Causes Torticollis may be congenital or acquired. \200 The congenital causes may be due to an underlying muscular abnormality, accounting for 80% of congenital torticollis. Causes include a sternocleidomastoid mass, sternocleidomastoid t ightness or may occur despite a normal sternocleidomastoid. The remaining 20% of con- genit al torticollis results from bony abnormalities. These include failure of formation of the u pper cervical bones (for example, a congenital hemi-atlas) or due to failure Figure 5.6 This lateral plain radiograph of the neck in \202 exion demonstrates an increa sed atlanto-axial distance. CHAPTER 5 Regional musculoskeletal anatomy and conditions 127 of segmentation of the upper cervical spine bony ele- ments (such as occurs in Kippel \200 \223Feil syndrome). A com- bination of these bony abnormalities may be present. Acquired to rticollis is best classi \201 ed as painful or non- painful. The most common cause of pain ful acquired torticollis is trauma resulting in atlanto-axial rotatory subluxation. Tumors such as eosinophilic granuloma and osteoid osteoma may cause painful torticollis, and need to be entertained in the differential diagnosis in a child presenting with pain and an abno rmal attitude of the head and neck. In \202 ammatory causes include JIA and post-infectiou s torticollis. Gastro-oesophageal re \202 ux may be associated with painful torticollis an d is referred to as the Sandifer syndrome. The most important differ- ential diagnosis in t he older child presenting with a non- painful torticollis is an underlying central nervous system tumor or a syrinx, although the commonest cause is ocular, with the child compensati ng for weakness of the ocular muscles. Hysterical torticollis is a diagnosis of exclusion. Treatment Treatment is normally conservative with regular follow-up. Orthoses do not seem t o be helpful. Exercise and stretch- ing have been demonstrated to yield good results and up to 90% improve with this method. The best results are obtained in patients less than 3 mon ths of age with less successful results in children over 18 months of age. Indications for surgery Surgery is indicated in patients with signi \201 cant head tilt an d restriction of movement, where a tight band is palpable in the sternocleidomastoid. Surge ry is usually delayed until the patient is over age 1 year and where there has been a failu re of non-operative treatment. Surgery may involve a release of the muscle from one or two sites of its attach- ment, and may involve complete division of the tendon or Z-plasty. Par tial or complete muscle resection has also been performed. In general, 90% of patients unde rgoing surgery have a good result. Further reading Clarke CR (ed.). The Cervical Spine, 4th edn. The Cervical Spine Clinical presentation The appearance of the deformity may be variable, but usually the chil d demonstrates a restricted range of movement of the cervical spine. There may be associate d plagiocephaly or facial asymmetry depending on the duration of symptoms. A mass is palpab le in the sterno- cleidomastoid on the ipsilateral side of the head tilt before 6 weeks of life in up to one-third of patients. Torticollis that corrects on covering one of the eyes is due to an underlying ocular cause, and a compensatory maneuvering of the head and neck. Research Society/Lippincott, Williams and Wilkins, 2004. Hildingsson C, Toolanen G. Outcome after soft tissue injury of the cervical spine: Prospect ive study of 93 car-accident victims. Acta Orthop Scand 1990; 61: 357 \200\2239. Riise T, Jacobsen BK, Gran JT. High mortality in patients with Rheumatoid Arthritis and atl anto-axial subluxation. J Rheumatol. 2001; 61: 357 \200\2239. Roche CJ, Eyes BE, Whitehouse GH. The rheumatoid cervical spine: signs of instability on pl ain cervical radiographs. Clin Radiol 2002; 57: 241 \200\2239. Santavirta S, Slatis P, Kankaanpaa U, Sandelin J, Laasonen. Treatment of the cervical spine in rheumatoid arthritis. J BJS(a) 1988; 70: 658 \200\22367. Investigations Investigations should include anteroposterior and lateral radiographs of the cervical spine to exclude underlying bony abnormalities. In children presenting with painf ul tor- ticollis a CT scan should be undertaken to exclude under- lying tumor, such as oste oid osteoma. An MRI scan is useful to exclude underlying central nervous system tumors in p atients with painless torticollis. Cheung JCY, Wong MWN, Tang SP, Chen TMR, Shum SLF, Wong EMC. Clinical determinates of the o utcome of manual stretching in the treatment of congenital muscular torticollis in infants. JBJS (a) 2001; 83; 679 \200\22387. Demirbilek S, Atayurt H. Congenital muscular torticollis and ster- nomostoid tumor: results of non-operative treatment. J Pediatr Surg 1999; 34: 549 \200\22351. Natural history The natural history is variable. If there is a sternocleido- mastoid mass p alpable there is a 50 \200\22370% chance of resolu- tion by 1 year. A small sub-group of ab out 10% of patients require surgical intervention. THORACIC SPINE AND CHEST WALL: REGIONAL MUSCULOSKELETAL CONDITIONS 128 Thoracic spine and chest wall: regional musculoskeletal conditions bodies, at either single or multiple levels in the spine, most commonly involving the thora cic spine. This process results in wedging of the vertebral body and multiple vertebral bod y involvement results in kyphosis. The cause is unclear but Scheuermann \200\231s disease i s a risk factor for developing osteoarthritis in later life. Main differential diagnosis of thoracic and chest wall pain Thoracic vertebral body \200 \200 Fracture, e.g. osteoporotic fracture. Tumors, e.g. pathological fracture, metastases, osteo id osteoma. Metabolic bone disease, e.g. Paget \200\231s disease, osteomalacia. Pathology Ossi \201 cation of the vertebral bodies occurs in three places, the primary cen ter being the middle of the vertebral body and the other, secondary centers being in the up per and lower margins of each vertebral body. The secondary cen- tres are also known as rin g epiphyses, and these appear around puberty in the adolescent within the cartilaginous end plates that lie between the developing vertebral body and the intervertebral disc. In Sche uermann \200\231s disease, the cartilaginous end plate and ring epiphysis do not develop no rmally, and the disc protrudes through the cartilage into the vertebral body. The anterior surface is that portion of the vertebral body, which is exposed to the greatest weight-bear ing force and is, therefore, that portion most likely to be involved. The disc space narrow s anteriorly and wedging of the vertebral body occurs. Mechanical \200 \200 \200 \200 \200 Osteoarthritis of the thoracic spine. Scoliosis. Costovertebral joint disease. Diffuse idio pathic skeletal hyperostosis. Olecranon bursitis. Nerve derived \200 Nerve root compression by herniated disc or osteophyte. Pathology of intercostal nerve, e.g . herpes zoster, neuroma. In \202 ammatory/infection \200 Spondylarthropathy. \200 Disciitis osteomyelitis. \200 Crystal, e.g. calcium pyrophosphate deposition. History Pain in the thoracic spine in children aged between 13 and 16 is typical, although this pain is usually self-limiting after a few months. Pain may recur at a later stage as s econdary degenerative change develops. Chest wall lesions \200 \200 Examination Examination reveals a tender kyphosis during the \200\230active \200\231 phase of Scheuermann \200\231s disease, although this tenderness settles, leaving a pain free ky phosis. Rib, e.g. fracture, tumors, osteomalacia. Costochondral pathology, e.g. degenerative, rheum atoid arthritis. Soft tissue, e.g. intercostal muscle tear, myofascial pain, \201 bromyal gia, enthesitis. Pleural disease, e.g. infection, in \202 ammation, in \201 ltration. Bre ast pathology, e.g. mastitis. Investigations Plain radiographs con \201 rm deep notches in the anterior corners of the v ertebral bodies. The corresponding epi- physeal rings may also appear irregular. The disc s paces are narrowed, particularly anteriorly. Wedging may be obvious in the anterior portion of the vertebral body and there may be degenerative change later in life. See Figure 5.7. \200 Others \200 \200 Scheuermann \200\231s. Cardiac/praecordial disease. Treatment Conservative treatment with analgesia and physiotherapy is the main stay of thera py. Intervertebral grafting is rarely undertaken and only in severe cases. Thoracic pain is less common that cervical and lumbar pain, and a lower threshold for inves tigating thoracic pain is therefore warranted. Thoracic spondylosis Spondylosis of the thoracic spine presents in a similar fash- ion to t hat of the cervical and lumbar spine. Investigations and management are discussed in these sections. Scheuermann \200\231s disease Scheuermann \200\231s disease was previously called osteochon - dritis, although this term is now generally avoided. The intervertebral disc protrudes in to the adjacent vertebral CHAPTER 5 Regional musculoskeletal anatomy and conditions 129 (a) (b) Figure 5.7 This is lateral plain radiograph (a) and a sagittal T2-weighted MR (b) of the lo wer thoracic spine in a patient with Scheuermann s disease demonstrating anterior wedging a nd endplate irregularity over three contiguous levels. Musculoskeletal chest wall pain History A careful history is important to exclude non-muscu losk- eletal cause of chest pain. Features of bone pain systemic features and other associa ted muscu-loskeletal symptoms should be sought. Table 5.2 Important features in the history in patients with chest pain Cardiac pain Angina \200\223 pain less than 30 mins, usually exertional, typically central and crush- i ng with radiation into arms and jaw. Associated nausea, dyspnoea and sweating. Examination Tenderness may be revealed over the costochondral joints in costochondritis, an d soft tissue tenderness is common in myofascial pain. Localized rib pathology may reveal b ony tenderness over the affected rib. There may be hypomobil- ity of that proportion of the chest wall on deep inspiration. A full medical and neurological exami-nation should be un- dertaken in all patients with chest pain and thoracic pain. Myocardial infarction is usually more severe and pro-longed. Pericardial disease is typically central sharp pain which may be eased on leaning forward Investigations Elevation of serum alkaline phosphastase is suggestive of bone pathology and requires further investigation. Imag-ing is best undertaken with plain radiographs, althou gh isotope bone scintigraphy will detect increased uptake in, metastatic disease, Paget \200\231s disease and osteoid osteomas. CT gives more speci \201 c bone detail and MRI is indicated in patients with symptoms suggestive of nerve root or cord compression. Aortic disease \200\223 severe and of acute onset. Pleural disease Sharp and exacerbated by inspiration. Pain is super \201 cial. There may be a history of h aemoptysis. Gastrointestinal disease Retrosternal burning which may be related to eating. Peptic disease may radiate to the back Treatment The treatment should be aimed at the underlying condi- tion. In patients with loc alized chest wall pain but without signi \201 cant underlying pathology, reassurance and p atient education is central. Physical therapies, simple analgesia and topical or oral NSAID s may help. Neuralgic pain may respond to amytryptiline and local glucocorticoid with local anesthetic in \201 ltration may relieve localized tender- ness or costochondral pain. Mediastinal pain May be intense and radiate to shoulder or may mimic pleural pain. Musculoskeletal Insidious in onset, often with a history of recent unfamiliar repetitive activity or upper body. The position of the pain may be localized or diffuse in position and may be exacerbat ed by speci \201 c movements. It may be persistent and prolonged LUMBAR SPINE: REGIONAL MUSCULOSKELETAL CONDITIONS 130 Lumbar spine: regional musculoskeletal conditions degenerative change on plain radiographs, and investiga- tions are only indicated if there is doubt about the clinical diagnosis. Main differential diagnosis of lumbar pain Lumbar vertebral body \200 \200 \200 Fracture, e.g. osteoporotic fracture. Tumors, e.g. multiple myeloma, metastases. Metabolic bone disease, e.g. Paget \200\231s disease, osteomalacia. Treatment The natural history of low back pain is that 50% improve after a week, and more t han 90% are better at 8 weeks. Treatment is therefore conservative, with analgesia and exer cise. Bed rest should be actively discouraged. Early activity helps pain and reassurance sh ould be given that exercise is not causing harm despite pain. Exacerbations of pain are com mon and there is weak evidence that exer- cise alone has any impact on the prevention of fu rther episodes. Mechanical \200 \200 \200 \200 \200 \200 \200 Non-speci \201 c low back pain. Osteoarthritis of the lumbar spine. Spondylolisis. Scolios is. Spinal stenosis. Diffuse idiopathic skeletal hyperostosis. Hypermobility. Chronic low back pain 7 \200\22310% of those with an acute episode of back pain have contin uing symptoms after 6 months, often with diffuse, non-speci \201 c leg pain. There is ofte n an underlying cause identi \201 ed, such as chronic disc herniation, degenerative disc d isease, \201 bromyalgia, psychological factors, or scar tis- sue following surgery, altho ugh altered chronic pain path- ways also contribute to ongoing pain patterns. Altered pain behavior, with widespread super \201 cial pain, non-anatomical weakness and sensory loss, and restricted straight leg raise on formal testing, but ability to sit with the legs exten ded all suggest a non-organic cause. Investigations include rou- tine blood tests and imagi ng to exclude other pathology. Pharmacological options include simple analgesia, non-ste- r oidal anti-in \202 ammatory agents, and tricyclic antidepres- sants or antiepileptic drugs in those with a neuralgic com- ponent. Exercise and physiotherapy encourage physical funct ion, and build on patient education. Local injections can be helpful in some cases, and inc lude facet joints injec- tions, epidurals, and trigger point injections. Back pain pro- gra mmes involve the full multidisciplinary team, including psychologists, and offer some succe ss in the management of pain, but access to these places is often restricted. Nerve derived Nerve root compression by herniated disc or osteophyte. In \202 ammatory/infection \200 \200 Spondylarthropathy/sacroiliitis. Disciitis/osteomyelitis. Referred \200 \200 \200 \200 Retroperitoneal \201 brosis. Renal disease, e.g. infection. Abdominal aortic aneurysm. Gy necological disease. Others \200 \200 Schueurmann \200\231s disease. Fibromyalgia. Acute low back pain Low back pain is extremely common and is estimated to affect 14% of the population at any time. There is a lifetime prevalence of between 58 and 80%. Associated f actors include lower social class, work-related injuries particularly in manual occupations , neck pain, and other widespread musculoskeletal pain, and depression. Although back pain is common in all age groups, the highest prevalence is in those in their 5th and 6th decade . The costs of low back pain in the UK are huge with 4.9 billion working days lost per annu m, with an estimated cost of 5 billion to the economy in 2005. The average time of work f or each episode of low back pain is 19 days according to the Labor Force Survey 2003/4. Lumbar spondylosis The causes of spondylosis are multifactorial, with both ge- netic and en vironmental factors playing a role. Predisposing conditions include Schueurmann \200\231s d isease. The joints most commonly affected are the body to body (central) joint between vert ebral bodies, and the posterior intervertebral or facet joints. In the central disks, disc space narrowing is often the \201 rst manifestation, with subsequent osteophyte formation . Osteophytes may encroach on the nerve root foramen. History Low back pain is common, often exacerbated by activity and often positional, so tha t particular activities such as putting on shoes and socks cause discomfort. There may be e xacerbations of acute pain on a background of more chronic pain. History The onset of pain is acute, and there may be a history of precipitating activity or injury. The pain is improved by immobility and exacerbated by particular actions or moveme nt. There is usually little night pain. Examination The aim of examination is to exclude underlying patholo- gies. Range of movemen t is generally unhelpful in delineat- ing the underlying cause, as movements are generally restricted by muscle spasm. Examination The clinical \201 ndings are non-speci \201 c and there may be some global r estriction of lumbar movements. Neurological \201 ndings are rare. Investigations There is poor correlation between the extent of radiographic abnormalities a nd the severity of clinical symptoms. Investigations Investigations are normal in mechanical back pain, and indeed most patients do not require investigations. There is little correlation between low back pain and CHAPTER 5 Regional musculoskeletal anatomy and conditions 131 Less common sites of symptomatic disc herniation include foraminal disc protrusions and far lateral disc protrusions. These far lateral variants tend to compress the exiting nerve ro ot. A far lateral L4/5 disc protrusion could be expected, therefore, to cause symptoms rela ted to L4 nerve root compression. Treatment Simple analgesics and exercise is indicated for spinal spon- dylosis, with NSAIDs best reserved for \202 ares. Physiotherapy encourages regular exercise. Targeted injecti ons, such as facet joints injections and epidurals can be repeated in those who \201 nd t hem helpful. History The patient is typically a young adult in the third or forth decade of life. There may be an antecedent history of back pain related to an underlying annular tear. The patien t typically reports a sudden onset of severe leg pain in association with their back pain. The distribution of the leg pain may suggest which nerve is involved. S1 radiculopathy mani fests as posterior thigh, calf, and heel pain with pain radiating into the lateral border o f the foot. Pain related to L5 radiculopathy more typically involves the lateral aspect of the calf and dorsum of the foot. There is frequent overlap of the distribution of pain howe ver. Spondylolysis and spondylolisthesis Spondylolisis is de \201 ned as a defect in the pars i ntra-articularis, usually of the 5th neural arch, although less commonly the 4th neural arc h may be affected. Congenital defects cause the majority of cases, but injury in childhood or adoles- cence, particularly among those who play sport, is now increasingly recognized. Spondylolysis is a common \201 nding and often of no clinical signi \201 cance. However, deep low back pain is sometimes described. Spondylolisthesis describes spontaneous displac ement of a vertebral body in relation to the vertebral body directly beneath. Usually, the direction of displacement is anterior, but occasionally it may be posterior, termed a retro spondylolisthesis. Under- lying causes of spondylolisthesis include congenital malfor- mati on, spondylolysis, and posterior facet osteoarthritis. The commonest congenital abnormality is an inadequate posterior intervertebral joint, which normally prevents an- terior displa cement of the vertebral bodies. Spondylolisis allows separation of the two halves of the ne ural arch with gradual displacement on the vertebral body, particularly in young adulthood. Osteoarthritis of the posterior facet joint results in thinning of the cartilage, which ca uses insta- bility of the facet joint and posterior displacement. In both the congenital an d spondylolisthesis types, neurological compromise may arise and may be severe, but in the osteo- arthritis associated model neurological involvement is rare. Examination The patient may present with a list. L5 radiculopathy may result in dysfunction of the hip abductors and may lead to a Trendelenberg-type gait or a positive Trendelenberg \200\231s test. The knee jerk may be absent when the L5 nerve root is involved and in S1 n erve root involvement the ankle jerk may be absent or diminished. Weakness of the tibialis ante- rior or extensor hallucis longus muscles implicates L5 nerve root compression and wea kness of \202 exor hallucis and ankle eversion suggests S1 compression. The dermato- mal alteration of sensibility may also suggest particular nerve root involvement. A particularl y important sign is the presence or absence of nerve root tension signs. The most widely us ed of these is the straight leg raise test where the lower limb is elevated by \202 exing the hip pas- sively with the knee fully extended. Reproduction of the radicular type pain suggests nerve root compression. Pain aggravated by passive dorsi \202 exion of the ankle is said to indicate a positive sciatic stretch test and lends further support to the diagno sis of radiculopathy. Clinical \201 ndings Spondylolisis is often asymptomatic, and those with symp- toms of a spondylolisthesis often depend on the underlying mechanism. Pain may present in young adult s or conversely may present in an older population who develop osteoar- thritis. Often pain is worse on standing. Examination is often unhelpful, but neurological signs should be sou ght. Investigations The currently most widely used investigation is MRI. \200 Investigations Plain radiographs in the oblique view demonstrate abnor- malities of the neu ral arch and the extent of the spondylo- listhesis. MRI is the investigation of choice when there are neurological symptoms. MRI demonstrates the extent and direction of disc pro- trusion and con \201 rms if there a re sequestrated fragments. MRI also allows clear visualization of the cauda equina and has replaced CT myelography as the investigation of choice. It is possible to demonstrate disc protrusions on conventional CT, but there is less good soft tissue de \201 ni- tion and ve ry large disc protrusions, which occupy most of the spinal canal can be mistakenly interpre ted on CT to represent a normal cauda equina. Treatment Conservative treatment with analgesia and physiotherapy is appropriate, in all bu t the most severe cases, where spi- nal fusion may be offered. Lumbar disc herniation The L 4/5 and L5/S1 disks are most commonly involved in lumbar disc herniation leading to symptom atic radiculopathy. An annular tear facilitates herniation of the nucleus pulpo- sus. Radic ular pain arises both due to the compressive affects of the disc protrusion on the involved nerve root and also a chemically mediated in \202 ammatory process. \200 Treatment The vast majority of symptomatic lumbar disc protrusions respond to non-operative treatment. Patients should be prescribed analgesics and, where appropriate, non-steroidal anti-in \202 ammatory medication. Strict bed rest should not be enforced and the patient s hould be encouraged to mobilize as much as comfort allows. Approximately 80% of patients ha ve resolution of their radicular symptoms within 6 \200\2238 weeks of initial presentation. In instances where conventional analgesics are not effecting in controlling radicular pain , an epidural steroid injection or selective nerve root block under CT or \202 uoroscopic guidance usually relieves the leg pain. The most common site for lumbar disc protrusion is in the posterolateral disc region due to the relative de \201 - ciency in the posterior longitudinal ligaments in this region. Suc h protrusions tend to cause compression of the traversing nerve roots. A posterolateral L4/ 5 disc pro- trusion could therefore be expected to cause symptoms related to an L5 radiculo pathy. LUMBAR SPINE: REGIONAL MUSCULOSKELETAL CONDITIONS 132 Surgical treatment Surgical treatment is reserved for: \200 Facet joint hypertrophy, most typically of the medial side of the superior articular facet. Buckling of the ligamentum \202 avum. There may also be associated loss of disc height l eading to narrowing of the exit foramina. \200 Patients with severe intractable pain that does not settle with non-operative treatment, re gardless of duration of symptoms. Patients with progressive neurological deterioration in t he presence of a lumbar disc protrusion. This may be manifested by progressively worsening weakness of tibialis anterior, which if left untreated may result in a permanent foot drop. Cauda equina syndrome: this represents compression of the cauda equina elements, which inn ervate the bowel and bladder, and are responsible for autonomic function. It typically pres ents with bilateral sciatica, severe back pain, and there may be variable urological proble ms ranging from increased urinary frequency to overt over \202 ow incontinence. A rectal e xamination must be performed in any such patient with particular attention paid to the abse nce of perianal sensibility and loss or diminution of anal sphincter tone. Emergency surgic al decompression is required. A large meta-analysis has suggested that the outcome is more favorable in patients who have decompressive surgery within 48 h of presentation with cauda equina syndrome. The overall effect of these pathological changes is narrowing of the space available for th e neural elements within the spinal canal. Classi \201 cation Lumbar spinal stenosis can be broadly divided into congenital and acqui red forms. There may be idiopathic congenital narrowing of the spinal canal. Congenital lum bar stenosis is also commonly seen in achondroplasia. The most commonly recognized acquired form of lumbar spinal stenosis is degenerative stenosis. It may also occur following previ ous trauma or secondary to metabolic bone disease such as Paget \200\231s disease. Lumbar s pinal stenosis may be further classi \201 ed according to the site of the spinal canal nar rowing. \200 Lateral recess stenosis refers to narrowing of the space bounded by the lateral edge of the dura and the medial border of the pedicle. Central canal stenosis refers to narrowing of t he space within the spinal canal available for the cauda equina and the dura itself. These two variants frequently co-exist. Lumbar spinal stenosis Lumbar spinal stenosis is de \201 ned as narrowing of the lumbar sp inal canal with consequent symptomatic neural compression. The pathological \201 ndings t ypically include: \200 History Lumbar spinal stenosis typically presents in patients in later life and usually in those over the age of 55. It is more A central or paracentral disc bulge. (a) (b) Figure 5.8 This is a sagittal (a) and axial (b) T1- and T2-weighted MR of the lumbar spine demonstrating spinal stenosis at L3/4 and L4/5 where the CSF is completely effaced around t he cauda equina. CHAPTER 5 Regional musculoskeletal anatomy and conditions 133 common in males. The classical presentation is of neuro- genic claudication with the patien t reporting limitation of walking distance. On walking the patient typically experi- ences heaviness, weakness, in coordination, or pain in the lower limbs, which is eased by sitting and resting or by stooping forward. Degenerative sacroiliac pain Degenerative sacroiliac pain is rarely the cause of signi \201 - cant symptoms and is often picked up incidentally. However, in those with signi \201 cant symptoms or doubt about the origin of pain, an image-guided injection targeted to the sacroiliac joint may be bene \201 cial. Examination Examination is typically normal. Hip examination must be conducted to exclude h ip osteoarthritis and the peripheral circulation must be assessed to exclude vascular claud ica- tion. The patient typically stands and walks with a stooped forward posture, and has p ain which is aggravated by extension of the spine. Lumbar disciitis Vertebral osteomyelitis and disciitis usually arise from haematogenous spr ead, although the exact source of infec- tion may not be clear. The origin of infection may remain obscure. Clinical features The symptoms include insidious onset of pain with spinal tenderness on ex amination. 15% have symptoms and signs of nerve root compression at presentation. Fever is present in less than half of patient. Investigations The gold standard of investigation was conventionally a CT myelogram, which has the advantage of being a dynamic assessment of cauda equina compression. Its principle disadvantage is its invasive nature. It has largely been super- seded by MRI, which gives e xcellent anatomical detail of the soft tissue elements without the need for ionizing radiat ion or invasive procedure. See Figure 5.8. Investigations \200 In \202 ammatory markers are normally elevated as is the neutrophil count. The organism ma y be isolated on blood cultures. MR is the imaging technique of choice and details the absc ess clearly. Culture of biopsy material is positive in around 50% with S. aureus and coagul ase negative staphylococci the commonest causative organisms. \200 Treatment The natural history of lumbar spinal stenosis is variable. Many studies have demo nstrated that progression is not invariable and in one study of patients followed up for 4 years, approximately 40% of patients had no change in their symptoms with 40% showing some degree of improvement. This is relevant when developing manage- ment plans. \200 Management \200 Management is normally conservative with debridement indicated in those with neurological i nvolvement. Antibiotics should be continued for 4 \200\2236 weeks. Neurological examination should be performed regu- larly to detect neurological compromise due to spreading infecti on. Bony fusion often occurs after 1 \200\2232 years of infection. Non-operative treatment: non-operative treatment is advocated for most patients presenting with mild to moderate lumbar spinal stenosis. Simple analgesia and epidural injections may be effective. These can be repeated if symptomatic relief is obtained for a reasonable leng th of time. Operative treatment: surgery involves decompression of the neural elements. Thi s is usually achieved posteriorly either by conventional laminectomy or a laminotomy proced ure, which attempts to preserve the midline posterior elements. The aim of the surgery is t o remove the ligamentum \202 avum and the medial side of the facet joint to increase the cross-sectional area of the spinal canal and the lateral recess. Where there is an associ- ated spondylolisthesis the spine may be fused either with or without instrumentation. Coccydynia Coccydynia is the term used to describe pain arising from the region of the cocc yx. The commonest clinical presenta- tion of pain is of chronic pain arising from a previou s injury, and lasting weeks or even months. Pain is normally self- limiting, and may arise from trauma to the sacro-coccygeal joint or perioseal bruising. Pain is often worse on sitt ing and sometimes on defaecation. There may be localized tenderness, and clinical examinati on and radiographs must be performed to exclude other pathologies, such as infec- tion. Pla in radiographs may reveal a fracture if there has been suf \201 cient trauma. Treatment is conservative and includes reassurance about the natural history, although local anesthetic and steroid injection may alleviate symptoms. Rarely, surgical excision is necessary. Sacroiliac pain Sacroiliac disease may be in \202 ammatory (see Chapter 7 p. 210) or degen erative. Sacroiliitis A history of chronic pain lasting at least 3 months is typical, with early mor ning stiffness lasting more than 30 min. Pain is often described as buttock pain or proxima l posterior thigh pain. Symptoms are normally better with exercise and not improved by rest . Sleep may be disturbed, espe- cially in the early morning. Examination may reveal globaly restricted spinal movements, and Schober \200\231s test or a mod- i \201 ed Schober \200 \231s test may con \201 rm restriction of spinal move- ments. In \202 ammatory markers ar e often normal, and plain radiographic evidence of sacroiliitis may not be present in early disease. MR is a more sensitive technique for detect- ing early in \202 ammatory change w ithin the sacroiliac joints, although because the natural history of sacroiliitis remains u nclear, it remains to be established how many of those will develop plain radiographic chan ges in the future. Adult scoliosis Scoliosis is de \201 ned as sideward bending of the spine, resulting in a deformity of the spine in the coronal plane. Adult scoliosis is broadly de \201 ned into t wo groups: \200 Idiopathic adult scoliosis: this represents scoliosis that has been present since adolescen ce, which has contin- ued to progress into adulthood. The patient may or may not present wi th superimposed degenerative changes. Adolescent idiopathic scoliosis may continue to progr ess into adulthood. This is particularly true for curves in the lumbar region which are gre ater than 50 in magnitude, and where there is signi \201 cant apical or lateral listhesi s. The prevalence of adult scoliosis is approximately 6%. Where there is pre-existing adole scent idiopathic LUMBAR SPINE: REGIONAL MUSCULOSKELETAL CONDITIONS 134 scoliosis the rate of progression is approximately 1 \200\2232 per year. De novo adult sc oliosis: as a consequence of degenera- tive changes within the spine a deformity arises de novo in a previously straight spine. De novo scoliosis tends to present in the older age gr oup, typically in patients in their 60s and 70s. The curve progression in the de novo group appears to be more rapid and averages 3 \200\2234 per year. strengthening. Pain management strategies are crucial and include the use of NSAIDs, as wel l as epidural steroid injections, facet joint injections and nerve root blocks. Obese patie nts are encouraged to lose weight, although in this elderly age group weight loss and exerc ise compliance are often poor. Surgical treatment should be reserved for patients who have severe intractable pain that is not controlled by non operative measures. Surgery is also i ndicated where, uncommonly, there is progressive neurological deterio- ration. Progression of the deformity is also a relative indication for surgical treatment. Surgery may be fairl y minimal, decompressing a single stenotic segment, but in those with progressive disease m ore extensive surgery to stabilize the spine and provide a solid arthrodesis is necessary. This is often required in a high risk population in whom preoperative assessment and medica l optimiza- tion is vital. Complications of surgery can be serious and the complication rat es are high with pseudoarthrosis demonstrated in up to 28%. There is a signi \201 cant ris k of intraoperative bleeding, graft site morbidity and neuro- logical complications. Infect ion, wound breakdown and instrumentation failure are not uncommon. History \200 The patient with de novo scoliosis typically presents with back pain. This is due to a comb ination of factors includ- ing facet joint degeneration, disc degeneration, and cost- opelv ic impingement when there is a signi \201 cant kyphotic deformity in association with the scoliosis. The patient may also present with pain secondary to osteoporotic compression fra ctures or due to muscle fatigue because of the abnormal spinal posture. Adult scoliosis pat ients may also present with spinal claudication or radiculopathy secondary to neural com- p ression. Patients may report progressively increasing deformity and loss of height. Examination Examination establishes the degree of rigidity of the curve, as well as the deg ree of coronal and sagittal imbalance. A careful neurological examination needs to be perfo rmed. Further reading Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equi na syndrome secondary to lumbar discherniation. A meta-analysis of surgical outcomes. Spine 2000; 25: 1515 \200\22322. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term out- comes of surgical and non-surgical management of lumbar spinal stenosis: 8-10 year results from the Maine Lumbar Spine Study. Spine 2005; 30: 927 \200\223935. Investigations \200 Standard scoliosis radiographs including long cassette posterior-anterior and lateral X-ray s should be obtained. Bending \201 lms aid the assessment of the rigidity of the curves. MRI should be performed in all patients presenting with stenotic symptoms or with radicular symptoms, with CT myelograms reserved for those in whom MRI is contraindicated. Daubs MD, Lenke LG, Cheh G, Stobbs G, Bridwell KH. Adult spinal deformity surgery: complica tions and outcomes in patients aged over 60. Spine 2007; 32: 2238 \200\22344. Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res 1992; 279: 82 \200\2236. Peul WC, van Houwelingen HC, van der Hout WB, Brand R, Eekhof JAH, Tans JTJ, Thormeer RTWM, Koes BW. Surgery versus prolonged conservative treatment for sciatica. NEJM 2007; 356: 224 5 \200\22356. Treatment \200 Non-surgical treatment should initially be undertaken. Physiotherapy may help with core sta bility and muscle This page intentionally left blank THE SHOULDER 136 The shoulder The shoulder has evolved to provide ability for the hand to reach almost any position relat ive to the trunk. which the coracoid process arises from the anterolateral margin of the scapular. When viewe d from the lateral side these two processes (spine of scapular posteriorly and coracoid pro cess anteriorly) appear to arise from the region of the neck of the glenoid at the 10 \200 \231o \200\231clock and 2 \200\231o \200\231clock positions, respectively, and account for the \200\230propellar \200\231 appearance of a \200\230lateral scapular \200\231 X-ray vi ew (viewing the lateral aspect of the scapular end-on). Regional anatomy Movement in the shoulder occurs in four linked articular areas: at the ste rnoclavicular joint (SCJ), at the acromiocla- vicular joint (ACJ), at the glenohumeral join t (GHJ), and at the scapulothoracic articulation. Movement at the GHJ can occur in isolatio n, but movement at the scapulothoracic articulation is accompanied by movement at the ACJ a nd SCJ joints (See also Plate 1). Muscles either take origin from or insert into almost every aspect of the scapular, and hol d the scapular in place over the posterolateral chest wall. Bones The upper limb is attached to the axial skeleton indirectly, \201 rst by the clavic le, which articulates with the sternum at the sternoclavicular joint, and secondly by muscl es, which attach the humerus to the scapula. Joints of the shoulder Glenohumeral joint The head of the humerus lies adjacent to the glen oid and beneath the acromion process, which arches above, with a concave undersurface in bo th anteroposterior and medio- lateral directions. The humeral head is held in place by a co mbination of ligaments and muscles. The articular sur- face of the glenoid fossa on the sca pula is lined by articular cartilage (the glenoid labrum). See Figure 5.9. The clavicle The clavicle acts as a bony strut holding the shoulder joint away from the che st wall. The anterior aspect of the clavicle is convex medially and concave laterally, and the medial end is bulbous, whereas the lateral end is \202 attened. It articulates with t he sternoclavicular joint at the medial end and the acromioclavicular joint at the lateral end.