Spine
A Anatomy (see Chapter 2, Anatomy)
B History and physical examination (Table 8-1; Figure 8-1)
Table 8-1
Examination of Patients with Disorders of the Spine
| Component | Features |
| Inspection | Overall alignment in sagittal and coronal planes (sciatic scoliosis) |
| Gait | Wide-based (myelopathy), forward-leaning (stenosis), antalgic |
| Palpation | Localized posterior swelling (trauma), acute gibbus deformity, tenderness |
| Range of motion | Flexion/extension, lateral bend, full versus limited |
| Neurologic function | Motor, sensory, reflexes, assessment of long-tract signs (see also Table 8-7) |
| Special tests | Straight-leg raise, Spurling test, Waddell signs of inorganic pathology |
1. Localized pain (tumor, infection)
2. Mechanical pain (instability, discogenic disease)
3. Radicular pain (herniated nucleus pulposus [HNP], stenosis), night pain (tumor)
4. Systemic symptoms such as fever or unexplained weight loss (infection, tumor)
5. The physical examination must evaluate both the spine and the neurologic function of the extremities (Table 8-2).
6. Localized hip and shoulder pathology may simulate spine disease and must also be evaluated.
1. Plain radiographs should be obtained 4 to 6 weeks after onset of symptoms; add flexion-extension views for suspected instability.
2. Magnetic resonance imaging (MRI) is excellent for further imaging of HNP, stenosis, soft tissue, tumor, and infection.
3. Computed tomography (CT) with fine cuts ± myelographic dye is used to examine bony anatomy after previous surgery and the quality of fusion.
4. Bone scan is helpful in evaluating metastatic disease and may be negative with multiple myeloma.
5. Laboratory evaluation consists of C-reactive protein and erythrocyte sedimentation rate for infection, metabolic screening, serum/urine protein electrophoresis for myeloma, and a complete blood cell count (there is often a high-normal white blood cell count with infection or anemia with myeloma).
D Workup of back pain—Complaint of back pain is second only to upper respiratory tract infection as a cause of office visits, with 60% to 80% lifetime prevalence. Standard workup begins with a history (most important) and progresses to physical examination (see Table 8-1). Radiographic and laboratory studies rarely help in acute cases. The following considerations in the evaluation of back pain are important:
Children may be affected by congenital or, more often, developmental disorders or infection.
Young adults are more likely to suffer from disc disease, spondylolisthesis, or acute fractures.
2. Radicular signs and symptoms
Often associated with disc herniation or spinal stenosis
Herpes zoster is a rare cause of lumbar radiculopathy, with pain preceding the skin eruption.
3. Systemic symptoms—Careful history-taking can help guide diagnosis of systemic conditions with associated spine pathology.
Infection (confirmed by laboratory studies)
Chronic back pain is often refractory to localized treatment in many patients with fibromyalgia.
4. Sources of referred back pain
5. Psychogenic pain—may play important role in some patients with chronic low back disorders
A Cervical spondylosis—Chronic disc degeneration and associated facet arthropathy result in three clinical entities:
Discogenic neck pain (axial pain)
Radiculopathy (root compromise)
Myelopathy (cord compression) and combinations of these conditions
2. Pathoanatomy—Cervical spondylosis involves the intervertebral disc and four other articulations (Figure 8-2):
Two uncovertebral joints (of Luschka)
Cord compromise as canal diameter decreases
Usually posterolateral, between the posterior edge of the uncinate process and the lateral edge of the posterior longitudinal ligament, it may result in acute radiculopathy.
Ossification of the posterior longitudinal ligament
Neck flexion results in slight increase in canal diameter and relief of cord compression.
3. Signs and symptoms—Degenerative discogenic neck pain may present as the insidious onset of neck pain without neurologic signs or symptoms, exacerbated by excess vertebral motion.
Can involve one or multiple roots
Neck, shoulder, and arm pain; paresthesias; and numbness
Overlapping findings because of intraneural intersegmental connections of sensory nerve roots
Relief of radicular pain with shoulder abduction is suggestive of a cervical etiology.
Caudal nerve root at a given level is usually affected (see Table 8-2).
4. Physical examination findings
Effectively demonstrates neural compressive pathology
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Extraforaminal cervical nerve blocks
Temporary collar immobilization
Pain clinic modalities are helpful in most cases of discogenic neck pain and radiculopathy
Combined anterior (cervical) Smith-Robinson discectomy and fusion (ACDF)
Involves excision of osteophytes and corpectomy with a strut graft fusion with or without instrumentation
Used for multilevel spondylosis and myelopathy and ossification of posterior longitudinal ligament (OPLL)
Allows for more extensive decompression
Lower incidence of instability compared with multilevel laminectomies
Contraindicated in setting of fixed kyphosis
1. Congenital versus acquired (traumatic, degenerative)
2. Absolute stenosis (anteroposterior canal diameter <10 mm)
3. Relative stenosis (anteroposterior canal diameter 10 to 13 mm)
4. Pavlov (Torg) ratio (canal/vertebral body width) should be 1.0.
Ratio of less than 0.80 or a sagittal diameter of less than 13 mm is considered a significant risk factor for later neurologic involvement.
5. Minor trauma such as hyperextension may lead to a central cord syndrome, even without overt skeletal injury.
6. Surgery may serve a prophylactic function but is usually reserved for patients who develop myelopathy or radiculopathy.
Cervical spine involvement is common in rheumatoid arthritis (occurring in up to 90% of patients) and is more common with long-standing disease and multiple joint involvement.
Neurologic impairment with rheumatoid arthritis has been classified by Ranawat (Table 8-3).
Table 8-3
Ranawat Classification of Neurologic Impairment in Rheumatoid Arthritis
| Grade | Characteristics |
| I | Subjective paresthesias, pain |
| II | Subjective weakness; upper motor neuron findings |
| III | Objective weakness; upper motor neuron findings |
| IIIA | Ambulatory |
| IIIB | Nonambulatory |
Look for subtle signs of neurologic involvement.
Assess the radiographic markers for impending neural compression (Figure 8-3).
Indications for surgical stabilization:
Patients with rheumatoid arthritis should have flexion/extension films before elective surgery.
2. Atlantoaxial subluxation—occurs in 50% to 80% of cases of rheumatoid arthritis and is often the result of pannus formation at synovial joints between the dens and the ring of C1, resulting in destruction of transverse ligament, dens, or both
Anterior subluxation of C1 on C2 is the most common finding, but posterior and lateral subluxation can also occur.
Findings on examination may include limitation of motion, upper motor neuron signs, and weakness.
Transarticular screw fixation (Magerl) across C1-C2 eliminates the need for halo immobilization associated with wiring alone.
Nonreducible atlantoaxial subluxation
Anterior cord compression because of pannus often resolves after posterior spinal fusion.
Odontoidectomy should be reserved as a secondary procedure.
Surgery is less successful in Ranawat grade IIIB patients but should be considered.
3. Cranial settling (basilar invagination)
The second most common manifestation of rheumatoid arthritis in cervical spine
Forty percent of patients with rheumatoid arthritis
Cranial migration of the dens from erosion and bone loss between the occiput and C1-C2
Often seen in combination with fixed atlantoaxial subluxation
Measurements are shown in Figure 8-3.
Cervicomedullary angle less than 135 degrees (on MRI) suggests impending neurologic impairment.
Transoral or retropharyngeal dens resection for brainstem compression
Occurs in 20% of cases of rheumatoid arthritis
Seen in combination with upper cervical spine instability
D Cervical spine and cord injuries—See Chapter 11, Trauma, for classification and treatment of cervical spine injuries.
Spinal shock usually involves a 24- to 72-hour period of paralysis, hypotonia, and areflexia.
Injuries below the thoracolumbar level (conus or cauda equina) may permanently interrupt the bulbocavernosus reflex.
In complete injuries, further neurologic improvement is minimal.
3. Physical and neurologic examination
Facial injuries, hypotension, and localized tenderness or spasm should be investigated.
Careful neurologic examination to document the lowest remaining functional level and to assess the patient for the possibility of sacral sparing (sparing of posterior column function, indicating an incomplete spinal cord injury) is essential (see Figure 8-1).
Complete cervical spine series (C1-T1)
Oblique views to investigate facet subluxation, dislocations, or fractures
Figure 8-4
Incomplete spinal cord injury syndromes.
Defined as some sparing of distal motor or sensory function
Three important generalizations regarding prognosis:
Anatomic classification of incomplete spinal cord injury (Table 8-4)
Presents as upper greater than lower extremity motor and sensory loss
Often seen in patients with preexisting cervical spondylosis who sustain a hyperextension injury
Cord is compressed anteriorly by osteophytes and posteriorly by the infolded ligamentum flavum.
The second most common incomplete cord injury
Damage is primarily in the anterior two thirds of the cord.
Posterior columns spared (proprioception and vibratory sensation)
Patients demonstrate greater motor loss in the legs than the arms.
CT may demonstrate bony fragments compressing the anterior cord.
6. Treatment—See Chapter 11, Trauma.
Used acutely to realign the spine in the presence of a displaced fracture with or without neurologic injury
Potentially negative outcomes are numerous and include neurologic injury, nonunion, and malunion.
Associated with greater than 3.5 mm of subluxation and greater than 11 degrees of difference in angulation between adjacent motion segments
8. Prognosis—The Frankel classification is useful when assessing functional recovery from spinal cord injury (Table 8-5).
Table 8-5
Frankel Classification of Cervical Spine Injuries
| Frankel Grade | Function |
| A | Complete paralysis |
| B | Sensory function only below injury level |
| C | Incomplete motor function (grades 1-2 of 5) below injury level |
| D | Fair to good (useful) motor function (grades 3-4 of 5) below injury level |
| E | Normal function (grade 5 of 5) |
E Sports-related cervical spine injuries
Commonly associated with stretching of the upper brachial plexus by bending the neck away from the depressed shoulder or neck extension toward the painful shoulder in the setting of foraminal stenosis (root irritation)
Symptoms include burning dysesthesia and weakness in the involved extremity.
Usually seen after axial load injury (spearing) but may also be seen after forced hyperextension or hyperflexion
Presents as bilateral burning paresthesia and weakness or paralysis
The third and fourth cervical levels are the most commonly affected.
It has no definitive association with future permanent neurologic injury.
A Differential diagnosis—The physical examination, imaging studies, and laboratory tests assist with the differential diagnosis (Table 8-6).
Table 8-6
Differential Diagnosis of Disorders in the Lumbar Spine
Modified from Weinstein JN, Wiesel SW: The lumbar spine, Philadelphia, 1990, WB Saunders, 1990, p 360.
B Herniated nucleus pulposus (HNP)
Aging results in loss of water content
Myxomatous changes, resulting in herniation of nuclear material
