I'm an orthopedic spine surgeon from Northwestern University. I'll get right down to it. So we'll be conducting a spine review. My clinical practice does involve treating both collegiate and professional athletes, but it's important for me to note that none of my opinions that I will be expressing today is any reflection of any of the teams that I cover, the leagues that I work for, but they are my own opinions. So we'll review some anatomy, diagnostic tests, when do you perform an EMG, cervical spine MRI. We'll talk about cervical, thoracic, and lumbar conditions. Just as a disclaimer, I did take off some of the slides from the handout that you have in my talk because I was supposed to shorten the talk a little bit. So if it doesn't follow slide by slide, that's the reason why. But I will highlight all of the things that I think that you guys should know. So we'll start with nerve root pathology. One of the common themes in the questions that you guys get is identifying the nerve root that is pinched when you have a certain disc herniation. So for example, a C5-6 disc herniation will classically affect the C6 nerve root. You'll have to recite which muscle groups it covers, the dermatomes, reflex, and we won't go over those specific things, but it's important to know that the disc herniation that occurs usually affects the lower nerve root or the traversing nerve root. The only time when this is not the case is with a far lateral or a foraminal disc herniation in the lumbar spine. This is never the case in the cervical spine because the exiting nerve root is actually that nerve root that is below, C5-6 being the C6 nerve root. However, in an L4-5 far lateral disc herniation, you're actually affecting the exiting nerve root and that's why you would get an L4 radiculopathy. And these are very uncommon. Probably 5% of the time you'll see a disc herniation like this, but in the red you'll see the classic posterolateral disc herniation that will affect the lower nerve root. But in the foramen, it's the exiting nerve root that will get affected. And again, knowing your dermatomes, knowing what L4 innervates, what L5 innervates is going to be important in getting these softball type questions. So the other nerve root that I need to mention is the C8 nerve root. This falls in between the C7-T1 junction. There is no C8 vertebral body. The C8 nerve root affects grip strength, so is an important nerve root that can be affected from a C7-T1 disc herniation and can also be masked with ulnar nerve cubital tunnel syndrome and they are overlapping disorders. So we'll go over some tests as to when to order what, because this is also a common theme in the questions that I've been reviewed, or that I have reviewed. Static plane views are the best screening shot for a fracture, especially for one that's displaced. Congenital problems can also be seen, clipophile syndrome, congenital stenosis, scoliosis, but very little benefit for patients with chronic neck pain. We classically will order a dynamic view, a flexion and extension view if we're concerned about instability, and this can either be instability from a fracture or it could be something like a Down syndrome patient with atlantoaxial instability. Motion is physiologic, meaning that not all motion necessarily means that you're unstable. CT scan is generally ordered for someone who needs to have a detailed bony anatomy evaluation in a setting where you do not necessarily need to see a nerve root or the spinal cord. Rear spondylosis or ankylosing spondylitis slash diffuse interstitial skeletal hyperostosis, best diagnosed with a CT scan, and the canal diameter can be measured, but this is a bony canal diameter, not necessarily from the disc or from the soft tissues. MRI is your treatment of choice, or the diagnostic test of choice in evaluating soft tissues including the discs, the ligaments, and also for diagnosing somebody with an infection or a metastatic or primary tumor. Very high sensitivity, meaning that not everybody with pathology in the MRI will necessarily be symptomatic, so we always try to match these findings with associated symptoms in a methodical way. A SPECT scan really will only come up if you're worried about lumbar spondylolisis. I'll tell you in practice, we very rarely use this test nowadays because the amount of radiation that is required for this test is very similar to a CT scan, and in a young 15-year-old, which is our classic patient who will need a SPECT scan to diagnose spondylolisis, we try to avoid that and we replace it with an MRI. You will see this on your test, though, likely because the test questions are lagging behind what we do in a clinical setting. There are only two conditions where an EMG or an NCB test is helpful, and this is, again, by the book, meaning that if you are concerned about someone who has an overlapping disorder, carpal tunnel syndrome versus a C6 radiculopathy, an EMG can be beneficial. The other time an EMG can be beneficial is when you're suspicious of Lou Gehrig disease or ALS. It is pathognomonic for that disease process. All other times, when you see EMG on your exam, it is likely not the right answer. A CT myelogram is what we order for someone who can't get an MRI, either because of a pacemaker or a cochlear implant, someone with prior surgery, and that sort of thing. Okay, so a couple questions are interspersed in here that I think are important to sort of catapults and topics we'll be talking about. This is a 26-year-old football player with numbness, shooting in the right arm, really only one minute, but then his symptoms resolve. And then this patient has a stinger or a burner, and I'll make that distinguishing factor as to what a stinger is, brachial plexopathy, and then spinal cord injury. And then the question is, what will you expect to see with electrodiagnostic studies two days later after a stinger? And really, you're not expected to see anything, and EMGs really don't show anything after an acute injury, typically three, four, five weeks after that injury. So softball, again, for you guys. Okay, let's talk about the cervical spine, and there are a couple of conditions that I think are important to cover, including the cervical disc herniation, cervical stenosis, which is an evolving topic in this field, or in this realm, I should say, and then spinal cord injury and trauma. So cervical stenosis is classically defined as a space less than 14 millimeters, but this cutoff was really in the rheumatoid arthritis literature, so it's somewhat outdated, especially in the athlete population, especially in the patients that you guys are seeing. So I would use the 10 millimeter mark, typically, as absolute stenosis much more accurately nowadays than the 14 millimeter mark. Cervical cord neuropraxia is essentially like a cervical cord concussion, where it's a transient neurological deficit following a cervical spinal cord trauma, but it does resolve. And spinal cord injury, though, means that there is some permanence to the injury that you're seeing in the spinal cord. An incomplete spinal cord injury is classified from ages B through D, whereas in Asia, A is a complete spinal cord injury. The difference is that a complete spinal cord injury, those patients really have no chance of recovery of their motor function or their neurologic function at all, whereas incomplete patients can still get recovery after their injury, regardless of the class that they're in. When somebody has cervical radiculopathy, very rarely will we take them to surgery right away. So initial management will be steroids, neuropathic agent, even traction. X-rays generally are not helpful, and an MRI is typically ordered if anybody has signs or symptoms of myelopathy or any progressive neurologic deficit. In the National Football League, this is a very high-risk population for cervical types or cervical pathology. One particular condition is a spear-tackler spine, which is a relative contraindication to return to play. These patients have kyphosis, have severe degenerative changes, and typically this occurs because of the way they tackle. There are natural loaning patterns, and this certainly puts the risk in this patient population at the forefront, and we have been able to study this on a number of different levels. So the one article that probably is important to point out is the one article that came from our institution in 2010 that documented that if somebody has a one-level cervical fusion, that is compatible to returning to a collision sport. Our data show that the operative patients actually got back at a higher rate than the non-operative patients, but certainly that there is some selection bias in that statistical analysis. The other thing I would point out from this study is that there are positional risks for this type of problem, and in particular, the defensive back is a much more common position to see this kind of problem in, and not only that, when they do get a disc herniation compared to all other positions, their careers are shortened much quicker, and they play a lot fewer years in games. So in my opinion, this is also a testable issue as well. The other issue with cervical disc herniations in a collision athlete-type population is the type of natural history or the pathology that's a little bit different. So typically in the general population, we'll see cervical disc herniations at C5-6, C6-7. Those are the most common areas to get a lot of range of motion, and you'll get disc herniations in that area. However, we have found that in the collision athlete, this may not be the case. In this particular study, looked at athletes both with upper and lower cervical disc herniations, and if you see the general population of the distribution of where the disc herniations are and then compare them to a collision athlete, there's no question that there's going to be a heightened incidence of a C3-4 disc herniation or an upper level cervical disc herniation compared to the general population, and this is important to look for that. The other conclusion is that the cervical disc herniation on the upper level and lower level tend to behave the same, meaning that at one point, many spine surgeons were not operating on the upper cervical spine, upper cervical herniations with the thought that they may lead to adjacent segment degeneration and shorten the careers of these individuals, but that has not been shown to be the case. And then so the final point with the cervical disc herniation is what procedure to perform. We certainly have more data now to guide us because each one of these procedures is a valid way of approaching a cervical disc herniation, whether it's a fusion, a foraminotomy, or a cervical disc replacement. And the data that I'm referring to has come out in the last couple years where 101 professional athletes have been categorized, and a number of different procedures have been performed in these athletes, and I think the take-home points is that if you have a foraminotomy performed for a cervical disc herniation, your reoperation rate is going to be significantly higher than if you either have a fusion or a disc replacement. However, that being said, if you have a foraminotomy, your chances of getting back to play are significantly higher than if you have a fusion. So there is a give and take with each kind of procedure, and depending on what that said player wants, both or all three of these procedures are certainly reasonable to treat the cervical disc herniation definitively. Now we'll jump to stenosis. So stenosis is a little different. Stenosis can mean that you have a problem from an acute cervical disc herniation, but it can also occur through a congenital problem. You can acquire stenosis from a disc, from ligament hypertrophy, osseous compression, and the incidence of cervical stenosis increases the risk of transient neuropraxia, radiculopathy, and stingers. And the guidelines for return to play have been very controversial, however I'll just take you through the evolution of how we've defined cervical stenosis over the past 20 years. So 25 years ago, all we had were x-rays, so we used a 15 millimeter cutoff for stenosis. This changed when TORG came around and used the vertebral body for the canal distance as a ratio, and anything less than .8 being cervical stenosis. CT scans came onto the fray in 1997, and then we started to hone down that definition a little bit more, less than 13 millimeters being stenotic canal. And then with MRI in 2005, now we started using even more critical criteria. Cervical stenosis means that the patient may have a canal that is 13 millimeters or wider, however, if there's an absent cerebrospinal fluid pattern around the cord, then these patients are functionally stenotic and can still be ruled out to play. It's a qualitative diagnosis instead of a quantitative one. This study from IEBLI looked at general patients in the population and defined 8 millimeters as a sagittal canal diameter that increased the risk of a spinal cord injury after a minor trauma. So many of us in the field use this study now to transfer to patients who are particularly asymptomatic and they have canals 8 millimeters or less, and in my opinion, those players should not be participating in a collision sport because of this study that shows that there's an increased risk of spinal cord injury. And then finally, there have been players that have been defined and shown to have a 10 millimeter canal or less diameter and still go on to successful NFL careers, so helps us at least define what the historical significance is. So again, functional stenosis is when you have a loss of CSF surrounding the cord or compression. You can see this on a contrast enhanced CT, MRI, or myelography. And again, a qualitative way of saying, yeah, you have stenosis and you have an event of some kind, transient quadriparesis, and that is a contraindication to return to a collision sport. Okay, so a stinger is when an injury occurs that will likely be in the distribution of a single nerve root. This is different from a brachial plexopathy because you'll have multiple nerve roots involved in that type of injury. Stingers usually will not have significant neck pain. They're usually sensory symptoms as opposed to motor loss, although this can lead to motor loss as well. And in patients with stingers, the most important factor, and when you answer a question about a stinger, the most important factor is to rule out a transient cervical cord neuropraxia because it can mask each other and the same mechanism can create both problems. A transient cervical cord neuropraxia can be diagnosed with bilateral upper limb symptoms or any lower limb symptoms, bilateral burning of the hands, numbness and tingling, all of this can be suggestive of a spinal cord issue. There have been many different studies that have shown that cervical stenosis is a, or correlates to the incidence of burners and stingers, and we certainly see this in our player population as well. In this particular study, a chronic burner syndrome of 55 athletes, over 90% had advanced cervical spondylosis and pyramidal narrowing, and other studies have shown that if you have a tight cervical canal, your incidence of cervical stingers will go up significantly. The management, though, for a stinger is a lot different than cervical cord neuropraxia, which is important, which is the reason why we need to separate these two type of diagnoses. For a stinger, we immediately check motor and sensory exams. We try to define a single nerve distribution. If there is more than one externity that's involved, then we're starting to think less that it's a stinger, rather, and it's more of a global issue. If there is a suspected plexus or a cord injury, that patient cannot return to play, whereas somebody with a stinger can return to play as long as they exhibit normal range of motion in a normal neurological exam. Recurrent stingers are somewhat more fuzzy in terms of return to play. Return to play only when the symptoms of the first stinger are resolved, but if that player gets a second stinger, then you have to watch that player a little more carefully in terms of the length and the completeness of the recovery period. Stingers in different dermatomes will suggest that you have a brachial plexus injury, and if that's the case, then you want to image that area, or even image the cervical spine area to rule out stenosis. So this is one of the questions from last year's test, looking at a 21-year-old collegiate football player with acute neck pain. This player had persistent weakness, numbness, and burning pain, but after three weeks of appropriate conservative management, he continued to have weakness in shoulder abduction and external rotation. So this patient likely has a stinger, but with this continued weakness, the question is what do you do at this point? Because it certainly is possible that that player can have a brachial plexus injury. The answer here is continued physical therapy and monitoring, mainly because an MRI of the brachial plexus at three weeks after an injury likely won't show anything. That goes with an EMG and that sort of thing. So the better answer right now is to try to observe that patient, and you really can't treat a brachial plexopathy, perhaps without any intervention. So delaying that MRI of the brachial plexus is then reasonable. For those patients with this injury, it is more than one nerve root. It's often a proximal nerve involvement, such as a long thoracic nerve. The EMG is useless in the first three weeks, and have to remember the condition of brachial plexitis in the absence of any clear trauma, meaning that some patients can still get an inflammation of their brachial plexus without any perceived hit or collision. Transient quadriparesis is different, and because this usually involves the lower extremities as well as the upper extremities. This condition, where usually patients can't move their arms or their legs for a short period of time, typically resolves within minutes to hours. The timeframe in which it resolves is very important as to the severity of the transient quadriparetic event. A patient typically with transient quadriparesis is in a completely different category for return to play than one without. So again, trying to determine the difference between quadriparesis, brachial plexopathy, and stingers is very important on a diagnosis perspective. These return to play criteria are somewhat outdated. So I'll go over some of the things that have evolved over the past 20 years. So when we evaluate someone with congenital stenosis, this has become much better defined over the past five years with some recent data because if somebody has a really bad arthritis of the neck, that's not congenital stenosis. The congenital stenosis only really occurs through a bony abnormality or something that you were born with. So this is actually now defined as a posterior-based anomaly, whereas in the lumbar spine, one has congenital stenosis because the pedicles are shorter. We have found that patients with congenital cervical stenosis, those patients with more than two levels of stenosis and at the pedicle level, not at the disc level, these patients tend to have abnormal posterior anatomy. And what do I mean by that? This is an axial view of a normal canal. You can see that the canal is wide open because of the angle in which the lamina has made with the disc space. And you can also see that the length of the lateral mass is also a determinant of the diameter of the canal, and that's in a normal patient. In somebody with a congenitally stenotic patient, like you see on the right here, that angle is a lot flatter and the lateral mass is a lot shorter. So again, the reason this is important is that if you're treating somebody with congenital stenosis of the cervical spine, this should be a posterior-based treatment. An ACDF may not necessarily correct the congenital stenosis that we see here. And again, better defining those patients with congenital stenosis. So return to play really is a combination of the type of sport that your athlete plays. And we've made a distinction between non-contact, contact, and collision. I think especially with a cervical spine, collision and contact sports are different. Imaging characteristics, such as myomalacia, are absolute contraindications to return to play. One could argue after surgery, if that myomalacia is not resolved, if that patient can return to play, that certainly is controversial. And then finally, clinical symptoms. If somebody has severe episode of transient quadriparesis, that patient is much less likely to return to play than somebody just with a stinger or radicular-type pain. And then finally, the physical examination. So this 25-year-old football player was evaluated for cervical spine pain, was found to have stenosis of the cervical canal, and normal cervical lordotic curvature on lateral radiographs, meaning that that patient does not have spear, tackle, or spine. Which of the following injuries is not an absolute contraindication to return to play? As we talked about, a one-level ACDF is not a contraindication. There is a debate now going on whether or not we are allowing two-level fusions to get back. But three-level fusions are an absolute contraindication to return to play, even though we know of a couple of players in the league with this surgery. But every other entry here is an absolute contraindication, and for the reasons that we already talked about. So core signal changes, mechanical instability, and then substantial sagittal malalignment. Now relative disqualifiers are these. And this patient's with like a cervical syrinx, a Chiari malformation, spina bifida occulta, even an odds on dentoidium. There is some controversy as to whether those players can get back, but we list them on this relative contraindication list. Okay, so again, this is a question from two years ago. 19-year-old male with x-rays of the cervical spine, and which of the following is consistent with congenital stenosis of the cervical spine? The only legitimate answer here, again, the TORG ratio is not really used nowadays, but even if it were to be used, it's actually the opposite. It should be lower than 1.2 or lower than 0.8 testinosis. So canal diameter of less than 13 millimeters is consistent with this. The Atlantodense interval is important in individuals with a fracture, or in patients with Down syndrome. And it is a very common, it commonly comes up in players who are in the Special Olympics, and those who are considering a collision or a contact sport. Normally, the ADI is less than three millimeters for adults, and less than five millimeters in children. In Down syndrome patients, though, because of the ligamentous laxity, it's normal for these patients to have ADI up to five millimeters. Anything over that suggests instability. Doesn't necessarily mean they need surgery, or what have you, but it can affect whether or not they can participate in something like the Special Olympics. ADI is seen up to 40% of Down syndrome patients. These patients may or may not have neck pain, torticollis, or gait changes. Dynamic x-rays are the answer in terms of how you evaluate it. Supine CT scan will not show you what that dynamic instability is. We typically use 10 millimeters as a cutoff in order to operate on them without any symptoms, over 10 millimeters. And then between five and 10 millimeters, we typically rule out a Down syndrome patient to any collision sport, but they still don't need to have surgery if they don't participate in any contact, or I should say contact sports. Osondatoidium is often an incidental finding. It's an inability or the failure of ossification of the DENS in the tip of the DENS. And if somebody has this, they can get a spinal cord injury. And a spinal cord injury at this level can lead to instant death. So we use this as a debate oftentimes as to whether or not patients can return to collision-type sports. But any type of failure of ossification will raise a lot of issues as to whether somebody can endure the repetitive tackling or collision that is required with a collision sport. So example of a question. Is a 16-year-old female with Down syndrome chosen to participate in Special Olympics? If she has neck pain, a physical exam is normal, what is the next best step in the management of this patient? And as we talked about, it is flexion and extension of the cervical spine. That is the only way that you're going to determine what that ADI interval is, both with dynamic instability. On field management, you'll get a lot of questions about this as well. This is evolving somewhat, and I'll kind of interject as to where I think things are changing a bit. But these players all require a complete neurologic exam. The ABCs are the most important, and that's why face mask removal for anybody with a suspected spinal cord injury is very important because of access to the airway. Neck and support and traction, we'll talk about the recommendation is to keep your helmet and your pads on for transport. However, I will say that that's likely evolving because many training staff are comfortable with removing the helmet and pads, and they may be more, or they may be better equipped to do that than somebody in the emergency room. But again, for the book answer, it is you almost always keep your helmet and your pads on, but take the face mask off. Really, no role for steroids or cooling or anything like that, and none of the evidence-based literature suggests that any of these interventions can change in this outcome. This is another common theme in the testing as well. A 16-year-old high school football player is able to move his extremities but has midline cervical pain, and he's placed on a spine board. What is the best way to transport that patient? There have been a couple of studies now to show that the eight-person lift leads to less spine trauma in the unstable spine than any of these other lifts, whether it's the log roll, there's a scoop stretcher technique, there's a slide technique. All of these, or none of them, have shown to have any better results than the eight-person. However, the issue with the eight-person is that most of the time, there aren't eight people around in order to do this kind of lift. But, okay, so cervical fractures. It is not uncommon to have a player get a occult fracture or one that's not diagnosed until a week later or two weeks later, because these patients usually have severe neck pain, but they just kind of play through it. They may not have any other motor sensory symptoms. The most common mechanism is flexion and compression, and we still see it. So this patient has a fracture dislocation. So we'll talk about the management here in a sec here, because this is a relatively common injury in those patients with cervical trauma and fractures in a collision sport. You're looking at a picture of a perched facet on the left and then a subluxation on the right on MRI that shows the relative stenosis as a result of the unstable cervical region. Again, no role for steroids or cooling. Early decompression and reduction is critical, which means that when you see this patient, we often skip the MRI. We try to put them in traction. We reduce them in the ER, especially if they're incomplete spinal cord injury. There's really nothing that we can see on an MRI that will change our ability to reduce them as long as that patient is awake, cooperative, and can give you a neurologic exam. The worry, or the historical worry, is that somebody with a disc herniation, if you reduce them in tongs, that that disc herniation can then paralyze the patient. There has been only one case of that ever published, and it is an outdated sort of study because we now know that as long as you're awake and cooperative, and you can usually tell if there is something that's going on that will stop you from doing that traction. So that will be reflected in your exam answers as well. So this is a 21-year-old male football player, has a burning sensation radiating down from his neck to his left shoulder. He's weak. And then after, even though his pain resolves, the weakness persists. Serial exams show a complete strength in any absence of any neck pain or neurologic abnormalities was the next best step in management. The key here is that if you have a normal exam, a normal range of motion exam, normal neurologic exam, and despite the symptoms that you have, unless it's a spinal cord injury, or unless it's a brachial plexopathy, that player can then return to play without any further workup. Those patients with transient quadriparesis, no matter how normal they are, still require workup and a decision on whether or not they can return to play. This is a classic question to make you identify what the dermatomes are. So this is a C5-6 disc herniation. They're basically asking you what the symptoms are for that. So C6 is a thumb and even the index finger, whereas the C7 is typically the index finger and the middle finger. So in this case, it would be sensory abnormalities of the dorsal thumb. Okay, so hospital sort of evaluation, fracture dislocations. We talked about tongs. Patients who are awake and cooperative, we slap the tongs on right away, and we only save an MRI in the remote case of somebody with no neurologic symptoms whatsoever and a dislocated neck. In that case, some would get an MRI just to make sure that you're not doing more harm than good. But again, I think for the book answer here, for your test, that really doesn't come into play. We'll typically do tongs on everybody who is awake and cooperative. We can clear a cervical spine without any additional testing if the player has no neck pain, fully cooperative, no midline tenderness of palpation, normal range of motion, and no additional distracting injuries. So this question sort of tries to trick you in terms of what to remove. The high school football player is injured in a collision. He has pins and needles in all four extremities. He basically has an incomplete spinal cord injury. What does appropriate on-field management include? As I talked about, you really don't wanna remove the shoulder pads or the helmet because you wanna transport that patient to a control setting, but you want to remove the face mask. So none of these answers actually show that sort of scenario. So the best answer here is removal of neither the helmet nor the shoulder pads and to transport that patient as is with the face mask off because of the airway issue or because of the airway concern. Another question here, 20-year-old college football player had jammed his neck while making a tackle. He's alert and oriented. He wants to return to play immediately, and he basically has a normal exam. So in this scenario, he can be cleared for immediate return to play because he has met all the criteria that we talked about. And this is, yeah, I'll just skip on that. And then finally, college basketball player goes up and rebounds and lands on his head. He sees severe cervical pain, and then a routine lateral radiograph shows a very bad injury that we have to determine on what to do. So if they only show you these views, all you need is that top right view to show that the facet is not aligned. And that facet right here will tell you that that patient has a fracture dislocation. The rest of the facets are well aligned, both above and below. So that is the only picture they need to show you as to tell you what the condition is and what to do. So as we talked about, especially if somebody was awake and cooperative, we want to reduce them right away. Whoops. But we don't put halos on anybody anymore. So again, there's an antiquated question. We would put that patient in a cervical collar. We'd leave them in traction, or we'd operate on them right away. But the traction reduction is important. Okay, moving on to the thoracic spine. The thoracic herniated disc is very rare. And usually this is a chronic condition. It's not an acute one, meaning that somebody has a disc that is sat there. It becomes calcified. It then becomes, causes cervical or a thoracic stenosis, or it can cause a radicular type picture as well. Common symptoms include chest and upper back pain. You can get lower extremity weakness, difficulties with balance if you have central stenosis. And the initial management, unless you have myelopathy, is rest, NSAIDs, and perhaps even a steroid injection. You're very, the previous talk had talked about how steroid injection is a common sort of treatment for hand injuries. You very rarely, and if you choose the answer of an epidural steroid injection as the correct answer on a test like this, you probably want to rethink it because very rarely is that one of the correct answers. It's one of the things we do in clinical practice, but there are many other conditions that have been shown with evidence-based literature. Okay, it's very rare to get an acute soft disc herniation. As we talked about, the differential diagnosis with somebody with a thoracic disc herniation includes costochondritis and even referred cervical pain. So somebody with intrascapular pain, I'm more commonly thinking of a cervical disc herniation versus a thoracic one. Sherman's kyphosis has distinct criteria. These are patients with over 50 degrees of kyphosis. They have wedge-shaped vertebrae at three consecutive levels and the apex is usually between T7 and T9. These patients usually have surgery because of aesthetic reasons. It's not usually because of pain, but it is a condition that we can see in the athlete population. Scoliosis has different causes. The idiopathic scoliosis is most commonly seen in adolescent females. We typically do not brace any curvatures over 25 degrees or so. And if somebody has pain in their back and scoliosis, we wanna find another cause for the pain because scoliosis is not classically painful all of the time. We have to suspect neoplasm, tethered cord, or infection. Okay, so let's move on to the lumbar spine and we'll talk about lumbar disc herniations, fusions, spondylolisis, as well as lumbar degenerative disc disease. So the key components of a history of somebody with back pain includes separating out the axial back pain from the radicular pain in the leg. We wanna find or we wanna investigate their neurological status and also assess for any potential risk factors for people who are going to get a lumbar disc herniation or perhaps a osteoporotic traumatic fracture and so on and so forth. The risk factors for cancer include those patients with unexplained weight loss, duration of pain over a month, age over 50 years, and patients with risk factors for infection include a fever, IV drug use, dialysis dependence, recent severe systemic infections, immunocompromised patients, as well as a recent spinal injection. Risk factors for compression fracture include age, osteoporosis, poor nutritional status, history of cancer, and chronic steroid use. So the motor and sensory exam is one of the most important for the lower extremities, one of the most important in terms of determining whether somebody has radicular versus myelopathic findings. Reflexes are typically normal or hyporeflexive. If somebody is hyperreflexic, we're looking for an issue in the cervical or the thoracic spine because of the indication or the suggestion that there could be a spinal cord injury. Straight leg raise can be tested either in the sitting or the supine position. And the typical positive straight leg raise positivity won't come until after 30 degrees of lifting. So it's usually between 30 and 70 where you get the positive reproduction of the radicular type complaints. Diagnostic workup really is unnecessary in somebody with low back pain, especially on a test like this, except if somebody has a neurologic deficit, has any signs or risk factors for a tumor or infection, or perhaps is at risk for a fracture. Fractures can be obviously diagnosed with a X-ray, but if the acuity of the fracture is somewhat not known, then an MRI can be very helpful as to determining how much swelling in the bone is in the bone marrow edema. Spondylosis is the term we use for degenerative disc disease. It is a normal phenomenon or a normal finding that we see that is age-related. My partner, Alpesh Patel, published a genetic predisposition paper showing that those patients with degenerative disc disease are more likely to pass it on to their relatives, and they will have then a diagnosis of degenerative disc disease. And that is the most common reason why you see an awful-looking MRI, not because somebody is a manual laborer or not because they play professional football or what have you. It is a genetic predisposition that is most common reason for this. Risk factors for spondylosis include genetics and then sports with repeated hyperextension. The diagnosis is, from historical perspective, you may have focal tenderness and have a single-leg hyperextension test that is positive. Patients with very tight hamstrings, in addition to low back pain, also have a higher incidence of a spondylosis issue. Acute versus chronic spondylolisis. So spondylolisis is the Farr's fracture that we see most commonly in adolescent patients. It is important to determine those who are acute and those who are chronic, because those who are acute have a potential for healing. We like bracing those patients, or at least limiting them from any sporting activities. If they heal the spondylolisis, we do believe that their outcome is better in the long run. If you have a chronic spondylolisis, those patients are prone to developing spondylolisthesis, which may cause pain a little bit later, but may not be symptomatic in the immediate adolescent period. The SPECT scan is certainly the most sensitive test for biologic healing or having acute fracture. But as I talked about, the amount of radiation that kids are exposed to with a SPECT scan have really eliminated as the first line diagnosis for a spondylolisis. We're commonly using MRIs now. We're much better at using that technology, and there's no radiation to the patient. Non-surgical treatment of spondylolisis, including bracing, activity or sport modification, and core pelvic strengthening program. No brace has ever been shown to change the natural history of the healing of spondylolisis, but oftentimes we use brace to kind of remind these kids that they can't be doing and participating in these sports with impact and such. There are two options for surgery. A direct PARS repair is typically saved for somebody with a unilateral spondylolisis, not bilateral, although we do do it in the bilateral setting. And then we do a fusion for anybody with degenerative disc disease, wearing away of the disc, or any type of spondylolisthesis. Those are the indications for that. This is an example of somebody with spondylolisis. This is somebody with a chronic spondylolisis because you can see the well-corticated edges on the sagittal on the top right. And if you can see it on the X-ray, the way you see it on this X-ray, it's also more commonly a chronic spondylolisis and not an acute one. These are treated differently. Patients with chronic spondylolisis basically don't need any treatment because there's no potential for that to heal. Those patients are returned back to the field as long as they have normal range of motion and no pain. Those with acute ones, though, we save, we brace. We usually limit them from any sporting activity anywhere between four and eight weeks. It depends on the sport. It depends on the position, certainly in my practice. Spondylolisthesis comes in different shapes, sizes, and forms. The ischemic spondylolisthesis is as a result of a spondylolisis. The dysplastic or congenital PARs can elongate that PARs and also cause a spondylolisthesis. Degenerative spondylolisthesis occurs with later age when the degeneration of the facet joints allow one bone to shift on another. And then you can also get it through traumatic means as well. So this question, I'll point out that it is kind of changing here, but this is a 13-year-old female who had low back pain and she was performing her tumbling routine and she complained of no neurological symptoms, but she has a sister with spondylolisthesis and the concept here is that she may have spondylolisthesis as well. So the next step of management here, the correct answer is stop tumbling, rest, and give a trial of NSAIDs. But I would argue that in today's world, we're actually MRI-ing these patients a little bit quicker and if we do find an acute spondylolisthesis, we may choose to brace that patient or we may choose to take them out of their activity for a longer period of time. So in this setting, the thought is that you rest that patient no matter what and that would be treating their presumed spondylolisthesis, but in my opinion, it's much better to know that that patient has a spondylolisthesis so that you know how much time that you're gonna limit them from participating in that activity. Spondylolisthesis is pretty prevalent. About five to 7% of the United States population has it. Most of them are asymptomatic and not unstable. They're usually ismic and this is not a disqualifier for participation in any way, shape, or form because most people don't even know they have a spondylolisthesis. Most will not require surgery and those who do require surgery will involve an instrumented fusion of some kind. You could go front, back, all back, but that's not beyond the scope of this talk. And return to play is just based on symptoms. It's not based on stability or anything like that. So this is an example of a question that you may see regarding this. A 19-year-old collegiate football athlete with a two-month history of slowly progressive low back pain. He was recently pulled out of practice by a team athletic trainer. He has no history of injury, but has vague low back pain. So he has spondylolisthesis, grade one, and a spondylolisthesis, or an ismic spondylolisthesis. And so the answer here is that he can return to play as pain permits. There's really no treatment for somebody with a chronic spondylolisthesis. There are no restrictions. We do know that these patients may progress in their spondylolisthesis in time, but it typically doesn't occur until age 50 or 60. So playing a collision sport with this does not increase your risk of an increased slippage or any increased disability. Right, so the lumbar stress fracture is the PARS fracture. There's also a pedicle fracture that can be a stress fracture that we're seeing a lot more common now, especially with throwing athletes. It's usually the contralateral side of their dominant arm. And in this situation, an X-ray may not be helpful, a CT scan may not be helpful, but a SPECT scan can be helpful. Again, the most sensitive test to detect one of these stress fractures. That and the MRI, in my opinion, are likely equally sensitive, so that's why we use an MRI more commonly now. And the same management principles for someone with a stress fracture, they actually can heal, so they're actually taken out of their sport if it is an acute injury. So one of the misnomers, and historically we always thought that somebody with acute back pain should be treated with bedrest, that is always going to be the wrong answer in 2019. So bedrest leads to deconditioning, it causes a loss of range of motion, and it can actually lead to other medical complications. So at no point does somebody with acute low back pain, are they treated with bedrest. They are treated with light exercise, hamstring stretches, and brace or no brace, that really doesn't change the natural history of this condition, but certainly can affect somebody symptomatically if they want to get better. These are the dermatomes that you need to know. The perineal region is innervated by S2 through S4. Any motor weakness or sensory changes need to be correlated with that dermatome in order to get these answers right. From a book perspective, the L4 nerve root innervates your tibialis anterior, and your L5 nerve root innervates your extensor hallucis longus. But we commonly see L4-5 disc herniations cause tibialis anterior weakness, the common foot drop. So that's more of a anecdotal sort of crossover phenomenon that we see. But by the book though, an L4 radiculopathy will be the one that will cause the foot drop, not necessarily the L5, to point that out. So somebody with an L4-5 perineal disc will most commonly have the L5 nerve root be affected, will have pain in their lateral calf, the dorsum of their foot, will have 90% leg pain, 10% back pain, will have numbness in their great toe, also along that distribution, and tend to be worse with sneezing, coughing, or having a Valsalva maneuver. We do have data on disc herniations in athletes. And this study was published in 2011, looking at disc herniations in four different sports. And a couple of highlights just to point out. So these players can get back to play. 82% return to play, regardless if you have surgery or not. Surgery does not change your outcome as a whole, if you look at all athletes who have a lumbar disc herniation and your average return to play, or your average career length after a disc herniation is over three years. Now the return to play rates are a little different, but it's important to delve into how the sport may affect somebody with a disc herniation. It's easy to see that baseball players get back at a higher rate than perhaps NFL football players do, and this is statistically significant. But if you just stopped here, you would be missing the boat, because if you, and we know that career length is not necessarily affected by sport, meaning that you can have a long career after a lumbar microdiscectomy, or having a lumbar disc herniation treated with non-operative means. But the key here is that you have to delve a little deeper to determine whether or not a discectomy would affect somebody on the long-term basis, and that goes beyond just looking at the return to play. So for example, collision athletes, such as football players, tend to have a better result from surgery, and that tends to happen right away. So players who have surgery tend to get back a little bit more often than somebody who doesn't, and you see that difference right from the get-go. But in baseball players, it's a little bit different. Even though non-operative patients seem to play longer, I'm sorry, even though everybody seems to get back from a lumbar disc herniation at a high rate, the non-operative patients tend to do better. And what we tend to see with this Kaplan-Meier survivorship curve is that these players who play baseball have drop off if they have surgery later in their career, and this may be secondary to the wear and tear that the sport imposes on the spine, as opposed to something like collision football. So I think the take-home points for somebody with a lumbar discectomy in the athlete population is that 82% can return to play. It is affected by sport. It is affected by age, and it's also affected by one's experience in that field. Cauda-Quina syndrome is a surgical emergency. This does happen from a central disc herniation, and is classically defined as somebody with saddle anesthesia so they have perineal numbness with rectal dysfunction, lower extremity weakness, associated with numbness, and yeah, these patients need to have surgery. Otherwise, their long-term outcome will be significantly affected. For an acute disc herniation, we just treat symptomatically. PO steroids, anti-inflammatory medications, physical therapy, even an epidural injection. Again, the epidural injection will not be the right answer on the test, but it is a reasonable way to treat this. In subacute, or patients with over six weeks of pain, we start thinking about surgery or other invasive options. An example of a test question from this past year, a 35-year-old laborer with acute onset of back pain and right lower extremity pain has mild weakness in their extensor hallucis longus and a decreased medial hamstring reflex on that side. So again, EHL is going to be L5, tibialis anterior is L4. Very rarely, I think, will they ask you to determine the difference between the two if somebody has a foot drop, because a foot drop can occur from a number of different disc herniations. But the answer here would be an L4-5, paracentral disc herniation that would affect the traversing nerve root, which would be L5. Spinal stenosis is a little different from a disc herniation. These are patients that typically are born with a congenitally small canal, or they have degenerative changes that have led to the decrease in the absolute stenosis in the central region. These patients have neurogenic claudication and not necessarily radicular pain. So the radicular pain is typically down one leg and one dermatomal area. Neurogenic claudication is defined as somebody with posterior buttock pain, posterior thigh pain, worse with standing and walking, better with sitting. It's typically a phenomenon of the cauda quina. It's not a phenomenon necessarily of a particular nerve root. It is improved with flexion. Again, usually leg issues, less back issues, and weakness is very uncommon until it's like late in its onset. We'll talk about trauma briefly. Thoracolumbar spine trauma is one of the most frequently accounted injuries with motor vehicle accidents, falls, sporting activities a little bit less so, I would say. And the TLIC score is probably one to highlight. It's not because we use it on a regular basis for patients with thoracolumbar burst fractures or thoracolumbar injuries. It's because the concepts here, I think, can help one walk through a problem if you are to get a question regarding thoracolumbar trauma. So the injury morphology as well as the integrity of the posterior ligament of complex are two very important concepts from this new way of classification of injuries. So the injury morphology, somebody with a compression-type injury or a burst-type fracture has a more stable spine than somebody with distraction or translational and rotational. And the distraction you can see when the spine kind of separates from each other, whereas compression is just that. You just see that local compression in that one area. The other important concepts to recognize when managing somebody with thoracolumbar trauma are the integrity of the posterior ligament as complex. That can only be, not only, but best evaluated by an MRI. And if that is injured, that implies a lot more instability than somebody without a PLC injury. Neurologic status, finally, is also very important. You can have an awful-looking burst fracture with a normal neurologic exam, and that patient is much more likely to be treated non-operatively than somebody with a neurologic deficit and with a benign-appearing fracture. This example of a case of a 31-year-old snowboarder who had back pain, had an injury, clearly has a burst fracture. You can see that all three columns of that vertebral body are harmed, and there actually is posterior cortex disruption, and it's actually retro-pulsing into the canal. But if this patient is intact, he really doesn't need to have any surgery. In fact, we have data now to show that non-operatively treated burst fractures tend to do better 15, 20, 25 years later than ones who have surgery, regardless of the type of injury, and so on and so forth. So we really try to treat these patients non-operatively as much as possible. Again, no role for steroids or cooling in this patient population as well. Patients with lumbar discitis have some risk factors, including the fact that they are bacteremic, either IV drug abuse, dialysis-dependent, they're immunosuppressed, or they have recent lumbar surgery. The most common organism is Staphylococcus aureus. An MRI is a test of choice in order to determine if somebody has discitis or not. In an adult, you always want an IR-guided biopsy in order to find the bug before you administer IV antibiotics. In a pediatric patient, you just administer IV antibiotics, so there's no need for a IR biopsy in that setting. Okay, we'll go through a couple of questions here that I've kind of compiled. So this is a 15-year-old female gymnast with insidious onset of low back pain. She has normal radiographs. She has pain with a single leg lumbar hyperextension. This is pathognomonic for somebody with a PARS fracture or an acute spondylolisthesis. And what is the most sensitive test for diagnosis of this condition? Again, the answer here is a SPECT scan, but I would again argue that an MRI, we're becoming much more or much better at administering this with this patient population. And the reason, the reason that MRI is not the answer here is that you never need gadolinium in order to diagnose somebody with a PARS fracture. You only need gadolinium for somebody with a tumor infection or a recurrent disc herniation. Those are really the three conditions that you need any kind of contrast for MRI. And if you're looking for somebody with an acute spondylolisthesis, that gadolinium does not help in any way. This is a 48-year-old woman who falls from a horse. She has severe low back pain. She has weakness in both legs, so she has a neurologic deficit. She has clear, if she has decreased perineal sensation, we're implying that she has cauda quina syndrome. She has a burst fracture that looks to be unstable. This sort of split in the middle does imply instability. And so the best course of treatment here would be surgical decompression and stabilization. You would never be able, or you would never be asked to determine the difference between an anterior and a posterior fusion in this setting because even spine surgeons can't agree on something like that. But the answer here is that this patient needs surgery of some kind stabilization in order to preserve their spinal canal. Okay, this patient is a 24-year-old male who had placed flag football. He has spasms of his sparse spinous muscles. He has lower lumbar spine pain. And then which of the following is the most appropriate initial management? So the key here is that you don't really need an MRI. You don't need any imaging for one day of pain. Even if they have a normal neurologic examination, there's really no need to do anything in this particular patient other than rest, activity modification, and oral anti-inflammatories. Again, you see epidural and spiroid injection. Don't ever pick that. And if you pick that, just think twice. Okay, and I think there's a last one. A 12-year-old female gymnast with persistent low back pain falls off the balance beam. Neurologic exam is normal. And we actually commonly get this. Somebody with some kind of remote trauma, but then they have back pain. And then the MRI clearly shows abnormalities. You don't need to be a spine surgeon to notice that there's increased signal intensity in the bone marrow around the L4-5 disc, and that L4-5 disc looks very abnormal. So there's only one condition that can cause these changes in the MRI, and that is discitis. And again, the difference in the treatment of this is that all patients get broad-spectrum IV antibiotics. And I think the reason is because the cultures often don't grow anything. And secondly, it's a presumed staph anyway for these patients, so. Okay, and that's, or I'm sorry, there's one more question. 17-year-old female, high school varsity soccer athlete has a head-to-head collision. She has brief loss of consciousness. This is a concussion-type injury. And the answer here is that a physical and cognitive arrest for one or two days followed by return to activity based on symptom progression would be the answer for the treatment of concussions, so. Thank you very much for your attention.

spine conditions

nerve root pathology

diagnostic tests

treatment options

CT scans

MRIs

disc herniations

spinal stenosis

concussions