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1

Key aspects of the spine physical examination

2

Cervical Neurologic Examination

3

Findings in Cervical Compression

4

Findings in Lumbar Compression

5

Lower Extremity Neurologic Exam

6

Cervical Spine Anatomy

7

Review Cervical Myelopathy

Spinal cord compromise without reference to specific pathologic entity

Presenting symptoms can be subtle

Finger clumsiness, deterioration of handwriting, difficulty in fine motor control of hands, weakness of pinch

Ataxia with wide-based gait, leg heaviness, and inability to perform tandem walk

Urinary retention, urgency, or frequency

Lower extremity weakness (corticospinal tracts) can be associated with worse prognosis.

Natural history of cervical spondylotic myelopathy is characterized by one of three presentations:

Stepwise deterioration in symptomatology followed by a period of stability (most common, 65%–80%)

Slowly progressive decline (over months to years, 20%–25%)

Rapidly progressive decline (over days to weeks, 3%–5%)

Physical examination

Upper motor neuron findings in myelopathy

 

Myelopathy hand and the finger escape sign (small finger spontaneously abducts because of weak intrinsic muscles)

Hyperreflexia, Hoffmann sign, clonus, or Babinski sign

Inverted radial reflex (ipsilateral finger flexion when brachioradialis reflex being elicited)

Funicular pain—central burning and stinging with or without L’hermitte sign (radiating lightning-like sensations down the back with neck flexion)

Upper motor neuron findings not always present in all patients

Upper extremities may have radicular (lower motor neuron) signs along with evidence of distal myelopathy.

Treatment

Nonsurgical treatment—NSAIDs, cervical epidural injections, isometric exercises, traction, and occasionally temporary collar immobilization

Surgical indications—natural history of myelopathy is typically progressive; therefore surgical decompression is frequently indicated.

Procedures

Anterior procedures include ACDF versus ACCF or combination (hybrid). Anterior-based procedures are options for patients with either kyphotic or lordotic cervical sagittal alignment.

Posterior options include laminectomy and fusion versus laminoplasty. Posterior-based options are contraindicated in patients with fixed cervical kyphosis owing to the surgical inability to indirectly decompress the spinal cord.

Combined anterior and posterior procedures (circumferential surgery). Considered for patients requiring multilevel corpectomy resection with strut reconstructions (highly unstable spine).

8

Common measurements in C1-C2 disorders

9

Rheumatoid Cervical Spine

Overview

Less common owing to improvement and increased use of disease-modifying antirheumatic drugs (DMARDs)

Patients with rheumatoid arthritis (RA) should undergo flexion/extension radiography before elective surgery.

When spine is involved, cervical spine, more specifically occipitoatlantoaxial joint (O–C2), is site most commonly affected.

Atlantoaxial subluxation (AAS)—typically the first manifestation of cervical instability in rheumatoid patient

Atlantoaxial invagination (AAI)—typically occurs next, after AAS

Subaxial subluxation (SAS)—usually occurs after AAS and AAI

Occurs in up to 90% of patients with RA and is more common with long-standing disease and with multiple joint involvement

Presenting complaints

Axial neck pain

Stiffness

Occipital headaches

Due to erosion of the C1–2 joint, with subsequent compression of greater occipital branch of C2 nerve

Results more specifically in pain in posterior aspect of base of skull that is typically relieved with manual traction

Myelopathy, radiculopathy, or myeloradiculopathy, depending on neurologic structures at risk

Physical examination

Subtle signs of neurologic involvement should be sought.

Neurologic impairment (weakness, decreased sensation, hyperreflexia) in patients with RA usually occurs gradually and is often overlooked or attributed to other joint disease.

Neurologic impairment with RA has been classified by Ranawat (Table 8.6).

Imaging

Radiographic markers are assessed for indications of impending neural compression (Fig. 8.8).

Anterior atlantodens interval (AADI), frequently referred to simply as atlantodens interval (ADI)

Posterior ADI (PADI), sometimes also referred to as space available for the cord (SAC)

MRI

Cervicomedullary angle (CMA) (Fig. 8.9) is measured by drawing a line along anterior aspect of cervical spinal cord and the medulla.

Normal: 135–175 degrees

In patients with progressive superior migration of the odontoid, the CMA decreases owing to draping of the brainstem over the odontoid.

Reduced CMA has an increased association with respiratory dysfunction and sudden death.

Atlantoaxial subluxation (AAS)

Typically first stage of cervical spine involvement in the rheumatoid patient

Occurs in 50%–80% of patients with RA

Often the result of pannus formation at synovial joints between the dens and ring of C1, resulting in destruction of transverse ligament, dens, or both

Leads to instability between C1 and C2, with subsequent subluxation

Diagnosis

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.

Plain radiographs that include patient-controlled flexion and extension views are evaluated to determine AADI as well as PADI.

Instability is suggested by AADI motion of more than 3.5 mm on flexion and extension views, although radiographic instability in RA is common and not necessarily an indication for surgery.

PADI less than 14 mm may be more sensitive than AADI measurement for spinal cord compression in patients with RA.

Surgical indications

Intractable pain

Progressive neurologic instability, cervical myelopathy

Can be due to mechanical instability

Direct compression by pannus of C2

Mechanical instability; evaluation of C1–2 motion/relationship

AADI greater than 9–10 mm

PADI less than 14 mm

PADI may be more sensitive for identifying patients at increased risk of neurologic injury

PADI less than 14 mm usually requires surgical treatment.

Surgery is less successful in patients with Ranawat grade IIIB neurologic impairment but should still be considered.

Treatment

Surgical fixation

Gallie fusion—mostly of historical significance

Brooks fusion—mostly of historical significance and rarely used alone

C1–2 transarticular screw fixation (Magerl)

Still used but less commonly since advent of C1–2 Harms construct (see later)

Requires preoperative CT to evaluate position of vertebral arteries

Requires reduction of C1–2 joint

Poses increased risk for vertebral artery and C2 nerve injury

C1 lateral mass—C2 pedicle/pars fixation (Harms construct)

Lower rate of vertebral artery and C2 nerve injury

Biomechanically strongest construct of C1–2 fixation techniques

Does not require reduction of C1–2 joint

Odontoidectomy

Should be reserved as a secondary procedure

Anterior cord compression by pannus often resolves after posterior spinal fusion.

AAI

Also known as cranial settling, basilar invagination, cranial invagination, and other names.

Second most common manifestation of RA in cervical spine

Occurs in 40% of patients with RA

Results in cranial migration of the dens from erosion and bone loss between the occiput and C1–2

Often seen in combination with fixed atlantoaxial subluxation

Measurements are shown in Fig. 8.8.

Landmarks may be difficult to identify.

Ranawat line is most reproducible.

Diagnosis

Progressive cranial migration of dens

Findings on examination may include limitation of motion, upper motor neuron signs, weakness, and, in severe cases, bulbar symptoms.

Surgical indications

Intractable pain

Progressive cranial migration or neurologic compromise may require operative intervention (occiput–C2 fusion).

Cervicomedullary angle less than 135 degrees (on MRI) suggests impending neurologic impairment.

Treatment

Occipitocervical fusion

Typically from occiput to C2

Gentle traction to help bring odontoid process out of foramen magnum

Transoral or retropharyngeal odontoid resection for persistent brainstem compression after occiput–C2 fusion.

SAS

Occurs in 20% of cases of RA

Seen in combination with upper cervical spine instability

Pathoanatomy

Pannus formation in uncovertebral joints (joints of Luschka) and facet joints. Subluxation may occur at multiple levels.

Radiographic markers of instability

Subaxial subluxation of greater than 4 mm or more than 20% of the body is indicative of cord compression.

A cervical height index (cervical body height/width) of less than 2.00 approaches 100% sensitivity and specificity in predicting neurologic compromise.

Surgical indications

Intractable pain

Progressive neurologic compromise, cervical myelopathy

Mechanical instability—subluxation greater than 4 mm

Procedure

Posterior spinal fusion with or without decompression

Fusion to the most distal unstable level.

Occiput and/or C1–2 joint included if AAI or AAS exists.

Anterior spinal fusion

May be required to restore sagittal alignment

May be necessary to increase likelihood of fusion on multilevel posterior spinal fusion

Surgery may not reverse significant neurologic deterioration, especially if a tight spinal canal is present, but can stabilize it.

10

What is the cervicomedulary angle and what does it mean

an angle less than 135 degrees on MRI suggests impending neurologic impairment

11

what is the cervical height index?

12

Diagram of the cervical nerve root orientation

Diagram of the lumbar nerve root orientation

13

Anterior soft tissue shadows normal numbers for trauma evaulation:

6mm C2

20mm C6

14

Review the ASIA classification

15

Review incomplete spinal cord injuries

Central cord syndrome

Most common incomplete spinal cord syndrome

Typical mechanism is hyperextension with preexisting canal stenosis.

Cord is compressed anteriorly by osteophytes and posteriorly by the infolded ligamentum flavum.

Cord is injured in the central gray matter, resulting in proportionately greater loss of motor function to upper extremities than to lower extremities.

The upper extremity is affected more than the lower extremity.

Variable sensory sparing

The prognosis is good for the recovery of ambulation, but the patient is less likely to recover upper extremity function.

Anterior cord syndrome (spinothalamic tract injury)

The second most common incomplete cord injury

No typical mechanism for injury

Direct compression to anterior spinal cord

Less commonly, vascular injury to anterior spinal artery, or spinal cord ischemia (e.g., anterior spinal artery, artery of Adamkiewicz)

Damage is primarily in the anterior two-thirds of the cord.

Loss of motor response, pain reception, and temperature reception below the level of injury

Patients demonstrate greater motor loss in the legs than the arms.

Preservation of posterior/dorsal column; vibration sensation, proprioception, and deep pressure sensation intact

The prognosis for motor recovery is poor.

Brown-Séquard syndrome (spinal cord hemisection)

Typical cause is penetrating trauma.

Ipsilateral loss of motor and loss of position/proprioception function on the side of injury

Contralateral loss of pain and temperature to the side of injury (usually one to two levels below the insult)

Best prognosis for recovery of ability to walk (90%)

Posterior cord syndrome

Very rare; least common incomplete spinal cord pattern

Injury to posterior/dorsal column—loss of proprioception, vibrator sensation, and deep pressure sensation

Preservation of anterior column; motor response, pain reception, and temperature reception intact

16

Review the safe zones for halo pin placement:

Adults: 4 pins at 6 to 8 inch-lb pressure; children: 8 to 10 pins at 2 inch-lb pressure

Complications—pin loosening, pin infection, pressure sores, nerve injury, dural penetration

Gardner-Wells (GW) tongs

Can be used more acutely to realign the spine in the patient with a displaced fracture with or without neurologic injury

Pins parallel to the external auditory meatus approximately 1-cm above pinna

17

What are the absolute contraindications to giving high dose steroids for a spinal cord injury

Penetrating spinal wounds, particularly gunshot wounds

Injury more than 48 hours old

Peripheral nerve injuries such as brachoplexopathy, stingers, root level injuries, cauda equina

Pregnancy

Age younger than 13 years

18

key facts about rehab after spinal cord injury

Functional level determined by both sensory and motor level as dictated by

Most distal intact functional sensory level and

Most distal motor level where motor grade is 4 or greater

Respiratory function by level of cord injury

C1–2 injury

Vital capacity only 5%–10% of normal

Ventilator dependence

Cough absent

C3–5 injury

Vital capacity 20% of normal

Cough weak and ineffective

Lower cervical and upper thoracic injury

Vital capacity 30%–50% of normal

Cough weak but may be effective

T11 injury and below

Respiratory dysfunction minimal

Vital capacity near normal

Cough strong

Mobility and function determined by highest motor level

C3 or above—respiratory dependent

C4—transfer dependent

C5—transfer assist

C6—independent transfers

 

Activities of daily living

C6—independent grooming and dressing; can operate flexor hinge wrist-hand orthosis

C7—able to use knife to cut food

19

key testable components about a syrinx

Introduction

Confluent collection of abnormal CSF within the spinal cord

In regard to orthopaedic spine, most common etiology is posttraumatic syrinx and secondary to herniated disc.

Other primary causes of spinal syringomyelia include postinflammatory, arachnoid abnormalities (arachnoid cyst), tumor, and idiopathic.

Syringomyelia can also be related to abnormalities of the foramen magnum: tonsillar descent (Chiari malformation), arachnoid veil with fourth ventricle outlet obstruction.

Differentiating syringomyelia from hydromyelia

Hydromyelia—confluent CSF cavity within spinal cord that is a remnant of central canal of spinal cord

Typically considered a normal variant

Spinal cord typically not expanded by hydromyelia and therefore not associated with symptoms and not considered a pathologic entity

Differentiating syringomyelia from spinal cord edema

Spinal cord edema is increased fluid that is interstitial, and not a confluence of fluid.

Edema can be secondary to spinal cord contusion or tumor-associated cyst.

Presentation

Variable but typically due to the etiology of the syrinx and its associated pathophysiology

Symptoms associated with partial CSF obstruction (e.g., tussive headaches, strain-related activities)

Symptoms related to brainstem compression (e.g., swallowing difficulty, voice changes, nystagmus, ataxia, sleep apnea)

Symptoms related to syringomyelia (e.g., sensory loss [upper greater than lower typically], upper extremity weakness, hand and upper extremity atrophy, gait impairment, lower extremity spasticity, bowel and bladder dysfunction, dysesthetic pain)

Imaging

MRI is method of choice

Does not disrupt CSF dynamics

T1-weighted image demonstrates intramedullary fluid-filled cavity.

MRI with gadolinium necessary to rule out possibility of associated spinal tumor.

T2-weighted images may help identify anatomic detail such as septa in the subarachnoid space.

CT myelogram

May have a role in determining obstructive arachnoid disease

In these cases, performing myelography puncture at C1–2 rather than using lumbar route may allow for pooling of the contrast at the level of the web.

This pooling may not be seen if contrast is introduced from the lumbar route, because the obstructive subarachnoid web acts as a one-way valve.

20

C1 injury

A sum of 6.9 is indicative of injury

 

 

21

C2 Odontoid Fractures

Type I—avulsion of alar ligaments from the tip

Type II—fracture at the base of odontoid

Type IIA—comminuted fracture of the base of odontoid

Type III—fractures that extend into the body of C2

Treatment

Operative indications—based on risk of development of nonunion. Risk factors for nonunion in type II

Displacement greater than 5 mm

Posterior displacement

Age greater than 40 years

Delayed treatment

 

Angulation greater than 10 degrees

Type I—immobilization in rigid cervical orthosis

Type II and IIA

Nondisplaced—immobilization in rigid cervical orthosis (controversial)

Displaced types II and IIA fractures are generally considered to require operative treatment because of the high rate of nonunion with nonoperative treatment.

Type III—typically high incidence of union; most heal in rigid external cervical orthosis. Operative treatment considered if initial displacement greater than 5 mm.

Procedures

Posterior C1–2 fusion

Direct osteosynthesis—anterior odontoid screw (Fig. 8.33)

           Fracture must be reducible. Nonreduced fracture is a contraindication to anterior odontoid screw.

Fracture geometry must be favorable: anterior superior to posterior inferior (posterior oblique pattern) (Fig. 8.34)

This procedure is associated with a higher failure rate than posterior fusion but theoretically preserves atlantoaxial motion.

 

Complications

 

Overall nonunion rate for type II: approximately 32%

Patients older than 80 years do poorly whether treatment is operative or nonoperative.

Airway problems postoperatively or with halo vest immobilization

22

C2 Body Fracture:

 

Hangmans

Type I—minimally displaced fracture of the pars secondary to hyperextension and axial loading (<3 mm displacement, no angulation)

Type IA—same as type I except fracture lines are asymmetric

Type II—displaced fractures (>3 mm) of the pars, with subsequent flexion after hyperextension and axial loading

Type IIA—flexion without displacement; care must be taken not to mistake this for a type I fracture, which represents total disc avulsion, because traction may worsen a type IIA fracture.

Type III—bilateral pars fracture with bilateral facet dislocations (rare)—mechanism is flexion-distraction followed by hyperextension

Treatment

Type I—rigid cervical orthosis

Type II—operative; typically C1–2 fixation or direct osteosynthesis

Type IIA—halo vest or surgery (no traction)

Type III—generally operative, usually C2–3 fusion (may require C1–3 fixation, depending on comminution of pars and quality of fixation into C2)

Complications—vascular injury; vertebral artery injury is rare but increasingly diagnosed by MR angiogram.

23

Surgical Techniques of C1-C2 Fusion

C1–2 modified Gallie fusion

Autograft iliac crest placed over C2 spinous process and against posterior arch of C1

Held in place by sublaminar wire under arch of C1 and under spinous process of C2 (total of one sublaminar wire)

C1–2 Brooks fusion

Two separate iliac crest autografts placed between C1 and C2

One sublaminar wire is placed on either side (total of two sublaminar wires).

C1–2 transarticular (Magerl) screws

Preoperative CT scan to assess for location of vertebral artery at C1–2 junction is imperative.

Adequate intraoperative radiographs are required, or the technique should not be used.

Cannulated screw is placed under fluoroscopic guidance over a guidewire.

Screw is placed through the C1–2 facet joint (transarticular), thereby coupling C1–2.

C1 lateral mass–C2 pedicle (Harms) screws

C1 screws are placed through the lateral masses. Starting point of the screw is the center of the lateral mass.

C2 screws are placed traditionally as pedicle screws. In the case of aberrant vertebral artery a shorter, more straight-ahead pars screw can be used in C2 instead.

Complications

Vertebral artery may be injured as it runs in the transverse foramen of C2 or as it lies on the superior aspect of C1 in the groove/sulcus of the vertebral artery.

C2 (greater occipital) nerve lies just dorsal to the C1–2 joint. Injury can result in numbness in the posterior aspect of the skull.

Neurologic injury

Dural leaks

Nonunion/malunion

24

Review the SLIC 

Based on three separate injury axes

Fracture morphology

Discoligamentous complex (DLC) integrity

Neurologic status

Scoring

Each axis considered an independent determinant for prognosis and management

Each axis receives numerical score, with increasing severity receiving a higher numerical value

No set value defined as requiring surgical treatment; however, higher numerical values suggest increased need for operative intervention

Treatment goals

Address neurologic deficits.

Typically, approach is selected according to location of compression.

Anterior cervical discectomy and/or corpectomy for anterior compression

Posterior laminectomy for posterior compression

Restoring spinal alignment can help through indirect decompression.

Achieve immediate stability and long-term fusion. Approach varies depending on injury pattern and presence of associated neurologic instability.

Restore spinal alignment.

25

What is the Allen-Ferguson sub-axial classification system?

Based on position of the head and neck at the time of injury (flexion/extension) and the mode of failure (distraction/compression) (Table 8.11)

Compressive flexion

Distractive flexion

Compressive extension

Vertical compression

Distractive extension

Lateral flexion

Decision for surgery using mechanistic classification can be difficult, but general considerations include:

Patient with associated neurologic instability

 

Disruption of PLC

Fracture dislocations and distractive flexion injuries (jumped facets)

Burst fracture without neurologic injury and with intact PLC and acceptable alignment can be considered for treatment with external immobilization (controversial).

26

Special Considerations of jumped facet joints

27

what tumors should you consider pre-op embolization for

Thyroid and Kidney tumors

28

Review metastatic lesions of the spine

Metastasis—the most common tumors of the spine, spreading to the vertebral body first and later to the pedicles

Diagnosis

History of cancer

Breast, lung, thyroid, renal, gastrointestinal, and prostate metastases are the most common tumors to metastasize to bone.

Lymphoma, myeloma

Recent unexplained weight loss

Night pain

Age older than 50 years

Examination—careful physical and neurologic examinations vital

Imaging

Should include plain radiographs of entire spine

MRI with gadolinium of suspected levels; may require imaging of entire neuraxis

CT scan of chest, abdomen, and pelvis can help identify possible primary lesion.

Bone scan can assist in assessing for primary lesion and remote sites of involvement (but results can be negative in up to 25% of cases).

Percutaneous biopsy of spinal lesion may avoid surgical open biopsy and can confirm diagnosis.

Treatment

Regardless of surgical or nonsurgical intervention, treatment should include multispecialty involvement.

Nonsurgical treatment

Nonoperative treatment should be considered for tumors that are radiosensitive, chemosensitive, or hormonally responsive.

Radiosensitivity varies among primary tumor types, but newer techniques have made traditionally radioresistant tumors radioresponsive.

Surgical intervention along with adjuvant radiation and/or chemotherapy should be considered for patients with mechanical instability or evolving/progressive neurologic deficit.

In the case of epidural spinal cord compression, radiation therapy should be combined with direct surgical decompression for the best clinical outcomes.

Surgical treatment

Indications

Progressive neurologic dysfunction that is unresponsive to radiation therapy

Persistent pain despite radiation therapy

Need for an open diagnostic biopsy

Pathologic mechanical instability

Radioresistant tumor

Life expectancy should play an important role with regard to whether surgical treatment is performed.

Techniques

Vertebroplasty is gaining favor in cases of metastatic disease of the spine (myeloma, breast) without instability or neurologic compromise and represents a minimally invasive alternative to open surgery.

In cases of neurologic deficit and/or spinal instability, anterior decompression and stabilization (preserving intact posterior structures) may result in recovery of neurologic function.

Posterior stabilization or a circumferential approach is indicated in cases of multiple levels of destruction, involvement of both the anterior and posterior columns, or translational instability.

29

Review primary lesions of the spine

Osteoid osteoma (<2 cm in size) and osteoblastoma (≥2 cm in size)

Diagnosis

Common in the spine

May manifest as painful scoliosis in a child

Pain typically relieved by aspirin and/or NSAIDs

Osteoblastomas typically occur in the posterior elements in older patients, with neurologic involvement in more than half.

Imaging

Bone scan can help localize the level.

Thin-cut CT can direct surgical excision.

MRI is sensitive but not specific; surrounding hyperemic soft tissue may be misidentified as an aggressive lesion.

Treatment

Scoliosis (lesion is typically at apex of convexity) resolves with early resection (within 18 months) in a child younger than 11 years.

If there is no scoliosis, aspirin and/or NSAIDs are the mainstay of treatment.

Surgery is performed if nonoperative treatment fails.

En bloc resection versus marginal or intralesional excision

CT-guided radiofrequency ablation (controversial)

Posterior spinal fusion may be required, depending on extent of resection

Aneurysmal bone cyst

Diagnosis

May represent degeneration of more aggressive tumor

Manifests during second decade of life

Arises in the posterior elements, but possibly also involves the anterior elements

Treatment

Marginal or wide excision if possible

Alternatively, curettage and bone grafting

Radiation therapy if lesion inaccessible

Hemangioma

Diagnosis

Common; typically seen in asymptomatic patients

Symptomatic patients older than 40 years may seek treatment after small spinal fractures.

The classic patient with hemangioma has “jailhouse striations” on plain films with spikes of bone on CT.

Vertebrae are typically of normal size and not expanded (as in Paget disease).

Treatment

Observation or radiation therapy in cases of persistent pain after pathologic fracture

Anterior resection and fusion are reserved for refractory cases or pathologic collapse and neural compression, but massive bleeding may be encountered.

Eosinophilic granuloma

Diagnosis

Usually seen in children younger than 10 years

More common in thoracic spine

May manifest as progressive back pain

Classically, vertebral flattening (vertebra plana [Calvé disease]) seen on lateral radiographs

Biopsy may be required for diagnosis unless the radiographic picture is classic.

Treatment

Symptoms are usually self-limiting.

Chemotherapy is useful for the systemic form.

Bracing may be indicated in children to prevent progressive kyphosis.

Low-dose radiation therapy may be indicated in the patient with neurologic deficits.

At least 50% reconstitution of vertebral height may be expected.

Giant cell tumor

Diagnosis

Usually seen in the fourth and fifth decades of life

Destruction of the vertebral body in an expansile fashion

Treatment

Surgical excision and bone grafting

High recurrence rate is reported.

Radiation therapy should be avoided because of the possibility of malignant degeneration of the tumor.

Plasmacytoma/multiple myeloma

Diagnosis

Shown as osteopenic lytic lesions on radiographs

Workup includes skeletal survey.

Lesions are “cold” on bone scans in up to 25% of cases.

Pain secondary to pathologic fractures

Increased calcium level and decreased hematocrit levels as well as abnormal protein measurements are common.

Treatment

Radiation therapy with or without chemotherapy

Surgery is reserved for patients with spinal instability and those with refractory neurologic symptoms.

Chordoma

Diagnosis

Slow-growing lytic lesion in the midline of the anterior sacrum or the base of the skull

May occur in other vertebrae (cervical spine next most common)

Patient with this tumor may present with intraabdominal complaints and a presacral mass.

Physaliferous cells in biopsy specimens

Treatment

Surgical excision—treatment of choice (tumor is radioresistant)

Typically requires resection of sacral nerve roots to achieve margin

If half of the sacral roots (i.e., all roots on one side) are preserved, patient may still maintain bowel and bladder function.

High recurrence rate

Although a complete cure is rare, patients typically survive 10–15 years after diagnosis.

Lumbopelvic reconstruction is required after surgical resection of sacral lesions.

Osteochondroma

Arises in the posterior elements and is frequently seen in the cervical spine

Treatment is by excision, which may be necessary to rule out sarcomatous changes.

Neurofibroma

Benign tumor of neural origin

Can manifest as enlarged intervertebral foramina seen on oblique radiographs

Malignant degeneration to fibrosarcoma can occur, which may manifest as new-onset neurologic deficit.

Malignant primary skeletal lesions

Diagnosis

Osteosarcoma, Ewing sarcoma, and chondrosarcoma are uncommon in the spine.

When they occur they are associated with a poor prognosis.

Treatment

Chemotherapy and irradiation are the mainstays of treatment, but aggressive surgical excision may have a role.

The lesions may actually be metastases, which are treated palliatively.

Lymphoma

Can manifest as “ivory” vertebrae

Usually associated with a systemic disease

Lymphoma typically treated with radiation and/or chemotherapy

Surgery typically only necessary if pathologic fracture is present

Fibrous dysplasia

At least 60% of patients with polyostotic fibrous dysplasia have spinal involvement, mostly in the posterior elements.

There is a strong correlation between the presence of a lesion and scoliosis, making scoliosis screening very important in the population with polyostotic disease.

30

What is vertebrae plana?

l: vertebrae planae), also known as the pancake or silver dollar or coin-on-edge vertebra, is the term given when a vertebral body has lost almost its entire height anteriorly and posteriorly, representing a very advanced compression fracture.

 

Think EG in children