Spinal Cord Injury: Injuries to the Spine and Spinal Cord
Traumatic injuries of the spine represent neurosurgical emergencies that require immediate evaluation and treatment to optimize neurological recovery.
Learn more about the specialized management of spinal trauma.
Spinal Trauma: An Absolute Emergency
Spinal cord injury is one of the most devastating injuries a person can suffer. In Mexico, motor vehicle accidents are the number one cause, followed by falls from height and violence-related injuries.
Critical facts:
- Therapeutic window: The first 8 hours after injury are CRITICAL for intervention
- Immobilization: EVERY patient with high-energy trauma must be assumed to have a spinal injury until proven otherwise
- Pre-hospital management: Inadequate immobilization can turn an injury without deficit into a complete injury
- Urgent evaluation: Complete spine CT + spinal cord MRI within <24 hours
Classification of Spinal Cord Injuries (ASIA Scale)
| ASIA Grade | Description | Motor Function | Sensory Function | Prognosis |
|---|---|---|---|---|
| A - Complete | No motor or sensory function in sacral segments S4-S5 | Absent below the level | Absent below the level | Recovery <5%, generally permanent |
| B - Incomplete | Sensation preserved but no motor function below the level, including S4-S5 | Absent below the level | Preserved (incl. S4-S5) | Recovery 20-30%, usually partial |
| C - Incomplete | Motor function preserved below the level, but >50% of muscle groups grade <3/5 | Preserved but weak | Preserved | Recovery 50-75%, most walk with assistance |
| D - Incomplete | Motor function preserved below the level, and ≥50% of muscle groups grade ≥3/5 | Preserved, functionally useful | Preserved | Recovery 80-95%, most walk independently |
| E - Normal | Normal motor and sensory function in all segments | Normal (5/5) | Normal | Complete recovery |
Spinal Shock vs. Permanent Injury
Spinal shock: A transient phenomenon (24-72 hours) after injury in which all neurological function below the injury is abolished, including reflexes. This does NOT necessarily mean a complete permanent injury.
Resolution of shock: Return of reflexes (especially the bulbocavernosus reflex) indicates the end of shock. The neurological exam AFTER shock is the one that predicts recovery.
Clinical implication: A definitive prognosis cannot be given in the first 48-72 hours. The presence of ANY function (especially sensory) below the injury during shock suggests an incomplete injury with a better prognosis.
Types of Traumatic Vertebral Injuries
Compression Fractures
Mechanism: Axial load (fall onto the buttocks, motor vehicle accident)
Most common at: The thoracolumbar junction (T12-L1), osteoporosis
Stability:
- Stable:<50% of anterior height, no canal compromise, posterior column intact
- Unstable:>50% height loss, fragments in the canal, posterior compromise
Treatment:
- Stable: Bracing, analgesia, early mobilization
- Unstable: Surgery (decompression + instrumentation)
Burst Fractures
Mechanism: Severe axial load, with vertebral body fragment(s) retropulsed into the canal
Danger: Fragments may compress the spinal cord
Evaluation:
- Percentage of canal occupation
- Post-traumatic kyphosis
- Neurological compromise
Treatment:
- No deficit + <50% canal: May be managed conservatively
- With deficit or unstable: Urgent surgery
Fracture-Dislocations
Mechanism: Flexion + rotation + distraction (high-energy accidents)
Severity: Highly unstable, frequently with complete neurological injury
Urgency:
- Urgent reduction (closed or open)
- Decompression if neural compression persists
- Surgical stabilization
Prognosis: Depends on the severity of the spinal cord injury, but with appropriate treatment many improve by at least 1 ASIA grade
Specific Cervical Injuries
Jefferson fracture (C1): Burst of the atlas from axial load
Hangman's fracture (C2): Bilateral fracture of the pars interarticularis of the axis
Odontoid fracture (C2): Type II (base) is unstable, frequently requires fusion
Cervical facet injury: Unilateral or bilateral dislocation, urgent reduction needed
High Mortality Requires Experience
Critical Decision: Early vs. Late Surgery in Spinal Cord Trauma
The timing of surgery in spinal cord injury is controversial, but recent evidence suggests:
Ultra-early surgery (<8 hours):
- Associated with better neurological recovery in incomplete injuries
- Reduces secondary injury (edema, ischemia)
- Requires an experienced team available 24/7
Absolute indications for urgent surgery:
- Documented spinal cord compression with progressive neurological deterioration
- Incomplete injury with >50% canal compression
- Dislocation not reducible by traction
- Fracture-dislocation with malalignment
My philosophy: In incomplete injuries with compression, early surgery (<24 hours, ideally <8 hours) to maximize recovery. In stable complete injuries, surgery may be elective for stabilization.
Hope in Spinal Cord Injury
Although spinal cord trauma can be devastating, NOT all is lost:
- Incomplete injuries: Most have significant recovery, especially ASIA C and D
- Neuroplasticity: Recovery may continue for 12-24 months after injury
- Intensive rehabilitation: Specialized programs maximize functional recovery
- Assistive technology: Exoskeletons, epidural spinal cord stimulation, and brain-computer interfaces are advancing rapidly
- Quality of life: Even with a complete injury, with appropriate support many patients achieve independence and a satisfying life
Crucial message: Aggressive management in the first hours/days can make the difference between walking again and using a wheelchair. That is why early neurosurgical evaluation is CRITICAL.
Infections of the Spine
Spinal infections are serious conditions that can cause bone destruction, spinal cord compression, sepsis, and, if not treated appropriately, permanent paralysis or death.
Review our dedicated page on spinal infections to learn about their diagnosis and treatment.
Spinal Infections: An Infectious and Neurological Emergency
Infections of the spine are relatively rare (incidence 2-7 per 100,000), but their incidence is increasing due to:
- An aging population
- Rising rates of diabetes and obesity
- More spinal surgeries
- Greater intravenous drug use
- Immunosuppression (HIV, chemotherapy, transplants)
Main danger: Delayed diagnosis. Initial symptoms are nonspecific, frequently mistaken for mechanical back pain.
Types of Spinal Infections
Vertebral Osteomyelitis and Discitis
Definition: Infection of the vertebral body (osteomyelitis), frequently with infection of the adjacent disc (discitis). They rarely occur in isolation.
Route of Infection:
- Hematogenous (most common): Bacteria travel through the bloodstream from a distant infectious focus (UTI, pneumonia, endocarditis, IV catheters)
- Direct inoculation: After spinal surgery, penetrating trauma, injections
- Contiguity: Extension from adjacent soft tissues (retroperitoneal abscess)
Common Microorganisms:
- Staphylococcus aureus: 40-60% (including MRSA)
- Streptococcus spp: 10-15%
- E. coli: 10-15% (especially with prior UTI)
- Pseudomonas: In IV drug users
- Mycobacterium tuberculosis: 5-10% (Pott disease)
- Brucella: Endemic regions, animal exposure
- Fungi: Candida, Aspergillus (immunosuppressed patients)
Clinical Presentation:
- Back pain (95%): Insidious, progressive, nocturnal, does NOT improve with rest
- Fever (35-50%): May be low-grade or absent (especially in the elderly)
- Neurological deficit (10-35%): A late sign, indicating spinal cord/nerve root compression
- Constitutional symptoms: Weight loss, night sweats, general malaise
- Laboratory findings: Elevated ESR (90%), elevated CRP (95%), variable leukocytosis
Red Flags for Spinal Infection
Suspect spinal infection if there is back pain plus any of the following:
- Fever (even if mild or intermittent)
- History of recent infection (UTI, pneumonia, dental procedure)
- IV drug use
- Immunosuppression (diabetes, HIV, corticosteroids, chemotherapy)
- Recent spinal surgery (<3 months)
- Severe nocturnal pain that wakes the patient
- Markedly elevated ESR/CRP with no other explanation
Action: URGENT MRI with contrast. MRI is >90% sensitive and shows bone edema, disc enhancement, and collections.
Treatment:
Targeted antibiotics (6-12 weeks IV):
- Microbiological diagnosis FIRST: CT-guided biopsy or surgery before antibiotics (if stable)
- Initial empiric therapy: If septic or with neurological deterioration, vancomycin + a third-generation cephalosporin
- Adjustment based on culture: De-escalate antibiotics according to sensitivities
- Monitoring: Weekly CRP (should decline), follow-up MRI at 4-6 weeks
Surgery is indicated if:
- Spinal cord/nerve root compression with neurological deficit
- Epidural abscess (frequently requires urgent drainage)
- Vertebral instability (bone destruction >50%, progressive kyphosis)
- Failure of medical treatment (persistent fever/pain after 2-4 weeks of appropriate antibiotics)
- Need for tissue for diagnosis and culture that cannot be obtained percutaneously
Spinal Epidural Abscess (SEA)
Definition: A collection of pus in the epidural space (between the dura mater and the bone), an absolute neurosurgical emergency.
Natural Evolution (Heusner's Triad):
- Phase 1 (1-3 days): Severe focal back pain + fever
- Phase 2 (3-5 days): Radicular pain, neck stiffness, signs of nerve root irritation
- Phase 3 (5-7 days): Motor, sensory, and sphincter deficit (spinal cord compression)
- Phase 4 (>7 days): Complete paralysis
Epidural Abscess = SURGICAL EMERGENCY
Time is spinal cord: The progression of symptoms can be RAPID (hours to days).
Prognosis depends on the pre-operative status:
- Surgery in Phase 1-2 (before motor deficit): >90% complete recovery
- Surgery in Phase 3 (recent motor deficit <24-48h): 50-70% significant recovery
- Surgery in Phase 4 (paralysis >48-72h): <30% functional recovery
Critical message: If you have severe back pain + fever + ANY neurological symptom (weakness, numbness, difficulty urinating) → GO TO THE EMERGENCY ROOM IMMEDIATELY. Do not wait. Hours can make the difference between walking and permanent paraplegia.
Treatment:
- Urgent decompressive laminectomy: Drainage of the abscess + culture
- Prolonged IV antibiotics: 6-8 weeks guided by culture
- Occasionally conservative: ONLY if the abscess is small, there is no deficit, and there is rapid improvement with antibiotics
Pott Disease (Spinal Tuberculosis)
Definition: Vertebral osteomyelitis caused by Mycobacterium tuberculosis, the most common form of skeletal tuberculosis (50%).
Distinctive Features:
- Slower course: Symptoms for months before diagnosis
- Severe vertebral destruction: Anterior collapse → angular kyphosis (Pott's hump/gibbus)
- Cold abscess: Collections without acute inflammatory signs, which can extend far away (psoas abscess)
- Affects multiple levels: Typically destruction of 2-3 adjacent vertebrae
- Active pulmonary TB: Present in only 30-50% (most cases are reactivation of latent TB)
Diagnosis:
- MRI: Lesions in multiple vertebrae, relative preservation of the discs, paravertebral abscesses
- Biopsy: Caseating granulomas, TB culture (takes 4-8 weeks), PCR for TB
- Tuberculin skin test (PPD) or QuantiFERON: Frequently positive
Treatment:
- Anti-TB regimen: RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) for 9-12 months
- Surgery is indicated if: Neurological deficit, severe instability, progressive deformity, failure of medical treatment
- Decompression + fusion: Frequently necessary because of extensive bone destruction
High Suspicion of Spinal TB If:
- The patient comes from an endemic area (Mexico has areas of high prevalence)
- History of prior pulmonary TB (even if treated)
- HIV positive or immunosuppression
- Back pain + constitutional symptoms (weight loss, night sweats) for MONTHS
- Progressive angular kyphotic deformity
- Paravertebral abscess on imaging with no response to conventional antibiotics
Deformities of the Spine
Spinal deformities are alterations in the normal alignment of the spine in the coronal plane (scoliosis) or sagittal plane (kyphosis, lordosis), which can cause pain, functional limitation, and cardiopulmonary problems if severe.
See detailed information about spinal deformities and their correction options.
Understanding Normal Spinal Alignment
Normal curvatures (seen from the side - sagittal plane):
- Cervical lordosis: Posteriorly concave curvature (40-60°)
- Thoracic kyphosis: Posteriorly convex curvature (20-50°)
- Lumbar lordosis: Posteriorly concave curvature (40-60°)
Coronal alignment (front view): The spine should be straight, with no lateral deviation
Deformity = Deviation from these normal curvatures
〰 Scoliosis: Lateral Curvature of the Spine
Definition: Lateral deviation of the spine with associated vertebral rotation, measured by a Cobb angle >10° on X-ray.
Classification by Age of Onset:
Infantile Scoliosis (0-3 years)
Frequency: Rare (<1% of scoliosis)
Features:
- Most resolve spontaneously
- If progressive, it can be severe
- Association with congenital malformations (cardiac, renal)
Treatment: Observation if mild, corrective casting if progressive
Juvenile Scoliosis (4-10 years)
Frequency: Uncommon (10-15% of scoliosis)
Risk: High probability of progression (years of growth remaining)
Treatment:
- Observation if <25°
- Brace if 25-40° and growth remaining
- Surgery if >40-45° or progression despite bracing
Adolescent Idiopathic Scoliosis (10-18 years)
Frequency: The MOST common (80% of scoliosis)
Prevalence: 2-4% of adolescents (most cases mild)
Sex: Female > Male (ratio 7:1 for curves requiring treatment)
Risk factors for progression:
- Magnitude of the curve at diagnosis
- Skeletal immaturity (Risser sign 0-2)
- Thoracic curve (progresses more than lumbar)
- Female sex
Adult Scoliosis
Two types:
- Progression of adolescent scoliosis: An existing curve that worsens in adulthood
- De novo (degenerative): New scoliosis from asymmetric disc/facet degeneration
Main symptoms:
- Mechanical axial pain
- Neurogenic claudication (stenosis on the concavity)
- Sagittal imbalance ("leaning forward")
Evaluation and Follow-up:
- Full-spine X-rays (AP and lateral): Measurement of the Cobb angle, coronal/sagittal balance
- Risser sign: Degree of skeletal maturity (0-5), predicts remaining growth
- Neurological exam: Rule out a secondary etiology (tumor, syringomyelia)
- Adams forward bend test: Rib prominence indicates vertebral rotation
Treatment Options by Magnitude:
| Cobb Angle | Skeletal Maturity | Treatment | Follow-up |
|---|---|---|---|
| <10° | Any | Observation only | Annually until maturity |
| 10-25° | Immature (Risser 0-2) | Observation + specific physical therapy | Every 4-6 months |
| 10-25° | Mature (Risser 4-5) | Observation | Annually or as needed |
| 25-40° | Immature | Brace (TLSO) 18-23 hours/day | Every 3-4 months |
| 25-40° | Mature | Observation (low progression risk) | Annually |
| 40-50° | Immature | Surgery (instrumented fusion) | - |
| 40-50° | Mature | Observation if asymptomatic, surgery if symptoms/progression | Annually |
| >50° | Any | Surgery (cardiopulmonary risk if >70-80°) | - |
Non-Idiopathic Scoliosis: Red Flags
Most adolescent scoliosis is idiopathic (with no identifiable cause). However, actively look for a secondary cause if:
- Age <10 years: Infantile/juvenile forms have a stronger association with malformations
- Rapid progression:>5° in 6 months suggests a secondary etiology
- Significant pain: Idiopathic scoliosis rarely hurts; pain suggests tumor, infection, osteoblastoma
- Left thoracic curve: Atypical, requires MRI
- Neurological deficit: Weakness, hyperreflexia, clonus → urgent MRI
- Cutaneous stigmata: Café-au-lait spots (neurofibromatosis), dimple/hair tuft (dysraphism)
- Very rigid curve: Does not correct on side-bending X-ray
If ANY of these red flags is present: Full-spine MRI is MANDATORY before starting treatment.
Scoliosis Surgery: What to Expect
Typical procedure: Posterior instrumented fusion (pedicle screws + rods)
Goals:
- Stop progression (fusion prevents motion)
- Correct the deformity (typically 50-70% correction)
- Balance the spine (shoulders and hips level)
- Prevent future complications (cardiopulmonary, pain)
Hospital stay: Typically 4-7 days
Recovery:
- Mobilization from day 1-2 after surgery
- Return to school: 4-6 weeks
- Non-contact sports: 3-6 months
- Contact sports: 9-12 months (if the neurosurgeon allows it)
- Complete fusion: 9-12 months
Success rate:>90% patient satisfaction, major complications <5% at experienced centers
Kyphosis: Increased Curvature in the Thoracic Spine
Definition: Thoracic kyphosis >50° (normal 20-50°) measured on a lateral X-ray.
Main Types:
Postural Kyphosis
Cause: Poor postural habits, muscle weakness
Features:
- Flexible (corrects with voluntary hyperextension)
- No structural changes in the vertebrae
- Adolescents with rounded shoulders
- Generally asymptomatic
Treatment: Physical therapy, back strengthening, postural awareness
Benign Reversible
Scheuermann's Disease
Cause: Abnormal growth of the vertebral endplates during adolescence
Radiographic features:
- Wedging >5° in ≥3 adjacent vertebrae
- Vertebral endplate irregularity
- Schmorl's nodes (intraosseous herniation)
- Rigid kyphosis (does not correct with extension)
Presentation: An adolescent with a visible "hump," who may have pain
Treatment:
- <50° and growth remaining: Milwaukee brace
- >70-75° or refractory pain: Surgery (posterior fusion)
Structural Treatable
Congenital Kyphosis
Cause: Vertebral malformation (failure of formation or segmentation)
Presentation: Detectable from birth/early childhood
Danger:
- High probability of progression
- Risk of neurological deficit (spinal cord "bent")
- Association with malformations (cardiac 20%, renal 20%)
Treatment:
- Close follow-up from diagnosis
- Early surgery if progressive (best before age 5)
High Progression Early Surgery
Degenerative/Osteoporotic Kyphosis
Cause: Multiple compression fractures (osteoporosis), disc degeneration
Presentation: An older adult with height loss, leaning forward
Symptoms:
- Mechanical back pain
- Functional limitation (difficulty standing upright)
- Cardiopulmonary problems (if very severe)
- Early satiety (abdominal compression)
Treatment:
- Prevention: Osteoporosis treatment (bisphosphonates, denosumab)
- Acute fractures: Vertebroplasty/kyphoplasty if pain is refractory
- Severe deformity: Complex reconstructive surgery (high risk)
Prevention Is Key Multifactorial
Impact of Severe Kyphosis
When thoracic kyphosis is >80-90°:
- Pulmonary restriction: Reduced vital capacity, exertional dyspnea
- Cardiac problems: Cor pulmonale in extreme cases
- Extrinsic compression syndrome: Difficulty swallowing, early satiety
- Chronic pain: Paravertebral muscle overload, compensatory low back pain
- Psychosocial impact: Self-image, activity limitation
For this reason, severe progressive kyphosis may justify surgery even without a neurological deficit.
Congenital Malformations of the Spine and Spinal Cord
Conditions present from birth that affect the normal development of the spine, spinal cord, or related structures.
Other complex conditions such as arteriovenous malformations and syringomyelia also require specialized neurosurgical management.
Chiari Malformation
Definition: Abnormal descent of the cerebellar tonsils through the foramen magnum into the cervical spinal canal.
Types:
Chiari Type I
Most common in adults
Definition: The cerebellar tonsils descend >5mm below the foramen magnum
Typical symptoms:
- Headache: Occipital, worsens with Valsalva (coughing, straining)
- Neck/shoulder pain
- Dizziness, vertigo
- Cerebellar dysfunction: Ataxia, nystagmus
- Spinal cord symptoms: If associated syringomyelia is present
Diagnosis: MRI of the brain and cervical spine
Most Common Adults
Chiari Type II
Associated with myelomeningocele
More severe: Descent of the cerebellum + vermis + brainstem
Presentation: Neonatal, almost always with spina bifida
Symptoms:
- Respiratory difficulty
- Swallowing problems
- Apnea
- Hydrocephalus (95%)
Treatment: Neonatal surgery is frequently necessary
Severe Neonatal
Treatment of Chiari Type I:
- Asymptomatic/incidental finding: Observation only
- Mild symptoms: Trial of conservative management (analgesics, physical therapy)
- Significant symptoms or syringomyelia:
Posterior fossa decompression
- Suboccipital craniectomy
- C1 laminectomy (sometimes C2)
- Duraplasty (enlargement of the dura mater)
Surgical outcomes: 60-80% improvement in headache, >90% halting of syringomyelia progression
Syringomyelia
Definition: A fluid-filled cyst (syrinx) within the spinal cord. Frequently associated with Chiari but can be idiopathic, post-traumatic, or post-infectious.
Clinical Presentation (Syringomyelic Syndrome):
- Dissociated sensory loss: Loss of pain/temperature but preservation of fine touch (the syrinx affects the decussation of the spinothalamic tract)
- "Cape-like" distribution: Bilateral sensory loss over the shoulders/arms/trunk (level of the syrinx)
- Weakness and atrophy: Typically of the hands (affects motor neurons in the anterior horns)
- Neuropathic pain: Burning, poorly localized
- Areflexia in the upper limbs: If the syrinx is in the cervical spine
- Horner's syndrome: If it affects the cervical sympathetic center
- Spasticity in the legs: If the descending tracts are affected
Feared Complication: Painless Burns
Patients with cervical syringomyelia lose the sensation of pain/temperature in the hands/arms but preserve touch. This is DANGEROUS:
- Burns while cooking (they do not feel boiling water or a hot pan)
- They do not perceive injuries to the hands
- Charcot arthropathy (joint destruction from repeated painless trauma)
Patient education is CRITICAL: Hand protection, daily visual inspection, precautions in the kitchen/bathroom.
Treatment:
- If associated with Chiari: Posterior fossa decompression (frequently reduces or stabilizes the syrinx)
- Progressive idiopathic syrinx: Syringosubarachnoid or syringoperitoneal shunt
- Post-traumatic: Decompression of arachnoiditis, shunt if necessary
- Observation: If asymptomatic and stable (MRI every 6-12 months)
Goal: Halt progression. Recovery of lost function is variable (better with early intervention).
Neural Tube Defects: Spina Bifida
Definition: Failure of the neural tube to close during embryonic development (3-4 weeks of gestation), resulting in malformations of the spine and spinal cord.
Spectrum of Severity:
Spina Bifida Occulta
Mildest and most common (10-20% of the population)
Defect: Lack of fusion of the posterior arch of a vertebra (usually L5-S1)
Features:
- Intact skin over the defect
- Normal spinal cord
- Usually asymptomatic
- Incidental finding on X-ray
Cutaneous stigmata (sometimes): Dimple, hair tuft, hemangioma
Benign Common
Meningocele
Moderate severity (5% of spina bifida)
Defect: Herniation of the meninges (without spinal cord) through a vertebral defect
Presentation:
- A cystic mass covered by skin (frequently thinned)
- Spinal cord generally normal
- Neurological function usually preserved
Treatment: Elective surgery to close the defect (prevent infection, rupture)
Moderate Good Prognosis
Myelomeningocele
Most severe (80-90% of spina bifida)
Defect: Herniation of the meninges AND the spinal cord through the defect
Neonatal presentation:
- Exposed spinal cord ("neural plate")
- Neurological deficit below the level
- Leg paralysis (variable degree)
- Neurogenic bladder/bowel
- Association with hydrocephalus (80-90%)
- Chiari type II (nearly 100%)
Severe Multidisciplinary
Management of Myelomeningocele:
Neonatal surgery (24-72 hours):
- Goal: Close the defect, prevent infection (meningitis)
- Technique: Reconstruction of the spinal cord, dura mater, muscle, and skin
- Does not restore function: Prevents further deterioration
Fetal surgery (experimental but promising):
- Closure of the defect in utero (19-25 weeks of gestation)
- Reduces the severity of Chiari type II
- Decreases the need for a shunt for hydrocephalus
- Improves motor function compared with postnatal surgery
- Requires a specialized center, with risks for mother and fetus
Long-term management (multidisciplinary team):
- Neurosurgery: Hydrocephalus (shunt), tethered cord
- Urology: Neurogenic bladder, intermittent catheterization
- Orthopedics: Hip/foot deformities, scoliosis
- Rehabilitation: Physical therapy, orthotics, mobility
- Psychology: Emotional support, development
Prevention of Neural Tube Defects
Peri-conceptional folic acid: HAS REDUCED the incidence by 50-70%
Recommendation:
- All women of reproductive age: 400-800 mcg of folic acid daily
- If history of a prior child with a neural tube defect: 4 mg daily (10x the normal dose) starting 1 month before conception
- If on antiepileptic medications: A higher dose (consult with a neurologist)
In Mexico: Fortification of corn flour with folic acid since 2000 has reduced NTDs, but individual supplementation remains important.
Tethered Cord
Definition: Abnormal adhesion of the lower end of the spinal cord (conus medullaris) to bony or fibrotic structures, preventing its normal ascent with growth.
Normal Anatomical Context:
At birth, the conus medullaris is at the L3 level. With growth, the spine grows faster than the spinal cord, so the conus relatively "ascends" to L1-L2 in adults. If the cord is tethered, this ascent does not occur, causing progressive stretching with growth.
Causes:
- Spina bifida occulta: With lipoma, thickened filum terminale
- Post-surgical: After myelomeningocele surgery (secondary tethered cord)
- Diastematomyelia: Splitting of the cord by a bony or fibrous bar
- Lipomatous filum terminale: Fatty thickening of the filum
Symptoms (typically appear with growth):
- Orthopedic: Cavus foot, leg length discrepancy, scoliosis
- Pain: Low back, buttocks, legs (worsens with exercise)
- Weakness: Legs, usually asymmetric and progressive
- Sensory: Numbness in an L5-S1 distribution
- Bladder/bowel: Incontinence, recurrent urinary tract infections
- Cutaneous stigmata: Dimple, hemangioma, hair tuft in the lumbar midline
Diagnosis: MRI of the lumbosacral spine (shows a low conus, thickened filum, lipoma)
Treatment:
- Untethering surgery: Sectioning of the filum terminale or removal of the lipoma/tethering tissue
- Timing: Ideally before a permanent deficit develops (surgery does NOT recover lost function, it only prevents deterioration)
- Outcomes: Halting of progression in >90%, pain improves in 60-80%, bladder/motor function improvement variable
Do Not Ignore Cutaneous Stigmata in the Lumbar Midline
If your child has a dimple, hair tuft, hemangioma, or subcutaneous mass in the lumbar midline:
- MRI of the lumbosacral spine: To rule out occult spinal dysraphism
- Pediatric evaluation: Leg strength, reflexes, bladder function
- Do not wait for symptoms: Prophylactic surgery can prevent a future deficit
These stigmata are visible from birth, but many pediatricians/parents are not aware of their significance. Early detection prevents disability.
Osteoporotic Vertebral Fractures
Vertebral compression fractures are the most common complication of osteoporosis, affecting 25% of postmenopausal women and causing severe pain, deformity, and a decline in quality of life.
Learn about vertebroplasty for osteoporotic fractures, a minimally invasive procedure for pain relief.
Epidemiology of Osteoporotic Fractures
- Frequency: 700,000 vertebral fractures/year in the USA, 1.5 million globally
- Underdiagnosis: 2/3 of vertebral fractures are asymptomatic or undiagnosed
- Fracture cascade: One vertebral fracture increases the risk of an additional vertebral fracture 5-fold
- Mortality: Multiple vertebral fractures increase 5-year mortality by 20-30%
Clinical Presentation:
Acute Fracture
Typical presentation:
- Sudden-onset pain: During trivial activity (lifting a light object, coughing, turning in bed)
- Location: Well localized at the level of the fracture
- Intensity: Severe initially (8-10/10), gradually improving
- Pattern: Worsens with movement, improves with rest
- No radiculopathy: Usually does not radiate to the legs (unlike a herniated disc)
- No neurological deficit: Normal strength and sensation
Natural history: Pain peaks in the first 2 weeks, significant improvement in 4-6 weeks, resolution in 8-12 weeks
Chronic/Multiple Fractures
Long-term consequences:
- Height loss: 1-2 cm per fracture, can be >10 cm with multiple fractures
- Progressive kyphosis:"Dowager's hump"
- Chronic pain: Mechanical, from compensatory muscle overload
- Functional limitation: Difficulty with daily activities, compromised balance
- Pulmonary restriction: If kyphosis is severe, reduced vital capacity
- Early satiety: Abdominal compression from kyphosis
- Psychosocial impact: Depression, social isolation, fear of falling
Treatment Options:
| Treatment | Indication | Mechanism | Outcomes |
|---|---|---|---|
| Conservative | First-line for most acute fractures | Analgesia, brief initial rest (2-3 days), progressive mobilization, bracing if needed | 70-80% significant improvement in 4-6 weeks |
| Vertebroplasty | Refractory pain >4-6 weeks, fracture <6-12 months old | Percutaneous injection of cement (PMMA) into the vertebral body under fluoroscopy | 70-90% significant pain relief within 24-72h, outpatient, rapid recovery |
| Kyphoplasty | Similar to vertebroplasty, attempts to restore height | Balloon inflation to create a cavity + cement injection at lower pressure | Similar to vertebroplasty in pain relief, variable height restoration (20-40%) |
| Anti-osteoporosis medications | ALL patients with an osteoporotic fracture | Bisphosphonates, denosumab, teriparatide according to risk profile | Reduces the risk of future fractures by 40-70% |
Controversy: Vertebroplasty/Kyphoplasty - When Is It Indicated?
Controlled studies have shown conflicting results on the efficacy of vertebro/kyphoplasty vs. placebo (injection of local anesthetic). Nonetheless:
Current consensus:
- First-line: Always appropriate conservative treatment for 4-6 weeks
- Consider the procedure if:
- Severe pain refractory to appropriate analgesics (including opioids if necessary)
- Fracture <6-12 months old (edema on MRI = a "fresh" fracture)
- Significant functional deterioration (bedridden because of pain)
- A well-informed patient aware of the conflicting evidence
- NOT indicated: Fractures >1 year old, multiple old consolidated fractures, osteopenia without fracture
My philosophy: Although the evidence is mixed, in clinical practice I see patients with dramatic improvement after the procedure. I offer vertebroplasty/kyphoplasty as an option after explaining the evidence, for patients with refractory pain that significantly affects their quality of life.
Prevention of Osteoporotic Fractures
The best strategy is PREVENTION:
Primary Prevention (Before a Fracture)
- Bone densitometry: Women >65 years, men >70 years, or with risk factors
- Calcium + Vitamin D: 1200 mg Ca + 800-1000 IU Vit D daily
- Weight-bearing exercise: Walking, dancing, strengthening
- Fall prevention: Risk assessment, home modification
- Medications: If T-score <-2.5 or osteopenia with risk factors
Secondary Prevention (After a First Fracture)
- Anti-osteoporosis treatment MANDATORY: Bisphosphonates, denosumab, or teriparatide
- Medication adherence: Critical to prevent future fractures
- Densitometry follow-up: Every 1-2 years
- Vitamin D optimization: Levels >30 ng/mL
- Vertebral protection: Avoid forward flexion, lifting
Key message: A vertebral fracture is NOT a "normal part of aging." It is a sign of bone fragility that MUST be treated aggressively to prevent future fractures that can be disabling.