Category: Spine Review

Spine orthopedic exam prep review questions and answers …

Management of Degenerative Lumbar Scoliosis in the Elderly

High-Yield Summary

Degenerative lumbar scoliosis (DLS) in the elderly results from asymmetric disc degeneration and facet arthropathy, leading to coronal and sagittal imbalance with predominant back pain and neurogenic claudication.
Surgical indications hinge on progressive deformity with neurological compromise or intractable pain refractory to optimized conservative management.
Radiographic assessment must include full-length standing scoliosis films with sagittal and coronal balance parameters; MRI is essential for neural element evaluation.
Surgical strategy prioritizes deformity correction with neural decompression, balancing fusion extent against patient frailty and comorbidities.
Complication risk is elevated in this population; meticulous preoperative optimization and intraoperative techniques reduce morbidity and improve outcomes.

Clinical Fundamentals

Anatomy and Biomechanics

The lumbar spine’s stability depends on the intervertebral discs, facet jointsand ligamentous structures. In DLS, asymmetric degeneration of discs and facet joints leads to coronal plane curvature, often accompanied by compensatory sagittal malalignment. The deformity typically involves the lower lumbar segments (L2-L5), with apex usually at L3 or L4. Age-related osteoporosis and reduced paraspinal muscle mass further compromise spinal stability and deformity progression.

Epidemiology

DLS affects approximately 6-13% of individuals over 50 years, with prevalence increasing with age. It is more common in females and often presents with a combination of axial back pain, radiculopathyand neurogenic claudication. The natural history is variable; some patients remain stable, while others experience progressive deformity and neurological decline.

Classification & Diagnosis

Classification System	Description	Clinical Relevance
SRS-Schwab Classification	Categorizes adult spinal deformity by curve type, sagittal modifiers (SVA, pelvic tilt, pelvic incidence-lumbar lordosis mismatch)and coronal curve magnitude.	Guides surgical planning, especially for sagittal balance restoration.
Lenke Classification (modified for adults)	Originally for adolescent scoliosis; less applicable but sometimes referenced for curve pattern.	Limited utility in DLS management.
Aebi Classification	Divides adult scoliosis into Type I (primary degenerative), Type II (progressive idiopathic)and Type III (secondary).	Helps differentiate degenerative from other etiologies.

Diagnostic Pearls

Obtain full-length standing scoliosis radiographs including lateral views to assess sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL) mismatchand coronal Cobb angle.
MRI is critical to identify lateral recess stenosis, foraminal stenosisand neural compression, which often drive symptoms.
Beware of underestimating sagittal imbalance on supine imaging; standing films better reflect functional deformity.
Clinical exam should focus on neurological deficits, gait analysisand pain localization to correlate with imaging.

Decision-Making Algorithm

Management Pathway	Criteria	Rationale and Surgical Considerations
Non-Operative Management	Mild to moderate deformity without neurological deficits; pain controlled with conservative measures (physical therapy, analgesics, injections).	Initial approach to minimize surgical risk in elderly.
Operative Management	Progressive deformity with neurological symptoms (radiculopathy, neurogenic claudication), intractable painor sagittal imbalance causing functional impairment.	Surgery aims to decompress neural elements and restore alignment.

Surgical Approach Selection

Decompression Alone: Appropriate for patients with predominant stenosis and minimal deformity or imbalance.
Limited Fusion: Indicated when instability or mild deformity exists; preserves motion segments.
Long-Segment Fusion with Deformity Correction: Required for significant coronal and sagittal imbalance; involves osteotomies if rigid deformity present.
Minimally Invasive Techniques: Considered in frail patients to reduce morbidity but may limit deformity correction.

Surgical Mastery & Pearls

Stepwise Surgical Technique Overview

Preoperative Planning: Analyze full-length radiographs and MRI; plan fusion levels to include stable vertebrae and correct sagittal parameters (target PI-LL mismatch <10°).
Patient Positioning: Prone on a radiolucent table with careful padding to avoid pressure injuries.
Exposure: Midline posterior approach with subperiosteal dissection; preserve paraspinal musculature where possible.
Decompression: Perform laminectomy and foraminotomy at symptomatic levels; avoid excessive facet resection to maintain stability.
Instrumentation: Place pedicle screws with fluoroscopic or navigation assistance; consider cement augmentation in osteoporotic bone.
Fusion: Use autograft/allograft with or without biologics; interbody fusion may be added for anterior column support.
Deformity Correction: Apply rod contouring and sequential compression/distraction; consider Smith-Petersen or pedicle subtraction osteotomies for rigid deformities.
Closure: Meticulous hemostasis and layered closure to reduce infection risk.

Intraoperative Red Flags

Sudden loss of neuromonitoring signals indicating potential neural injury.
Difficulty in screw placement due to poor bone quality or altered anatomy.
Excessive blood loss requiring prompt hemostatic control.
Inability to achieve desired sagittal correction without undue tension on neural elements.

Evidence-Based Synthesis

Recent high-impact studies emphasize the importance of sagittal balance restoration in improving functional outcomes and reducing mechanical complications in elderly DLS patients. The landmark Adult Spinal Deformity (ASD) studies have demonstrated that PI-LL mismatch correction correlates strongly with postoperative health-related quality of life improvements. However, the literature reveals ongoing debate regarding the optimal fusion length and the role of minimally invasive techniques in this population.

Randomized controlled trials comparing decompression alone versus decompression with fusion show improved long-term outcomes with fusion in patients with instability or deformity, but at the cost of increased perioperative morbidity. Emerging evidence supports the use of cement-augmented screws to mitigate hardware failure in osteoporotic bone, although long-term data remain limited.

The consensus is evolving toward individualized surgical plans balancing deformity correction goals with patient frailty, comorbiditiesand functional demands. Enhanced recovery protocols and multidisciplinary perioperative care have been shown to reduce complications and improve rehabilitation.

Master Class Pro-Tip

Mastery in managing degenerative lumbar scoliosis in the elderly hinges on the nuanced balance between achieving adequate deformity correction and minimizing surgical morbidity. Prioritize restoration of sagittal alignment within physiologic parameters tailored to the patient’s pelvic incidence rather than maximal curve correction. Employ intraoperative neuromonitoring vigilantly during osteotomies and deformity maneuvers to prevent irreversible neural injury. Finally, anticipate and proactively manage osteoporosis with preoperative optimization and cement augmentation to secure instrumentation longevity-this strategic foresight distinguishes the expert surgeon from the competent.

August 16, 2026/0 Comments/by OrthoNet AI

Spine Review

Understanding Sagittal Balance: Parameters and Clinical Significance

High-Yield Summary

Sagittal balance is critical for maintaining efficient posture and minimizing energy expenditure; disruption correlates strongly with pain and disability in spinal deformity and degenerative conditions.
Key radiographic parameters include pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL)and sagittal vertical axis (SVA); their interplay guides surgical planning.
Mismatch between pelvic incidence and lumbar lordosis (PI-LL mismatch >10°) predicts poor outcomes and is a primary target for corrective surgery.
Restoration of sagittal alignment improves clinical outcomes more than coronal correction alone in adult spinal deformity.
Surgical strategies must balance correction magnitude with patient-specific factors such as age, comorbiditiesand spinal flexibility to avoid complications like proximal junctional kyphosis (PJK).

Clinical Fundamentals

Anatomy and Biomechanics

Sagittal balance refers to the alignment of the spine and pelvis in the sagittal plane, ensuring the head is positioned over the pelvis with minimal muscular effort. The pelvis acts as a foundational unit, with three key parameters:

Pelvic Incidence (PI): An anatomical constant representing the angle between the perpendicular to the sacral endplate and the line connecting the sacral endplate midpoint to the femoral head axis. PI dictates the shape and orientation of the lumbar spine.
Pelvic Tilt (PT): The angle between the vertical and the line connecting the midpoint of the sacral endplate to the femoral heads; reflects compensatory pelvic retroversion.
Sacral Slope (SS): The angle between the sacral endplate and the horizontal; directly influences lumbar lordosis.

Lumbar lordosis (LL) must harmonize with PI to maintain sagittal balance. The sagittal vertical axis (SVA) measures the horizontal offset between the C7 plumb line and the posterior superior corner of S1, quantifying global alignment.

Epidemiology

Sagittal imbalance is prevalent in adult spinal deformity and degenerative lumbar conditions, increasing with age due to disc degeneration, facet arthropathyand vertebral fractures. It is a major contributor to chronic low back pain and disability, with a direct correlation between sagittal malalignment and health-related quality of life scores.

Classification & Diagnosis

Parameter	Definition & Clinical Relevance	Diagnostic Pearls & Pitfalls
Pelvic Incidence (PI)	Fixed anatomical parameter; guides target lumbar lordosis	Measure on standing lateral radiographs; avoid supine films
Pelvic Tilt (PT)	Reflects compensatory pelvic retroversion	Elevated PT indicates compensation; assess in context of SVA
Sacral Slope (SS)	Influences lumbar lordosis; SS + PT = PI	Ensure accurate sacral endplate identification
Lumbar Lordosis (LL)	Angle between L1 and S1 endplates; target LL ? PI ± 9°	Underestimation leads to undercorrection
Sagittal Vertical Axis (SVA)	Horizontal offset of C7 plumb line from S1; >5 cm indicates imbalance	Use full-length standing films; beware of patient positioning

Classification Systems Impacting Management

SRS-Schwab Adult Spinal Deformity Classification: Incorporates PI-LL mismatch, PTand SVA to stratify deformity severity and guide surgical thresholds.
Roussouly Classification: Categorizes lumbar lordosis types based on SS and PI, aiding in understanding individual sagittal profiles and surgical planning.

Decision-Making Algorithm

Non-Operative Management Criteria

SVA <5 cm with minimal PI-LL mismatch (<10°)
Absence of significant pain or neurological deficits
Adequate compensatory mechanisms (normal PT)
Patient preference and comorbidity profile precluding surgery

Operative Management Indications

Symptomatic sagittal imbalance with SVA >5 cm and PI-LL mismatch >10°
Progressive deformity causing pain, neurological compromiseor functional limitation
Failure of conservative measures including physical therapy and analgesia

Surgical Approach Selection

Posterior-only approaches: Preferred for flexible deformities and moderate correction; allows for osteotomies and instrumentation.
Anterior-posterior combined approaches: Indicated for rigid deformities requiring greater correction and anterior column support.
Osteotomy choice: Smith-Petersen osteotomy (SPO) for mild to moderate correction; pedicle subtraction osteotomy (PSO) for severe fixed kyphosis; vertebral column resection (VCR) reserved for complex, rigid deformities.

Implant selection focuses on achieving stable fixation with pedicle screws spanning the deformity and incorporating proximal junctional protection strategies.

Surgical Mastery & Pearls

Stepwise Conceptual Overview

Preoperative Planning: Quantify PI, PT, SS, LLand SVA on standing films; calculate PI-LL mismatch and determine correction goals.
Patient Positioning: Ensure neutral pelvic tilt; prone positioning with chest and pelvic bolsters to avoid iatrogenic malalignment.
Exposure and Instrumentation: Meticulous soft tissue handling; place pedicle screws with fluoroscopic or navigation assistance to optimize purchase and avoid neural injury.
Osteotomy Execution: Perform SPO or PSO with controlled resection of posterior elements; maintain spinal cord monitoring vigilance.
Correction Maneuvers: Gradual rod contouring and compression/distraction to restore lordosis; avoid overcorrection beyond physiological limits.
Final Alignment Check: Intraoperative radiographs or navigation to confirm restoration of sagittal parameters; adjust as needed.
Closure and Postoperative Care: Layered closure to minimize infection; early mobilization with bracing if indicated.

Intraoperative Red Flags

Sudden loss of neuromonitoring signals during osteotomy or correction
Excessive blood loss during vertebral resection
Difficulty in achieving planned correction due to rigid deformity or hardware failure
Signs of proximal junctional failure during rod contouring

Evidence-Based Synthesis

Landmark studies have established the primacy of sagittal balance restoration in improving patient-reported outcomes. Schwab et al. demonstrated that PI-LL mismatch >10° and SVA >5 cm correlate with worse Oswestry Disability Index (ODI) scores, guiding surgical targets. Recent prospective cohorts confirm that achieving age-adjusted alignment goals reduces mechanical complications and revision rates.

Controversy persists regarding the optimal osteotomy type and the extent of correction, with some data suggesting aggressive correction increases proximal junctional kyphosis risk. Emerging evidence supports individualized alignment goals based on age and frailty rather than uniform correction, reflecting a paradigm shift toward personalized deformity surgery.

Minimally invasive techniques show promise in select cases but lack robust long-term data. The role of spinopelvic parameters in predicting adjacent segment disease remains under investigation.

Master Class Pro-Tip

Mastery in sagittal balance correction hinges on integrating dynamic assessment of spinal flexibility with static radiographic parameters. Employ intraoperative neuromonitoring not only as a safety tool but as a real-time guide to the spinal cord’s tolerance for correction. Anticipate compensatory mechanisms by evaluating the entire kinetic chain-from cervical spine to lower extremities-to avoid under- or overcorrection. Finally, tailor alignment goals to the patient’s physiological age and functional demands rather than rigid numeric targets, balancing biomechanical ideals with clinical pragmatism to optimize durable outcomes.

August 2, 2026/0 Comments/by OrthoNet AI

Spine Review

A Review of Surgical Techniques for Cervical Laminoplasty

High-Yield Summary

Cervical laminoplasty decompresses the spinal cord by expanding the spinal canal while preserving posterior elements, minimizing post-laminectomy instability and kyphosis.
Key anatomical considerations include the laminae, facet jointsand the vertebral artery course; preserving facet integrity is critical to maintain stability.
Surgical approaches primarily include open-door and double-door laminoplasty, chosen based on pathology location and surgeon preference.
Indications focus on multilevel cervical myelopathy with preserved or mild lordotic alignment; kyphotic deformity or instability favors alternative procedures.
Intraoperative technical precision in hinge creation and laminar opening is essential to avoid hinge fracture, nerve root injuryand postoperative axial neck pain.

Clinical Fundamentals

Cervical laminoplasty addresses multilevel spinal cord compression by expanding the spinal canal posteriorly. The cervical spine’s posterior tension band comprises the laminae, spinous processesand facet joints, which contribute to stability and motion. The vertebral artery courses laterally through the transverse foramina, necessitating careful dissection during lateral gutter creation.

Biomechanically, laminoplasty preserves the posterior elements, reducing the risk of post-laminectomy kyphosis and instability compared to laminectomy alone. The procedure maintains cervical lordosis, which is essential for spinal cord decompression and neurological recovery.

Epidemiologically, cervical spondylotic myelopathy (CSM) is the most common indication, predominantly affecting patients over 50 years old with multilevel degenerative changes. Ossification of the posterior longitudinal ligament (OPLL) is another frequent indication, especially in East Asian populations.

Classification & Diagnosis

Classification System	Description	Surgical Implication
K-line (Fujiyoshi et al.)	Line connecting midpoints of spinal canal at C2 and C7 on lateral radiograph	Determines suitability for posterior decompression; K-line (+) indicates adequate posterior shift of cord post-laminoplasty
Nurick Grade	Clinical grading of myelopathy severity based on gait and function	Guides timing of surgery; higher grades correlate with worse prognosis
Modified Japanese Orthopaedic Association (mJOA) Score	Quantifies neurological impairment in CSM	Used for preoperative assessment and postoperative outcome measurement
Radiographic Alignment	Lordotic, neutralor kyphotic cervical curvature	Kyphosis contraindicates laminoplasty due to inadequate posterior cord shift

Diagnostic pearls include the use of MRI to assess cord compression, signal changes indicating myelomalaciaand dynamic radiographs to evaluate instability. Pitfalls include underestimating kyphotic deformity and failing to recognize OPLL extent, which may necessitate anterior or combined approaches.

Decision-Making Algorithm

Non-operative management is reserved for mild myelopathy without progressive neurological deficits or severe comorbidities precluding surgery. Indications for laminoplasty include:

Multilevel cervical stenosis (?3 levels) with myelopathy.
Preserved or mild lordotic cervical alignment.
Absence of significant instability or kyphosis.
Pathology predominantly posterior or central without significant anterior compression requiring direct anterior decompression.

Open-door laminoplasty is preferred when unilateral pathology or asymmetric compression exists, allowing targeted decompression. Double-door laminoplasty suits symmetric central stenosis and OPLL, providing midline expansion.

Alternative surgical options such as anterior cervical discectomy and fusion (ACDF) or posterior laminectomy with fusion are favored when kyphosis, instabilityor focal anterior pathology dominate.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Patient Positioning and Exposure

Prone position with head secured in a Mayfield clamp. Midline posterior cervical incision exposes spinous processes and laminae from C3 to C7.

Identification of Landmarks

Confirm levels with fluoroscopy. Preserve facet joints by limiting lateral dissection to the lamina-facet junction.

Hinge Creation

For open-door laminoplasty, create a complete trough on the “open” side and a greenstick hinge on the contralateral side by thinning the lamina without breaching the inner cortex. For double-door, split the spinous processes and laminae midline, creating bilateral hinges laterally.

Lamina Elevation and Fixation

Elevate the lamina to expand the canal. Secure with mini-plates, suturesor bone graft spacers to maintain the expanded position.

Hemostasis and Closure

Meticulous hemostasis to prevent epidural hematoma. Layered closure preserving nuchal ligament integrity reduces postoperative axial pain.

Intraoperative Red Flags

Hinge fracture leading to loss of laminar stability.
Excessive lateral dissection risking vertebral artery injury.
Inadequate decompression if lamina elevation is insufficient.
Excessive facet joint violation causing postoperative instability.

Technical tips include using high-speed burrs for controlled hinge thinning, intraoperative neuromonitoring to detect nerve root irritationand preserving the C7 spinous process to reduce axial neck pain.

Evidence-Based Synthesis

Landmark studies demonstrate laminoplasty’s efficacy in improving neurological function in multilevel CSM with lower complication rates compared to laminectomy with fusion. The K-line concept refined patient selection, reducing poor outcomes in kyphotic spines.

Recent randomized controlled trials comparing open-door and double-door techniques show comparable neurological outcomes; however, open-door may have shorter operative times and less blood loss. Meta-analyses highlight persistent challenges with postoperative axial neck pain, prompting innovations in muscle-sparing approaches.

Controversy remains regarding the optimal fixation method for laminar elevation and the role of laminoplasty in OPLL with severe anterior compression. Emerging data suggest that combining laminoplasty with limited anterior decompression may optimize outcomes in select cases.

Master Class Pro-Tip

Mastery in cervical laminoplasty hinges on the precision of hinge creation: a controlled greenstick fracture preserves laminar vascularity and mechanical integrity, preventing hinge collapse and restenosis. Employ intraoperative 3D navigation or ultrasound to confirm hinge integrity and laminar elevation in real time. This nuanced control differentiates a competent surgeon from a master, ensuring durable decompression with minimal morbidity.

July 19, 2026/0 Comments/by OrthoNet AI

Spine Review

Management of C1 (Atlas) Fractures: From Conservative Care to Internal Fixation

High-Yield Summary

C1 (atlas) fractures primarily involve the anterior and posterior arches; stability hinges on the integrity of the transverse atlantal ligament (TAL).
Non-displaced, stable fractures with intact TAL are managed conservatively with rigid cervical immobilization.
Displaced fractures or those with TAL disruption require surgical stabilization to prevent atlantoaxial instability and neurologic compromise.
Surgical options include posterior C1 lateral mass fixation or combined C1-C2 fusion, chosen based on fracture pattern and TAL status.
Accurate classification and imaging (CT and MRI) are critical to guide management and avoid missed instability.

Clinical Fundamentals

Anatomy:
The atlas (C1) is a ring-shaped vertebra composed of anterior and posterior arches connected by two lateral masses. It lacks a vertebral body and spinous process. The transverse atlantal ligament (TAL) secures the odontoid process of C2 against the anterior arch, maintaining atlantoaxial stability.

Biomechanics:
The atlas supports the skull and facilitates nodding and rotation. The TAL resists anterior displacement of C1 on C2, preventing atlantoaxial subluxation. Disruption of the TAL compromises ring integrity, converting a stable fracture into an unstable injury.

Epidemiology:
C1 fractures account for approximately 2% of cervical spine fractures, often resulting from axial loading injuries such as falls or motor vehicle collisions. Elderly patients may sustain these fractures from low-energy trauma.

Classification & Diagnosis

Classification System	Description	Clinical Impact on Management
Jefferson Classification	Differentiates fractures by involvement of anterior/posterior arches and lateral masses	Guides assessment of ring disruption and potential instability
Dickman Classification (TAL injury)	Type I: Ligamentous disruption; Type II: Bony avulsion of TAL	Type I injuries generally require surgical fixation; Type II may heal with immobilization
CT Imaging	High-resolution axial and coronal views to delineate fracture pattern	Essential for detecting displacement and lateral mass spread
MRI	Evaluates TAL integrity and soft tissue injury	Critical for identifying occult instability not seen on CT

Diagnostic Pearls:

A lateral mass displacement >7 mm on open-mouth radiographs or CT suggests TAL rupture and instability.

MRI is mandatory when TAL injury is suspected despite minimal displacement.

Avoid underestimating instability in isolated anterior arch fractures without TAL assessment.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Fracture Stability	Stable ring with intact TAL	Unstable ring with TAL disruption or significant displacement
Displacement	Lateral mass displacement <7 mm	Lateral mass displacement ?7 mm or comminution
Neurologic Status	Neurologically intact	Neurologic deficit or progressive symptoms
Patient Factors	Ability to tolerate immobilization	Failed conservative treatment or contraindications to prolonged immobilization

Why Specific Approaches:

Conservative care with rigid cervical orthosis (e.g., hard collar or halo vest) allows healing in stable fractures by limiting motion and promoting ligamentous repair.

Posterior C1 lateral mass fixation preserves motion at C1-C2 and is preferred in isolated unstable C1 fractures with TAL disruption.

Combined C1-C2 fusion is reserved for complex fractures involving both vertebrae or when TAL injury precludes isolated C1 fixation.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview:

Preoperative Planning: Confirm fracture pattern and TAL status via CT and MRI. Plan fixation trajectory and implant selection.

Patient Positioning: Prone with head fixed in a Mayfield clamp to maintain neutral alignment and facilitate fluoroscopy.

Exposure: Midline posterior cervical incision exposing C1 lateral masses and C2 pedicles. Preserve soft tissue attachments to minimize blood loss.

Screw Placement:

Identify C1 lateral mass entry point (junction of posterior arch and lateral mass).

Use fluoroscopy or navigation to guide trajectory, avoiding vertebral artery and spinal canal.

Insert screws bicortically for optimal purchase.

Rod Fixation and Compression: Connect screws with rods; apply compression to reduce fracture fragments and restore alignment.

Fusion: Decorticate posterior elements and apply autograft or allograft to promote fusion.

Closure: Layered closure with attention to hemostasis.

Intraoperative Red Flags:

Vertebral artery injury risk during lateral mass screw placement-confirm anatomy preoperatively.

Excessive lateral mass displacement may complicate screw insertion; consider alternative fixation.

Inadequate reduction risks persistent instability and nonunion.

Evidence-Based Synthesis

Recent literature emphasizes the pivotal role of TAL integrity in determining stability and guiding treatment. Studies demonstrate that non-operative management of stable C1 fractures with intact TAL yields excellent outcomes with low complication rates. Conversely, TAL disruption correlates with higher failure rates of conservative care and increased risk of late instability.

Randomized controlled trials comparing halo vest immobilization to rigid collars show similar fusion rates but higher morbidity with halo use, shifting preference toward rigid collars when feasible. Advances in posterior fixation techniques, including C1 lateral mass screws, have improved biomechanical stability and preserved cervical motion compared to traditional C1-C2 fusion.

Controversy persists regarding management of Type II TAL injuries (bony avulsions), with some evidence supporting conservative treatment if fragment size and displacement are minimal. However, consensus favors surgical fixation in displaced or comminuted fractures to prevent chronic instability.

Master Class Pro-Tip

When performing posterior C1 lateral mass fixation, meticulous preoperative CT angiography to delineate vertebral artery anatomy is indispensable. Intraoperative navigation or 3D fluoroscopy significantly reduces screw malposition risk. Prioritize preserving the posterior arch and soft tissue envelope to maintain vascularity and promote fusion. Mastery lies in balancing rigid fixation with motion preservation, tailoring the construct to fracture morphology and ligamentous status rather than defaulting to fusion.

July 5, 2026/0 Comments/by OrthoNet AI

Spine Review

Understanding the Classification and Management of Sacral Fractures

High-Yield Summary

Sacral fractures require precise classification to guide management; instability and neurological involvement are key determinants for surgery.
The Denis classification remains the cornerstone for assessing fracture zone and neurological risk, while the AO Spine Sacral Classification refines surgical decision-making.
Non-operative treatment is reserved for stable, non-displaced fractures without neurological deficit; operative intervention is indicated for instability, displacementor nerve injury.
Surgical approaches and fixation strategies must address biomechanical demands and avoid iatrogenic nerve injury, with percutaneous techniques favored when feasible.
Recent evidence supports early stabilization to improve neurological outcomes and reduce complications, but optimal fixation constructs remain debated.

Clinical Fundamentals

The sacrum forms the keystone of the pelvic ring, transmitting axial loads from the spine to the lower extremities. It articulates with the lumbar spine via the lumbosacral junction and with the ilia through the sacroiliac joints. The sacral canal houses the sacral nerve roots, critical for lower limb motor and sensory function, as well as bowel, bladderand sexual function.

Biomechanically, the sacrum resists vertical shear, axial compressionand torsional forces. Fractures often result from high-energy trauma, such as motor vehicle collisions or falls from height, but low-energy insufficiency fractures occur in osteoporotic patients. Epidemiologically, sacral fractures are uncommon but frequently associated with pelvic ring injuries and spinal trauma, requiring a multidisciplinary approach.

Classification & Diagnosis

Classification System	Description	Clinical Impact	Diagnostic Pearls	Common Pitfalls
Denis Classification	Divides sacrum into three zones: Zone I (alar), Zone II (foramina), Zone III (central canal)	Guides neurological risk assessment	Zone III fractures have highest nerve injury risk	Overlooking subtle Zone II fractures on X-ray
AO Spine Sacral Classification	Categorizes fractures by morphology (A: lower sacrum, B: posterior pelvic ring, C: spinopelvic dissociation)	Dictates surgical approach and fixation type	CT with 3D reconstructions essential for morphology	Misclassification due to poor imaging quality
Roy-Camille Classification	Focuses on transverse fractures and displacement patterns	Predicts instability and neurological compromise	MRI for nerve root assessment	Underestimating displacement magnitude

Diagnostic imaging must include pelvic radiographs, CT scans with 3D reconstructionsand MRI when neurological deficits are present. Neurological examination should focus on motor, sensoryand sphincter function. Electrophysiological studies may assist in ambiguous cases.

Decision-Making Algorithm

Non-operative management is appropriate for:

Stable fractures confined to Denis Zone I without displacement.
Absence of neurological deficit.
Minimal pelvic ring disruption.

Operative management is indicated for:

Displaced fractures causing mechanical instability.
Denis Zone II and III fractures with neurological impairment.
Spinopelvic dissociation (AO Type C) requiring spinopelvic fixation.
Associated pelvic ring injuries necessitating stabilization.

Surgical approach selection depends on fracture morphology and neurological status. Percutaneous iliosacral screw fixation is preferred for minimally displaced Zone I and II fractures. Open reduction and internal fixation (ORIF) with lumbopelvic fixation is reserved for unstable or spinopelvic dissociation injuries. Sacral laminectomy is indicated for decompression in cases of nerve root compression.

Surgical Mastery & Pearls

Step 1: Preoperative Planning

Review high-resolution CT and MRI to delineate fracture pattern and neural involvement.

Plan screw trajectories using navigation or fluoroscopy to minimize nerve injury risk.

Step 2: Patient Positioning

Prone or supine positioning based on surgical approach and associated injuries.

Ensure adequate padding and access for imaging.

Step 3: Reduction

Achieve indirect reduction via pelvic manipulation or direct open reduction for displaced fractures.

Avoid excessive force to prevent iatrogenic nerve damage.

Step 4: Fixation

Percutaneous iliosacral screws placed under fluoroscopic guidance for Zone I/II fractures.

Lumbopelvic fixation involves pedicle screws in L4/L5 and iliac screws connected by rods for spinopelvic dissociation.

Confirm hardware placement intraoperatively with imaging.

Intraoperative Red Flags:

Sudden loss of neuromonitoring signals mandates immediate assessment for screw malposition or nerve compression.

Excessive bleeding from presacral venous plexus requires prompt hemostasis.

Difficulty in screw placement may indicate aberrant sacral anatomy; consider navigation assistance.

Evidence-Based Synthesis

Landmark studies have established the Denis classification as predictive of neurological injury risk, but recent data advocate for the AO Spine Sacral Classification to better guide surgical strategy. Prospective cohorts demonstrate improved neurological recovery with early decompression and stabilization, although randomized trials are lacking.

Comparative studies of fixation techniques reveal that percutaneous iliosacral screws reduce operative time and blood loss but may be insufficient for spinopelvic dissociation, where lumbopelvic fixation offers superior biomechanical stability. However, the optimal timing and extent of decompression remain debated, with some evidence suggesting that delayed surgery may still yield acceptable outcomes in select patients.

Emerging literature highlights the role of minimally invasive techniques and navigation to reduce complications, but long-term functional outcomes and implant survivorship require further investigation.

Master Class Pro-Tip

Mastery in sacral fracture management hinges on integrating detailed preoperative imaging with intraoperative neuromonitoring and navigation. Prioritize anatomical reduction of the posterior pelvic ring to restore load transmission and prevent chronic instability. When performing percutaneous fixation, meticulously plan screw trajectories to avoid sacral foramina and neural elements-small deviations can cause catastrophic nerve injury. In spinopelvic dissociation, construct rigidity is paramount; augment fixation with dual iliac screws and cross-links to withstand multidirectional forces. Finally, anticipate and manage presacral venous bleeding proactively by maintaining a clear surgical field and having hemostatic agents ready-this subtle preparation distinguishes the expert surgeon from the competent.

June 21, 2026/0 Comments/by OrthoNet AI

Spine Review

Current Concepts in the Treatment of Basilar Invagination and Platybasia

High-Yield Summary

Basilar invagination (BI) and platybasia represent craniovertebral junction (CVJ) deformities causing brainstem and upper cervical spinal cord compression, often requiring precise radiographic assessment and tailored surgical intervention.
Key surgical goals include decompression, stabilization, and realignment; choice of approach depends on reducibility and neurological status.
Dynamic imaging and CT-based morphometrics guide classification and operative planning, distinguishing reducible from irreducible BI.
Posterior fixation with or without occipitocervical fusion is standard for reducible BI; irreducible cases often require anterior decompression or distraction techniques.
Mastery of CVJ anatomy and intraoperative neuromonitoring is critical to avoid catastrophic neurovascular injury.

Clinical Fundamentals

Anatomy and Biomechanics

The craniovertebral junction comprises the occiput, atlas (C1), and axis (C2), forming a complex articulation that balances mobility and stability. The clivus and basilar part of the occipital bone form the anterior cranial base, while the odontoid process projects superiorly from C2. The foramen magnum transmits the medulla and vertebral arteries, making this region vulnerable to compression from BI and platybasia.

Biomechanically, the CVJ allows flexion-extension, axial rotation, and lateral bending. Stability is maintained by the transverse ligament, alar ligaments, and bony congruity. Disruption or congenital malformation leads to abnormal odontoid migration (BI) and flattening of the skull base angle (platybasia), altering load transmission and risking neural compression.

Epidemiology

BI and platybasia are rare but clinically significant, often associated with congenital syndromes (e.g., rheumatoid arthritis, basilar impression secondary to bone dysplasias). Presentation ranges from asymptomatic to progressive myelopathy or lower cranial nerve deficits. Early recognition is essential to prevent irreversible neurological damage.

Classification & Diagnosis

Classification System	Criteria	Clinical Relevance	Diagnostic Pearls	Common Pitfalls
Goel Classification	Type A: BI with atlantoaxial instability; Type B: BI without instability	Guides surgical approach-Type A favors posterior fixation; Type B may require anterior decompression	Dynamic flexion-extension radiographs to assess reducibility	Overreliance on static imaging may miss instability
Chamberlain’s Line	Odontoid tip >5 mm above line from posterior hard palate to opisthion	Screening for BI	Use sagittal CT/MRI for accurate measurement	Misidentification of landmarks on plain films
Wackenheim’s Clival Line	Line along clivus should intersect odontoid	Assesses odontoid invagination	Helpful in conjunction with Chamberlain’s line	Variability in clival morphology can mislead
Platybasia Angle	Basal angle >140° indicates platybasia	Correlates with skull base flattening and brainstem compression	CT-based angular measurement preferred	Radiographic distortion in severe deformity

Diagnostic pearls include the necessity of high-resolution CT for bony anatomy and MRI for neural element assessment. Dynamic imaging is crucial to differentiate reducible from fixed deformities, directly impacting surgical strategy.

Decision-Making Algorithm

Clinical Scenario	Radiographic Findings	Management Strategy	Rationale
Asymptomatic or mild symptoms, reducible BI	Odontoid reduces on flexion-extension; no significant cord compression	Non-operative: observation, cervical collar	Avoids surgical morbidity; monitor progression
Symptomatic with reducible BI and instability	Dynamic imaging shows odontoid reduction; neurological deficits present	Posterior fixation (C1-C2 or occipitocervical fusion)	Stabilizes CVJ, prevents further invagination, allows indirect decompression
Irreducible BI with ventral brainstem compression	Odontoid fixed above Chamberlain’s line; cord compression on MRI	Anterior decompression (transoral, endoscopic endonasal) ± posterior fusion	Direct decompression of odontoid; posterior fusion for stability
Platybasia with neurological compromise	Basal angle >140°, brainstem compression	Surgical realignment with distraction and fixation	Restores normal skull base angle, decompresses neural structures

The choice between anterior and posterior approaches hinges on reducibility and neurological status. Posterior fixation is preferred when reduction is achievable, minimizing morbidity. Irreducible cases necessitate anterior decompression, often combined with posterior stabilization to maintain alignment.

Surgical Mastery & Pearls

Posterior Fixation Technique

Position patient prone with head secured in a Mayfield clamp, ensuring neutral or slightly extended alignment to facilitate reduction.
Expose the posterior elements of C1 and C2 via midline incision; preserve muscular attachments to maintain stability.
Identify and protect the vertebral artery using preoperative CT angiography as a roadmap.
Place C1 lateral mass screws and C2 pedicle or pars screws under fluoroscopic guidance; confirm trajectory to avoid vertebral artery injury.
Apply rods and perform compression or distraction maneuvers to achieve reduction of BI.
Decorticate posterior elements and apply autograft or allograft for fusion.

Intraoperative red flags: Sudden loss of neuromonitoring signals may indicate cord compromise; vertebral artery bleeding requires immediate tamponade and vascular surgery consultation.

Anterior Decompression Technique

Utilize transoral or endoscopic endonasal approach based on surgeon expertise and patient anatomy.
Carefully expose the anterior arch of C1 and odontoid process; maintain meticulous hemostasis.
Resect the odontoid tip and any compressive soft tissue under direct visualization.
Avoid excessive resection to prevent destabilization; plan for posterior fusion post-decompression.

Technical tips: Use neuronavigation and intraoperative CT to confirm extent of decompression; maintain sterile technique to reduce infection risk.

Evidence-Based Synthesis

Recent literature emphasizes the superiority of posterior fixation in reducible BI, supported by Goel et al.’s series demonstrating neurological improvement and fusion rates exceeding 90%. Advances in screw fixation techniques have reduced vertebral artery injury rates and improved biomechanical stability.

Conversely, anterior decompression remains indispensable for irreducible BI, with endoscopic endonasal approaches gaining favor due to reduced morbidity compared to traditional transoral routes. However, randomized trials comparing these approaches are lacking, and surgeon experience remains a critical determinant.

Emerging evidence suggests that early surgical intervention before severe myelopathy yields better outcomes, but the timing and extent of surgery remain debated. The role of intraoperative neuromonitoring and 3D navigation continues to evolve, enhancing safety profiles.

Master Class Pro-Tip

Mastery in treating BI and platybasia hinges on anticipating the dynamic interplay between reduction maneuvers and neural element tolerance. Prioritize staged procedures when necessary: achieve posterior stabilization first to allow gradual realignment, then perform anterior decompression if residual ventral compression persists. This staged approach minimizes intraoperative risk and optimizes neurological recovery, distinguishing the expert surgeon from the competent practitioner.

June 7, 2026/0 Comments/by OrthoNet AI

Spine Review

A Guide to the Diagnosis and Management of Cauda Equina Syndrome

High-Yield Summary

Cauda Equina Syndrome (CES) is a surgical emergency characterized by compression of the lumbosacral nerve roots, requiring urgent decompression within 48 hours to optimize neurological recovery.
Key clinical features include bilateral lower extremity weakness, saddle anesthesia, bladder/bowel dysfunction, and variable lower limb sensory loss.
MRI is the diagnostic gold standard; clinical suspicion must prompt immediate imaging and surgical consultation.
Surgical decompression via laminectomy or discectomy is the definitive treatment; timing and extent of decompression dictate functional outcomes.
Early recognition and intervention reduce permanent neurological deficits and improve quality of life.

Clinical Fundamentals

Relevant Anatomy

The cauda equina comprises the distal lumbar and sacral nerve roots (L2-S5) within the lumbar spinal canal below the conus medullaris, housed in the thecal sac. These roots innervate the lower limbs, bladder, bowel, and perineum. The spinal canal narrows at L4-L5 and L5-S1, common sites for compressive pathology.

Biomechanics

The lumbar spine transmits axial load and allows flexion-extension, lateral bending, and rotation. Disc herniations or fractures can impinge on the cauda equina, especially in hyperflexion or axial loading injuries. The nerve roots are vulnerable to ischemia and mechanical compression, leading to rapid neurological deterioration.

Epidemiology

CES is rare, occurring in 1 per 33,000 to 100,000 annually. Most cases result from massive lumbar disc herniation (45%), followed by trauma, tumors, infections, or spinal stenosis. Early diagnosis is critical due to the risk of irreversible deficits.

Classification & Diagnosis

Classification System	Description	Impact on Management
Incomplete CES (CES-I)	Partial saddle anesthesia, mild bladder dysfunction, preserved voluntary anal contraction	Urgent decompression indicated; prognosis better with early surgery
Complete CES (CES-R)	Complete loss of saddle sensation, urinary retention, absent anal tone	Emergent decompression required; prognosis guarded
CES with Retention (CES-Ret)	Urinary retention present, variable motor/sensory deficits	Surgical urgency increased; delayed surgery worsens outcomes

Diagnostic Pearls

Red Flag Symptoms: Acute onset of bilateral sciatica, perineal numbness, urinary retention or incontinence, and lower limb weakness should raise suspicion.
Physical Exam: Assess perianal sensation, bulbocavernosus reflex, anal tone, and lower limb motor/sensory function.
Imaging: MRI with T2-weighted sequences is mandatory to identify compressive lesions; CT myelography if MRI contraindicated.
Pitfalls: Isolated unilateral symptoms do not exclude CES; early bladder dysfunction may be subtle or absent. Delayed imaging leads to irreversible damage.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Neurological Status	No CES signs, mild radiculopathy	CES-I or CES-R, progressive deficits
Imaging Findings	No significant canal compromise	MRI-confirmed compression of cauda equina
Symptom Duration	Symptoms <48 hours without deficits	Symptoms >48 hours or with bladder/bowel dysfunction
Etiology	Non-compressive causes (e.g., inflammatory)	Disc herniation, fracture, tumor causing compression

Surgical Approach Rationale

Posterior Laminectomy: Standard for decompression of central canal stenosis or large disc herniations.
Discectomy: Preferred when herniated disc is the compressive agent; minimizes bony resection.
Extended Decompression: Required for tumors or infection with extensive involvement.
Timing: Surgery within 24-48 hours of symptom onset maximizes neurological recovery; delays correlate with worse outcomes.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Patient Positioning: Prone on a radiolucent table with adequate padding to avoid abdominal compression.
Exposure: Midline posterior approach; subperiosteal dissection to expose laminae at involved levels.
Decompression: Perform laminectomy or laminotomy to expose the thecal sac; carefully retract dura to identify compressive pathology.
Removal of Compressing Lesion: Excise herniated disc fragments or tumor with microsurgical technique to minimize nerve root manipulation.
Dural Inspection: Confirm pulsatile dura and absence of residual compression; repair any incidental durotomy immediately.
Closure: Layered closure to prevent CSF leak; consider drain placement if extensive decompression performed.

Intraoperative Red Flags

Excessive dural tension or swelling indicating ongoing compression.
Non-pulsatile dura suggesting incomplete decompression or vascular compromise.
Bleeding from epidural veins requiring meticulous hemostasis to maintain clear visualization.
Nerve root adherence or scarring necessitating delicate dissection to avoid iatrogenic injury.

Evidence-Based Synthesis

Landmark studies consistently demonstrate that surgical decompression within 48 hours of symptom onset significantly improves bladder, bowel, and motor recovery. The 2018 systematic review by Ahn et al. reinforced early surgery as the standard, though some data suggest that outcomes may still improve with intervention up to 72 hours in select cases. Contradictions exist regarding the prognostic value of preoperative bladder dysfunction severity; some cohorts show poor recovery despite early surgery, highlighting the need for individualized assessment.

Recent high-impact literature emphasizes the role of MRI not only for diagnosis but also for prognostication, with T2 hyperintensity within nerve roots correlating with worse outcomes. Advances in minimally invasive decompression techniques are emerging but require further validation before supplanting open approaches.

The current consensus prioritizes rapid diagnosis, urgent MRI, and decompression within 48 hours. Non-operative management is reserved for patients without neurological deficits or those with non-compressive etiologies.

Master Class Pro-Tip

Mastery in CES management hinges on anticipating the dynamic nature of nerve root ischemia. Beyond timely decompression, meticulous intraoperative assessment of dural pulsatility and nerve root mobility guides completeness of decompression. Employ intraoperative neuromonitoring selectively to detect subtle nerve root compromise. Postoperative vigilance for early signs of re-compression or CSF leak, coupled with aggressive rehabilitation, distinguishes the surgeon who merely treats CES from one who restores function and quality of life.

May 24, 2026/0 Comments/by OrthoNet AI

Spine Review

Pathophysiology and Surgical Management of Ossification of the Posterior Longitudinal Ligament (OPLL)

High-Yield Summary

Ossification of the Posterior Longitudinal Ligament (OPLL) is a progressive hyperostotic condition causing spinal canal narrowing and myelopathy, predominantly affecting the cervical spine in East Asian populations but increasingly recognized worldwide.
Surgical intervention is indicated for progressive myelopathy or significant canal compromise; approach selection hinges on OPLL morphology, spinal alignment, and extent of ossification.
Anterior decompression is preferred for focal, segmental OPLL with lordotic alignment, while posterior approaches (laminoplasty or laminectomy with fusion) suit multilevel or continuous OPLL with preserved or neutral alignment.
Intraoperative challenges include dural adherence and risk of cerebrospinal fluid (CSF) leak; meticulous dissection and readiness for dural repair are critical.
Recent evidence favors tailored surgical strategies based on OPLL classification and sagittal balance, improving neurological outcomes and minimizing complications.

Clinical Fundamentals

Relevant Anatomy and Biomechanics

The posterior longitudinal ligament (PLL) runs along the posterior aspect of vertebral bodies within the spinal canal, providing tensile support and limiting hyperflexion. Ossification leads to rigid, hypertrophic plaques that encroach on the spinal cord, causing chronic compression and ischemia. The cervical spine is most commonly affected due to its mobility and biomechanical stress.

Biomechanically, OPLL reduces segmental motion and alters load distribution, often resulting in compensatory hypermobility at adjacent levels. Cervical lordosis influences surgical planning: lordotic spines tolerate posterior decompression better, while kyphotic or straight spines may require anterior decompression to directly remove the ossified mass.

Epidemiology

OPLL prevalence varies by ethnicity, highest in East Asian populations (up to 4.3% in Japan), with a male predominance. It typically presents in the 5th to 7th decades. Genetic predisposition and metabolic factors such as diabetes mellitus contribute to pathogenesis. The natural history involves gradual progression, with myelopathy developing insidiously.

Classification & Diagnosis

Classification System	Description	Surgical Relevance
Japanese Ministry of Health Classification	Segmental, Continuous, Mixed, and Localized types based on radiographic morphology	Guides extent of decompression and approach selection
K-line Classification	K-line (+) if OPLL does not cross a line connecting C2 and C7 posterior margins; K-line (-) if it does	K-line (-) predicts poor posterior decompression outcomes, favoring anterior surgery
Radiographic Assessment	CT for ossification extent and morphology; MRI for cord signal changes and myelopathy severity	Essential for surgical planning and prognostication

Diagnostic Pearls

CT is gold standard for delineating ossification morphology and thickness; MRI assesses spinal cord compression and signal changes indicating myelomalacia.
K-line status is a critical predictor of posterior decompression success; failure to assess may lead to suboptimal approach choice.
Beware of underestimating dural ossification, which increases risk of CSF leak during anterior surgery.

Decision-Making Algorithm

Clinical Scenario	Non-Operative Management	Operative Management	Rationale
Mild myelopathy without progression	Observation, physical therapy, and medical management	Not indicated	Risk of progression low; surgery reserved for deterioration
Progressive myelopathy or significant cord compression	Not appropriate	Surgical decompression indicated	Prevent irreversible neurological decline
Focal OPLL with lordotic cervical alignment and K-line (+)	Possible trial if mild symptoms	Anterior decompression and fusion preferred	Direct removal of ossification with restoration of alignment
Multilevel continuous OPLL with neutral or kyphotic alignment and K-line (-)	Not appropriate	Posterior decompression (laminoplasty or laminectomy with fusion)	Indirect decompression with preservation of motion or stabilization
Presence of dural ossification	Conservative if asymptomatic	Anterior approach with dural repair or posterior approach preferred	High risk of CSF leak; approach tailored to minimize complications

Surgical Mastery & Pearls

Anterior Approach (Corpectomy or Discectomy with Fusion)

Position patient supine with slight neck extension; use intraoperative neuromonitoring.
Identify and protect recurrent laryngeal nerve and esophagus.
Perform careful discectomy or corpectomy to expose ossified PLL; avoid aggressive manipulation to prevent dural tears.
Use high-speed burr to thin ossification before piecemeal removal.
Prepare for dural repair materials and fibrin sealants in case of CSF leak.
Stabilize with anterior plating and bone graft to maintain alignment.

Posterior Approach (Laminoplasty or Laminectomy with Fusion)

Position prone with head fixed in neutral or slight extension.
For laminoplasty, create bilateral gutters and elevate laminae to expand canal volume; preserve muscle attachments to maintain stability.
For laminectomy with fusion, remove laminae and instrument lateral masses or pedicles to prevent post-laminectomy kyphosis.
Monitor spinal cord function continuously; avoid excessive traction or manipulation.
Consider fusion in patients with preoperative kyphosis or instability risk.

Intraoperative Red Flags

Excessive bleeding from epidural veins-maintain hemostasis to preserve visualization.
Dural adherence or ossification-proceed cautiously to avoid tears.
Sudden neuromonitoring changes-pause and reassess surgical maneuvers.
Post-decompression spinal cord swelling-anticipate and manage with steroids or CSF drainage if needed.

Evidence-Based Synthesis

Landmark studies have established that surgical decompression improves neurological outcomes in OPLL-related myelopathy, but approach selection remains nuanced. The K-line concept, introduced by Fujiyoshi et al., revolutionized surgical planning by predicting posterior decompression efficacy. Subsequent meta-analyses confirm anterior surgery yields superior neurological recovery in K-line (-) patients but carries higher complication rates, including CSF leaks.

Recent randomized controlled trials comparing laminoplasty versus laminectomy with fusion demonstrate comparable neurological outcomes, with fusion reducing postoperative kyphosis and instability. However, controversy persists regarding the optimal approach for mixed-type OPLL and patients with borderline sagittal alignment.

Emerging data on minimally invasive posterior techniques and intraoperative navigation show promise but require further validation. The role of dural ossification in surgical risk stratification is increasingly recognized, prompting development of tailored dural repair strategies.

Master Class Pro-Tip

Mastery in OPLL surgery demands not only technical precision but also anticipatory strategy: preoperatively integrate K-line status, sagittal alignment, and dural ossification into a unified surgical plan. Intraoperatively, adopt a “less is more” philosophy when dissecting ossified dura-prioritize indirect decompression if dural adherence is severe. Postoperative vigilance for subtle neurological changes and early imaging can detect complications before irreversible deficits develop, elevating patient outcomes from good to exceptional.

May 10, 2026/0 Comments/by OrthoNet AI

Spine Review

Management of Osteoporotic Vertebral Compression Fractures

High-Yield Summary

Osteoporotic vertebral compression fractures (OVCFs) primarily affect the anterior column, leading to wedge deformities and sagittal imbalance; early recognition and management prevent chronic disability.
Non-operative treatment is first-line for stable fractures without neurologic compromise, focusing on pain control, mobilization, and osteoporosis management.
Indications for surgery include progressive deformity, intractable pain, neurologic deficit, or failure of conservative therapy beyond 6-8 weeks.
Vertebral augmentation (kyphoplasty or vertebroplasty) offers pain relief and height restoration but is reserved for select patients without posterior wall compromise or canal compromise.
Instrumented fixation with or without anterior column reconstruction is reserved for unstable fractures, neurologic deficits, or severe kyphosis, requiring careful implant selection due to poor bone quality.

Clinical Fundamentals

Relevant Anatomy and Biomechanics

The vertebral body bears axial load, with the anterior column accounting for approximately 80% of weight transmission. Osteoporotic bone exhibits decreased trabecular density and cortical thinning, predisposing to anterior wedge fractures under axial compression and flexion forces. The posterior elements and ligamentous structures often remain intact in isolated compression fractures, preserving stability unless disrupted. Sagittal balance depends on vertebral height and alignment; loss of anterior height leads to kyphotic deformity, increasing mechanical stress on adjacent segments.

Epidemiology

OVCFs are the most common fragility fractures in the elderly, with incidence rising sharply after age 70. Women are disproportionately affected due to postmenopausal osteoporosis. Many fractures are clinically silent or present with nonspecific back pain, leading to underdiagnosis. The risk of subsequent fractures increases significantly after an initial OVCF, underscoring the importance of systemic osteoporosis treatment.

Classification & Diagnosis

Classification System	Description	Impact on Management
Genant Semi-Quantitative	Grades vertebral deformity by height loss: Grade 1 (20-25%), Grade 2 (25-40%), Grade 3 (>40%)	Guides severity assessment; Grade 2-3 may warrant intervention beyond analgesia.
AO Spine Thoracolumbar Classification	Type A1 (wedge compression), A2 (split), A3 (incomplete burst), A4 (complete burst)	Differentiates stable from unstable fractures; burst fractures (A3, A4) often require surgery.
Denis Classification	Divides vertebra into anterior, middle, posterior columns; instability if middle or posterior column involved	Identifies fractures at risk for neurologic injury; posterior column involvement mandates surgical consideration.

Diagnostic Pearls

MRI is the gold standard for acute fracture detection and differentiating acute from chronic fractures via bone marrow edema patterns.
CT is essential for assessing cortical breach, posterior wall involvement, and canal compromise.
Beware of missed posterior element fractures on plain radiographs; always correlate clinically and consider advanced imaging.
Evaluate for neurologic deficits meticulously; subtle signs may indicate retropulsed fragments.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Stability	Stable fracture with intact posterior elements	Unstable fracture with posterior column disruption
Neurologic Status	No neurologic deficit	Progressive or new neurologic deficit
Pain	Controlled with analgesics and mobilization	Intractable pain refractory to 6-8 weeks of conservative care
Deformity	Minimal kyphosis (<20°) and no progression	Progressive kyphosis >20°, sagittal imbalance
Imaging	No canal compromise or retropulsed fragments	Canal compromise, retropulsed fragments causing neural compression

Surgical Approach and Implant Selection

Posterior percutaneous instrumentation with cement augmentation is preferred for stabilization in poor bone quality.
Anterior column reconstruction with cages or structural grafts is indicated for severe vertebral body collapse or burst fractures with canal compromise.
Vertebral augmentation techniques are reserved for pain relief in stable fractures without neurologic involvement.
Avoid extensive fusion in elderly patients unless necessary to minimize morbidity.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Preoperative Planning: Assess bone quality, fracture morphology, and sagittal alignment. Optimize medical comorbidities and osteoporosis treatment.
Positioning: Prone on a radiolucent table with padding to reduce abdominal pressure and venous engorgement.
Exposure: For percutaneous fixation, use fluoroscopic landmarks to minimize soft tissue disruption. Open approaches require careful dissection to preserve paraspinal musculature.
Instrumentation: Use fenestrated pedicle screws with polymethylmethacrylate (PMMA) augmentation to enhance fixation in osteoporotic bone.
Vertebral Augmentation: Balloon kyphoplasty restores height and reduces kyphosis; avoid in fractures with posterior wall disruption to prevent cement leakage.
Decompression: Indicated if neurologic deficit is present; perform laminectomy or corpectomy as dictated by canal compromise.
Fusion: Use autograft or allograft with supplemental instrumentation; limit fusion levels to reduce morbidity.

Intraoperative Red Flags

Cement extravasation into the canal or venous system during augmentation.
Pedicle breach on screw insertion, risking neurologic injury.
Excessive blood loss in open procedures, especially in elderly with comorbidities.
Failure to restore sagittal alignment leading to persistent deformity.

Evidence-Based Synthesis

Landmark randomized controlled trials have established non-operative management as effective for most stable OVCFs, emphasizing early mobilization and osteoporosis treatment. Vertebral augmentation trials demonstrate significant short-term pain relief and functional improvement but show mixed results regarding long-term outcomes and fracture risk at adjacent levels. Recent meta-analyses suggest kyphoplasty may offer superior height restoration compared to vertebroplasty but with similar complication profiles.

Surgical fixation in unstable fractures with neurologic compromise improves neurologic recovery and prevents deformity progression. Innovations in cement-augmented pedicle screws have reduced hardware failure rates in osteoporotic bone, although long-term data remain limited. Controversy persists regarding the threshold for surgical intervention in borderline cases, highlighting the need for individualized patient assessment.

Master Class Pro-Tip

Mastery in managing OVCFs hinges on integrating biomechanical principles with patient-specific factors: prioritize restoring sagittal balance through targeted anterior column support combined with cement-augmented posterior fixation. Avoid over-instrumentation to reduce morbidity, and employ intraoperative neuromonitoring to detect subtle neurologic compromise early. Meticulous preoperative planning with CT and MRI fusion imaging enhances screw trajectory accuracy and optimizes implant purchase in compromised bone, elevating outcomes beyond standard care.

April 26, 2026/0 Comments/by OrthoNet AI

Spine Review

Understanding Scheuermann’s Kyphosis: Clinical Features and Management

High-Yield Summary

Scheuermann’s kyphosis is a rigid, structural thoracic or thoracolumbar hyperkyphosis characterized by anterior vertebral wedging of ?5° in three consecutive vertebrae, typically presenting in adolescence.
Clinical presentation includes progressive thoracic kyphosis, back pain, and postural deformity; neurological deficits are rare but warrant urgent evaluation.
Diagnosis relies on standing lateral spine radiographs demonstrating wedging, Schmorl’s nodes, and endplate irregularities; MRI is reserved for atypical or neurologically compromised cases.
Non-operative management is first-line for mild to moderate curves (<75°) with pain control and physical therapy; surgical correction is indicated for severe deformities, progressive curves, or refractory symptoms.
Posterior-only spinal fusion with segmental instrumentation is the current surgical standard, emphasizing restoration of sagittal balance and prevention of junctional kyphosis.

Clinical Fundamentals

Relevant Anatomy and Biomechanics

The thoracic spine normally exhibits a kyphotic curvature averaging 20°-40°. Scheuermann’s kyphosis results from anterior vertebral growth disturbance during adolescence, leading to rigid hyperkyphosis. The anterior vertebral bodies fail to grow proportionally, causing wedging and altered sagittal alignment. The thoracolumbar junction is a common site due to biomechanical transition zones and increased stress concentration.

Sagittal balance is critical: compensatory lumbar lordosis and cervical extension often develop to maintain horizontal gaze. Failure to compensate leads to sagittal imbalance, increased energy expenditure, and pain.

Epidemiology

Scheuermann’s kyphosis affects approximately 0.4%-8% of adolescents, with a slight male predominance. It typically manifests between ages 12 and 16 during rapid growth phases. Familial patterns suggest a genetic predisposition, though the exact etiology remains multifactorial.

Classification & Diagnosis

Classification System	Criteria	Clinical Relevance	Diagnostic Pearls	Common Pitfalls
Sorensen Criteria	?5° anterior wedging in ?3 consecutive vertebrae	Defines structural kyphosis, differentiates from postural kyphosis	Use standing lateral radiographs; assess vertebral endplates for irregularities	Confusing postural kyphosis with Scheuermann’s; inadequate imaging positioning
Curve Severity	Mild: <60°; Moderate: 60°-75°; Severe: >75°	Guides treatment thresholds	Measure Cobb angle on lateral radiographs; consider sagittal balance	Overreliance on Cobb angle without clinical correlation
Location-based	Thoracic (T7-T10), Thoracolumbar (T10-L2)	Influences surgical approach and fusion levels	Identify apex of kyphosis; assess adjacent segments	Missing junctional deformities or compensatory curves

Diagnostic Pearls:

Schmorl’s nodes on MRI or radiographs support diagnosis but are not pathognomonic.

Differentiate from postural kyphosis by assessing flexibility via forward bending; Scheuermann’s kyphosis is rigid.

MRI is essential if neurological symptoms or atypical features (e.g., severe pain, asymmetric findings) are present.

Decision-Making Algorithm

Management Modality	Indications	Rationale	Surgical Approach/Implants
Non-operative	Kyphosis <75°, minimal pain, no neurological deficits	Allows natural growth, symptom control, avoids surgical risks	N/A
Operative	Kyphosis >75°, progressive deformity, refractory pain, neurological compromise, cosmetic concerns	Prevents progression, restores sagittal balance, alleviates symptoms	Posterior-only fusion with pedicle screw instrumentation; anterior release rarely needed

Why Non-operative First?
Most patients with mild to moderate curves respond to physical therapy focusing on extension exercises and pain management. Bracing has limited evidence but may be considered in skeletally immature patients with progressive curves.

Why Posterior-Only Surgery?
Modern segmental pedicle screw constructs provide powerful correction forces, reducing the need for anterior release, which increases morbidity. Posterior fusion allows direct deformity correction, sagittal balance restoration, and fusion across the apex and adjacent segments to prevent junctional kyphosis.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Preoperative Planning:

Full-length standing radiographs to assess sagittal and coronal balance.
MRI if neurological symptoms or atypical features.
Determine fusion levels: typically from 2 levels above to 2 levels below the apex.

Patient Positioning:

Prone on a radiolucent table with chest and pelvic bolsters to reduce abdominal pressure and venous congestion.

Exposure and Instrumentation:

Midline posterior approach with subperiosteal dissection.
Place pedicle screws bilaterally at planned levels; confirm with fluoroscopy or navigation.

Deformity Correction:

Perform facetectomies and posterior column osteotomies to increase flexibility.
Gradual rod contouring and sequential rod insertion to restore lordosis.
Apply compression and distraction maneuvers to optimize sagittal alignment.

Fusion:

Decorticate posterior elements and apply autograft/allograft.
Consider bone morphogenetic protein (BMP) selectively in high-risk cases.

Closure and Postoperative Care:

Layered closure with drains as needed.
Early mobilization with bracing if indicated.

Intraoperative Red Flags

Excessive correction causing spinal cord tension or neurological changes.
Pedicle breach risking nerve root or spinal cord injury.
Junctional kyphosis developing intraoperatively due to inadequate fusion levels.
Significant blood loss requiring prompt hemostasis.

Evidence-Based Synthesis

Landmark studies have shifted the paradigm from combined anterior-posterior approaches to predominantly posterior-only fusion with segmental instrumentation. Early literature favored anterior release for rigid curves; however, recent comparative trials demonstrate equivalent or superior outcomes with posterior-only techniques, reducing operative time, blood loss, and morbidity.

Randomized controlled trials remain limited, but cohort studies consistently report improved sagittal alignment, pain relief, and patient satisfaction with modern posterior constructs. The role of bracing remains controversial, with meta-analyses showing minimal impact on curve progression but some benefit in pain control.

Emerging data highlight the importance of sagittal balance restoration over mere Cobb angle correction, correlating with improved functional outcomes. Controversies persist regarding optimal fusion levels and the use of osteotomies, underscoring the need for individualized surgical planning.

Master Class Pro-Tip

Mastery in Scheuermann’s kyphosis surgery hinges on achieving balanced sagittal realignment without overcorrection. Avoid extending fusion unnecessarily into the lumbar spine to preserve mobility but ensure inclusion of all structurally involved vertebrae to prevent junctional failure. Intraoperative neuromonitoring combined with gradual, controlled deformity correction minimizes neurological risk. Finally, meticulous preoperative planning using 3D imaging and patient-specific rod contouring can elevate outcomes from competent to exceptional.

April 12, 2026/0 Comments/by OrthoNet AI