Spine - Orthobullets

L5/S1

• 4th + 5th decade
• Male 3:1
• Recurrent torsional strain leads to tear of outer annulus > herniation of nucleus pulposus

• Sequestered disc
• Macrophage phagocytosis

• Annulus fibrosus
• Nucleus polpous

• Type I
• high collagen/low proteoglycan
• Extensibility and tensile strenght

• Type 2
• Low collagen/high proteoglycan
• COmpressibility

• Cervical: above pedicle
• Rest: below pedicle

Central

Posterolateral: at L4/L5 affects L5

Foraminal: At l4/l5 affects l4

Axillary: can affect both exiting and traversing roots

Posterolateral: PLL weakest here

Eccentric bulging with intact annulus

disc material herniates through annulus but remains continuous with disc space

Disc material herniates through annulus and is no longer continuous with disc space

• Straight leg raise
• Contralateral SLR: more sensitive but less specific
• Lesegue sign SLR aggravated by forced ankle dorsiflexion
• Bowstring sign: SLR aggravated by compression popliteal fossa

Trendelenburg: glut medius innervated by L5

Distinguish between post surgical fibrosis ( enahnces) and recurrent disc (does not enhance)

First line

• Meds: NSAIDs, Muscle relaxant, steroid taper
• PT: Extension exercice

Second line: Selective nerve root injection with steroids

Persistent disabling pain lasting more than 6 weeks that have failed non op

Progressive significant weakness

Cauda equina

If done after 6 weeks

Surgery better pain and function

• Leg pain is chief complaint
• Positive SLR
• Weakness that correlates with nerve root impingement on MRI
• Married

Workman compensation

• Dural tear
• Recurrence
• Discitis
• Vancular catastrophy

No diference

• Age >41
• No joint problems
• High school education or less
• no CSST
• SYmptoms >6 months
• Married
• Worsening symptoms at baseline
• MCS < 35

• Central cord
• C spine

• Decreased perfusion
• Lipid peroxidation
• Free radicals/cytokines
• Cell apoptosis

• Atlas fracture
• facet dislocation

• Basilar artery insufficiency
• Stenting: only if symptomatic

Abscence of bulbocavernosus reflex

• Hypotension and tachycardia
• Circulatory collapse from loss of sympathetic tone

• Nonpenetrating SCI within 8 hours of injury
• NASCIS III
• 30mg/kg over 1st hour then 5.4 mg/kg/hr fro 23-47 hours

• GSW
• Pregancy
• Under 13
• >8 hours after injury
• Brachial plexus injuries

• Skin problems
• Venous thromboembolism
• Urosepsis
• Sinus tachycardia
• Orthostatic hypotension
• Autonomic dysreflexi: headache, hypertension, agitation
• MDE: 11%

• Vent dependent + Electric wheelchair with head or chin control
• Can become vent independent + electric chair with head or chin control
• Vent independent + electric wheelchair with hand control
• Can feed themselves + manual wheelchair with sliding board transfers
• Manual wheelchair + independent transfers
• Tully independent tranfers
• Wheelchair dependent
• Can do unsupported seated activities
• Variable ability to ambulate
• Various amounts ofB/B function and sexual dysfuction

Skeletal muscle

It stimulates skeletal muscle: for improved strenght

• Degenerative cervical spondylosis: discosteophyte complex
• Disc herniation: posterolateral>>>btw posterior edge of uncinate and lateral edge of pll

Pedicle/nerve root mismatch: Root exits above in c spine and below in l spine

HOrizontal vs vertical nerve root anatomy


Vertical anatomy of lumbar nerve root > paracentral and foraminal disc affect different nerve roots

Horizontal anatomy of cervical discs > central and foraminal nerve root affect same nerve root

C5: Deltoid and bicep weakness + diminished bicep reflex

C6: brachioradialis and wrist extension weakness + diminished brachioradialis reflex + thumb parasthesia

C7: Tricep and wrist flexion weakness + diminished tricep reflex + thumb parasthesi

C8: Weakness distal phalanx flexion of middle and index finger + parasthesia little finger

Spurling: Simultaneous extension, rotation to affected side, lateral bend, vertical compression reproduces symptoms

Injection at C1-2

75%

Formainal disc herniation causing single level radiculopathy

Sigle level ACDF

• Smoking 
• Diabeted
• Multi level fusion

• Degenerative cervial spondylosis: MOst common...casued by degenerative change
• Congenital stenosis
• OPLL
• Tumor
• Epidural abcess
• Trauma
• Cervical kyphosis

• Neck pain or stiffness
• Extremity parasthesias
• Weakness and clumsiness
• Gait instability
• Urinary retention

• Cervical myelopathy
• Hold fingers extended and adducted> small finger has spontaneous abduction due to weak intrinsics

Hyperreflexia

Inverted radial: tapping brachioradialis > finger flexion

Hoffman

Sustained clonus: > 3beats

Babinski

• Toe heel walk
• romberg: arms held forward and eyes closed > loss of balance

Ratio of canal to vertebral body <0.8 suggest a congenital narrow canal

Smallest AP diameter of cord/largest transverse diameter of the cord

if <0.4 poor prognosis

• Smith robertson
• 1-2 level disease or fixed kyphosis >10 degrees

• Lower infection
• Less blood loss
• Less post op pain

FIxed kyphosis >13 degrees: will not adequately decompress due to bowstriging

Multilevel compression in OPLL: less complication vs anterior

• 5%
• Tethering of cord anteriorly if doing post decompression
• Good

• Smith robertson
• Right side: more aberrant path

Watch and refer to ENT if no improvement in 6 weeks..

If revision do same side as palsy

Lower motor neuron disorder

• Facet osteophytes
• Uncinate spurs
• Spondylolisthesis
• Herniated disc
• Ligamentum flavum hypertophy or buckling
• Synovial facet cysts

<100mm2

or <10mm AP diameter

Overgrowth of superior articular facet

• non specific symptoms of lower nerve root
• Descending nerve root
• Exiting nerve root
• Exiting nerve root

Unilacular radicular pain from foraminal stenosis made worse by extension of back

Postural changes: worsen neurogenic, no difference in vascular

Standing stationary: causes neurogenic, relief vascular

Stair climbing: Up easier neurogenic, down easier vascular

Stationary bike: Reliefs symptoms neurogenic, causes symptoms vascular

Pulses: normal neurogenic, abnormal vascular

Failed conservative x 6 months

Progressive neuro deficit: weakness or bowel/bladder

Recurrence of disease above or below decompressed level

30% at 10 years

Use of microscope: doubles it to 1.4%

Instrumentation: as high as 10 %

• African americans
• Diabetics
• WOman over 40

• Sacralization of L5
• Sagitally oriented facet joints

If L4/L5

• L5 at the level of the lateral recess
• L4 from foraminal stenosis

Spondylolisthesis

• I: <35%
• II: 25-50%
• III: 50-75:
• IV: 75-100%
• V: spondyloptosis

4mm translation or >10 degrees agulation

Smoking

Superior hypogastric plexus

• Multi level
• Age >60
• Adjacent level laminectomy

• HLA-B27
• RF negative
• Axial spine

• Bilateral sacroiliitis
• +/- uveitis
• HLA b27 positive

• Acute uveitis
• Heart disease: conduction abnormalities
• Pulm fibrosis
• Renal amyloidosis
• Ascending aorta conditions
• Klebsielle synovitis

• Bilateral sacroiliitis
• Progressive spine kyphotic deformity
• Cervical spine fractures
• Large joint arthritis

ank spond

Ferguson pelvic tilt view: x ray directed 10-15 degrees cephalad

• Nonmarginal/marginal
• flowing candle wax/ bamboo spine
• Preserved/ossicified
• NO/yes
• older/younger
• No/bialteral sacroiliitis
• yes/no

Infliximab, etanercept/adalimumab: TNF alpha blocking

• Epidural hematoma
• Midcervical and cervicothoracic jct
• Extension type: involve all 3 columns

• Progressive deformity
• nonunion
• hardware failure
• infection

C7-T1 cervicalthoracic osteotomy: vert is external to transverse foramen + large canal diameter

Anterior dislocation: vertically oriented nd anteverted acetabulum

>5cm

• Thoracic
• Lumbar

• Osteoporosis
• Pre existing scoli
• Iatrogenic instability
• DDD

• Symptoms on convex side of curve
• Sagital plane inbalance

• Degenerative changes
• iatrogenic
• paralytic
• post traumatic

• > 60 degrees thoracic
• > 90 degrees

Smith petersen: 10 degree per level...need normal disc..correct through the disc

PSO: 30 degrees per level..correct through vertebral body

Vertebral column resection: up to 45 degrees

L5-S1 + thoracolumbar junction

• Age >55
• kyphosis > 20
• positive sagital balance >5
• hip OA
• smoking
• Thoracoabdominal approach
• Incomplete lumbopelvic fixation

• Vertebral fracture that involves the anterior and middle column
• Axial load with fleion

usually resorb and do not cause neuro deficits

• ALL
• Ant 2/3 vertebral body

• PLL
• Posterior 1/3 vertebral body

• Pedicles
• Lamina
• Facets
• LF
• SP
• Posterior ligament complex

• Widening of interpedicular distance on AP
• Loss of height of posterior cortex on lateral

• Supraspinous ligament
• Infraspinous ligament
• Ligamentum flavum
• Facet capsule

• Bony chance
• Widening of interspinous space
• Progressive kyphosis with non op Mgmt
• Facet diastasis

• Injury morphology
• Neuro status
• PLC integrity

• <4: non op
• 4: uncertain
• >4 operative

Neuro intact +

• PLC presrved
• kyphosis < 30 (controversial)
• Vertebral body height loss < 50% (controversial)
• TLICS<4

No difference to no brace

May help patient for pain control

Direct: transpedicular removal of retropulsed fragment

Indeirect: ligamentotaxis

Non op


Operative has been associated with higher complication and revision surgery rates with no benefit in functional outcome

Hyperflexion: anterior displacement > associated with transverse ligament failure and atlantoaxial instability

Hyperextension: casued by direct impact of posterior arch of atlas

5

• Transverse ligaments:limit anterior translation
• Apical ligaments: Limit rotation
• Alar ligaments: limit rotation

• Apex: internal carotid
• BasE: Vertebral artery

Watershed at location of type 2 #

• Type 1: oblique avulsion # tip odontoid
• Type 2: waist > high non union rates
• type 3: into cancellous body and involves c1-c3 joint

• ADI >10mm
• < 13mm Space available for cord (PADI)

• Type 1: collar
• Type 2 young: halo if no risk factors no union or PSF if risk factors present
• Type 2 elderly: collar if not surgical candidates
• Type 3: collar

elderly patient: do not tolerate > aspiration

• >6mm displacement
• Age >50
• Fx comminution
• Angulation >10 degrees
• Delay in treatment
• Smoker

In foramen c6-c2

At C2 deviates laterally to pass C1 foramen then wraps medially on top of arch of C1

Vert

25%

Sinuvertebral nerve from dorsal root ganglion: superficail fibers of annulus

It is replaced by fibrocartilage: change in properties

It increases

vertebral compression fracture

Hx f 2 VCF

• 33-44
• 19033

15%

Calcitonin: within 5 days

AAOS: recommend strongly against

AAOS: May be used but limited recommendation strenght

L5

• PI = PT  + SS
• PT = line from center S1endplate to center of femoral head + vertical line
• SS = Horizontal line + line parallel to sup endplate of S1

• L5 nerve root neuropraxia
• Improved sagital alignment

Sacral sparing: presence of voluntary anal contraction

central cord syndrome

• Descending (motor)
• Lateral corticospinal
• Ventral corticospinal

• Ascending
• Dorsal column: deep touch, vibration, propioception
• Lateral spinothalamic tract: pain temperatire
• Ventral spinothalamic tract: light touch

• Anterior cord syndrome
• Brown sequard
• Central cord
• Posterior cord

• Lateral corticospinal
• UE > LE weakness: hands and upper extremity more central in corticospinal tract

Lower extremity > bladder and bowel > proximal upper extremity >hands

• Direct compression: disc or bony
• Anterior spinal artery injury: 2/3 spine supplied by it

Lower extremity more affected than UE

• Loss
• Lateral corticospinal:motor
• Lateral spinothalamic: pain and temperature

• Preserved
• Dorsal column: Propioception and vibration

Anterior cord syndrome

Transection half cord: penetrating trauma

excellent prognosis

Ipsilateral deficits: Motor (LCS), vibration/proprioception (dorsal column)

Contralateral: Pain and temperature (LST)

2 levels below the

• Cranial fracture
• Infection
• Severe sof t tissue injury

8 lb/inch

Total 4

2 anterior pins: safe zone 1 cm above lateral 1/3 eyebrow...lateral to supraorbital nerve and anterior to temporalis

2 posterior pins: opposite form anterior pins

• 2-4 lbs
• 6-8

• Anterior pins
• Lateral 1/3 eyebrow and 1 cm above: safe zone 1 cm above lateral 1/3 eyebrow...lateral to supraorbital nerve and anterior to temporalis

Posterior pins: Exactly opposite to anterior

Abducens: diplopia and loss of lateral gaze

• Supraorbital nerve
• Supratrochlear nerve

• kids 70%
• adults 35%

Rotation C1-C1

T11-t12

Underlying scheuermanns disease

T2-T5

Lateral thorugh costotransversectomy

Intercoastal neuralgia

• EMG
• SEP: 25% sensitive + 100% specific
• MEP: 100% sensitive + 100% specific

• Afferent (sensory)
• Dorsal column
• Spinothalamic tract

• efferent (motor)
• Lateral corticspinal
• Ventral corticospinal

Record brain: somatosensory cortex

Lower extremity: stimulate posterior tibial nerve

Upper extrimity: stimulate uknar nerve

Unaffected by anesthetics

No reliable for monitorng anterior spinal cord (motor)

Ventral and lateral corticospinal cord: motor

• Initiate signal at brain
• Record signal at lower extremity

• Detect ischemia of anterior cord
• Unreliable due to anestheisa

T12-L1

Pudendal nerve

Better bowel and bladder symptom resolution if performed within 48 hours

• 25%
• 50%

Superior facet

Subaxial c spine c2-c7

Flexion distraction

Exiting nerve root below level ie if C6/7 C7 affected

Bilateral easier than unilateral: PLL torn >>also makes them less tabe

90% resolves within 1 year

Wadell signs: 3 positive is clinically significant

• Superficial non anatomic tenderness
• Pain with axial compression or simulated rotation of spine
• Negative SLR when distracted
• Non dermatomal distribution
• Overreaction to physical exam

High VAS scale prior to treatment

• Lumbar: 50-60
• Thoracic: 30-40
• Cervical: 10

• IV drugs
• diabetes
• recent systemic infection
• obesity
• malignancy
• immunosuppresed
• Malnutrition
• Trauma
• smoking

Staph aureus

Hematogenous spread: end plates are area of low flow vascular anastamosis > easier to seed

Direct: penetrating trauma or procedure

Contiguous spread: Retropharyngeal or retroperitoneal abcess

MRi with gado: disc and endplate enhancement with gado

• CBC: WBC only elevated in 50%
• ESR: elevated 90%
• CRP: elevated 90%
• Blood cultures: least invasive form to obtain organism

• Refractory to Abx
• euro deficits
• Progressive deformity and instability

• C2
• Spine injury

• 3
• Incomplete fusion of posterior arch

Type 1: isolated anterior or posterior arch fracture

Type 2: Jefferson...bilateral fracture of posterior and anterior arch from axial loading....Stability determined by integrity of transverse ligament

Type 3: Unilateral mass fracture >>stability determined by integrity of transverse ligement

• <3mm
• 3-5mm
• >5mm

Sum of lateral mass displacement: if>7mm transverse ligament rupture and considered unstable

• C1 lateral mass
• C2 pedicle
• C1-2 transarticular screw

Single level disease with no adjacent level disease

Total disc lower level of adjacent level disease

Accelerated disc degeneration and reactive endplate changes

L4-5

Facetectomy and instrumented fusion

• 60
• L3

• Separate ossification centers
• Project superiorly from superior articular facet

Become more coronal

Segmental arteries

• Atlantoaxial subluxation
• Basilar invagination
• Subaxial subluxation

Myelopathy

• Class I: pain no neuro
• Class II: subjective weakness, hyperreflexia, dyesthesias
• Class IIIA: Objective weakness + UMN + ambulatory
• Class IIIB:: objective weakness + UMN + non ambulatory

• Atlantoaxial subluxation: 50-80% RA
• Pannus btw dens and ring of c1>destruction of transverse ligament

>10 mm ADI 

<14mm PADI/SAC

>13mm of SAC/PADI

Canot reduce c1/c2: means that you need to decompress> loss stability

Basilar invagination

Ranawat C1-C2 index

• Draw line from posterior to anterior c1 arch
• Draw perpendicular from center of C2 pedicle >>if this line is <15mm it is abnormal

• McGregors line
• Posterior edge of hard palate to caudal posterior occipital curve
• Basialr invagination if tip of dens >4.5cm above this line

• Chamberlain's line
• Line from dorsal margin f hard palate to posterior edge os foramen magnum
• If tip dens >5mm above it is abnormal

McRae's line

• Line across foramen magnum
• Helps rule out basilar invagination if dens is below it

• Progressive cranial migration >5mm
• Neuro compromise
• Cervicomedullary angle <135 on MRI

Cervical height to width ratio <2 is almost 100% sensitive and specific

Presence of non marginal syndesmophytes at 3 succesive levels

Thoracic spine (right side) > cervical > lumbar

• Gout
• DLP
• DM

30-50% in DISH: more than normal

Thoracic spine

TB has contiguous multilevel involvement that skips the disc

• Retropulsion
• Subluxation
• lateal translation
• Toppling

80%

RHZE: for 2 months then RH for 9-18 months

• Rifampin
• Isoniazid
• Ethambutol
• Pyrazanamide

• Neuro deficit
• Spinal stability
• Kyphosis correction: >60 degrrees in adult
• Advanced disease with caseation
• Failed non op
• Panvertebral lesion

SPinal cord injury caused by abcess/bony sequestrum

HIV

Mostly elastin 

Rest of ligaments in spine are collagen

• 20-40
• 20-50: 35
• 20-80: 60

C2 and C7

or the rest, pedicles are too small so use lateral mass screws

• L3
• L1

Middle ganglion t the level of C6: close to medial border of longus coli

Leads to horners

Notocord

Posterior spinal artery

• Artery of adamkiewicz
• Left posterior intercoastal
• 75% left side btw T8 and L1

Choroid plexus in third, fourth, lateral ventricles

500 mL/day

Syrinx within the spinal cord that expands > neuro deficits

Syrinx in the brain stem

Chiari malformation: 50% have syrinx

Spinal cord trauma

Spinal cord tumor

Post infectious

• Developmental scoli
• Klippel-feil
• Charcot joints

Fix syrinx first then fusion 3-6 months later

Flexion / distraction

Bony

Ligamentous: Harder to heal

• Lumbar spine
• Male
• <5

In kids blood vessels reach the nucleus polpusus> direct onoculation

• Late intection
• Paraspinal abcess and neuro deficits
• Limited response to non op

Loss of lordosis

Disc space narrowing

Endplate erosion

• IV drug user
• Immunodeficiency
• Malignancy
• HIV
• Immunosuppresive meds
• Recent spinal procedure

Staph aureus

Preop degree of neuro deficits

MRI with GADO

• Neuro deficits
• Spinal cord compression on imaging
• Failed conservative
• Progressive deformity or instability

• Infection: grisel disease
• Trauma
• Recent head and neck surgery

• Downs
• RA
• TUmor
• Congenital anomalies

• Chin rotated to the opposite side of subluxation
• Spastic contralateral SCM
• reduced ROM: rotation

Dynamic CT: will see fixed c1/c2 subluxation

NSAID's, soft collar

Head-halter: 5lb then hardcollar x 3 months

Halo vest x 3 months


Postrior C1-C2 fusion

• > 45 degreed
• Anterior wedging >5 degrees of 3 consecutive vertebrae
• Rigid kyphosis

• Thoracic
• Autosomal dominant

• Hyperlordosis
• SPondylolysis
• Scoliosis

Pulmonary issues if curve > 100 degrees

Stretching and observation

Bracing if growth remaining: can stop progression

PSF with smith pete osteotomy +/- anterior release

C2-C6

C7

• C6
• C7

• SPinalis:most medial >>SP to SP
• Longissimus in the middle >> TP to TP
• Iliocostalis: most lateral

SCM contracture:

Packaging disorders

• Head tilt towards affected side chin rotates away from affected side
• Palpable neck mass

Condition < 1 year,limitation < 30 degrees: Stretching > 90% response

Failed stretching 1 year or limitation > 30 degrees: SCM lenghtening or release

• Asian
• Men
• C spine: C4-6

• DM
• Obesity
• High salt/low sodium
• Poor calcium absorption

Anterior corpectomy: either remove OPLL or let it fall into void

Posterior laminoplasty: Need spine lordois..considered safer

C5/6 + C6/7: because site of most flexion

• Excessive driving
• Smoking
• Lifting
• Professional athletes

Degeneration of the discand 4 joints in c spine

• 2 facet joints
• 2 uncovertebral joints

• Canal diameter < 10
• Canal diameter 10-13

• thoracolumbar junction
• Acceleration > deceleration injuries

Burst

In c spine Anterior column fails in flexion/compression

Posterior column fails in tension

Posterior portion of verebrae retropulsed

Usually unstable

Flexion teardrop #

• Small fleck of bone avulsed of anterior endplate
• Usually stable:treat wwith collar

• Compression# with 11 degrees of angulation or 25% loss of height
• Unstable burst
• Unstable flexion Tear drop with cord compression

Down syndrome

Powers Ratio

Basion-posterior arch / opistheon to anterior arch

• If > 1 anterior dislocation
• If <1 posterior dislocation

• Harris rule of 12
• Bastion to tip of dens >12mm abnormal
• Basion posterior axial interval > 12mm abnormal

Posterior axial interval is vertical line drain down posterior aspect of odontoid

AVOID: can pop the head off ifligaments compromised

Major dural venous sinus

Congenital fusion of 2 or more cervical vertebrae

• Fusion above c3
• Fusion below C3

Fusion involving C2

• Low posterior hairline
• Short webbed neck
• Limited cervical ROM

• heart
• Kidney
• Sprengel deformity

S3-4

C6 >5>7>4>3

Hyperextension, lateral compression, rotation

mostly surgical because high association with ligamentous injuries >>>use posterior approach because that is the location of the pathology

Lateral mass #

Type A: separation.. 2 fracture lines of unilateral lamina and pedicle

Type B: Comminuted >>multiple fracture lines with lateral wedging

Type C: split >> vertical fracture in coronal plane with invagination of superior articular process 

Type D: Bilateral horizontal # of pars >>separation of anterior and posterior elements

Bilateral pars # of C2

• Hyperextension: # pars
• Secondary flexion: tears PLL

Type I: < 3mm horizontal displacement ...axial compression and hyperextension...C2/3 disc are intact

Type 2: > 3mm horizontal displacement...hyperextension>>axial load >>>rebound flexion.....C2/3 disc +  PLL disrupted

Type 2A: Flexion distraction>>no horizontal displacement...significant angulation

Type 3: flexion distraction then hyperextension...same as type 1 but with facet dislocation

Type II: if displaced > 5mm

Type III: for reduction of facet

Type 2A #

Has horizontal line...treatment is compression halo vest

• Articulate with ribs
• Facet joints oriencted in coronal plane
• Disks are thin
• Kyphosis concentrates axial load on anterior column

Posterior

Costotransverse

Transthoracic

• Ank spond
• Reiter syndrome
• Pregnancy

FABER produces pain

• 83% above C3
• Lower cervical

• Bigger head
• Ligamentous laxity
• Horizontal facet joints
• Weak muscles

5 cm

<2/3 of adjacent vertebral width

In line cervical stabilization with ears in line with shoulders

• <4mm or 40% width or vertebrae
• Children <8
• C2 on 3
• Horizontal nature of facet joints

• Reduction of subluxation on extension views
• Absence of prevertebral soft tissue swelling

• Assesmen of pseudosubluxtion
• Line from spino laminar poin on C1 to spinolaminar point on C3

Spinolaminar point on C2 should be within 1.5mm of this point

• Downs
• RA
• Os odontoideum
• Trauma: transverse ligament injuries

• JRA
• Morquio
• Downs
• Trauma: AARD

Atlantoaxial joint

• < 3mm
• > 3.5
• > 10mm

<14: therefore indication for surgery

• < 8 years 
• > 8 years

• Spastic quad
• If bedridden: 100%

• Start at younger age
• long stiff c shaped
• Greater sagital plane deformity
• Associated with pelvic obliquity
• More likely to progress

Pelvic obliquity >15 degrees

• Defect in pars interarticularis
• Repetitive hyperextension
• 15%

• Larger slip
• Dysplastic type

• Dysplastic
• Isthmic: pars elongatiom
• Isthmic: pars acute fracture
• Isthmic: pars stress fracture
• Traumatic
• Neoplastic

Spine oblique

Scotty dig sign

SPECT

L1-L4 isthmic defect that failed non op

Positive SPECT: suspected stress or acute isthmic spondy

• Osteoid osteoma: apex of concavity
• Osteoblastoma: pain less severe

Removal of tumor before 18 months of onset of scoli

Child is <11 years old

• CP: UMN
• Rett: UMN
• SMA: Muscle weakness
• Muscular dystrophy: Muscle weakness
• Spina bifida/SCI: Paralytic
• Polio: Paralytic

• Muscular dystrophy
• SPina bifida/SCI

20-30 degrees: after this they get pulmonary deterioration

• Female 10x
• Right thoracic
• Curve >90 degrees

• Curve magnitude: >50 thoracic, >40 lumbar
• Remaining skeletal growth
• Curve type: thoracic > lumbar...double>single

• Younger age: <12
• Tanner stage: <3
• Risser stage: 0-1
• Peak growth velocity: if curve > 30 before peak growth velocity.....likely to need surgery

• I: Main thoracic
• II: Double Thoracic
• III: Double Major (T>L)
• IV: Triple Major
• V: Thoracolumbar/Lumbar
• VI: Double Major (L>T)

Sagital from t5-t12: If <10 kyphosis (-)...if >40 (+)

Lumbar modifier (CSVL relationship to pedicles of apical vertebrae): 

• A: BTW pedicles
• B: touches Pedicle
• C: Does not touch pedicle

Structural if

• >25 degrees on standing AP and does not bend to < 25 on bending films
• >20 in sagital plane
• Biggest curve

If 7 degrees on scoliometer corresponds to 20 degree curve

• Stable vertebrae: Most proximal vertebrae that is bisescted by CVSL
• Neutral vertebrae: Rotationally neutral
• End Vertebrae: Vertebre that s most tilted from horizontal
• Apical vertebrae: Deviates furthest from midline

• Cobb angle 25-45
• Risser 0-2

• Poor in brace correction
• Hypokyphosis
• Male
• Obese
• noncompliant

• Milwakee: extends to neck
• Boston

P acnes

• Compression of 3rd part of duodemun due to narrowing of space btw aorta and SMA
• Aorta at the level of L1
• NG and IVF

• Height <50th percentile
• weight <25th percentile
• Sagital kyphosis

4-6 weeks of gestation

• DIabees
• Alcohol
• Valproic acid
• Hyperthermia

• VACTERL
• Gondenhar: hemifacial microsomia
• Jarcho-Levin: 
• Klippel-feil: 
• Alagille: peripheral pulm stenosis, cholestasis

Unilateral unsegmented bar + contralateral hemi

Unilateral unsegmented bar

Fully segmented hemiverterbrae

• Failure of formation
• Faiure of segmentation
• Mixed

• Tethered cord
• Chiari
• Syrinx
• Diastematomyelia
• Intradural lipoma

fusion > 4 ribs

Osteotomy btw ribs

• Age 4-10
• Right main thoracic

• Syringomyelia
• Chiari syndrome
• Tethered cord
• Dysraphism
• Spinal cord tumor

• < 3 years
• Male> female
• Left thoracic
• Most resolve

• Plagiocephaly
• COngenital defects
• Neural axis
• Thoracic insufficiency

For infantile scoli

• Cobb > 20
• RVAD > 20
• phase 2 ribs

• Rib vertebral angle difference
• >20 degrees: Progression
• <20 degrees: recovery

• CObb>50/60
• Failed Mehta casting or bracing

If fusion < 10 >>>pulmonary compromis