Principles of Spine Trauma
Anundiagnosedorsuboptimallymanagedspineinjurycanresultinaneurologicdeficitand
permanently impair a patient's function and quality of life, and in
some cases may lead to death. Archeological records from over
45,000 years ago are noted to forewarn that paralysis is incurable
and this remains true today,
butthatdoesnotthatnothingcanbedoneforpatientswhosustainsevereneurologicdeficits.Patientswith
spinal cord injury today regain mobility, improve their quality of
life, and achieve prolonged survival. Fractures
anddislocationsofthespineareseriousinjuriesthatmostcommonlyoccurinyoungpeople.Nearly43%of
patientswithspinalcordinjuriessustainmultipleinjuries.itisestimatedthateachyear50peoplein1million
sustainaspinalcordinjury.Withthedevelopmentofregionaltraumacentersandincreasedtrainingof
paramedicsandemergencymedicaltechnicians,thechancesofsurvivalafterseriousspinalcordinjuryhave
increased.Overall,85%ofpatientswithaspinalcordinjurywhosurvivethefirst24hoursarestillalive10
years later compared with 98% of patients of similar age and sex
without spinal cord injury. TERMINOLOGYOFSPINAL CORDINJURY
Neuraltissueinjuriesaredividedintotwobroadetiologybasedcategories:primaryinjuryrefersto
physicaltissuedisruptioncausedbymechanicalforces,andsecondaryinjuryreferstoadditionalneuraltissue
damage resulting from the biologic response initiated by the
physical tissue disruption. The extent of structural
damagetoneuraltissueisindicatedbyotherdescriptiveterms.Concussionreferstophysiologicdisruption
withoutanatomicinjury.Contusionreferstophysicalneuraltissuedisruptionleadingtohemorrhageand
swelling(themostcommontypeofspinalcordinjury),orlaceration,whichdescribeslossofstructural
continuityoftheneuraltissue(rareinblunttrauma).Theclinicalresponsetoinjuryistypicallydescribedin
temporal terms: acute refers to the first few hours after injury;
subacute typically refers to several hours to days
followinginjury,andchronicreferstointervalsofweekstomonthsaftertheinjury.Thefunctional
consequencesofspinalcordinjuryareusuallydescribedbytermsthatrefertotheseverityandpatternof
neurologicdysfunction.Completespinalcordinjury,incompleteinjury,ortransientspinalcorddysfunction
describe different grades of severity of neurologic injury.
EVALUATION OF SPINAL INJURY History
Adetailedhistoryofthemechanismofinjuryisimportant,butfrequentlyisunobtainableat
theinitial
examination.Themostcommoncausesofseverespinaltraumaaremotorvehicleaccidents,falls,diving
accidents,andgunshotwounds.Spinalinjuryshouldbesuspectedinanypatientwithaheadinjuryorsevere
facial or scalp lacerations.In any patient with recent trauma,
complaints of neck pain or spinal pain should be considered
indicative of a spinal injury until proved otherwise. Other risk
factors associated with spinal injury,
includeaninabilitytoassessneckpainbecauseofasecondarydistractinginjury,abnormalneurological
findings,ahistoryoftransientneurologicalsymptoms,physicalsignsofspinaltrauma(e.g.,ecchymosisand
abrasions),unreliableexamination,significantheadorfacetrauma,oraninconsolablechild.Ifthecervical
spineisnotalreadyrigidlyimmobilizedinapatientwithanyoftheseriskfactors,immobilizationshouldbe
applied before the physical examination is continued. Stable and
unstable injuries Spinal injuries carry a double threat: damage to
the vertebral column and damage to the neural tissues. While the
full extent of the damage may be apparent from the moment of
injury, there is always the fear that movement may cause or
aggravate the neural lesion; hence the importance of establishing
whether the injury is stable or unstable and treating it as
unstable until proven otherwise.A stable injury is one in which the
vertebral components will not be displaced by normal movements;
inastableinjury,iftheneuralelementsareundamagedthereislittle risk
of them becoming
damaged.Anunstableinjuryisoneinwhichthereisasignificantriskof
displacementandconsequentdamageorfurtherdamagetothe
neuraltissues.Inassessingspinalstability,threestructuralelements
mustbeconsidered:theposteriorosseoligamentouscomplex(or posterior
column) consisting of the pedicles, facet joints, posterior bony
arch,interspinousandsupraspinousligaments;themiddlecolumn
comprising the posterior half of the vertebral body, the posterior
part of
theintervertebraldiscandtheposteriorlongitudinalligament;andthe
anterior column composed of the anterior half of the vertebral
body, the
anteriorpartoftheintervertebraldiscandtheanteriorlongitudinal
ligament(Denis,1983)(Fig.1).Allfracturesinvolvingthemiddle column
and at least one other column should be regarded as unstable.
Mechanism of injury There are three basic mechanisms of injury:
traction (avulsion), direct injury and indirect injury.
Tractioninjury.Inthelumbarspineresistedmuscleeffortmayavulsetransverseprocesses;inthe
cervical spine the seventh spinous process can be avulsed
(clayshovellers fracture).
Directinjury.Penetratinginjuriestothespine,particularlyfromfirearmsandknives,arebecoming
increasingly common.Indirect injury. This is the most common cause
of significant spinal damage; it occurs most typically in a fall
from a height when the spinal column collapses in its vertical
axis, or else during violent free movements of the neck or trunk. A
variety of forces may be applied to the spine (often
simultaneously): axial compression, flexion, lateral compression,
flexion-rotation, shear, flexion-distraction and
extension.Spinalinjuriesmaydamagebothboneandsofttissue(ligaments,facetjointcapsuleandintervertebral
disc).The bone injury will usually heal; however, if the bone
structures heal in an abnormal position the healed soft tissues may
not always protect against progressive deformity. Early management
The essential principle is that if there is the slightest
possibility of a spinal injury in a trauma patient, the spine must
be immobilized until the patient has been resuscitated and other
life-threatening injuries have been identified and treated.
Immobilization is abandoned only when spinal injury has been
excluded by clinical and radiological assessment. Cervical
spine.The head and neck are supported in the neutral position. A
backboard, sandbags, a forehead tape and a semirigid collar are
applied.Thoracolumbar spine. The patient should be moved without
flexion or rotation of the thoracolumbar spine. A scoop stretcher
and spinal board are very useful; however in the paralysed patient,
there is a high risk of pressure sores adequate padding is
essential. If the back is to be examined, or if the patient is to
be placed onto a scoop stretcher or spinal board, the logrolling
technique should be used. Fig.1.StructuralelementsofthespineThe
verticallinesshowDenisclassificationofthe structural elements of
the spine. Physical Examination
Ageneralphysicalexaminationisdonewiththe
patientsupine.Thepatientsmentalstatusandthelevelof
consciousnessshouldbedeterminedquickly,including pupillary size and
reaction. Epidural or subdural
hematoma,adepressedskullfracture,orotherintracranial pathological
conditions may cause progressive deterioration in
neurologicalfunction.TheGlasgowComaScaleisusefulin determining the
level of consciousness.Thepatientmaybesupportinghisorherheadwith
their hands a warning to the examiner to be equally careful!
Theheadandfacearethoroughlyinspectedforbruisesor grazes which could
indicate indirect traumatothecervicalspine.Theneckisinspectedfor
deformity, bruising or penetrating injury (Fig.2). The bones and
soft tissues of the neck are gently palpated for tenderness and
areas of bogginess, or increased space
betweenthespinousprocesses,suggestinginstabilityduetoposteriorcolumnfailure.Thespinousprocesses
should be palpated from the upper cervical to the lumbosacral
region. A painful spinous process may indicate a
spinalinjury.Palpabledefectsintheinterspinousligamentsmayindicatedisruptionofthesupporting
ligamentouscomplex.Thebackoftheneckmustalsobeexaminedbutthroughouttheentireexaminationthe
cervicalspinemustnotbemovedbecauseoftheriskofinjuringthecordinanunstableinjury.Thebackis
inspectedfordeformity,penetratinginjury,haematomaorbruising.Theboneandsoft-tissuestructuresare
palpated, again with particular reference to the interspinous
spaces. A haematoma, a gap or a step are signs of instability.
General Examination shock Three types of shock may be encountered
in patients with spinal
injury:Hypovolaemicshockissuggestedbytachycardia,peripheralshutdownand,inlaterstages,hypotension.
Neurogenicshockreflectslossofthesympatheticpathwaysinthespinalcord;theperipheralvesselsdilate
causinghypotensionbuttheheart,deprivedofitssympatheticinnervation,doesnotrespondbyincreasingits
rate. The combination of paralysis, warm and well-perfused
peripheral areas, bradycardia and hypotension with a low diastolic
blood pressure suggests neurogenic shock.
Spinalshockoccurswhenthespinalcordfailstemporarilyfollowinginjury.Evenpartsofthecordwithout
structural damage maynot function. Below the level of the injury,
the muscles are flaccid, the reflexes absent and sensation is lost.
This rarely lasts for more than 48 hours and during this period it
is difficult to tell whether the neurological lesion is complete or
incomplete. A positive bulbocavernosus reflex or return of the anal
wink
reflexindicatestheendofspinalshock.IfnomotororsensoryfunctionbelowthelevelofinjurycanbeFig.2
a.Severefacialbruisingalways suspectahyperextensioninjuryof the
neck. b.Bruisingoverthelowerback shouldraisethesuspicionofa lumbar
vertebral fracture.
documentedwhenspinalshockends,acompletespinalcordinjuryispresent,andtheprognosisispoorfor
recovery of distal motor or sensory function. Neurological
Evaluation A full neurological examination is carried out in every
case; this may have to be repeated several times
duringthefirstfewdays.Eachdermatome,myotomeandreflexistested.UseoftheAmericanSpinalInjury
Association(ASIA)formishelpfulinorganizingthisevaluation.Adetailedinitialneurologicalexamination,
including sensory, motor, and reflex function, is important in
determining prognosis and treatment .Thepresence of an incomplete
or complete spinal cord injury must be determined and documented by
meticulous neurological examination.Sensory examination is
performed with light touch, then pinpricks (using a sterile
needle), beginning at the head and neck and progressing distally,
to examine specific dermatome distributions (see Fig. 3).
Motorexaminationshouldbesystematic,
beginningwiththeupperextremities.During motor examination, it is
important to differentiate betweencompleteandincompletespinalcord
injuriesandpurenerverootlesions.Keymuscle
groupsandtheircorrespondingnerverootlevels
thatshouldbeevaluatedinapatientwithspinal
cordinjury.Afterexaminationoftheextremities and trunk, the presence
or absence of sacral motor
sparingshouldbedeterminedbyvoluntaryrectal
sphincterortoeflexorcontractions.Ifvoluntary
contractionofthesacrallyinnervatedmusclesis
presentwithsacralsensation,theprognosisfor recovery of motor
function is good. The
presenceofananalreflexwithoutsacralsensationis
consistentwithacompleteinjury.Quadriplegiais indicated by flaccid
paralysis of the extremities. Spinal Cord Syndromes
Spinalcordsyndromesresultfromincompletetraumaticlesions.Bydefinition,anincompletespinal
cord injury is one in which some motor or sensory function is
spared distal to the cord injury. A complete spinal cord injury is
manifested by total motor and sensory loss distal to the
injury.When thebulbocavernosus reflex is positive, and no sacral
sensation or motor function has returned, the paralysis is
permanent and complete in most patients.
AnincompletespinalcordsyndromemaybeaBrown-Squardsyndrome,centralcordsyndrome,
anterior cord syndrome, posterior cord syndrome, or rarely
monoparesis of the upper extremity. (see Fig. 5)
Centralcordsyndromeisthemostcommon.Itconsistsofdestructionofthecentralareaofthespinal
cord,includinggrayandwhitematter.Generally,patients
haveaquadriparesisinvolvingtheupperextremitiestoa
greaterdegreethanthelower.Sensorysparingvaries,but usually sacral
pinprick sensation is preserved. Brown-Squard syndrome is an injury
toeither half of the spinal cord.It is characterized by motor
weakness on thesideofthelesionandthecontralaterallossofpainand
temperaturesensation.Prognosisforrecoveryisgood,with significant
neurological improvement often
occurring.Anteriorcordsyndromeusuallyiscausedbya
hyperflexioninjuryinwhichboneordiscfragments
compresstheanteriorspinalarteryandcord.Itis
characterizedbycompletemotorlossandlossofpainand
temperaturediscriminationbelowthelevelofinjury.The
posteriorcolumnsaresparedtovaryingdegrees(seeFig.
35-9D),resultinginpreservationofdeeptouch,position
sense,andvibratorysensation.Prognosisforsignificant recovery in
this injury is poor.Posteriorcordsyndromeinvolvesthedorsal
columnsofthespinalcordandproduceslossof
proprioceptionvibratingsense,whilepreservingother
sensoryandmotorfunctions.Thissyndromeisrareand usually is caused by
an extension
injury.Conusmedullarissyndrome,orinjuryofthesacralcord(conus)andlumbarnerverootswithinthe
spinalcanal,usuallyresultsinareflexicbladder,bowel,andlowerextremities.Mostoftheseinjuriesoccur
between T11 and L2.Cauda equina syndrome, or injury between the
conus and the lumbosacral nerve roots within the spinal canal, also
results in arefl exic bladder, bowel, and lower limbs. Imaging
X-rayexaminationofthespine ismandatoryforallaccidentvictims
complaining of pain or stiffness in theneckorbackorperipheral
paraesthesiae,allpatientswithhead injuriesorseverefacialinjuries
(cervicalspine),patientswithrib fracturesorsevereseat-beltbruising
(thoracicspine),andthosewithsevere pelvicorabdominalinjuries
(thoracolumbarspine).Thisis performedduringthesecondarysurvey.
Accidentvictimswhoareunconscious shouldhavespinex-raysaspartofthe
routinework-up.(TRAUMASERIES: lateralviewofthecervicalspineand
anteroposteriorviewsofthechestand
pelvis.).Painisoftenpoorlylocalized; views should include several
segments above and below the painful area.In addition to
anteroposterior and lateral views, open-mouth views are needed for
the upper two cervical vertebrae and oblique views may be needed
for the cervical as well as the thoracolumbar region. Lateral
flexion
andextensionviewscanbemadetodeterminethestabilityofthecervicalspine,butthesearenotroutinely
recommended in the initial examination.CT is ideal for showing
structural damage to individualvertebraeanddisplacementofbone
fragmentsintothevertebralcanal.Infact,screening
CTisemployedroutinelyinmanycentres;the drawback is its high level
of radiation exposure. MRIisthemethodofchoicefordisplaying
theintervertebraldiscs,ligamentumflavumand neural structures, and
is indicated for all patients with
neurologicalsignsandthosewhoareconsideredfor
surgery.CTmyelography,withtheintrathecal
introductionofcontrastagent,providesinformation
onthedimensionsofthespinalcanal,impingement
byfracturefragmentsorintervertebraldisc,androot avulsion. This
investigation has been largely replaced by
MRI.Three-dimensionalreconstructionofCT
imagesdefinescertaincomplexfracturepatterns.
SpiralCTallowshighresolutionsagittal
reconstructionandwhenavailable,isusefulfor displaying fractures of
the odontoid process. Principles of treatment The objectives of
treatment are: to preserve neurological function; to minimize a
perceived threat of neurological compression; to stabilize the
spine; to rehabilitate the patient.
Theindicationsforurgentsurgicalstabilizationare:(a)anunstablefracturewithprogressive
neurological deficit and (b) controversially an unstable fracture
in a patient with multiple injuries. Patients with no neurological
injury Stable injuries. If the spinal injury is stable, the patient
is treated by supporting the spine in a position that will cause no
further strain; a firm collar or lumbar brace will usually suffice,
but the patient may need to rest in bed until pain and muscle spasm
subside. A progressive neurological deficit mayoccasionallydevelop,
which could be an indication for decompression and fusion.
Unstableinjuries.Ifthespinalinjuryisunstable,itshouldbeheldsecureuntilthetissueshealandthespine
becomes stable. Alternatively (particularly in the thoracolumbar
spine) internal fixation can be carried out. Patients with a
neurological injury Once spinal shock has recovered, the full
extent of the neurological injury is assessed. Caring for patients
with neurological injury requires the infrastructure of an
experienced multidisciplinary team; If the spinal injury is stable
(which is rare), the patient can be treated conservatively and
rehabilitated as soon as possible. With the usual unstable injury,
conservative treatment can be still be used; this is highly
demanding and is best carried out in a special unit. After a few
weeks the injury stabilizes spontaneously and the patient can be
got out of bed for intensive rehabilitation. This approach is
applicable to almost all injuries. Early operative stabili- zation
is preferred by many; it facilitates nursing by inexperiencedcarers
and reduces the risk ofspinal defor-mity. Fracture of the cervical
spine C1(Atlas) ring fracture
Suddensevereloadonthetopoftheheadmaycauseabursting
forcewhichfracturestheringoftheatlas(Jeffersonsfracture)(Fig.7).
There is no encroachment on the neural canal and, usually, no
neurological damage. The fracture is seen on the open-mouth view
(Fig.6) (if the lateral masses are spread away from the odontoid
peg) and the lateral view. A CT scan is
particularlyhelpfulindefiningthefracture.Ifitisundisplaced,the
injuryisstableandthepatientwearsasemi-rigidcollarorhalo-vestuntil
the fracture unites. If there is sideways spreading of the lateral
masses, this injury is unstable and should be treated by a
halo-vest for several weeks. If there is persisting instability on
x-ray, a posterior C1/2 fixation and fusion
isneeded.Ahyperextensioninjurycanfractureeithertheanterioror
posteriorarchoftheatlas.Theseinjuriesareusuallyrelativelystableand
are managed with a halo-vest or semi-rigid collar until union
occurs. Fig.6Open-mouthview:notethe C1lateralmassesoverhangover the
lateral edges of the C2(unstable lesion) C2 pars interarticularis
fractures (Hangmans Fractures) Thetermhangmansfracture
(bilateralfracturesofthepars interarticularis of C2) originally
referred toneckinjuriesincurredduringthe
hangingofcriminals(Fig.8).Themost commoncauseofhangmansfracture
nowisamotorvehicleaccidentwith
hyperextensionoftheheadontheneck.Incivilianinjuries,themechanismismorecomplex,withvarying
degrees of extension, compression and flexion. This is one cause of
death in motor vehicle accidents when the forehead strikes the
dashboard. Neurological damage, however, is unusual because the
fracture of the posterior arch tends to decompress the spinal cord.
Nevertheless the fracture is potentially unstable.
Levineclassifiedthesefracturesintothreetypes(Fig.8). TypeI
fractures are minimally displaced Because ligamentous injury is
minimal, these fractures are stable and usually heal with 12 weeks
ofimmobilizationinarigidcervicalorthosis.TypeIIfractureshave
morethan3mmofanteriortranslationandsignificantangulation.
Treatmentconsistsofapplicationofhaloring.Immobilizationina
halovestdoesnotachieveormaintainreduction,andhalotraction
withslightextensionmaybenecessaryfor3to6weekstomaintain anatomical
reduction. The patient can be mobilized in a halo vest for the rest
of the 3-month period.
TypeIIIinjuriescombineabipedicularfracturewithposteriorfacet
injuries.Theyusuallyhavesevereangulationandtranslation.Type III
injuries are the only type of hangmans fracture that commonly
require surgical stabilization. These fractures
frequentlyareassociatedwithneurologicaldeficits.Openreductionandinternalfixationusuallyarerequired
because of inability to obtain or maintain reduction of the C2-3.
After posterior cervical fusion at the C2-3 level, halo vest
immobilization for 3 months is necessary. C2 Odontoid process
fracture
Odontoidfracturesareuncommon.Theyusuallyoccurasflexioninjuriesinyoungadultsafterhighvelocity
accidentsorseverefalls.However,theyalsooccurinelderly,osteoporoticpeopleasaresultoflow-energy
trauma in which the neck is forced into hyperextension, e.g. a fall
onto the face or forehead. Odontoid fractures have been classified
by Anderson and DAlonzo (1974) as follows(Fig.9): Type I An
avulsion fracture of the tip of the odontoid process due to
traction by the alar ligaments. The fracture is stable (above the
transverse ligament) and unites without difficulty. Type II A
fracture at the junction of the odontoid process and the body of
the axis. This is the most common (and potentially the most
dangerous) type.The fracture is unstable and prone to non-union.
Type III A fracture through the body of the axis. The fracture is
stable and almost always unites with immobilization.Clinical
features.The history is usually that of a severe neck strain
followed by pain and stiffness due to muscle
spasm.Thediagnosisisconfirmedbyhighqualityx-rayexamination;itisimportanttoruleoutanassociated
occipito-cervical injury which commands immediate attention. In
some cases the clinical features are mild and continue to be
overlooked for weeks on end.Neurological symptoms occur in a
significant numberof cases. Imaging.Plain x-rays usually show the
fracture, although the extent of the injury is not always.
Tomography is helpful but MRI has the advantage that it may reveal
rupture of the transverse ligament; this can cause instability in
the absence of a fracture. Treatment TypeIfractures.Isolated
fractures of the odontoid tip are uncommon.Theyneedno
morethanimmobilizationina rigidcollaruntildiscomfort
subsides.TypeIIfractures Theseareoftenunstableand
pronetonon-union,especially ifdisplacedmorethan5 mm.Undisplaced
fractures can be held by fitting a halo-vest or in elderly patients
a rigid collar. Displaced fractures should be reduced by traction
and can then be held by operative posterior C1/2 fusion; Anterior
screw fixation(Fig.10)issuitableforTypeII
fracturesthatrunfromanterior-superior to posterior-inferior,
provided thefractureisnotcomminuted,that the transverse ligament is
not ruptured, thatthefractureisfullyreducedand the bone solid
enough to hold a screw. Iffulloperativefacilitiesarenot
available,immobilizationcanbe appliedbyusingahalo-vestwith repeated
x-ray monitoring to check for stability. Type III fractures If
undisplaced, these aretreatedinahalo-vestfor812 weeks. If
displaced, attempts should bemadeatreducingthefractureby
halotraction,theneckisthen immobilizedinahalo-vestfor812 weeks.
Lower cervical spine Fractures of the cervical spine from C3 to C7
tend to produce characteristic fracture patterns, depending on the
mechanism of injury: flexion, axial compression, flexionrotation or
hyperextension Posterior ligament
injurySuddenflexionofthemid-cervicalspinecanresultindamagetotheposteriorligamentcomplex(the
interspinous ligament, facet capsule and supraspinous ligament).
The upper vertebra tilts forward on the one below, opening up the
interspinous space posteriorly The patient complains of pain and
there may be localized
tendernessposteriorly.X-raymayrevealaslightlyincreasedgapbetweentheadjacentspines.Aflexionview
would, of course, show the widened interspinous space more clearly,
but flexion should not be permitted in the
earlypost-injuryperiod.Thisiswhythediagnosisisoftenmadeonlysomeweeksaftertheinjury,whenthe
patient goes on complaining of pain. The assessment of stability is
essential in these cases. If the angulation of
thevertebralbodywithitsneighborexceeds11degrees,ifthereisanteriortranslationofonevertebralbody
upon the other of more than 3.5 mm or if the facets are fractured
or displaced, then the injury is unstable and it
shouldbetreatedasasubluxationordislocation(Fig.11).Ifitiscertainthattheinjuryisstable,asemi-rigid
collar for 6 weeks is adequate;if the injury is unstable then
posterior fixation and fusion is advisable. Wedge compression
fracture A pure flexion injury results in a wedge compression
fracture of the vertebral body (Fig. 12). The middle and posterior
elements remain intact and the injury is stable. All that is needed
is a comfortable collar for 612 weeks. A note of warning: The x-ray
should be carefully examined to exclude damage to the middle column
and posterior displacement of the vertebral body fragment, i.e.
features of a burst fracture (see below) which is potentially
dangerous. If there is the least doubt, an axial CT or MRI should
be obtained. Burst and compression-flexion (teardrop) fractures
Thesesevereinjuriesareduetoaxialcompressionofthecervicalspine,
usually in diving or athletic accidents
(Fig.13).Ifthevertebralbodyiscrushedinneutralpositionoftheneck
theresultisaburstfracture.Withcombinedaxialcompressionand
flexion,anantero-inferiorfragmentofthevertebralbodyisshearedoff,
producing the eponymous tear-drop(Fig.14) on the lateral x-ray. In
both
typesoffracturethereisariskofposteriordisplacementofthevertebral
bodyfragmentandspinalcordinjury.Plainx-raysshoweitheracrushed
vertebralbody(burstfracture)oraflexiondeformitywithatriangular
fragmentseparatedfromtheantero-inferioredgeofthefracturedvertebra
(theinnocent-lookingteardrop).Thex-rayimagesshouldbecarefully
examinedforevidenceofmiddlecolumndamageandposterior
displacement(evenveryslightdisplacement)ofthemainbodyfragment.
Traction must be applied immediately and CT or MRI should be
performed to look forretro-pulsion of bone fragments into the
spinal canal.TREATMENT
Ifthereisnoneurologicaldeficit,thepatientcanbetreatedsurgicallyor
by confinement to bed and traction
for24weeks,followedbyafurtherperiodofimmobilizationinahalo-vestfor68weeks.(Thehalo-vestisunsuitableforinitialtreatment
becauseitdoesnotprovideaxialtraction).Ifthereisanydeteriorationof
neurologicalstatuswhilethefractureisbelievedtobeunstable,andthe MRI
shows that there is a threat of cord compression, then urgent
anterior
decompressionisconsideredanteriorcorpectomy,bonegraftingand plate
fixation(Fig.15), and sometimes also posterior
stabilization(Fig.16). Fracture-dislocations
Bilateralfacetjointdislocationsarecausedbysevereflexionor
flexionrotationinjuries.Theinferiorarticularfacetsofonevertebraride
forward over the superior facets of the vertebra below. One or both
of the articularmassesmaybefracturedortheremaybeapuredislocation
jumped facets. The posterior ligaments are ruptured and the spine
is unstable; often there is cord
damage.Thelateralx-rayshowsforwarddisplacementofavertebraontheonebelowofgreaterthanhalfthe
vertebrasantero-posteriorwidth.Thedisplacementmustbereducedasamatterofurgency.Skulltractionis
used, starting with 5 kg and increasing it step-wise by similar
amounts up to about 30kg. The entire procedure
shouldbedonewithoutanaesthesia(orundermildsedationonly)andneurologicalexaminationshouldbe
repeated after each incremental step. If neurological symptoms or
signs develop, or increase, further attempts at closed reduction
should be stopped. When x-rays show that the dislocation has been
reduced, traction is diminished to about 5 kg and then maintained
for 6 weeks. During this time MRI can be performed to rule out the
presence of an associated disc disruption. At the end of that
period the patient should still wear a collar for another 6 weeks;
however, it may be more convenient to immobilize the neck in a
halo-vest for 12 weeks(Fig.17). Anotheralternativeisto carry out a
posterior fusion as soon as reductionhasbeenachieved;the
patientisthenallowedupina cervicalbracewhichiswornfor68
weeks.Posterioropenreductionand fusionisalsoindicatedifclosed
reduction fails.(fig.16) Theneedforpre-reduction
MRIisfortheabilitytodiagnosean extrudeddiscfragmentwhichmay
furthercompromiseanyneurological lesionbutcanbedealtwithby
anteriordecompression(fig.15).This
isparticularlyapplicabletoelderly patientsinwhomimmediateclosed
reduction may be hazardous and long periodsontheirbackscanleadto
pressure sores.
UnilateralfacetdislocationThisisaflexionrotationinjuryinwhichonly
one apophyseal joint is dislocated. There may be an associated
fracture of the facet.
Onthelateralx-raythevertebralbodyappearstobepartiallydisplaced(lessthan
one-halfofitswidth);ontheanteroposteriorx-raythealignmentofthespinous
processes is distorted. Cord damage is unusual and the injury is
stable. Management is the same as for bilateral dislocation.As a
general rule, if closed reduction fails, open reduction and
posterior fixation are
advisable.Afterreduction,ifthepatientisneurologicallyintacttheneckis
immobilized in a halo-vest for 68 weeks. Patients left with an
unreduced unilateral facet dislocation may develop neck pain and
nerve root symptoms longterm if poorly managed. Double injuries
Withhigh-energytraumathecervicalspinemaybeinjuredatmorethanonelevel.Discoveryofthe
most obvious lesion is no reason to drop ones guard. Avulsion
injury of the spinous
processFractureoftheC7spinousprocessmayoccurwithsevere voluntary
contraction of the muscles at the back of the neck; it is known
astheclay-shovellersfracture.(Fig.18)Theinjuryispainfulbut
harmless.Notreatmentisrequired;assoonassymptomspermit,neck
exercises are encouraged. Cervical disc
herniationAcutepost-traumaticdischerniationmaycauseseverepain
radiatingtooneorbothupperlimbs,andneurologicalsymptomsand
signsrangingfrommildparaesthesiatoweakness,lossofareflexand blunted
sensation.Rarelyapatientpresentswithfull-blownparesis.ThediagnosisisconfirmedbyMRIor
CTmyelography. Sudden paresis will need immediate surgical
decompression. With lesser symptoms and signs,
onecanaffordtowaitafewdaysforimprovement;ifthisdoesnotoccur,thenanteriordiscectomyand
interbody fusion will be needed.(Fig.15) Neurapraxia of the
cervical cord
Accidentscausingsudden,severeaxialloadingwiththeneckinhyperflexionorhyperextensionare
occasionally followed by transient pain, paraesthesia and weakness
in the arms or legs, all in the absence of any x-ray or MRI
abnormality. Symptoms may last for as little as a few minutes or as
long as two or three days.
Theconditionhasbeencalledneurapraxiaofthecervicalcordandisascribedtopinchingofthecordbythe
bony edges of the mobile spinal canal and/or local compression by
infolding of the posterior longitudinal
ligamentortheligamentumflavum.Congenitalnarrowingofthespinalcanalmaybeapredisposingfactor.
Treatmentconsistsofreassurance(afterfullneurologicalinvestigation)andgradedexercisestoimprove
strength in the neck muscles. Sprained neck (WHIPLASH INJURY)
Soft-tissue sprains of the neck are so common after motor vehicle
accidents that they now constitute a veritable epidemic. There is
usually a history of a lowvelocity rear-end collision in which the
occupants body is forced against the car seat while his or her head
flips backwards and then recoils in flexion. This
mechanismhasgeneratedtheimaginativetermwhiplashinjury.Womenareaffectedmoreoftenthanmen,
perhaps because their neck muscles are more
gracile.ClinicalfeaturesOftenthevictimisunawareofanyabnormalityimmediatelyafterthecollision.Painand
stiffnessoftheneckusuallyappearwithinthenext1248hours,oroccasionallyonlyseveraldayslater.Pain
sometimesradiatestotheshouldersorinterscapularareaandmaybeaccompaniedbyother,moreill-defined,
symptomssuchasheadache,dizziness,blurringofvision,paraesthesiainthearms.Neckmusclesaretender
and movement often restricted. X-ray examination may show
straightening out of the normal cervical lordosis, a sign of muscle
spasm;in other respects the appearances are usually normal
TreatmentCollarsaremorelikelytohinderthanhelprecovery.Simplepain-relievingmeasures,including
analgesic medication, may be needed during the first few weeks.
Thoracolumbar injuries
MostinjuriesofthethoracolumbarspineoccurinthetransitionalareaT11toL2betweenthe
somewhatrigidupperandmiddlethoraciccolumnandtheflexiblelumbarspine.Theupperthree-quartersof
the thoracic segments are also protected to some extent by the
rib-cage and fractures in this region tend to be
mechanicallystable.However,thespinalcanalinthatareaisrelativelynarrowsocorddamageisnot
uncommonandwhenitdoesoccuritisusuallycomplete.ThespinalcordactuallyendsatL1andbelowthat
level it is the lower nerve roots that are at risk. Pathogenesis
Pathogenetic mechanisms fall into three main groups: low-energy
insufficiency fractures arising from comparatively mild compressive
stress in osteoporotic bone;minor fractures of the vertebral
processes due to compressive, tensile or tortional
strains;highenergy fractures or fracture-dislocations due to major
injuries sustained in motor vehicle collisions, falls or diving
from heights, sporting events, horse-riding and collapsed
buildings. Examination Patients complaining of back pain following
an injury or showing signs of bruising and tenderness over
thespine,aswellasthosesufferingheadorneckinjuries,chestinjuries,pelvicfracturesormultipleinjuries
elsewhere, should undergo a careful examination of the spine and a
full neurological examination, including rectal examination to
assess sphincter tone. Imaging X-rays The anteroposterior x-ray may
show loss of height or splaying of the vertebral body with a crush
fracture. Widening of the distance between the pedicles at one
level, or an increased distance between two adjacent spinous
processes, is associated with posterior column damage. The lateral
view is examined for alignment, bone outline, structural integrity,
disc space defects and soft-tissue shadow abnormalities.CT and MRI
Rapid screening CT scans are now routine in many accident units.
Not only are they more reliable
thanx-raysinshowingboneinjuriesthroughoutthespine,andindispensableifaxialviewsarenecessary,but
they also eliminate the delay, discomfort and anxiety so often
associated with multiple attempts at getting the
rightviewswithplainx-rays.InsomecasesMRIalsomaybeneededtoevaluateneurologicalorothersoft-tissue
injuries. Treatment Treatment depends on: (a) the type of
anatomical disruption; (b) whether the injury is stable or
unstable; (c) whether there is neurological involvement or not; and
(d) the presence or absence of concomitant injuries. MINOR INJURIES
Fractures of the transverse processes The transverse processes can
beavulsedwith sudden muscular activity.Isolated injuries need
nomore than symptomatic treatment. More ominous than usual is a
fracture of the transverse process of L5; this should alert one to
the possibility of a vertical shear injury of the pelvis. Fracture
of the pars interarticularis A stress fracture of the pars
interarticularis should be suspected ifagymnast or athlete
orweight-lifter complains of the sudden onset of back pain during
the course of strenuous activity. The injury is often ascribed to a
disc prolapse, whereas in fact it may be a stress fracture of the
pars interarticularis (traumatic spondylolysis). This is best seen
in the oblique x-rays.Bilateral fractures occasionally lead to
spondylolisthesis. The fracture usually heals spontaneously,
provided the patient is prepared to forego his (more often her)
athletic passion for several months. MAJOR INJURIES
Flexioncompression injury This is by far the most common vertebral
fracture and is due to severe spinal flexion(Fig 19a), though in
osteoporotic individuals fracture may occur with minimal trauma.
The posterior ligaments usually remain intact,
althoughifanteriorcollapseismarkedtheymaybedamagedbydistraction.Painmaybequiteseverebutthe
fractureisusuallystable.Neurologicalinjuryisextremelyrare.Patientswithminimalwedgingandastable
fracturepatternarekeptinbedforaweekortwountilpainsubsidesandarethenmobilized;nosupportis
needed. Those with moderate wedging (loss of 2040 per cent of
anterior vertebral height) and a stable injury can be allowed up
after a week, wearing a thoracolumbar brace(Fig.19c) or a body cast
applied with the back in extension. At 3 months, flexionextension
x-rays are obtained with the patient out of the orthosis; if there
is no instability, the brace is gradually discarded. If the
deformity increases and neurological signs appear, or if the
patient cannot tolerate the orthosis, surgical stabilization is
indicated(Fig.19b).
Iflossofanteriorvertebralheightisgreaterthan40percent,itislikelythattheposteriorligaments
havebeendamagedbydistractionandwillbeunabletoresistfurthercollapseanddeformity.Ifthepatientis
neurologicallyintact,surgicalcorrectionandinternalfixationisthepreferredtreatment.Ifnervelossis
incompletethereisthepotentialforfurtherrecovery;anyincreaseinkyphoticdeformityorMRIsignsof
impending cord neurological compression would be an indication for
operative decompression and stabilization. If there is complete
paraplegia with no improvement after 48 hours, conservative
management is adequate; the
patientcanberestedinbedfor56weeks,thengraduallymobilizedinabrace.Withseverebonyinjury,
however, increasing kyphosis may occur and internal fixation should
be considered. Axial compression or burst injury Severe axial
compression may explode the vertebral body, causing failure of both
the anterior and the
middlecolumns.Theposteriorpartofthevertebralbodyisshatteredandfragmentsofboneanddiscmaybe
displacedintothespinalcanal.Theinjuryisusuallyunstable.Posteriordisplacementofboneintothespinal
canal (retropulsion) is difficult to see on the plain lateral
radiograph; a CT is essential. If there is minimal anterior wedging
and the fracture is stable with no neurological damage, the patient
is kept in bed until the acute symptoms settle and is then
mobilized in a thoracolumbar brace or body cast which is worn for
about 12 weeks.However, any new symptoms such as tingling, weakness
or alteration of bladder or bowel function must be reported
immediatelyand should call for further imaging by MRI; anterior
decompression and stabilization may then be needed if there are
signs of present or impending neurological compromise
Fracture-dislocation Segmentaldisplacementmay
occurwithvariouscombinationsof flexion,compression,rotationand
shear.All three columns are disrupted andthespineisgrosslyunstable.
These are the most dangerous injuries andareoftenassociatedwith
neurologicaldamagetothe lowermostpartofthecordorthe
caudaequina.Theinjurymost commonlyoccursatthe
thoracolumbarjunction.X-raysmay showfracturesthroughthevertebral
body,pedicles,articularprocesses andlaminae(Fig.20);theremaybe
varyingdegreesofsubluxationor even bilateral facet dislocation. CT
is helpfulindemonstratingthedegree ofspinalcanalocclusion.In
neurologicallyintactpatients,most
fracture-dislocationswillbenefitfromearlysurgery.Infracture-dislocationwithparaplegia,thereisno
convincingevidencethatsurgerywillfacilitatenursing,shortenthehospitalstay,helpthepatients
rehabilitationorreducethechanceofpainfuldeformity.Infracture-dislocationwithapartialneurological
deficit,thereisalsonoevidencethatsurgicalstabilizationanddecompressionprovidesabetterneurological
outcome than conservative treatment. In fracture-dislocation
without neurological surgical stabilization will prevent future
neurological complications and allow earlier rehabilitation. Cord
transection Motor paralysis, sensory loss and visceral paralysis
occur below the level of the cord lesion; as with cord
concussion,themotorparalysisisatfirstflaccid.Thisisatemporaryconditionknownascordshock,butthe
injuryisanatomicalandirreparable.Afteratimethecordbelowtheleveloftransactionrecoversfromthe
shockandactsasanindependentstructure;thatis,itmanifestsreflexactivity.Within48hourstheprimitive
anal wink and bulbocavernosus reflexes return. Within 4 weeks of
injury tendon reflexes return and the flaccid
paralysisbecomesspastic,withincreasedtone,increasedtendonreflexesandclonus;flexorspasmsandcontractures
may develop with inadequate management. Spinal Deformities
Introduction A thorough understanding of spinal anatomy is crucial
for a comprehensive evaluation of a patient with
spinaldisorders.Theprimaryrolesofthespinearemaintainingstability,protectingtheneuralelements,and
allowing range of motion. Specifically adapted anatomic features
facilitate these functions. The vertebra is the
structuralbuildingblockofthespine,withspecificmorphologicandfunctionalrolesbasedonthevertebras
positioninthespinalcolumn.Theintervertebraldisks,ligaments,andmusclesaddstabilityandcontrol.The
spinal cord travels within, and is protected by, the spine. Paired
nerve roots exit at each spinal level. Anatomy and Biomechanics
Theaxialskeletoniscomposedof33vertebrae,including
7vertebraeintheneck,12vertebraeinthethoracicregion,5
vertebraeinthelumbarregion,5fusedvertebraeinthesacrum,
andthecoccyxthattypicallyincludes4vertebralbodies,
sometimespartiallyortotallyfusedtogether(Fig.21). Intervertebral
discs separate the vertebrae except between the first
andsecondcervicalvertebrae(C1andC2,respectively)and between the
sacrumandthecoccyx.Thebodyofavertebraisshapedlikea short cylinder
and is composed primarily of
cancellous,well-vascularizedbonecoveredbyathinlayerof
corticalbone.Withincreasingweight-bearingloads,thevertebral
bodybecomesprogressivelytallerandwiderfromabove downward. The
posterior arch includes right and left pedicles that
projectposteriorlyfromtheposterolateralsurfaceofthevertebral
body,andrightandleftlaminaethatprojectposteromediallyto fuse with
the spinous process (Fig.22). The arch and body enclose
andprotectthespinalcordandcaudaequinaandformthe
vertebralforamen,throughwhichthenerverootspass.The
spinousprocessprojectingposteriorlyandthetwotransverse
processesthatextendlaterallyfromthepedicle-laminajunction
provideoutriggerinsertionsitesforthemultiplemusclesand
ligamentsthatmoveandstabilizethetrunk.Thefacetjointsprovidemotionbetweentwovertebrae.The
superiorarticularprocessandfacetjointextendfromthepedicleofthevertebrabelow(caudal)toarticulate
with the inferior articular process and facet joint that extends
from the lamina of the vertebra above.
The vertebral canal extends from the foramen magnum to the
sacrumand encloses the spinalcord and
itsnerveroots.Theduramaterisseparatedfromthebonesbyanepiduralspacethatcontainsfatandan
extensiveplexusofepiduralveins.TheduralsaccontinuesinferiorlytoapproximatelythemiddleoftheS2
vertebra. Inferior to the conus, the dural sac contains the cauda
equina (lumbosacral nerve roots) and the filum terminale, a cord of
tissue that travels inferiorly from the conus to merge with the
periosteum on the dorsum of the coccyx . The first and second
cervical vertebrae are different from the lower five cervical
vertebrae (Fig 23). The atlas (C1 vertebra) lacks a spinous process
and is essentiallyan oval ring of bone. The lateral portions of the
C1 ring are thickened into a lateral mass that articulates with the
occipital condyle superiorly and with the lateral mass of C2
inferiorly. The axis (C2 vertebra) has a toothlike protuberance,
the dens, that projects upward from the body to provide structural
support for the atlas. The dens provides a pivot point on which the
head and atlas can rotate relatively freely on the relatively flat
C1-C2 articular facets.
Thecervicalspineisamobileplatformfortheskullandisthemostflexibleportionofthevertebral
column. Motion of the cervical spine includes flexion and
extension, right and left lateral bending, and right and
leftrotation.Inyoungadults,normalneckmotionis70flexion,70extension,50lateralbending,and90
rotation to each side. The degree of motion between two vertebrae
is determined primarily by the orientation of the facets;
therefore, different vertebral segments contribute differing
amounts to each plane of motion. The total arc of flexionextension,
however, is greater in the lower cervical vertebral segments, with
peak motion occurring at the C5-C6 level. Motion of the spine is
often coupled. For example, lateral bending of the neck is
accompaniedbyrotation,androtationofthecervicalspineiscoupledwithlateralbendingandflexion-extension.
Thoracic vertebrae have costal facets at the upper and lower edges
of the junction of the body with the
archoneachside.Primarymotioninthethoracicspineislateralbendingandrotation,withlateralbending
being greater in the lower thoracic segments and rotation being
greater in the upper thoracic spine.Because of the increased axial
loads and the lack of surrounding rib support, the horizontal
diameter of a lumbar
vertebraisgreaterthanitsheight.Lumbarvertebraearelargerandthickeranteriorly.Thesuperiorarticular
facet of a lumbar vertebra faces mostly medially, and the inferior
facet is directed laterally. Flexion-extension is the primary arc
of motion in the lumbar spine, with greater movement occurring in
the lower lumbar segments. The vertebral bodies of the lumbar spine
support an average of 80% of the axial load experienced by the
spinal column; the facet joints support the other 20%.
Intervertebral Discs Theintervertebraldiscs
contributeapproximately20% ofthelengthofthecervical
andthoracicspineand approximately33%ofthe length of the lumbar
region.In thecervicalandlumbar regions,thediscsarethicker
anteriorlyThoracicdiscshave uniformheight.The
intervertebraldiscincludesthe annulusfibrosusandthe
nucleuspulposus(Fig.23).Thecentralnucleuspulposusiscomposedofwater,typeIIcollagen,and
proteoglycanaggregates.Thiscompositestructureprovidesgoodresistancetorepeatedloadinginboth
compression and tension. The load at the L3-L4 disc ranges from 30
kg while the individual is lying supine to more than 300 kg when
the person is lifting a 20-kg weight with the spine flexed and the
knees straight. Curves of the spine The vertebral column has four
distinct curvescervical lordosis, lumbar lordosis, thoracic
kyphosis, and
sacralkyphosis(Fig.21).Instance,thesagittalverticalaxispassesthroughtheodontoid,posteriortothe
cervical verte-brae,through the C7-T1 intervertebral disk, anterior
to the thoracic vertebrae, through the T12-L1interver-tebral disk,
posterior to the lumbar vertebrae, through the L5-S1 intervertebral
disk, and anterior to the sacrum.
Theprimarycurvesarethoseofthekyphoticthoracicandsacralregions.Theseformduringthefetal
period.The secondary curves are those of the lordotic cervical and
lumbar regions. These are initiated during the late fetal period
but do not become significant until after birth when the spinal
column begins to bear the weight
ofthebodyandhead.Primarycurvesarecausedbythewedge-shapednatureofinvolvedvertebrae,whereas
secondary curves are caused by differences in the anterior and
posterior dimensions of the intervertebral disks.
Thecervicallordoticcurvenormallyrangesfrom25to50degreeswithanapexatC4.Thethoracic
spine anatomically refers to the named vertebral levels from T1 to
T12. This region is usually kyphotic, with its apex around T7. The
caudal aspect of the kyphosis typically decreases in sagittal
angulation until the relatively
neutralthoracolumbarjunction,whichhasarelativelystraightinflectionpoint.Normalthoracickyphosis
usually ranges from 20 to 50 degrees in adults. The normal lumbar
lordosis is between 40 and 70 degrees
withanapexlocatedattheL3-4interspace.The
lumbosacraljunctionisaninflectionpointforthe
lordoticsegmentofthelumbarspinetothe
kyphoticsacrum.Localkyphosisismeasuredby
theanglecreatedbetweenalinealongtheinferior aspect of L5 and a line
along the superior border of
S1.Oneofthemostcriticalrelationshipsinthe
humanspinethatsetsparametersforsagittal
balanceisthelumbosacralpelvis.Recentstudies report that sagittal
plane balance is mediated by the
followingindependentfactors:sacralslope,pelvic tilt, pelvic
incidence, and lumbar lordosis (Fig. 24). Sacral slope is the angle
between the superior border of S1 and a line parallel to the
horizon. The pelvic tilt is the angle between a line perpendicular
tothehorizonandalinejoiningthemiddleofthe
superiorsacralendplate.Pelvicincidence(PI),or pelvisacral angle, is
defined as the angle between a line perpendicular to the sacral
plate at its midpoint andalineconnectingthesamepointtothecenter
ofthebicoxofemoralaxis.Thisnumberisfixed and some believe it is the
angle on which all other spinal curves are based. SCOLIOSIS
Scoliosisisanapparentlateral (sideways)curvatureofthespine.Apparent
because, although lateral curvature does occur,
thecommonestformofscoliosisisactuallya triplanar deformity with
lateral, anteroposterior and rotational components. Two broad types
of deformity are defined: postural and structural.Postural
Scoliosis Inposturalscoliosisthedeformityis
secondaryorcompensatorytosomecondition
outsidethespine,suchasashortleg,orpelvic
tiltduetocontractureofthehip.Whenthe
patientsits(therebycancellingleglength asymmetry) the curve
disappears. Local muscle
spasmassociatedwithaprolapsedlumbardiscmaycauseaskewback;althoughsometimescalledsciatic
scoliosis this, too, is a spurious deformity.(Fig.31) Structural
scoliosis
Instructuralscoliosisthereisanon-correctabledeformityoftheaffectedspinalsegment,anessential
componentofwhichisvertebralrotation.Thespinousprocessesswingroundtowardstheconcavityofthe
curveandthetransverseprocessesontheconvexityrotateposteriorly.Primarycurvespresentscharacteristic
modifications:cuneiformvertebraeatthecenterofcurvature,whileoutheredgevertebraesarerhomboidand
reseamblestonormalaspect(neutralvertebrae).Inthethoracicregiontheribsontheconvexsidestandout
prominently, producing the rib hump, which is a characteristic part
of the overall deformity(gibbus) determining
thecharacteristicovalar-obliquethoraciccage.Secondary(compensatory)curvesnearlyalwaysdevelopto
counterbalance the primary deformity; they are usually less marked
and more easily correctable, but with time they, too, become fixed.
Oncefullyestablished,thedeformityisliabletoincreasethroughoutthegrowthperiod.Thereafter,
further deterioration is slight, though curves greater than 50
degrees may go on increasing by 1 degree per year. With very severe
curves, chest deformity is marked and cardiopulmonary function is
usually affected. Classification Aetiology Most cases have no
obvious cause (idiopathic scoliosis). This group constitutes about
80 per cent of all
casesofscoliosis.Thedeformityisoftenfamilialandthepopulationincidenceofseriouscurves(over30
degrees and therefore needing treatment) is three per 1000; trivial
curves are very much more common.
Othervarietiesarecongenitalorosteopathic(duetobonyanomalies)(fig.32),neuropathic,myopathic
(associated with some muscle dystrophies poliomyelitis,
syringomyelia, Friedreich heredoataxia), scoliosis in
neurofibromatosis Recklinghausen, posttraumatic scoliosis, skeletal
genetic disorders (Morquio disease, Marfan disease, osteogenesis
imperfecta), scoliosis in vertebral tumors . Primary curvature
Thoracic scoliosis (Th6-Th12) ussualy with right side convexity and
lombar compensatory curvature. Progression is more severe with
early-onset Thoraco-lumbar scoliosis(Th11-L3) - right side
convexity, sever prognosis Lumbar scoliosis(Th6-L2) left side
convexity, with better outcome than the first two
Cervico-Thoracicscoliosisleftsideconvexitywiththoracicandthoraco-lumbarcompensatory
curvature. Develops ussualy in individuals with poliomyelitis and
neurofibromatosis Double primary curve scoliosis(Th6-Th11 and
Th11-L4) one thoracic dextroconvex curvature and a lumbar one with
left side convexity, balanced, fearly good prognosis. Degree of
curvature I.