Growth and hormonal factors  melatonin.
 Biomechanical factors.
 Prevalence and Natural history

 Curve > 100  0.5-3% children and adolescent.

 Curve > 300  1.5-3 per 1000.
 The ratio boys girls is equal for minor curve,
affected girls rises as curve , reaching 1:8 for
those who requiring treatment
 AIS Develops > 10 yrs
 Severe curves ( > 90º ) may be associated with
cardio-pulmonary dysfunction, pain and early death
 Idiopathic Scoliosis
SRS (Scoliosis Research Society) divides 4 types :
 Infantile (0-3 yr)
 Juvenile (3-10 yr)
 Adolescent (>10 – 18)
 Adult (>18)
 Prevalence and Natural history

 Risk factors for progression:

 Sex.
 Female > Male
 Menses help determine the growth spurt. Within 12 mo after menses
 Skeletal growth .
 Risser 1 or less, prog  60 – 70%.
 Risser 3 reduce to 10%
 Curve location.
 Apex T12 or above > progress than isolated Lumbar curve.
 Curve magnitude.
 Greater curve  more progress.
Clinical Manifestations of
Idiopathic Scoliosis

Test for Hyperlaxity

Radiographic for
Scoliosis

A 36” cassete is prefer.

At least from T1 – L5 should be seen clearly
Standing PA/Lateral.
Force side bending R and L.
Pelvic AP.
 Management
 Goal of treatment.
1. To prevent progression and maintain balance.
2. Maintain respiratory function.
3. Reduce pain and preserve neurologic status.
4. Cosmesis.

 Consequences of untreated
1. Mortality rate  low especially >900.
2. Pulmonary and cardiac function.
3. Back pain.
 The Management
 Treatment option.
 Observation.
 Orthoses The Three O’s
 Operation

 There is no evidence that exercise programs,

electrical stimulation, special diets, chiropractic
adjustment, acupuncture, traditional treatment are
effective.
Bracing for Scoliosis

Milwaukee Brace
Boston Brace
 Surgery :
Correction & Fusion

 Indications of surgery
 Progressive curves >40-450 in growing children.
 Failure of bracing.
 Progressive curves beyond 500 in adults.
X-ray Erect
X-ray Bending
X-ray
Post Op
Intradural Tumors
 Male, 43 y.o
 9 months of low back pain  Xray Lumbosacral :

 Pain aggravated after excercise or No abnormality

sports activities

 Normal daily activities

 No neurological disturbances
 Osteotomized Lamina

Caudal
Cephalad
Durotomy

Carefully excised tumor

 7 days post op : no
complications

 Lumbar spinal orthosis applied

for 3 months

 10 months post op : daily activity

without pain, regular sports
activity.

 Histopathlogy : Schwannoma
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