Spine

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Spondylolysis is a condition where there is a defect or fracture in a part of the vertebral bone known as the pars interarticularis. This typically occurs in the fifth lumbar vertebra and less frequently in the fourth lumbar vertebra. Meanwhile, spondylolisthesis refers to the forward slippage of one vertebral body over another.

The precise cause of spondylolysis is not completely understood, but it is often associated with genetics, overuse activities (especially those that involve hyperextension, such as gymnastics), and previous spinal surgeries. Spondylolisthesis can occur when the spine's stabilizing structures weaken, which may result from spondylolysis, congenital factors, spinal degeneration, trauma, or even cancer.

Symptoms and Diagnosis

Patients with spondylolysis or spondylolisthesis may experience back pain due to unstable vertebral movement and leg pain caused by nerve pressure. Other symptoms can include:

Symptoms

Low back pain: A common symptom due to the instability of the vertebra.

Tightness in the back of the thighs: This sensation can be a sign of nerve compression.

Pain radiating down the legs: Often associated with pressure on the nerves.

Difficulty with upright posture and gait: These issues can arise from changes in spinal alignment.

Diagnosis 

A thorough history and physical examination can help your doctor suspect spondylolysis or spondylolisthesis. Diagnostic procedures are used to confirm the diagnosis:

X-rays: The initial investigation provides confirmation of the diagnosis and possible cause. Special X-rays taken while bending forward and backward may be necessary for further assessment.

Magnetic Resonance Imaging (MRI): MRI scans are essential for visualizing nerves and identifying any compression on them, making them a crucial part of the diagnostic process. 

Treatment

Treatment options for spondylolysis and spondylolisthesis can be either surgical or non-surgical, depending on the severity of the condition and the patient's specific circumstances. A thorough examination and investigation are necessary to determine the most appropriate approach for each individual, taking into account the extent of the condition and the patient's age.

Non-Surgical Treatment

Most patients with spondylolysis or spondylolisthesis experience acute episodes of pain with periods of relief in between. These symptoms often improve with rest and time. Non-surgical treatment may include:

- Analgesics (pain relievers)

- Belts or braces to provide support and stability to the back

- Physiotherapy to strengthen the surrounding muscles

- Activity modification to limit activities that exacerbate symptoms

Patients may need surgery if they experience any of the following:

- Worsening back or persistent leg pain despite adequate rest and medication

- Leg weakness

- Bowel or bladder dysfunction

- Progressive forward slipping of the vertebra

Surgical Options

Surgery aims to prevent further slipping of the vertebra and relieve pressure on the spinal nerves.

- Posterior Instrumentation and Fusion: This procedure involves joining the two unstable vertebrae to create a single unit. Metal plates, screws, and rods stabilize the vertebrae until they fuse.

- Transforaminal or Posterior Lumbar Inter-body Fusion (PLIF): In addition to posterior instrumentation and fusion, metal cages are inserted between the vertebral bodies to facilitate a solid fusion.

Infections can affect the spine much like any other bone, with both pyogenic and tubercular infections being possible. Spinal tuberculosis is the most common form of bony tuberculosis and can lead to the rapid destruction of vertebrae, causing a collapse of the spine and a noticeable 'hunch back' deformity. Children are especially susceptible to developing this deformity, which can continue to worsen even after the infection is resolved. This can result in severe compression and stretching of the spinal cord, potentially leading to paralysis of the lower limbs.

In the early stages of spinal tuberculosis, anti-tubercular medications can provide a complete cure. In more severe cases or when there is weakness or paralysis in the legs, surgical decompression of the spinal cord alongside medication is often necessary. Surgery can alleviate pressure on the spinal cord, prevent further deformity, and effectively relieve pain. Specialised metal implants and bone grafts are used to stabilise the spine during the healing process.

Spinal tuberculosis is caused by the bacterium Mycobacterium tuberculosis. Infection usually occurs due to hematogenous spread from a primary source, often the lungs, although an active focus is found in fewer than 10% of cases. The most common site of infection is at the paradiscal region, where two adjacent bones surrounding a disc are typically involved.

Symptoms

The most common initial symptom of spinal tuberculosis is back pain, which is often accompanied by restricted movement of the spine. Patients may also experience general symptoms such as fatigue, loss of appetite, weight loss, low-grade fever in the evening, and night sweats. However, these symptoms may be absent in individuals with good nutrition.

As the disease advances, spinal collapse becomes more apparent, with a sharp deformity (due to a prominent spinous process) in the early stages, potentially progressing to a significant hump (kyphosis) in later stages. Tuberculosis can also cause the formation of large abscesses, known as cold abscesses, due to the absence of high-grade fever and heat. These abscesses may become clinically evident on the back.

The presence of pus and spinal deformity can exert pressure on the spinal cord, leading to various degrees of paralysis. Neurological involvement may initially manifest as incoordination and clumsiness while walking, gradually worsening to more severe paralysis.

Diagnosis

Blood tests for spinal tuberculosis often reveal a significantly elevated erythrocyte sedimentation rate (ESR) greater than 70 mm/hr. Monitoring ESR levels over time can help gauge the response to treatment. Elevated white blood cell counts, especially a rise in lymphocytes, may also be observed.

X-rays can show signs of bony destruction and deformity in the spine, while CT scans provide a more detailed assessment of the extent of bone damage and can help identify involvement of posterior elements or specific sites such as the craniovertebral and cervicodorsal junctions, as well as the sacroiliac joints and sacrum.

MRI is the gold standard for evaluating the soft tissue involvement and the spread of tuberculous abscesses. It is also the most effective imaging method for demonstrating spinal cord compression and the extent of the disease.

The definitive diagnosis is confirmed through histopathological examination (biopsy) of the infected tissue, providing a clear view of the presence of tuberculosis.

Treatment

Treatment for spinal tuberculosis involves a combination of general supportive measures and medication. Initially, patients are advised to rest in bed, use external bracing, follow a nutritious diet, and receive appropriate care for their bladder and bowels. Nursing care is essential for overall support. Modern anti-tubercular drugs have made it possible to achieve excellent clinical cure, making spinal tuberculosis primarily a medical condition with selective indications for surgery.

A multidrug chemotherapy regimen is administered to all patients, with bed rest and external bracing recommended in the early stages. Close monitoring continues until the condition is fully healed. Surgical intervention may be necessary in certain situations such as severe pain, instability, spinal deformity, extensive neurological deficits, and inadequate response to medication.

The recommended first-line drug therapy consists of four medications: Isoniazid (5 mg/kg), Rifampicin (10 mg/kg), Pyrazinamide (20-25 mg/kg), and Ethambutol (15 mg/kg) for a duration of two to three months. This is followed by Isoniazid and Rifampicin for an additional four to six months.

The goals of surgical treatment for spinal tuberculosis include obtaining a tissue sample for biopsy, draining an abscess cavity, debriding the focus of the disease, and stabilising the spine. These surgical procedures are only considered when the patient's condition requires more direct intervention.

Spine fractures can occur due to various reasons, with the most common causes being:

Road Traffic Accidents: High-impact collisions can lead to severe spinal injuries.

Falls from Height: Falling from a significant height can result in fractures, particularly in the spine.

Sports Accidents: High-risk sports, especially those with a chance of heavy impact, can cause spinal fractures.

Depending on the severity of the fracture, the spinal cord may also suffer damage. Spine fractures often involve high-energy trauma, so associated injuries are more common than not. Additionally, in elderly individuals, spine fractures can occur even with minimal trauma due to weakened bones from osteoporosis or other conditions such as tumors or infections.

Treatment

In treating thoracolumbar spine injuries, the primary objectives include:

Protecting spinal cord function: Safeguarding the integrity of the spinal cord is crucial.

Restoring alignment and stability: Proper alignment and stability of the spine need to be reestablished.

Allowing an early return to pre-injury activity: The aim is to help the patient resume their normal activities as soon as possible.

The appropriate treatment approach will be determined by the doctor based on the type of fracture and other individual factors. In some cases, early surgical intervention may be necessary, particularly in fractures that are unstable or involve spinal cord or nerve injuries.

Non-Surgical Options

For certain low-energy thoracolumbar fractures, a brief period of rest followed by mobilisation with a brace or corset may be sufficient. Hospitalisation might still be necessary to manage acute pain and to evaluate for any underlying conditions. However, the following types of spinal injuries typically necessitate surgery:

Neurological deficit: When there is nerve damage or impairment.

Injuries involving more than two columns: This can lead to significant instability.

Potential instability: Where the spine may not remain stable without intervention.

Spinal cord compression due to bone or epidural hematoma: Immediate intervention may be required in these cases.

Surgery

Surgical intervention in thoracolumbar spine injuries aims to realign the spinal column and stabilize it using metal plates and screws (internal fixation) and/or spinal fusion. This approach serves multiple purposes, including:

Relieving pressure on the nerves and spinal cord: By decompressing the affected area, the procedure creates an environment conducive to early neurological recovery.

Stabilising the fractured spine: This helps to reduce pain during movement and allows the patient to sit and stand sooner, facilitating a quicker recovery process.