1
Q
What is DISH?
A
- Diffuse idopathic skeletal hyperostosis
- A very common disorder
- Unknown aetiology
- characterised by presence of non marginal syndesmophytes at 3 successive levels involving 4 contiguous vertebrae
2
Q
What is DISH aka ?
A
- FORRESTIER DISEASE
3
Q
What is DISH define by?
A
- By the PRESENCE of NON MARGINAL SYNDESMOPHYTES AT 4 CONTIGUOUS VERTEBRA, 3 successive levels
- ( different from Ankylosing spondylitis = MARGINAL SYNDESMOPHYTES)
4
Q
What are syndesmophytes?
A
- Vertical outgrowths that extend across the disc space
- Represent CALCIFATION OF THE ANNULUS FIBROSIS and ALL + PLL
5
Q
Where do syndesmophytes occur?
A
- Anywhere in the spine
- usually THORACIC T7-11 region, > on RIGHT side thought to be due to the protective effect of the pulsatile aorta on the left thoracic spine!!!
- Symmetrical ( R+L) in CERVICAL and LUMBAR SPINE
6
Q
What is the epidemiology of difuse idiopathic skeletal hyperostosis?
A
- Overall incidence 6-12%
- uncommon before 50 years
- less common in africans, asians
location
- anywhere in spine
- most common Thoracic spine - Right side >cervical >lumbar
- thought due to protective nature of pulsatile aorta on left thoracic spine
- symmetrical sides in cervical/lumbar
7
Q
What are the risk factors for developing diffuse idiopathic skeletal hyperostosis?
A
- Gout
- Hyperlipidaemia
- diabetes
8
Q
What is DISH associated with?
A
- Lumbar spine stenosis
- Cervical spine
- hoarness
- sleep apnoea
- cervical myelopathy
- dysphagia and stridor
- Spine fx and instablity
- Ankylosis creates long lever arm-> displacement with minimal force
- hyperextension injuries are common
9
Q
What are the symptoms and signs of diffuse idopathix skeletal hyperextosis?
A
Symptoms
- Often asymptomatic & discovered incidentally
- thoracic/lumbar spine
- mild chronic pain
- stiffness esp in mane
- aggrevated cold weather
- cervical
- pain & stiffness
- dysphagia
- stridor
- hoarness
- sleep apnoea
10
Q
What investigaitons are useful in dx of DISH?
A
- xrays
- ap and latera spine
- non marginal syndesmphytes at 3 successive levels ( 4 continous vertebrae)
- thoracic syndesmophytes on right side
- c spine ant bone formation with preservation of disc space ( unlike ank spon)
- lumbar spine- symmetrical syndesmophytes
- other joint involvement -elbow
- Technetium bone scan
- increased uptake in areas of involvement
11
Q
Is Diffuse idiopathic skeletal hyperextosis related to HLA-B27?
A
- NO associated with HLA-B28 -pt with DISH and DM
12
Q
what are the radiographic findings of DISH
A
- NON MARGINAL SYNDESMOPHYTES at 3 successive levels ( 4 contiguous vertebra)
- Flowing candlewax
- preservation of disc space
- no ostepenia
- no assoc with HLA- B27
- age - older middle age
- No involvement in SI JOINT
cf ankl spon
marginal syndesmophytes, bamboo spine, ossificiation of disc space, osteopenia, strong assoc wiht HLA b27, younger pts, bilateral sacroilitis
13
Q
What is the tx of someone with Diffuse Idopathic Skeletal Hyperextosis?
A
non op
- activity modification. physical therapy, brace wear, NSAIDS, BISPHOSPHONATES
- most cases
OPERATIVE
- SPINAL DECOMPRESSION and STABILISATION
- for lumbar stenosis, cervical myelopathy, adult spinal deformity
14
Q
What are the complications of DISH?
A
- Mortality
- C spine trauma in DISH
- 15% tx operatively
- 67% tx non operatively
- C spine trauma in DISH
- Heterotrophic ossification
- increased risk of HO after THR
- 30-50% for THR with DISH cf <20% wout
15
Q
Define ankylosing spondylitis?
A
A chronic systemic autoimmune spondyloarthropathy characterised by
- HLA- B27 histocompatablity complex positive
- RH negative- seronegative
- primarily affecting spine
16
Q
What is the pathoanatomy of ankylosing spondylitis?
A
- exact mechanism unknown
- likely autoimmune reaction to an envirnomental pathogen to gentically susceptible individual
- theories in relation to HLA- B27
- HLA- B27 aggregates with peptides in joint -> degenerative cascade
- Enthesitis
- entheses inflammation -> bony erosions, surrounding soft tissue ossification and joint ankylosis (diff from RA- synovial)
- Disc space involvement
- Inflammation of the annulus -> bridging of osteophyte formation- syndemosphyte
17
Q
What is the epidemiology of ankylosing spondylitis?
A
- 4:1 Male : female
- affects 0.2% caucasians population
- usually presents at 30 years
- juvenile form <16 yrs inc enthesitis
- fewer than 10% HLA-B27 positive pt have symptoms
- Genetics
- HLA- B27 on 6th chromosome, B locus
- genetic predisposition but mode of inheritance is unknown
18
Q
What are the dx criteria?
A
- Bilateral sacroilitis
- +/- uveitis
- HLA- B27
19
Q
What are the systemic manifestations?
A
- Acute anterior uveitis/ iritis
- Heart disease
- pulmonary fibrosis
- renal amyloidosis
- ascending aortic conditions- regurge, stenosis
- Klebsilella peumoniae synovitis
- HLA-B27 more susceptible to these
*
- HLA-B27 more susceptible to these
20
Q
What are the orthopaedic manifestations of ank spon?
A
- Bilateral sacroilitis
- progressive spinal kyphotic deformity
- cervical spine fractures
- large joint arthritis
21
Q
What is enthesis?
A
- Insertion of tendon, ligaments or muscle to bone
22
Q
What are the symptoms of ank spon?
A
- Lumbosacral pain and stiffness
- most pts
- worse in mane
- insidious onset 3rd decade
- Neck and upper thoracic pain
- late in life
- acute neck pain- raise suspicion of fracture
- Sciatic
- loss of horizontal gaze
- shortness of breath
- costovertebral joint involvement-> reduced chest expansion
23
Q
what are the signs of ank spon?
A
- Limited chest wall expansion
- <2cm more specific dx HLA- B27
- Decreased spine motion
- Schober test- used to elevate stiffness
- Kyphotic spine deformity
- chin on chest flexion- see pic
- caused by multiple microfx over time
- Chin brow to vertical angle
- measured on lateral
- correction of this angle- improved surgical outcome
- Hip flexion contraction
- exam in supine and sitting position helps differentiate sagittal plane imbalance due to hip flexion contractures or kyphotic spinal deformity
- Sacroiliac provocation test
- faber test
- flexion/abduction/ ext rotatation of ipislateral hip causes pain
24
Q
What imaging is useful in dx ank spon?
A
- Xrays spine
- full length AP, lateral axial spine
- negative in 50% with spinal Fx
- Squaring of vertebra with vertical Marginal syndemosphytes- see pic
- Late vertebral scalloping - bamboo spine
- measure chin to brow vertical angle
- xray of pelvis
- ferguson pelvic tilt view
- xray beam 10-15 degree cephalad-see SI
- Bilateral symmetrical sacroiliac erosions
CT
- Will show bony changes but no active inflammation
- best for dx of Cervical Fx
MRI
- Will detect Inflammation - detect early AS
25
What is the tx of ank Spon?
Non operative
* **NSAIDS, COX-2 inhibitors and PT**
* first line of tx for pain and stiffness
* oral steriods not recommended
* TNF alpha blocking agents
* 2nd line
* infliximab, etancerpt, adalimumab
* improvement in symptoms
Surgery
* depends on cervicothoracic fx
* spinal deformity
* large joint arthritis
26
What is the epidemiology of cervicothoracic fractures in AS?
* Most occur **midcervical and cervicothoracic junction**
* Often _extension type- involve all 3 columns_
* maybe occult- consider CT scan
* **High mortality rate 2ary to epidural haemorrhage**
* _75% neurologic involvement_
* neurologic symtpoms often present late
27
What is the tx of cervicothoracic Fx?
Non operative
* **Traction, orthotic, halo immobilisation**
* stable spine fractures with no neurological deficits
* low weight traction may faciliate reduction
Operative
* **Spinal decompression with instrumented fusion**
* Progressive neurological deficit
* epidural haematoma with neurologic compromise
* unstable fx pattern
* decision to go ant vs post depends on Fx level, presence & location of haematoma & osteoporosis
* Outcomes
* _high rate of complications_
* progressive deformity
* nonunion
* hardware failure
* infection
28
What are the tx for spinal deformity with AS?
* Kyphotic deformity
* elliminate hip conttractures as reason for deformity
Surgery
* _Lumbar osteotomy_
* thoracolumbar kyphotic deformity
* goal to restore sagittal balance & horizontal gaze
* **closing wedge (pedicle subtracting) osteotomy**
* **hinge located on ant spine**
* greater deformity correction 30-40o per level
* better fusion & stability due to direct bony apposition
* **Vertebral body resection**
* entire vertebral body resected and replaced by cage
* **Single-level opening wedge osteotomy**
* hinge on post edde vertebral body
* requires rupture of ALL
* _C7-T1 cervicothoracic osteotomy_
* for chin to chest deformity
* slight under correction with final chin to brow angle 10o
* adv vertebral art ext to transv foramen, larger canal diameter
* post op halo immobilisation used as pt poor bone quality
29
What is the tx for large joint arthritis in AS?
* Asymmetric involvement of large joints
* shoulder and hip commonly involved
TX
* **Total hip replacement**
* pt with severe arthritis hip 2ary to AS
* pts have more **VERTICAL/ ANTEVERTED Acetabulum**
* may lead to **ANTERIOR DISLOCATIONS** after THR
* **Bilateral total hip arthroplasty**
* kyphotic deformity due to hip flexion contracture deformity
* at risk of dislocation
30
What is the epidemiology of cervical spondylitis?
* Present in **90% of pts with Rheumatoid Arthritis**
* Diagnosis often missed
* included 3 main types
* **Atlantoaxial Subluxation**
* **Basiliar Invagination**
* **Subaxial Subluxation**
31
What is the classification of Rheumatoid cervical spondylitis?
* **Ranawat**
****
* **Class 1- Pain , no neurologic deficit**
* **Class 2-** **Subjective weakness, hyperreflexia, dyssthesias**
* **Class 3A-** Objective weakness, long tract signs, **ambulatory**
* **Class 3B-** Objective weakness, long tract signs **, non ambulatory**
32
What are the signs and symptoms of rhematoid cervical spondylitis?
Symptoms
* Similar to cervical myelopathy
* neck pain
* neck stiffness
* occipital headaches
* gradual onset of weakness and loss of sensation
Signs
* Hyperreflexia
* upper & lower extremity weakness
* Ataxia- gait instability/loss of hand dexterity
33
What imaging is useful in dx of cevical spondylitis?
* Xrays
* Flexion-extension
* obtain before elective surgery
* CT
* better for bone anatomy & surgical planning
* MRI
* identify degree of spinal cord compression
34
What is the general tx of cervical spondylitis?
Non op
* Pharmacology
Operative
* Spinal decompression and stabilisation
* goal is to prevent further neuroloigcal progression and surgery may no reverse existing deficit
35
What is atlantoaxial subluxation?
* Presents in **50-80% pts with RA**
* most common to have
* **Anterior Subluxation of C1 on C2** ( can have lat/post)
36
what is the mechanism for atlanoaxial subluxation?
* **A pannus forms between the dens and C1**
* Leads to **destruction** of **Transverse Ligament & Dens**
37
What measurements are used to define stability on lateral extension-flexion views?
* **Atlanto-Dens Interval = ADI**
* **instability = \>3.5mm of motion between flexion and extension views**
* instability alone is not an indication for surgery
* \> 7mm = alar ligament disruption
* **\>10mm** associated with increased risk of neurological injury= **surgery**
* **Space available for cord (SAC) & Posterior atanto-dens interval =PADI** same thing
* **\<14 mm** assoc with increaed risk of neurological injury = **surgery**
* **\>13 mm-most important radiological finding that may predict complete neural recovery after decompression surgery**
38
What is the tx of atantoaxial subluxations?
Non operative
* IN stable atlantoaxial subluxations
Operative
* **Posterior C1-2 Fusion**
* if **ADI \>10mm** (even if no neuro)
* **SAC/PADI \<14mm** (even if no neuro)
* Progressive myelopathy
* indication- must be able to reduce C1 onto C2 - no need to remove C2 post arch
* add transarticular screws avoid use of halo
* Post op ct to identify location of vertebral arteries
* **Occiput -C2 fusion**
* if atlantoaxial subluxation is combined with **basilar invagination**
* resection of C1 post arch required for complete decompression
* **Odontoidectomy**
* rarely indicated
* used as a secondary proceedure when there is redisual anterior cord compression due to pannus formation that fails to resolve with time following a posterior spinal fusion
39
What is Basilar invagination?
* **Superior migration of Odontoid**
* **Tip of dens migrates above foramen magnum**
* present in **40% RA pts**
* often seen in combination with fixed atlantoaxial subluxation
40
Describe the mechanism of basilar invagination?
* Cranial migration of dens from **EROSION and BONE loss** between **occiput and C1/C2**
41
What lines are useful on lateral xray to dx basilar invagination?
* **Ranawat C1-C2 index**
* Most reproducible measurement
* centre of C2 pedicle to line conecting the anterior & posterior C1 arches
* normal men 17mm, women 15mm
* **distance of \<13 mm consistent with impaction**
42
What is the tx of basilar invagination?
* Operative
* **C2 to Occiput fusion**
* for progressive canal migration \>5mm
* neurological compromise
* cervicomedullary angle \<135o on MRI
* **Transoral/ anterior retropharyngeal odontoid resection**
* for brainstem compromise
43
What is the epidemioogy of subaxial subluxation?
* Present in 20% pt wth RA
* Often occurs mutiple levels
* combined upper c spine instability
* lower spine involvment more common with
* steriod use
* males
* seropositive RA
* nodules present
44
What is the pathophysiology of subaxial subluxation?
* Pannus formation and soft tissue instability of facet joints and Luschka joints
45
What is seen of subaxial subluxation on radiographs?
* **Subaxial subluxation of vertebral body of \>4mm or 20% = cord compression**
* **Cervical height index ( body height/width) \<2.0** almost 100% sensitive and specific for predicting neurologic compromise
46
What are the tx of subaxial subluxation?
* Operative
* **Posterior fusion & wiring**
* for \>4mm subaxial subluxation in intractable pain and neurological symptoms
47
What are the operative complications are tx a pt with rheuamatoid cervical spondylitis?
* **Failure to improve symptoms**
* outcomes less reliable with Ranawat Grade 3B
* **Pseudoarthrosis**
* 10-20% pseudoarthrosis rate
* decreased by extension to occiput
* **Adjacent Level degeneration**
Spine FRCS
flashcards
Decks in class (20)
# Cards
-
biomechanics of the spine0
-
Lumbar disc Herniation21
-
Spinal cord injuries29
-
Spondylolysis7
-
Spondylolisthesis34
-
Thoracolumbar injuries18
-
Systemic conditions47
-
Scheuermann's kyphosis16
-
Spine Anatomy FRCS50
-
Degenerative Cervical spine40
-
Adult spinal deformity27
-
Degenerative thoracolumbar spine72
-
Infection38
-
Incomplete spinal cord injuries18
-
Syrinx, Syringomyelia and Disatematomyelia14
-
Cauda Equina syndrome11
-
Paediatric Idiopathic Scoliosis28
-
Congenital Scoliosis9
-
Paediatric Cervical spine20
-
Paedriatric14
