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Adolescent Idiopathic Scoliosis — Management
Lenke classification guides fusion levels using curve type, lumbar modifier, and sagittal modifier. Bracing is effective in skeletally immature (Risser 0–2) with 25–40° curves when worn adequately. PSF with pedicle screws is gold standard for surgical AIS; selective fusion aims to preserve motion segments. Assess sagittal profile to avoid hypokyphosis and junctional problems. Psychosocial support and cosmesis discussion are important in counseling.
Open topicAtlantoaxial Instability — Pediatric & RA
Causes: congenital anomalies (Down syndrome), os odontoideum, trauma, and rheumatoid arthritis with transverse ligament incompetence. Measure atlantodental interval (ADI): >3 mm in adults or >5 mm in children suggests instability; consider dynamic flexion–extension views. Symptoms: neck pain, myelopathy signs, vertebrobasilar symptoms; intubation risks in RA. Surgery: posterior C1–C2 fusion (Goel‑Harms C1 lateral mass–C2 pedicle/pars screws) ± transarticular screws; consider odontoidectomy for i...
Open topicCervical Spondylotic Myelopathy — Pathophysiology & Surgery
CSM is progressive spinal cord dysfunction due to degenerative stenosis (disc osteophyte complex, ligamentum flavum hypertrophy, OPLL). Symptoms: hand clumsiness, gait imbalance, Lhermitte sign; UMN signs below level (Hoffmann, Babinski) with possible segmental LMN at level. MRI is diagnostic; assess sagittal alignment, number of compressed levels, and canal diameter. Surgery for moderate–severe or progressive CSM: anterior (ACDF/corpectomy) vs posterior (laminoplasty/laminectomy + fusion) based...
Open topicKyphosis — Scheuermann vs Post‑TB
Scheuermann disease: rigid structural kyphosis with ≥3 adjacent vertebrae wedged ≥5° and Schmorl nodes. Post‑TB kyphosis is angular with short apex, often severe and progressive in children. Indications for surgery: progressive deformity, pain refractory to bracing, cosmetic concerns (Scheuermann >70–75°), neuro compromise (post‑TB). Surgical options range from posterior column osteotomies (SPO) to pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR) for sharp angular deformi...
Open topicLumbar Canal Stenosis — Decompression Options
Degenerative stenosis from disc bulge, facet arthrosis, and ligamentum flavum hypertrophy causes neurogenic claudication. MRI confirms stenosis; correlate with walking tolerance and posture‑dependent symptoms (relief on flexion). Nonoperative: activity modification, PT (flexion‑based), analgesia; limited role for epidural steroid injections. Decompression alone (unroofing/undercutting) suffices when there is no instability; add fusion for instability/deformity or wide facetectomy. MIS options (m...
Open topicScoliosis — Cobb Angle & Surgical Indications
Cobb angle measures curve magnitude; progression risk relates to age, Risser stage, menarchal status, and curve size. Bracing indicated for skeletally immature curves 25–40° with documented progression; surgery typically considered for >45–50°. Pre‑op planning includes flexibility (bending) films, sagittal alignment, and neurologic monitoring readiness. Posterior spinal fusion with segmental pedicle screws is standard; anterior approaches reserved for specific curves. Pulmonary considerations cr...
Open topicSpinal Infections — Pyogenic vs TB
Pyogenic: acute pain, fever, rapid neuro deficit; disc involvement early. TB: insidious course, night sweats, cold abscess, vertebral collapse, gibbus deformity. MRI: pyogenic—disc + endplates; TB—paradiscal, large abscesses, skip lesions. Management: pyogenic—IV antibiotics, drainage; TB—ATT + bracing, surgery for neuro deficit/instability. Complications: kyphotic deformity, chronic pain, neuro sequelae.
Open topicSpinal TB (Pott’s) — Anterior vs Posterior
First-line treatment is ATT with rest and bracing per Tuli’s 'middle path'. Surgical indications: neurological deficit not improving, instability/deformity, large abscess, severe pain, diagnostic uncertainty. Approach selection depends on pathology location and kyphosis: anterior debridement/fusion vs posterior decompression with instrumentation or combined 360°. Posterior‑only circumferential decompression via costotransversectomy/retropleural approaches is increasingly favored for multi‑level...
Open topicSpondylolisthesis — Wiltse Classification
Wiltse etiologic types: I dysplastic, II isthmic (IIA lytic, IIB elongated pars, IIC acute pars), III degenerative, IV traumatic (other than pars), V pathologic, VI iatrogenic. Meyerding grades I–V (25% increments) quantify slip; slip angle and pelvic incidence inform reduction strategy. Adult degenerative L4–5 listhesis: decompression with fusion when instability/foraminal stenosis present. High‑grade isthmic L5–S1 in adolescents may need reduction and circumferential fusion; monitor for L5 neu...
Open topicThoracolumbar Burst Fractures — Load Sharing
Assess stability and neurology with TLICS; Load Sharing Classification (McCormack) predicts need for anterior support. High load‑sharing score (≥7) → consider anterior column reconstruction with corpectomy/cage in addition to posterior fixation. Posterior pedicle screw constructs (short vs long segment) are standard; add intermediate screws at the fractured level to improve stability. Canal compromise alone is not an absolute indication for laminectomy—retropulsed fragments resorb over time if P...
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