Presentation on theme: "Musculoskeletal Diseases and Disorders: T and L Spine, Ribs"— Presentation transcript:
1 Musculoskeletal Diseases and Disorders: T and L Spine, Ribs
2 Anterior Column Fractures Wedge Fracture, stable fractureCauses:Hyperflexion forceAxial forceOsteoporosisCodfish spine appearance: biconcave appearance of vertebral end platesWill not cause a lot of problemsanterior-wedge-compr...
3 Middle Column Fracture Burst fractureAxial forceLower arrow points to intrusion into the spinal canal-more sci involvementradiographics.rsna.org/.../4/1009.figures-only
4 Posterior Column Fractures All three columns have a fracture. This particular fracture is called a Chance fracture Notice the almost horizontal line through the spinous process and the compression fracture anteriorly Caused by a seat belt, Force is hyperflexion, distraction and impaction forces Stable or unstable fracture?Cause SCI deficits by pushing anteriorly into the spinal canal, ususally high velocity injury.
5 FracturesCompression Fracture: wedge compression fracture of the vertebral body. MOI: flexion force or lateral flexion Hoppenfeld S. Treatment and Rehabilitation of Fractures
6 a. Posterior ligaments and posterior bone elements are intact b a. Posterior ligaments and posterior bone elements are intact b. Kyphotic angulation less than 10 degrees c. Loss of anterior vertebral body height is less than 40% d. Relatively stable injury
7 Unstable Compression Fracture Angulation is greater than 20 dgLoss of 50% or more of anterior heightCreates pull on posterior ligaments of the spine – supraspinous, interspinous,ligamentum flavum or facet joint capsule
8 Stable Burst Fracture: MOI: axial loading force (compression force)a. Anterior and middle columns are disrupted, posterior column is uninjuredb. Kyphosis is limited to 15 degreesc. Loss of vertebral body height is less than 50%d. Neurologically intactHoppenfeld S. Treatment and Rehabilitation of Fractures
9 Unstable Burst Fracture MOI: axial force (compression force)a. Anterior and middle columnsare disruptedRetropulsion of posterior column fragments into the vertebral canal occursb. Pedicle widening on x-rayc. Neurological injury varies based on the level of injury rather than the canal compromised by bone fragmentsd. Fractures above L2 have greater neurological involvementanything below L2, have very mobile nerve roots so they can get out of the way or find away around the fracture.
10 Flexion - Distraction injury MOI: seat belt injuries, lap belt injuriesa. Failure of posterior elements intension while the anterior and middlecolumns are compressedb. Widening of the spinous processesc. Vertebral body is wedged anteriorallyd. Variable neurological involvement-Middle and Anterior Column.
11 Chance Fracture MOI: hyperflexion injury over a secured lap belt (usually in back seat, flexion over the lap belt, fractures right into gut)Type of flexion distraction injury – involves more structures Tension failure of all spinal bone elements and/or ligaments – anterior, middle and posterior columnsBowel injuries occurs in 65%No compromise of anterior elements occurs only when the injury is primarily ligamentousSurgical candidate Hoppenfeld S. Treatment and Rehabilitation of Fractures
12 Compression Torsion/Translational injuries MOI: shear force or rotary force with compressiona. Force will fracture or dislocate facetjointsb. Neurological involvement occursc. Surgical candidate
13 RX for different fractures a. Stable fractures without neurological deficit: surgery is usually not neededb. Unstable fractures without neurological deficit: External immobilization for weeksOperate if neurological deficit becomes apparentc. Unstable fractures with progressive neurological damage: Reduction of fracture and internal stabilization - with or without a fusiond. Unstable fractures with incomplete neurological deficit: May or may not stabilize with internal fixation at first.Dependent upon improvement noted with a log rolling framee. Unstable fracture with complete neurological deficit: Paraplegiawill operate within 48 hours for stabilizationTeach pts. How to long roll and use a brace so that fragments so not dislodge.
14 Indications for Immediate Surgery a. Advancing or progressive neurological deficits-get weaker, or can not move “big toe”-Reflexes checkb. Paraplegia in absence of bony injuryc. Severe nerve root pain-Usually a boney fragment.
15 Rib Cage Fractures1. Minor: simple rib fracture, in 1 spot, do not do much.2. Major: fracture of 1 or more vertebrae resulting in a flail chest and/or a hemothorax or pneumothorax Copyright 2004 Nucleus Communications, Inc. All rights reserved.
16 Rib FractureSX: pain on inspiration Signs: palpable defect, tender to palpate, ecchymosis -Ask to breath in deep “if pain” then suspect a rib fracture. Or tap, vibrate to see if pain, symptoms increase. RX: simple fracture: can just bind the ribs to assist with pain management and coughing, will become stable within 1-2 weeks and heals by 6 weeks
17 Flail ChestDefinition: segment of the chest wall doesn't have continuity with the rest of the thoracic rib cage (two fractures of same rib-floating) Signs: Paradoxical motion occurs: moves in on inspiration and out on expiration splinting of chest wall muscles, decrease ventilation, decrease vital capacity, when breathing it will do the opposite of what ribs are suppose to do. Lab tests: x-ray and blood gases help to make a positive diagnosis
18 Joint Dysfunctions Rib Cage Dysfunctions Costochondritis: anterior chest wall syndromepain in the costochondral articulation without swelling,affects T3,T4,T5 costochondral junctionSimilar signs to MI so people may jump to conclusion
19 COSTOCHONDRITISRisk factors: women more than men, over 40 years old SX: pain and tenderness in the anterior chest wall, may radiate to the shoulder or arm, aggravated by sneezing, coughing, inspiration, bending, lying down or exertion Signs: pain with palpation over the costochondral joint, *also commonly a structural dysfunction, as something is irritating the cartiatlage
20 Tietze's syndromeTietze's syndrome is similar to costochondritis. SWELLING only Difference!!! The difference between the two is that there is swelling over the costal cartilage with Tietze's syndrome and not with costochondritis -some research says Tietze may be the “acute” form.
21 ScoliosisDefinitions: A lateral curve of the thoracic or lumbar spine or a combination of thoracic and lumbar curves Primary Curve: first curve or earliest curve to appear in the thoracic or lumbar spine Secondary Curve: curve above or below a major curve
22 Major Curve: largest structural curve Minor Curve: smallest curve, more flexible Apical Vertebrae: vertebrae which is furthest from the vertical axis of the vertebrae
23 End Vertebrae:The vertebrae are at the ends of the curve and are maximally inclined toward the concavity of the curve. a. cephal: most cephal vertebrae maximally inclined toward the concavity b. caudal: most caudal vertebrae maximally inclined toward the concavity
24 Rib Hump: Rotation of the thoracic spine which is noted in a flexed position. As the patient flexes forward,the ribs push posterior onone side of a scolioticcurve.
25 Rib HumpHump is on the side of the convexity, roatation (referenced to the anterior body) towards convexity
26 Apparent Deviation:Line from the sacrum (gluteal cleft) to the SP of C7. Deviation occurs when there is a linear distance between the vertebrae at C7 from the linear distance at the sacrum. Indicates curve compensation.-how much compensation.
27 EtiologyIdiopathic: unknown cause 1) infantile: onset less than 3 years of age % will resolve 2) juvenile: 3-10 years of age brace if curve is greater than 30 dg and less than 45 dg surgery if curve is greater than 45 dg after bracing -checked in school 3) adolescent: onset is puberty ~ 10 years of age until skeletal maturity
28 Paralytic scoliosis: muscle Sometimes can be corrected with seating, for organ function improvement.
29 NeurofibromatosisHave “cafe au lait” spots, in ped populaiton.
30 Adult ScoliosisAdult Scoliosis: spinal deformity may be more rigid Spinal stenosis, DDD, osteopenia are associated pathological conditions which may contribute to an increase in Cobb angle SX: pain on the convex side of the curve due to muscle fatigue
31 Prevalence, Risk factors, Surgical Considerations a. 5 % of all scoliotic curves are greater than 10 dg, .04% exhibit curves greater than 20 dg b. greater the angulation and rotation of the spinal curve, the higher the possibility of curve progression. c. younger the child when diagnosed, the higher the possibility for curve progression
32 Likeiness of Curve Progression d. Risser Score of skeletal maturity: score of 1 or less, higher possibility for curve progression -Gives skeletal “age” of a person by epiphyseal plates. e. A shorter curve progresses more f. the higher the curve in the spinal column, the more likely the curve is to progress -No stable base g. the stiffer the curve in an immature individual and the more flexible the curve in a mature individual, the more likely the curve is to progress
33 Radiographic Assessment 1. Cobb Method: preferred method of curve measurement. Very consistent between examiners a. caudal and cephal end vertebrae are identified. b. parallel lines to the end plates are drawn into the concavity of the curve c. lines drawn at right angles to the parallel lines will intersect at an angle. d. angle is measured for the degree of curvature
34 Cobb Method. Identify caudel and cephal end vertebrae Draw parallel lineDraw perpendicular linesMeasure angle of curve
35 2. Risser ScaleIndicates the ossification of the iliac epiphysis which begins at the ASIS and ends at the PSIS *Ossifies Anterior to Posterior a. Grades 0= 0% has closed,1= 25% or less has closed,2 are skeletally immature: 50% or less has yet to ossify b. Grade 3: progressing skeletal maturity: 75% or less has closed c. Grade 4: end of spinal growth, epiphyseal plate has closed but not fused =100% or less has closed d. Grade 5: epiphyseal plate has fused
36 Greulich and Pyle Atlas 3. Bone age: radiograph of the left wrist and hand and compared to standards set forth by Greulich and Pyle Atlas -compare to a series 4. Moire Thermography: heat pictures, from the muscles
37 Other Testing: greater than 70 dg have a decrease in vital capacity 1. Pulmonary function tests: curvesgreater than 70 dg have a decrease invital capacity
38 Management of Scoliosis 1. Goals of treatment: a. prevent progression and maintain balance b. maintain respiratory function c. reduce pain and preserve neurological status d. Cosmesis- important for the kid e. combo of bracing and physical therapy evidence says is bestCombo of bracing and Physical therapy together.
39 Non-operative treatment of scoliosis a. observation in curves less than 25 dg in skeletally immature patients and less than 50 dg in skeletally mature patients b. exercise in combination with bracing may be effective, without a brace has been proven ineffective in stopping the progression of a curve. c. Bracing occurs with any curve greater than 25 dg in a skeletally immature patient
40 Milwaukee CTLSO Bracing Milwaukee brace (MWB) or cervical-thoracic-lumbar- sacral orthosis (CTLSO)- curve has an apex at T8 or higher - provides pressure over the point of maximum convexity, traction between the occiput and the pelvis-Tries to stop curve at all parts, for T8 or higher, provides distraction
41 Boston TLSO BracingBoston Bracing System or thoracolumbar-sacral orthosis (TLSO) - pads are applied laterally below the apex of the curve - no head piece - works best with apex of curve lower than T8
42 GoalsStop curve progression with either type of bracing. The physician will look for a 50% reduction of the curve with the brace on Brace is worn 23 hours a day until a Risser 4 is reached and, if female, two years after menarche Patient will be weaned off brace for 1 year Patient will be followed up with a physician visit every 6 months and repeat x-rays every 12 months
43 SurgeryIndications: progressive curve dg in growing children failure to prevent progression of the curve with bracing or cannot get a 50% correction with the use of a brace progressive curves greater than 50 dg in adults.Goals: prevent progression of curve - spine and pelvic balance are more important than curve correction - prevent respiratory compromise - prevent back pain or decrease it - cosmesis
44 Types of Surgery posterior fusion anterior fusion combination of anterior and posterior
45 Instrumentation - Harrington Rod techniques - Drummond's technique using a combination of Harrington Rod's and Luque rods/wires - Luque rod with segmental sublaminar wires - Multiple hook systems
46 Thoracic Spine Dysfunctions Scheuermann's Disease: juvenile kyphosis, vertebral epiphysitis Etiology: may be secondary to repetitive trauma, growth retardation or vascular disturbances are all hypothesis MOI: stress fracture of the anterior aspect of the vertebral endplates.
47 Scheurmann’s DiseaseVertebral wedging of at least 3 consecutive vertebra End plate deformities -box is shorter, angled
48 Scheurmann’s Disease: Diagnostic Criteria Thoracic kyphosis > 45 deg (25 to 40 deg being normal); Wedging > 5 deg of three adjacent vertebrae Thoracolumbar kyphosis > 30 deg (thoracolumbar spine is normally straight);
49 Scheurmann’s DiseaseDX: lateral radiograph shows decrease in disc height,vertebral end plate irregularities such as Schmorl's nodes may occurRisk factors: adolescents, males and females about equal, autosomal dominant
50 Scheurmann’s DiseaseSX: back pain, worse with prolonged activity or standing for long periods of time, relieved by rest Signs: acute thoracic kyphosis and an increase in lumbar lordosis, local tenderness to palpation, limited extension & painful, sensory and motor exam is normal
51 Conservative RX: PainAt least two more years of skeletal growth remainingBraceActive exercises concentrating on extension, can help prevent,
52 Surgical Candidates: Apical wedging severe deformity with disabling painNeurologically compromisedContinued progression despite conservative treatmentType of surgery: Fusion if the curve is greater than 70 dg and rigid, severe
53 DISH: Diffuse Idiopathic Skeletal Hyperostasis, Ankylosis hyperostosis Definition: common disorder, osteophytes develop into bony spurs that may join to form bridges to each other Can occur in thoracic, lumbar or cervical spine Type of Enthesopathy
54 DISHOssification of the anterior longitudinal ligament of the spine -there is no anterior space. At least four vertebral levels Preserved disk space *If not 4 then ankylosis
55 DISHRisk factors: NIDDM (type II) diabetes, males 2:1 over females, middle aged or older Onset: insidious SX: back stiffness in the T or L spine, calcaneal pain common, the groups of ossified vertebrae will move as a group Signs: early on the examination is normal, as disease progresses, will see limitation is spinal movements
56 Lab tests: normal or slightly elevated ESR Radiograph: calcification and ossification of the ALL in 4 continuous vertebrae, preservation of disc height, absence of facet ankylosis, SI sclerosis RX: symptomatic, treat similar to OA patients with exercise to maintain mobility especially in the peripheral joints
57 T4 SyndromeClinical pattern of pain and parasthesia in one or both UE’s. Head pain can also occur due to embroyonic involvement.May occur alone or in conjunction with other pathology in the T spineArea of Involvement: T2-T7, T4 almost always includedIncidence and Prevelence: females > males 79% to 21%.Onset: variableSX: dull aching pain in head, one or both hands, forearms and shoulders can be affectedSymptoms are intermittent, variable during time most felt, better with movement
58 T4 SyndromeSigns:Positive palpation findings indicating some restriction of T spine movementDeviation of SP from midlineUneven spacing of SP
59 SpondylolysisDefinition: fracture of the pars interarticularis, unilateral or bilateral-Most common in Lumbar, but also can occur in thoracic and cervicalMOI: stress fracture, non union-like hiking with backpack, or bending forward with gardening so muscle spasms.
60 Spondylolysisa. Posterior elements have a reduced ability to stabilize the spinal unit b. Soft tissue undergoes plastic deformation Etiology: 5% in general population
61 SX: Related to activityAching pain in backMay radiate toward LERelieved by rest or decreasing activityStiffness noted
62 SpondylolysisSigns: paravertebral muscle spasm, flattening of the normal lumbar lordosis, tight hamstrings, decrease in SLR motion Radiograph: collar on the Scotty Dog RX: modify activities, primary repair or fusion if patient has unrelenting pain, stabilization exercises
64 Scottie Dog Body part of Dog Anatomical Bone Segment Eye Pedicle Ear Superior articulating process, ipsilateralNoseTransverse process, ipsiFront PawInferior articulating process, ipsiBodyLaminaNeckPars InterarticularisRear PawInferior articulating process, contraTailSuperior articulating process, contra
65 Spondylolisthesis Definition: forward slippage of one vertebral body on another, longstanding segmental instability, spondylolysis associated with it
67 Five Types of Spondylolisthesis Type I is called dysplastic spondylolisthesis and is secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra.
68 Type II: Isthmic (Skinny Island) Can be divided into three subcategoriesBone defectElongation of parsRepeated micro fractureStress spondylolisthesismost likely caused by recurrent micro-fractures caused by hyperextensionIt is also called a stress fracture of the pars interarticulariimuch more common in males.Usually a sport related injury: wrestling
69 Five Types of Spondylolisthesis Type III, is a degenerative spondylolisthesisOccurs as a result of the degeneration of the lumbar facet joints.The alteration in these joints can allow forward or backward vertebral displacement.
70 Five Types of Spondylolisthesis Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis.
71 Five Types of Spondylolisthesis Type Vpathologic spondylolisthesisoccurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases.
72 Grading SystemBased on the percent displacement of the superior vertebral body on the inferior vertebral body Grade I: % length of vertebral body slide of superior on inferior Grade II: % may still not need surgery Grade III: % surgery more than likely Grade IV: % (surgery) *Higher the Grade the more Neurological Involvement, so Grade IV is the Worst!
73 SpondylolisthesisSX: pain in the back, buttock or thigh. unilateral or bilateral aching, pulling, weakness, heaviness, numbness, burning Signs: pain with forward bending, muscle spasms or erector spinae muscles, decrease pain with flexed positions (such as supine with knees bent), increased with extension *Flexion in supine will decrease s(x), but flexion in standing will increase s(x). *Extension will not make it feel better, but if Spondylisis then extension will make it feel better
74 SpondylolisthesisRadiographs: Collar on Scotty Dog - + pars interarticularis fracture, lateral flexion radiograph shows the slippage RX: conservative for 6 months, PT for pain management, lumbar stabilization, may brace in grades II and III
75 SpondylolisthesisSurgery: if it is a grade III or more and conservative treatment has failed Goals of surgery: prevent further slippage, stabilize an unstable segment, prevention of neurological deficits, pain relief, cosmetic, posture and gait improvement
76 Ankylosing Spondylitis Marie Strumpell disease, rheumatoid spondylitisDefinition: chronic inflammatory arthritis which leads to deformity and fusion of the spine
77 Ankylosing Spondylitis Risk Factors:15-40 years of age,males 3:1 over females(fusion of entire spins in 20 years)Onset:insidiouscomplaints are related to spinal movements or sacroilitis
78 Ankylosing Spondylitis Medical Diagnosis: back pain greater than 3 monthsdecrease in spinal motiondecrease in chest expansionsacroilitisperipheral joint problemsLab Tests: 95% have a +HLA- B27 human leukocyte antigen
79 bamboo spine in advanced stages Radiograph: Ankylosing Spondylitisbamboo spine in advanced stagesSI fusion in one or both sides is earliest signShould be line, rather solid mass
80 Clinical Manifestations: Ankylosing Spondylitis Symptoms:spinal pain/stiffness worse in am or after restingpain/stiffness improves with exerciseSigns: normal neurological screenSI tenderness+ FABER's testdecrease in lumbar lordosisrib expansion less than 2 cm
84 T2 - T11: Specific to T and L spine Thoracic discs are very stable and herniations in this region are quite rare.Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations.Radiation of pain around the rib cage (dermatome pattern) can also occur
85 Lumbar Spine: Most common areas are L4-5 and L5-S1 T12 - L3: Reflexes: noneMMT: iliopsoas, quadriceps, adductorsDermatome pattern: specific to each nerve root Lumbar Spine: Most common areas are L4-5 and L5-S1
87 L4 Reflex: Quadriceps MMT: tibialis anterior Sensation: medial aspect of foot to big toe
88 L5: Reflex: Medial hamstring MMT: EHL Sensation: middle toes, dorsum of foot, big toe
89 S1:Reflex: AchillesMMT: peroneus longus and brevis, gastroc soleus, gluteus maximusSensation: little toe, outside of calf, lateral aspect and plantar surface of foot
90 Spinal Surgeries Decompression Back Surgery Small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to give the nerve root more space and provide a better healing environment.
91 MicrodiscetomyBest for treating radiculopathies rather than back pain
92 Open Decompression Laminectomy: Indications: spinal stenosis, herniated discRemove lamina and facet joints are trimmed a bit to give nerve more roomSuccess rate: % improve function, decrease back/leg pain
95 Thoracic Spine: Radiographic Views Standard ViewsAP ViewLateral ViewSpecial ViewsSwimmers ViewOblique ViewsUtilized for viewing the sternumConed Views of thoracolumbar region or other specialized areas
96 Radiology Thoracic spine radiology Anteroposterior view: *Know by the heart on the left side visible.Thoracic vertebral bodiesThe intervertebral disc spacesAlignment of the pediclesSpinous processesTransverse processesArticular processes and theCostovertebral jointsPosterior ribs.
97 Keys to viewing Alignment: In this view, pay attention to the position of the pedicles, they will indicate any rotation of the thoracic spineSymmetry of the vertebral bodies: any change in symmetry or curve of the spineBone Density:In this view, check each vertebral body, does one or two or many of them appear to have a different radiolucency than the others?
98 Cartilage Space and Disc Height SC joints are easily seen due to overlay of vertebral spineCostovertebral joints can be seen – better in upper thoracic than lowerDisc Heightshould appear similar as you move down the spine
99 Soft TissueHeart shadow should be on the patient’s left side Diaphragm should be overshadowing the lower ribs and vertebral spineLungs should appear black due to the amount of air This view is often used to detect the presence of pneumonia as lungs won’t be as dark
100 Pedicle Position:Rotation of the spine is determined by the position of the pedicles in relation to midline. The closer to the midline a pedicle is, the more rotation is occurring to that side. Distance between the pedicles represents the transverse diameter of the spinal canal (Nash CL, Moe JH. A study of vertebral rotation. J Bone Jt Surg Am 1969;51: )
102 Grade Pedicle Displacement 0 = no rotation of the vertebral body 1 or + = minimal rotation of the vertebral body 2 or ++ = pedicles on the concave side of the spinal curve rest on or near the margin of the vertebral body 3 or +++ = only one pedicle is seen and it is nearing the midline 4 or ++++ = the only visible pedicle is seen beyond the midline of the vertebral column
103 2. Lateral view:Demonstrates the thoracic vertebral bodies, intervetebral disc spaceFirst 2-3 vertebrae are not easily seen because of the shoulder and scapula being interposed between the body and the film.*Swimmers view gets the arm up and out of the way
104 Alignment3 column classification system by McAfee This picture includes a little more of the posterior structures than the one in the bookpediatrics/pemxray/v6c13.html
105 Swimmer's ViewA lateral view with arm closest to film is raised to see vertebrae C7-T1. *Therefore wrong view for Justin as his pain is T7.
106 Computed TomographyPicks up problems with the posterior elements best Evaluates spinal canal well Axial CT’s may miss small compression fracturesHighly effective and accurate in diagnosis of fracture 2-mm axial sections has a confidence level of 98% that a fracture will be seen (Nadalo, Moody, 2007)
107 Magnetic Resonance Imaging Superior to CT scans in detecting herniated disk, ligamentous edema and spinal cord compression: see arrows Does not pick up bone fractures as well as CT Minimally displaced fractures are difficult to seefull/69/24/E41/F117
108 Schmorl NodesHerniation of the disc through the end plate of the vertebral body May or may not be symptomatic
109 More schmorl nodes Axial CT radiopaedia.org/articles/schmorl_nodes MRI T2 sagittal image of large schmorl nodeAxial CTradiopaedia.org/articles/schmorl_nodes
110 Rib radiology Standard Views: AP or PA Above Diaphragm or below DiaphragmAnterior ObliquePosterior Oblique
111 Anteroposterior (AP) or Posterioanterior (PA) AP: posterior ribs are closest to the film cassette PA: anterior ribs are closest to the film cassette -used to look at lungs for pneumonia Also, note views are taken as above the diaphragm or below the diaphragm
112 Alignment:Thoracic vertebraePediclesRibsDensity: Uniformity of bone appearance
113 Rib Fractures Standard AP view Oblique View Oblique ViewThese are the same patient, elderly female, minor fall
114 Axial CT of Rib Cage and Lungs Black arrow – rib fracture White arrows – pneumothorax
115 Ultrasound and Rib Fractures Much better at seeing rib fractures.
116 Lumbar SpineOblquies: Scooty Dogs -will have a lateral view -Also cone-in view for L5 and Sacrum -look for where heart is, and it should be listed on the X-ray.