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Contents

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xiii

29 Klippel-Feil Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Mehmet Çetinkaya and Alpaslan Şenköylü

30 Chiari Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Robert Mertens, Majd Abdulhamid Samman, and Peter Vajkoczy

31 Spinal Dysraphism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Burak Karaaslan and Alp Özgün Börcek

32 Sacralization of the fifth Lumbar Vertebra . . . . . . . . . . . . . . . . . . . . . . 191

Federico Canavese

33 Osteoid Osteoma and Osteoblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

Krishna V. Suresh and Paul D. Sponseller

34 Osteochondroma and Multiple Hereditary Exostosis . . . . . . . . . . . . . . 201

Krishna V. Suresh and Paul D. Sponseller

35 Eosinophilic Granuloma (Vertebra Plana) . . . . . . . . . . . . . . . . . . . . . . . 207

Federico Canavese

36 Medulloblastoma and Other Seeding Tumors . . . . . . . . . . . . . . . . . . . . 211

Aydemir Kale and Hakan Emmez

37 Spinal Astrocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Aydemir Kale and Hakan Emmez

38 Osteosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Mehmet Çetinkaya and Alpaslan Şenköylü

39 Ewing’s Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Peter Pal Varga and Aron Lazary

40 Discitis in Pediatric Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Yat-Wa Wong

Part IV Adult Spine Pathology

41 Back Pain and Its Generators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

Philip K. Louie and Todd J. Albert

42 Cervical Degenerative Disc Disease (Including Cervical Disc

Herniation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Michael H. McCarthy and Todd J. Albert

43 Cervical Spondylotic Myelopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Yoshiharu Kawaguchi

44 Thoracic Disk Herniation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Yoshiharu Kawaguchi

xiv

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Contents

45 Lumbar Degenerative Disc Disease and Lumbar Disc Herniation . . . 267

James E. Dowdell III and Todd J. Albert

46 Lumbar Spinal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

Jason Pui Yin Cheung and Kenneth M. C. Cheung

47 Degenerative Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Yat-Wa Wong

48 Adult Idiopathic Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Ali Eren and Alpaslan Şenköylü

49 De Novo Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

Kenny Y. H. Kwan and Kenneth M. C. Cheung

50 Sagittal Plane Malalignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Caglar Yilgor, Altug Yucekul, and Ahmet Alanay

51 Post-Traumatic Kyhphosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Meric Enercan and Azmi Hamzaoglu

52 Post-Infectious Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

Shahnawaz Haleem

53 Paget’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Yann Philippe Charles

54 Ankylosing Disorders of the Spine: AS and DISH . . . . . . . . . . . . . . . . . 329

Yann Philippe Charles

55 Vertebral Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

Burak Karaaslan and Alp Özgün Börcek

56 Aneurysmal Bone Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

Murat Songür and Alpaslan Şenköylü

57 Giant Cell Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

Peter Pal Varga and Aron Lazary

58 Spinal Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Marcel Ivanov

59 Spinal Nerve Sheath Tumors (NST): Schwannoma

and Neurofibroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Marcel Ivanov and Ion Poeata

60 Spinal Ependymoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Peter Truckenmueller, Ruben Knappe, Julia Onken, and Peter Vajkoczy

61 Plasmacytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

İsmail Daldal, Aliekber Yapar, and Alpaslan Şenköylü

Contents

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62 Chordoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

Mehmet Ali Deveci and S. Aykın Şimşek

63 Metastatic Lesions of the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389

Vanessa Hubertus, Peter Vajkoczy, and Julia Sophie Onken

64 Tuberculosis of Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395

Yat-Wa Wong

65 Pyogenic Spondylodiscitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

Yat-Wa Wong

66 Postsurgical Spinal Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Alain Dimeglio and Federico Canavese

Appendix A: Classification of Upper Cervical Injuries . . . . . . . . . . . . . . . . . 417

Appendix B: Subaxial Cervical Spine Classification . . . . . . . . . . . . . . . . . . . 433

Appendix C: AO Spine Thoracolumbar Fracture Classification . . . . . . . . . 435

Appendix D: Sacral Fractures (AO Spine Classification System) . . . . . . . . 437

Appendix E: Osteoporotic Vertebra Fracture Classification . . . . . . . . . . . . 439

Appendix F: Glasgow Coma Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441

Appendix G: ASIA Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443

Appendix H: King etal. Classification System of Adolescent

Idiopathic Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445

Appendix I: Lenke etal. Classification System of Adolescent

Idiopathic Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447

Appendix J: Early Onset Scoliosis Classification (C-EOS) . . . . . . . . . . . . . . 449

Appendix K: Classification Systems for Spondylolisthesis . . . . . . . . . . . . . . 451

Appendix L: Castellvi Classification of Lumbosacral

Transitional Vertebrae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453

Appendix M: Bone Age—Ossification of Hand, Olecranon,

and Iliac Apophysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455

Appendix N: Oswestry Disability Questionnaire (ODI) . . . . . . . . . . . . . . . . 459

Appendix O: SRS-22 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463

Appendix P: Early-Onset Scoliosis Questionnaire . . . . . . . . . . . . . . . . . . . . . 465

Appendix Q: Post-Infectious Kyphosis Classification . . . . . . . . . . . . . . . . . . 467

List of Videos

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Video 1 Halo application Video 2 Lateral mass screw xation Video 3 Thoracic and Lumbar pedicle screw xation Video 4 Neurological examination of upper and lower extremities Video 5 Serial casting for early onset scoliosis Video 6 Cobb angle measurement Video 7 Navigation in spine surgery Video 8 Biopsy in spine lesions Video 9 Grip and release test for cervical spondylotic myelopathy Video 10 Genesis and progression of scoliosis

xvii

Part I

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Pediatric Spine Trauma

Pediatric Cervical Injuries

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MoyoC.Kruyt andF.CumhurÖner

1.1 Definition

Pediatric cervical spine injury is an uncommon but signicant condition, present in 1% of the very young and 3% of the adolescent trauma patient admissions. The cause of these injuries is predominantly due to transportation accidents and sports [1]. However child abuse should be considered especially in the presence of other skeletal injuries.

1.2 Natural History

The cervical spine is the most vulnerable part of the pediatric spine with about 80% of the spinal fractures occurring in this region compared to <50% in adults. The younger the child the more vulnerable the cervical spine and the more proximal the lesions occur. This is mainly due to the relatively huge head and weak ligaments. Nevertheless, high forces are still needed for these injuries which are reected by the high rate of concomitant spine fractures [2] and the relatively high mortality (5%) in these young patients [3]. Also spinal cord injuries (SCI) are relatively frequent with up to 16% in young children; the neurological symptoms fortunately are often temporary.

Supplementary Information The online version contains supplementary material available at (https://doi.org/10.1007/978- 3- 030- 80356- 8_1).

M. C. Kruyt (*) · F. C. Öner Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands e-mail: m.c.kruyt@umcutrecht.nl; f.c.oner@umcutrecht.nl

https://doi.org/10.1007/978-3-030-80356-8_1

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M. C. Kruyt and F. C. Öner

1.3 Physical Examination

In the emergency setting, the basic principles of ATLS apply. Children suspect of cervical trauma should be immobilized with head-blocks, and for physical examination, the log roll should be used. The use of seatbelts should not argue against injury, as these are used incorrectly in >50% [4]. Physical and specically neurological examination of a young child can be difcult because of limited attention and cooperation. It should be performed systematically by an experienced physician. Since neurological symptoms may worsen, the neurological exam should be repeated until stable (Video 1.4).

1.4 Imaging

After vital stabilization, radiological examination of the cervical spine can be done. For that purpose, plain radiographs have the advantage of less radiation; however, subtle fractures can be missed. In the case of unconsciousness, a multitrauma survey, or the need for a computed tomography (CT) scan of the brain, including a CT of the cervical spine is a logical step (Video 1.4). Be aware of the relatively large head that causes forward position and anteexion. A cushion between the scapulae or at least removal of the extra elevation of the head should be standard in children. In case of neurological symptoms, magnetic resonance imaging should be used to visualize ligament injury, potential SCI, and follow-up of these lesions; according to the mechanism of injury, and clinical presentation, SCIWORA syndrome must be ruled out (Chap. 4).

For initial assessment, the alignment of the vertebrae should be veried including T1. This can be done by drawing lines anterior and posterior to the vertebral bodies and spinous processes in the sagittal plane. The atlanto-dental interval and dens to basion (skull) distance should also be assessed, as well as soft tissue swelling (Fig.1.1). Specic features of pediatric cervical spine are discussed below.

1.4.1 Anatomical Considerations

The development of cervical spinal vertebrae is complex and varies greatly in the age and order of the events. All vertebrae initially consist of three ossifying nuclei, two posterior and one in the front, linked with neurocentral cartilage. The posterior arches fuse around 3–5years of age, and fusion with the vertebral body usually occurs 1–3 years later. During puberty, secondary nuclei develop consisting of the transverse and (two) spinous processes and the annular ring apophyses. A complete fusion of the vertebra may occur after the age of 20. Typical exemptions are C1 and C2. C1 does have three primary nuclei, but no vertebral body, and the position of the synchondrosis varies greatly. C2 is actually a fusion between C2 and the original vertebral body of C1. The dens consists of two primary nuclei that usually fuse in utero, but can be interpreted as a fracture in the rst years. The dens fuses with the

Dens must be below the foramen magnum

1 Pediatric Cervical Injuries

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a. Anterior arch of C1

Fig. 1.1 Radiographic examination of the cervical spine. (By courtesy of Prof. Senkoylu)

b. Dens axis c. Atlantodental interval (ADI)

(should be <5 mm in children) d. Prevertebral soft tissue e. Tracheal shadow

Synchondroses should be fused >6 years Global alignment Soft tissues T1 must be visible

body of C2 between 6 and 11years. This synchondrosis can fracture or fail to fuse, resulting in an os odontoideum that can cause instability. The dens has an additional nucleus at the tip that ossies around 3years and normally fuses with the dens around 12years. If not, it is referred to as ossiculum terminale. The cervical facet orientation is relatively horizontal and becomes more oblique with age. Together with some wedging in C3, the relatively loose ligaments, and weak muscles, this allows for kyphosis and translation up to 4mm especially between C2 and C3 (Fig.1.2).

1.5 Differential Diagnosis

For children, the same strategy as used for adults can be applied (Chaps. 5 and 6). Many classication systems have been developed, but none of them has proven to be perfect in terms of reliability and accuracy to predict instability and the need for stabilization. For the cervical spine, a distinction between high cervical (C0– C2=axial) and lower cervical (= subaxial) is helpful. The presence of neurological symptoms and (congenital) anomalies are important modiers. For the axial region, an increased distance between dens and basion (>10mm) is indicative of instability like rupture of the alar ligaments. C1 ring fractures are difcult to recognize because of the synchondroses; in extreme cases, the tip of the dens can subside into the foramen magnum, which can cause a dangerous basilar impression. Most important of C1 is the integrity of the transverse ligament, which may be torn or avulsed when

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Fig. 1.2 Physiological anteposition of C2–C3 and wedging of C3

M. C. Kruyt and F. C. Öner

a c

Fig. 1.3 (a and b) Subsidence of dens in foramen magnum, due to a (congenital) non-union of posterior laminae and a fracture through the anterior synchondrosis; (c) assessment of lateral position of C1–C2. When >7mm in total, the transverse ligament may be insufcient

the lateral masses of C1 project >7mm lateral from C2in the anterior-posterior plane, or if the atlanto-dental interval (ADI) exceeds 5mm (Fig.1.3). Dens fractures can most easily be seen on the lateral radiograph. Be aware of the subdental synchondrosis. C2 hangman fractures are uncommon and usually a type of spondylolysis/olistesis through the synchondrosis [5].

Subaxial injuries are less common in children and behave comparable to in young adults (Chap. 6). We prefer the AO classication that makes a distinction between compression-only (Type A), tension band injury (Type B), and translation in any plane (Type C) [6]. In addition the facet fracture is considered an important

1 Pediatric Cervical Injuries

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modier in this classication, especially in the case of a oating lateral mass or (sub) luxation.

SCIWORA syndrome to be ruled out (Chap. 4).

1.6 Treatment Options andExpected Outcomes

For treatment decisions, the most important, but also controversial, parameter is (in)stability. Instability may be acute, which means that the mechanical integrity will fail with loading; this one is easy to recognize, usually with CT imaging. Neurological instability is more difcult; it means a condition where cord or nerve injury has occurred, and (intermittent) compression can worsen the neurological outcome. MRI is usually needed as well as regular follow-up. Most difcult to recognize and treat is the long-term instability which may cause severe deformities, pain, or even neurological problems. In children, the remodeling potential should be considered at the same time, which can improve the posttraumatic deformity considerably. Instability is always a reason for stabilization. The younger the child the less invasive this stabilization can be achieved. Halo xation and especially Minerva casts are well tolerated and treatment of 1 to 2months is usually sufcient. In the case of deformity, closed reduction techniques should be considered such as tong or halo- gravity traction (Videos 1.1 and 1.4) or transoral reduction of dens fractures. Open reduction with or without xation is a valuable option which can usually be performed with standard cervical spine instrumentation even if this restrains the further development of the canal diameter which has largely developed by age 4 [7].

A painful neck without a radiological sign of fracture should be followed until normalized especially in the case of torticollis. If this takes more than 1 or 2 weeks, advanced imaging is recommended. After external stabilization with halo or cast, we typically wean with a soft collar. After surgical stabilization, this is usually not required.

1.7 What Family andPatients Should Know?

The prognosis is related to the severity and the location of the cervical spine injury.