Spine Fractures
Overview: Fractures can occur in the spinal column due to accidents, fall etc, in young and old alike. Depending on the impact it may cause minor symptoms like pain or devastating weakness of arms/ legs. Depending upon the stability of fracture and neurological compression conservative/ surgical treatment is advised.
Spine fractures are extremely common after road traffic accidents/ fall from height. These usually occur in young adults or older population. In elders it may be precipitated by trivial trauma compounded with osteoporosis. These can occur in cervical (neck), thoracic (back) or lumbar (lower back) spine. Patients usually complain of pain at the injured site. Depending upon neurological compression they may have weakness [complete/partial] of arms and/or legs. X-rays/ CT/ MRI is advised to look for spine fracture. If fracture is biomechanically stable and patient does not have any spinal cord injury– conservative treatment is advised. This is in form of rest, medications to control pain and gradual mobilization with Brace support. Serial radiological investigations are advised to document healing of fracture. In cases, where the fracture is biomechanically unstable and may cause harm to neural structures/ give rise to deformity- surgical management is advised. The urgency of this decision is usually taken based on the quantum of damage. Patients are operated with Decompression and Stabilization surgeryeither through Anterior/ Posterior approach in the cervical/ thoracic and lumbar spine.
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SPINE TUMOURS:
Overview: Tumour is an abnormal growth of tissue. They may be cancerous or non-cancerous. They may spread from various organs like breasts, prostrate, lungs, etc to spine and cause pain/ weakness or arms and legs. Depending upon the tumour surgery/ chemotherapy/ radiotherapy is advised.
A tumour/ neoplasm is defined as an abnormal growth of tissue. This tissue may be benign (non cancerous) or malignant (cancerous). If malignant- they may spread to other organs of the body (Primary) or they may have spread from other parts of the body (Secondary) (more commonly). Many times, a recently diagnosed spine tumour is actually the first symptom seen in a tumour which has metastasized (spread) from breasts, lungs, thyroid, kidneys and prostrate etc (being most common). Spine, particularly the mid back region (dorso-lumarregon) is one of the most common sites in the body where the tumour spreads. The reason for this is this area is rich in blood supply and tumours usually spread through blood vessels. Tumours are usually found in adults more than 50 years age though not exclusively. Patients usually complains of pain which is unrelenting and defies usual treatment. This pain is particularly more at nights and unrelated to activity, unlike most back pains which get better with rest. Compounded with this patients may have ‘Red Flag’ symptoms like fever, weight loss and loss of appetite. Depending upon the neurological compression, weakness- partial or complete of arms/legs may be present. The key is early diagnosis. X-rays are usually not very sensitive to diagnose tumours. Radiological investigations like MRI usually clinches the diagnosis. To know if the tumour is present in other parts of body, a PET scan may be ordered along with a set of blood tests. Finally a CT/ C-arm Guided Biopsy is necessary to know the exact nature of lesion. If the tumour is benign, a careful observation may be advised unless it compromises spinal stability or causes neurological compression. If malignant, chemotherapy or radiotherapy may be necessary in consultation with an Oncologist (Tumour Specialist). If the tumour causes significant neural compression or instability Surgery is recommended along with above modalities. This may be in the form of Minimally Invasive Techniques like Vertebroplastyto alleviate pain or Anterior/ Posterior Cervical/Thoracic/Lumbar Decompression and Stabilization.These surgeries may be palliative (symptomatic- to improve the quality of life) or definitive.
SPINE DEFORMITIES
- Scoliosis:
Overview: Scoliosis is an abnormal side to side curvature of spine. Though it may occur due to numerous causes, the reason for the most common type that affects young boys/girls is not known. Depending upon the magnitude of curve and age – observation, bracing or surgery to correct the deformity is advised.
Scoliosis is a side-to-side curvature of the spine. It may be structural or non structural. Non structural forms are more common and caused due to abnormal postures, back sprains and spasms or difference in leg heights. These do not require surgery and are usually temporary. Structural forms of scoliosis may occur in very small children at birth (early onset scoliosis), at a young age (adolescent scoliosis) or in adults (adult onset scoliosis). Most common amongst these is the adolescent scoliosis. Though these may be caused due to numerous reasons like defect during child birth (congenital) abnormal neuro muscular conditions like polio, cerebral palsy, etc. idiopathic (without any cause) scoliosis is the most common. These are usually seen in young girls. Fortunately, large deformities are found less commonly. These tend to grow with age until maturity (16-18 years of age) after which they grow rather slowly. These deformities are first noticed by the child/ child’s parents. Usually,one shoulder is higher than the other rib cage appears prominent on one side, higher on one side (also called a rib hump), one hip appears higher or more prominent than the other, the waist appears uneven, the body tilts to one side, or one leg may appear shorter than the other. Apart from back pain, these deformities may affect child’s emotional health due to abnormal body structure. Some curves which are large, may cause cardio respiratory compromise and neurological compression. On clinical examination, the curve is clearly visible. The surgeon tries to assess the magnitude and flexibility of the curve. A thorough neurological examination is done. He would usually ask for special X-rays of the full spine (scanograms) to quantify the deformity based on Cobb’s angle which is the angle between most tilted vertebrae at either ends of the curve. An MRI may be necessary to see any associated spinal cord abnormalities/ neurologic compression. Based on the magnitude of the curve and child’s skeletal maturity, either serial observation (biannualy/annually), bracing or surgical treatment- Deformity Correctionmay be recommended.
Observation. Typically, a doctor will advise observation for a scoliosis curve that has not yet reached 25 degrees. Every 4 to 6 months, the doctor will take another X-ray of the spine to see if the scoliosis is progressing or not.
Bracing. If the scoliosis has progressed past 20 or 25 degrees, a back brace could be prescribed to be worn until the adolescent has reached full skeletal maturity. The goal of bracing is to prevent the curve from getting worse and to avoid surgery.
Surgery. If the curve continues to progress despite bracing, surgery could be considered. The most common surgical option for scoliosis today is a posterior spinal fusion, which can offer better corrections with fewer fusion levels (preserving more back mobility) than what was done in years past.
Approximately 90% of people identified with idiopathic scoliosis have curves that never progress enough to require bracing or surgery.
2. Adult onset Scoliosis
This may be found due to two reasons. First, due to an early age scoliosis which has now grown and causes symptoms. Second, due to on going degeneration. These curves unlike young children does not cause much cosmetic deformity. However, they may cause back pain with/with leg pain and neurological compression. They usually have co-existent lumbar canal stenosis or degenerative spondylolisthesis which also needs to be treated. These are usually treated with conservatively with medications and physiotherapy. However, when they functionally affect patient’s life, surgical treatment is advised. The aim of surgery is to relieve neurological compression and maintain a good overall balance of the spine with limited/ total deformity correction.
3. Kyphosis:
Overview: Kyphosis is abnormal forward bending of the spine. It may be caused due to TB, Trauma, Osteoporosis, etc. Treatment is based upon the cause/ the magnitude of the deformity affecting patient’s quality of life and whether there is any neurological compression.
Kyphosis is an abnormal forward rounding of the spine.This spinal disorder generally affects the thoracic spine and sometimes the cervical spine. Kyphosis can cause back pain, muscle fatigue, and stiffness on the mild side of the spectrum. In severe cases, it can cause chest pain and make breathing difficult. The most common cause of kyphosis is non- structural and postural. It is usually seen in young adolescents and treated with postural training and physical therapy. However, there is another form of kyphosis seen in young children known as Scheuermann’s kyphosis– the cause of which is not known. It is usually diagnosed with X-rays and in severe cases may require Deformity Correction surgery. Similarly, those patients who have suffered from Spine Infections/ Tuberculosis in the past may also suffer from this deformity. In such patients, MRI may show neurological compression. Congenital kyphosis is the rarest and occurs due to defect in spinal bones since birth. These usually progress and require surgery. Apart from these, kyphosis may be caused due to Osteoporosis, Spine Fractures and Ankylosing Spondylitis. The doctor evaluates medical and family history and does an in-depth physical and neurological examination. The surgeon may order standing x-rays, CT scan, and/or magnetic resonance imaging (MRI) to fully assess the kyphosis. If previous imaging studies of the kyphosis are available, the spine specialist will compare the older images to the newest. The imaging studies are used to measure the size or angle of the kyphosis. Previous imaging studies can lend information about curve size progression—and answer the question, “Is the curve growing larger?”.Furthermore, the balance of your body, ability to stand up straight, and symptoms are potential indicators that nonsurgical or surgical treatment may be recommended. Other tests may include blood work, pulmonary function testing (measure lung capacity), and bone mineral density testing. Based on magnitude of deformity and its progression, neurological compression and functional disability conservative or surgical treatment Deformity Correction is advised.
ARTHRITIC CONDITIONS:
Ankylosing Spondylitis (AS):
Overview:Ankylosing Spondylitis a stiffening disorder caused due to an arthritis affecting spinal bones. Usually affects males in 2nd or 3rd decades as back pain. It has a variable course and medical management with anti arthritic medicines are advised.
Ankylosing ( abnormal stiffening of a joint due to fusion of bones) Spondyl (spine) litis (inflammation).
Ankylosing spondylitis means stiffening disorder of the spine due to inflammation involving its joints. The disease typically involves sacro-iliac joints ( joints connecting the spine to the pelvis/ hips) first and then spreads to the joints of the lower back, mid back and neck depending upon its severity. Though it involves the spinal column, it may also affect other joints of the body. It is usually affects young males> females during 2nd – 3rd decades of life. The exact cause of ankylosing spondylitis is unknown, however, it is linked to a protein human leukocyte antigen B27 (HLAB27) and thus has a genetic predisposition. Typically, it produces chronic low back pain in young males. This is associated with morning stiffness which gets better with activity as day progresses. The severity of AS can vary greatly from person to person. Some people experience intermittent back pain, and others have severe pain and stiffness for long periods of time. Almost all cases are characterized by acute pain followed by temporary remission when symptoms subside. In some cases, AS may affect other parts of the body, such as the eyes. In severe cases, it causes extreme stiffening of the spine causing deformities (Kyphosis) affecting activities of daily living. However, this is found to be less common. Based on clinical suspicion, doctor might advise you to get X-rays of Spine and Pelvis (hips). He would usually also require blood investigations including HLAB27. This marker is found in more than 95% of people with AS. The treatment of this disease is medical with anti-inflammatories, anti-arthritic medications like TNF Blockers and DMARDs. These are usually advised in consultation of a Rheumatologist (specialist in arthritic disorders) as long term medications. This in addition to an active lifestyle, physiotherapy and rehabilitation forms the core of treatment. Patients are advised to actively take up activities like walking, running, cycling and swimming. In severe cases (those having deformities) may require Deformity Correction surgery. These patients are also prone to developing spine fractures as the disease becomes severe. In such patients, spine is usually unstable with or without neurological compression causing weakness. These usually require Posterior Cervical/ Thoracic/ Lumbar Decompression and Stabilization surgery.