Common Spinal Disorders Explained [1 ed.] 1901346528, 9781901346527

If it were a disease, back pain would be called an epidemic. At least 5 million people will consult their GPs about back

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Common Spinal Disorders Explained [1 ed.]
 1901346528, 9781901346527

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Common spinal disorders explained

Remediea explained series I55N 1471-413l1

AlS 10 weeks

Summary The diagnosis of malignant spinal tumors is made by a thorough history, examination, and investigation. The history will often arouse suspicion and a diagnosis of spinal tumor should be considered in any patient who presents with pain that is relentless, is refractory to analgesia, is not relieved by rest or sleep, 71

Spinal tumors

and is located in the spine. The other principal diagnosis is infection, and the salient features for differentiation are that infection results in fever, rigors, nausea, vomiting, and sweating. Spinal tumors can be associated with weight loss, muscle weakness, and the symptoms of the primary rumor. Any child that presents with back pain must be investigated for spinal neoplastic lesions, as should any patient with an atypical history. All patients require referral to a specialist neurosurgical, orthopedic, or spinal unit. Any patient who presents with neurological compromise must be referred urgently (within hours).


Chapter 11 Inflammatory arthropathies affecting the spine There are many inflammatory conditions that can affect the spine. Some, such as ankylosing spondylitis and rheumatoid arthritis, are reasonably common. Olhers, such as diffuse idiopathic skeletal hyperostosis and Reiter's syndrome, are very rare.

Ankylosing spondylitis This chronic inflammatory condition has a prevalence of about 0.2% and is more common in men than in women. There is an imporrant genetic component to the disease: over 90% of sufferers are human leukocyte antigen (HLA)-B27 positive. The underlying pathological process is synovitis associated with destruction of articular cartilage. There is also inflammation of the fIbro-osseollS junctions, especially the intervertebral discs. initially, there is localized bone erosion with granulation tissue fonnation: this is subsequently replaced by fIbrous tissue, which is then ossified This causes ankylosis of the joint.

Signs and symptoms Signs and symptoms of ankylosing spondylitis include: 1) lower-back pain (LBP) and stiffness (especially limited extension),

which is often worse in the morning 2) sacroiliac pain and tenderness 3) hip and shoulder pain and stiffness

Investigations Radiologically, the follOwing first changes are usually seen in the sacroiliac joints: 1) erosions and "blurring" of the sacroiliac joint

2) 3) 4) 5) 6) 7) 8)

loss of sacroiliac joint space (see Figure 11.1) ~squaring" of vertebral bodies loss of cervical and lumbar lordoses thoracic kyphosis marginal syndesmophyte formation ~bamboo spine" (see Figure 11.2) destructive arthritis of peripheral joints


Inflammatory arthropathies affecting the spine

Figure Il.l.

Sacroiliac X-ray showing oblitcration of thc joint space.

Treatment Treatment is conservative in the vast majority of people, and consists of advice on posture and prescription of anti-inflammatory dmgs. Referral to a rheumatologist is recommended. Surgery is only considered if there are severe defonnities or if there is evidence of cervical instability. Atlantoaxial subluxation can occur, panicularly if the rest of the neck is fused. This should be treated with stabilization, panicularly if there is evidence of spinal cord compression. Patients with severe cervical kyphosis have difficulty looking ahead and can be offered osteotomy. There are, however, significant risks associated with this procedure, including massive hemorrhage and damage to the spinal cord and nerve roots. The C7-TI level is usually chosen for the osteotomy. Severe lumbar kyphOSis can also be corrected with osteotomy, the usual site being L2. Patients known to suffer from ank}'losing spondylitis who develop acute back or neck pain should be assumed to have suffered a new fracture until proven otherwise. [f a fracture is diagnosed, immobilization is required and surgical fusion is often undenaken to ensure union of the fracture.

Rheumatoid spondylitis The majority of patients with rheumatoid anhritis will have spinal involvement, invariably the cervical spine (see Chapter 18).

Sacroiliac pain Pain arising from the sacroiliac joint often manifests itself as LBP and buttock pain; examination should reveal whether or not the joint itself is responsible for the pain. Medial stressing of the joints usually elicits pain in a diseased joint. Causes of pain


Chapter 11

Figure 11.2.

Anteropostcrior lumbar spinc X-my showing "bamboo spinc' include degenemte change (the most common cause), ankylosing spondylitis, and the other spondyloatthropathies discussed below. Referred pain is often felt in the sacroiliac area Bone scanning is helpful in highlighting pathology, but is not able to distinguish between the arthropathies. Diagnostic injections using image intensification can also be therapeutic.

Diffuse idiopathic skeletal hyperostosis Also known as Forestier's disease or abbreviated to DiSH, this is a similar condition to ankylosing spondylitis in that ossification occurs in the anterior longitudinal ligament. Similar changes in the sacroiliac joint are often seen it is not an inflammatory disease. it is usually only seen in older men who present with back pain. Osteophyte fonnation in the cervical spine can lead to dysphagia. which occasionally requires surgery in the fonn of osteophyte excision. Defonnity is not usually severe and treaunent is supportive.

Reiter's syndrome This syndrome is a combination of arthIitis, urethIitis, and conjunctivitis and can also have lumbosacral involvement. Patients with Reiter's syndrome can present with LBp, which may be due to spondylitis or sacroiliitis. The sacroiliitis is usually unilatemL The treatment of spinal problems associated with Reiter's syndrome is conservative.


Inflammatory arthropathies affecting the spine

Psoriatic spondylitis Up to 20% of patients with psoriasis will develop spinal involvement. Patients usually have symptoms similar in magnitude to Reiter's syndrome. Some, however, have severe involvement that can mimic ankylosing spondylitis. Treatment is conservative, consisting of analgesia, rest, and physiotherapy.

Inflammatory bowel disease and spondylitis Patients suffering from Crohn's disease and ulcerative colitis are also known to suffer from spondylitis and sacroiliitis, These patients tend to have a similar disease to ankylosing spondylitis and those with severe disease are invariably HlA-B27 positive. Colectomy does not alter the course of the spondylitis.


';--::::::;,;~_/'~ ....

__ """~"

Inferior anlcular process

Spinal canal

Bilid spinous process

Raised lip on upper surface 01 body Ant&rlor tubercle 01 transverse process,,-"50°. It is wonhwhile considering those patients who have a high risk of curve progression, and these include: a) younger age « 12 years old) b) females c) Risser grade 0-1 (immature skeleton) d) those with curves of > 200 e) those with a thoracic hypokyphosis 122

Chapter 19

Neuromuscular scoliosis Neuromuscular scoliosis is divided into either neuropathic or myopathic causes: the most common scolioses include cerebral palsy (see Figure 19.4), syringomyelia, spinal cord tumor, muscular dystrophy, and arthrogryposis Examination

Scoliosis is a common feature of the neuromuscular disorders, so the spine should always be assessed in these patients The curves differ from the majority of those seen in other fonns of scoliosis in that they: 1) are frequently longer

2) involve a significant portion of the spine 3) are often unbalanced; there is no compensatory curve. This is one of the distinguishing features of patients with idiopathic scoliosis, who often have a compensatory curve. The compensation allows the head to be centered over the pelvis, which is frequently not the case in the neuromuscular disorders 4) are often associated with other skeletal defonnities of the neck and pelvis. All patients with neuromuscular scoliosis should be assessed for respiratory complications, which are relatively frequent. A functional assessment of the patient is paramount and, in particular, one should assess whether the patient is ambulatory or wheelchair bound. If wheelchair bound, then it is important to assess whether the patient can sit unaided Treatment

The treatment of neuromuscular scoliosis includes: 1) observation

2) bracing up until the age of 12 years. The most popular brace used is the Boston brace, as the Milwaukee brace often results in pressure sores 3) surgical fusion. The fusion is often extensive and frequently involves fusion of the spine to the pelvis. The primary goal of treatment is to pro~ide the patient with a stable spine that is relatively balanced 4) supportive therapy. This includes a multidisciplinary team, involving a pediatrician, a spinal surgeon, a physiotherapist, and an orthotist. Genetic counseling should also be made available to these families


Pediatric spinal conditions

Infection Infection is a rare but extremely important cause of pediatric back pain. The infective conditions include: 1) pediatric infective discitis

2) vertebral osteomyelitis 3) abscess fonnation These disorders are discussed separately in the chapter on spinal infection. Essentially, any child who presents with constant, deteriorating back pain that is refractory to analgesia and present at rest requires investigation for spinal infection. The child will frequently present with constitutional symptoms, such as anorexia, weight loss, fever, nausea, and vomiting. Examination often reveals extreme tenderness in the back, and spinal movements are severely restricted. All children presenting in this manner require urgent referral to an orthopedic or spinal team and should be investigated by measuring full blood count, erythrocyte sedimentation rate, and C-reactive protein level, and also by spinal imaging. The treatment often includes antibiotic therapy, bed rest, and a spinal orthosis. Operative intervention is usually restricted to those with: 1) abscess fonnation

2) 3) 4) 5)

neurological deficit infection that is refractory to antibiotic therapy biopsy for diagnosis and culture vertebral collapse with progressive kyphosis

Tumors Spinal tumors are a rare cause of pediatric back pain, which often results in misdiagnoses and delayed diagnoses. The most common tumors of the pediatric spine include: 1) osteoid osteoma

2) osteoblastoma 3) aneurysmal bone cyst Osteoid osteomas can be associated with a painful scoliosis in the child, whilst osteoblastomas are frequently linked with neurological involvement as they affect the posteJior column. Aneurysmal bone cysts typically emerge in the older child in late adolescence. The salient features in the history include constant, unremitting back pain that is present at rest. Patients with osteoid osteomas often fmd that aspmn therapy relieves their pain; this is almost diagnostic. Examination often 124

Chapter 19

reveals a significant reduction in the range of movement in the spine, with or without a scoliosis. Children who present in this fashion require an orthopedic or spinal referral urgently for appropriate therapy Surgical intervention is frequently indicated for tumor resection and spinal fusion. Chapter 10 provides more infonnation on this subject.

Psychogenic back pain Very rarely, children present with back pain that is secondary to some fonn of psychological upset, This is essentially a fonn of somatization. However, it is important to actively exclude all other causes of back pain. A thorough history is essential, including past medical and psychiatric history, as is an inquiry as to the child's family life and also the family setup. The child's schooling is also important, so actively inquire about bullying and truancy. An assessment of the child's development, both physically and mentally, is also important. Examination involves observation of the child and hi~er interaction both with the clinician and with the family. A thorough examination of the back is important for excluding all other causes of back pain, and signs of other past psychological insults, such as self-hann or even nonaccidental inJury, should be actively looked for Following a thorough investigation to e.xclude the other causes of back pam, children with psychogenic back pain need psychological counseling and support. It is important to include the family in the treatment to achieve the best results

Torticollis Torticollis is defined as a rotational defonnity of the neck in association \vith a tilting of the head, The most common causes of tonicollis in the child include: 1) congenital muscular torticollis

2) congenital anomalies: a) (1 facet abnonnalities b) Klippel-feU syndrome c) os odontoideum d) atlantoaxial instability or subluxation 3) secondary to upper respiratory tract infection The most common cause by far is congenital muscular torticollis, which is due to scaning and fibrosis of the sternomastoid muscle. The incidence is increased significantly in breech deliveries, Examination of the child reveals that the head is tilted to the affected side and palpation reveals an obvious cord-like sternomastoid muscle, which is usually nontender. X-rays of the neck are nonnal and if any


Pediatric spinal conditions

abnormalities are present another diagnosis should be considered. Approximately 10%-20% of these children have developmental dysplasia of the hip, and so a thorough examination of the child is essential to exclude any other pathology. Treatment includes physiotherapy to try to breakdown the scar tissue in the sternomastoid muscle and stretch the tissues on the affected side. The parents need to be advised regarding stretching exercises so that these can be carried out at home. If the deformity persists beyond 12-18 months then surgical release is often required Any child who presents with a torricollis in hi.s}her early years of life requires review by a spinal or orthopedic surgeon to exclude other pathologies.

Summary Back pain in children is relatively uncommon and, as such, presentation of a child with back pain should alerr the clinician to fully examine and investigate the child. The cause is often mechanical and related to some childhood activity; however, it is imperative that the other diagnoses are actively excluded. Any concern regarding the diagnosis should prompt referral to the local orrhopedic team.


Abbreviations AUF

anterior lateral interbody fusion




C-reactive protein


computed tomography


dual-energy X-ray absorptiometry


diffuse idiopathic skeletal hyperostosis


erythrocyte sedimentation rate


human leukocyte antigen


lower-back pain


magnetic resonance imaging


nonsteroidal anti-inflammatory drug


prolapsed intervertebral disc


posterior lateral interbody fusion


range of movement


straight leg raise




transcutaneous electrical nerve stimulation



CltlVlcal spine

-.... ~


"""""" spine

Lumbar spine

, Sacrum


Anlcroposlerior view.





, Lumbar


Lateral view.



Odontoid IKg view.


Index Page numbers in bold refer to figures. Page numbers in ilalic, refer to tablcs.

A abdominal exercises 44 abscess fOlTIlation 65.66 epidural abscess 35, 65 pamspinal abscess 65 pediatric 124 spinal tuhcrculosi;; (Pott's disease) 64,65 treatment 65 absolute stenosis 47 achondroplasia 48 acquired spinal stenosis 4K 49

activities of daily living 97 activity 2 adolescent idiopathic scoliosis sa scoliosis, adolescent idiopathic adolescents, spondylolisthesis treatment 57

adults, spondylolisthesis



aggravating facial'S, history 2 aging 39,47

alar ligaments 82,83 analgesia coccydynia 79 pediatric mechanical back pain 114 pediatric spondylolysis/spondylolisthesis 115 prolapsed thoracolumbar intervertebral discs 44

psoriatic spondylitis 76 Schcucnnann's disease II? spinal stenosis 51 anal tone 7,42 anastomosis 60 anatomy

cervical spine 15,81,81-4,82 coccyx 15,79 lumbar spine IS, 17 sacrum 15,77,77 thoracic spine 15. 16 thoracolumbar spine 15-19 vembroc 16, 16, 16-17 vembral column 15-16 anemia, malignant tumor 71 aneurysmal bone cyst 69, 124 aneurysms, aonic 33 ankle jerk reflex 3 ankle movement/power examination 4,4



ankylosing spondylitis 73-4,74, 75 invc.stigations 73 prevalence 73 sacroiliac pain 75 signs and symptoms 73 treatment 74 ankylosis, disc degenerntion 39 annular tears, disc degenerntion 39 annulus fibrosus 17, 17,32,39 anorexia 2,60, 124 anterior arch frncture 88 anterior column 60, 69 anterior cord syndrome 22, 106 anterior disceetomy 117 anterior longitudinal ligament 17-18 cervical spine 83 ossification 75 anterior lumbar interbody fusion (AUF) 35,37 anterior screw, ooontoid peg fracrure 89 anterior transthoracic surgical excision 46 anterior tubercle 81, 84 anteroposterior CAP) plain radiogrnphs 9 burst fractures 93 cen~cal spine injuric.s 85,86,86-7 comprc.ssion injuries 23 facet joint dislocation 92 fracture dislocations 27, 18 spinal stenosis 50 antibiotics 62,63,65,124 anti-inllammatorydrugs 44,74,104,115 AD classification of thorncolumbar trauma 23 aortic aneur~ms 33 apical ligament 82, 83 arthritis 55,75 see a/.ID rheumatoid spine arthrodc.sis 78 arthrogryposis 123 arthropathies, inflammatory 73-0 ankylosing spondylitis .leE ankylosing spondylitis Beh"et's syndrome 76 diffuse idiopathic skeletal hyperostosis 75 inflammatory bowel disease 76 psoriatic spond>1itis 76 Ikiter's syndrome 75 rheumatoid spondylitis 74 sacroiliac pain 74-5 articular cartilage dc.struction 73 articular facets 16, 17,81 articular processes 16, 84 ascending (sensory) tracts 21 aspirin therapy 68, 114



atlantoaxial instability 115 atlantoaxial joints 109 atlantoaxial subluxation 89, 109-10, 110 ankylosing spondylitis 74 tonicollis 125 transverse ligament rupture 89 atlamo-dens imerval, atlantoaxial subluxation 110, 110 atlanto-occipital dislocation 87 atlas ((l) 81,81-2 injury 88. 88, 89 ligaments 82, 83 auditory symptoms 96.97 autogenous bone graft 35 autologous bone graft 108 axial compression 92, 93 axial spine compression, atlas injury 88 axis ((2) 81-2,82 injury 89.90,90,91 ligaments 82, 83 B

back pain benign rumor 68 epidural abscess 65 malignant tumor 70 mechanical, pediatric 113, 114 prolapsed thoracolumbar intervertebral discs 41 Scheuemunn's disease 116 soft-tissue injury of cervical spine 96 thoracolumbar trauma 21 ~a alS' 74 L4-5 facet joints degenerative spond>1olislhesis 54-5,55 pediatric infecrive discitis 63 L5-S] facet join!, dysplastic spondylolisthesis 54, 54 L5 wedging 116 lamina 16,16,81,84 oblique radiograph 87 laminectomy, decompressive 51, 108 lap-belt injury 27,27 lateral conicospinallract 11 lateral plain radiograph 9 cef\ical spine injuries 85,86 compressIon mjunes 23.24 erect, burst fractures 26



fracture dislocations 27, 18 spinal stenosis 50 lateral spinothalamic tract 11 lateral stenosis 48. 48 leg pain 41,54 Lhermine's sign 105 ligaments destruction. rheumatoid spine 109 hypertrophy, cervical myelopathy 105 Sf/: abo specific ligamwts ligamentum fiavum 18 calcification 105 hypertrophy 48 ossification 106 limb length equality, adolescents 120 litigation issues 32,35.98 liver function test 71 liver ultrasound, metastases 71 longus capitis 18 longus coUi 18 lordosis 15 Sf/: also cervical lordosis; lumbar lordosis lower-back pain (LBP) ankylosing spondylitis 73 mechanical .let: mechanicallowcr-back pain plain radiographs 10-11 prolapscr\ thoracolumbar intervertebral discs 39 Reiter's syndrome 75 sacral chordoma 78 sacroiliac pain 74 sacrum fractures 78 soft-tissue injury of cervical spine % spondylolisthesis 56 lower-limb assessment 3 lower-limb =rcises 44 lumbar dermatomes 5 lumbar epidural 35 lumbar instability 32 lumbar intervertebral disc prolapse 39-41, 40, 41 lumbar intervertebral disc replacement 36 lumbarization 15,15 lumbar lordosis 15 loss 41,56,73 spinal stenosis 50 lumbar spinal stenosis sa spinal stenosis (lumbar) lumbar spine anatomy IS, 17 aneurysmal bone cyst 68 anteroposterior view 119 burst fraclUre 13 lateral view 130



magnetic rC$onance imaging 14 movement 18-19 plain radiographs II, II sa also thoracolumbar spine lumps 2.68.71 sa also abscess formation lung cancer 69 M magnetic rC$onance imaging (MRl) 9. II, 13 abscess formation 66 atlantoaxial subluxation 110 benign tumor 69 bUl'St fracrures 26, 93, 93 cauda equina syndrome 42 cervical cord injury 87 cervical myelopathy 106, 107 cervical radiculopathy 103, 103 cervical spine, sagiltal 14 cervical spine injuries 87 compression injuriC$ 23 contraindications 13 degenerate imcrvenebral discs 32 facet joim subluxations 92 intervcnebral discs 13 juvenile idiopathic scoliosis 119 lumbar spine, sagiltal 14 malignant tumor 71 mechanical lower-back pain 33, 33, 33-4 pediatric infective discitis 63 pediatric spinal conditions 114 pediatric spondylol)'sis/spondylolisthC$is 115 prolapsed thoracolumbar disc surgery 45 prolapsed thoracolumbar intervembral discs 43.43 pyogenic vembral osteomyelitis 61, 62 rheumatoid spine 109 sacral chordoma 78 spinal stenosis 50 spondylolisthesis 56 thoracic disc disease 46 thoracic spine, sagittal 14 malaise 2 malignant tumor'> .Ia tumor'>, malignant manipulation, coccydynia 79 mechanical back pain, pediatric 113, 114 mechanical lower-back pain 31-8 diagnosis 33-4 epidemiology 31 etiology 31-3 beet joints 31 intervcnebral discs 32



lumbar instability 32 muscle-related pain 32 prevalence 31 p,,>,chological factors 32 psychological ICSting 34 referred pain 32-3 treatmen! 34-7 discography 35 dynamic stabilization 37 epidural injections 34-5 facet joint injections 35 interbooy fusion 35,36,37 intervertebral disc replacement surgery 36 intradiscal c1ectrothemla1 therapy 35 nonsurgical 34-5 posterior fusion with autogenous bone graft 35 spinal fusion 35 spinal instrumentation 36 stabilization 35 surgical 35-7 metaphysis of vertebral booy 64 metastases 69,70, 71 bone scanning 12, 12 pathological s?Jndylolisthc.sis 55 Milwaukee brace adolescent idiopathic scoliosis 121 juvenile idiopathic scoliosis 119 neuromuscular scoliosis 123 $cheuennann's disease 117 mobilization compression injuries 23 pyogenic vertebral osteomyelitis 62 sacrum fractures 78 mood state change 97 motion segment 17,54 mOlOrvehicie accidents 21. 89, 95 movement ccr\~cal spine 84 cervical spine examination 5,6 pediatric spinal conditions 114. 115 reduced, benign tumor 68 resaicted, cervical radirulopathy 102 soft-tissue injury of cervical spine 96,99 thoracolumbar spine 3,4, 18-19 vertebral column 17, 18-19 multiple drug therapy 65 muscle-related pain 32 muscle relaxants 34,44 muscles 18,83 SEe abo specific mWides muscle weakness, cervical myelopathy 106



muscular dystrophy 113 myalgia 2 myelography 11 myeloma 70, 71 myelopathy, cervical see cervical myelopathy myofascial pain syndrome 32 myopathic neuromuscular scoliosis 123 N narrow canals 48, 105 nausea 124 neck muscles 83 neck pain cervical myelopathy 105 cervical radiculopathy 102 cervical spondylosis 105 flexion cxtension radiographs 87 odontoid peg fracture 89 rheumatoid spine 109 soft-tissue injury of cervical spine 96, 96 neck rotation deformity 125-6 neck stiffness 109 neck support 99, 104 needle biopsy 69 necdle localization, fluoroscopy 11 nerve root 18 nerve root compression 47 lumbar disc prolapse 40, 40-1 pediatric spondylolisthesis 115 spondylolisthesis 56 symptoms 39 nerve root entrapment cervical radiculopathy 102 decompression 44-5 differentiation from peripheral neuropathy 43 nerve root injections 44 neural arch 16 neural foramen 87 narrowing see spinal stenosis Oumbar) neurofibroma 70 neurological abnormality/defect pyogenic vertebral osteomyelitis 60 rheumatoid spine 109 soft-tissue injury of cervical spine prognosis 98 thoracolumbar trauma complication 28,29 sa also neurological injury neurological assessment 3 cervical spine examination 5 pediatric spinal conditions 114 thoracolumbar spine examination 3 neurological injury



atlallloaxial subluxation 110 thoracolumbar trauma 21-3 sec al~o neurological abnonnality/dcfcct ncuromuscular scoliosis 118, 121, 113 ncuropathic neuromuscular scoliosis 123 ncurophysiological studies 43 night swcats 2 nonsteroidal anti-inl1ammatory drugs (N$AlDs) 34.76.99, 108 nucleus pulposus 17, 17,39

o oblique plain radiographs 9,87 observation adolescent idiopathic scoliosis 111 cervical myelopathy 108 infantile scoliosis 119 neuromuscular scoliosis 123 thoracolumbar spine examination 3 occipital headache 96 occipitoatlantaljoint 109 occupation 97 odontoid peg 83 distance from anterior arch of atlas 85 fracture 89,90,90 Cl-2 fixation 89 plain radiographs 9,85,86,87 odollloid process IU dens (odontoid process); odontoid peg onhosis burst fractures 93 compressIOn lnJunes 23 odontoid peg fracture 89 pediatric infection 114 pediatric infective discitis 63 pyogenic venebral osteomyelitis 62 os odontoideum 125 osseous lesions 67 ossification abnormality 116 osteoarthritic facet joints 48 osteoblastoma 67,69,70, 124 osteochondroma 67 osteoid osteoma 67,69,114-5 osteomyelitis, pyogenic venebral 59-62, 124 clinical fearurcs 60 diagnosis 60-2,61 differentiating features from spinal ruberculosis 64-5 etiology 59--60 pathogenesis 60 treatment 62 osteopathy 34,99 ostcopenia 60 osteophytes



cCfvical radiculopathy 103 excision 75 fonnation, spinal stcnosis 48,49,50 osteoporosis 24, 78 osteoporotic compression fracture 23 osteoporotic-related spine fractures 14,24-5 osteoporotic wedge fracIDre 2 I osteosarcoma 70 osteolOmy 74 p Paget's disease 48,55.70 pam pyogenic vertebml osteomyelitis 60 thoracolumbar !rnuma 2K 29 sa (lIS