Contraindications

It is often easier to define patients who are not good candidates for a given procedure than to accurately define those who would be suitable. To some extent, the same can be said for lumbar disc arthroplasty. In recent years, much attention has turned toward defining and understanding the established contraindications for TDR, and this, in turn, has generated some controversy. In an epidemiological study to investigate the contraindications to lumbar total disc arthroplasty in their patient...

Clinical Case Examples

MC, a 66-year-old woman with medical contraindications to open surgery, was treated with SRS for a spinal schwannoma. She initially presented with a chronic cough and generalized weakness. Routine laboratory studies showed pancytopenia, and flow cytometry was consistent with acute lymphocytic leukemia. The diagnosis was confirmed by bone marrow biopsy. While undergoing chemotherapy in December 2008, she developed lower back pain with subjective right leg weakness. A 10-by 7-mm epidural lesion,...

Needle Insertion Techniques

There are four common ways to insert a needle finger pressing insertion, pinching needle insertion, pinching skin insertion, and tight skin insertion. The skin at the insertion site is cleaned with an alcohol pad. The needle insertion angle can be perpendicular, oblique, or horizontal to the skin surface with various depths, depending on the location of the acupuncture points, the medical conditions being treated, and the patient's general health. Finger pressing insertion. This technique is...

Other Implant Types Figure 547

Interspinous Implant Titanium

There are a variety of other implants with comparable biomechanical effects. Most of them are implanted through a posterior midline approach. Coflex (Paradigm Spine, New York, NY, USA) This is a U-shaped titanium implant with two bendable wings on its cranial and caudal parts. The Coflex is a dynamic extension stopper that acts like a spring in such a way that extension leads to an elastic compression of the U (Figure 54-9). It is either used as an adjunct to open decompression in spinal...

The Role of Deformity in the Clinical Presentation

Early studies indicated that the incidence of back pain in adult scoliosis patients is about the same as in age-matched controls. Kostuik found a 60 incidence of back pain in adult patients with scoliosis, which was similar to that noted in patients without spinal deformity22. In other studies, patients with adult scoliosis were found to have more severe back pain as compared to controls, especially if the curve progressed beyond 45 degrees23. In more recent studies, Weinstein et al. have...

Subaxial Cervical and Upper Thoracic Spine Fractures in the Elderly

Harrod, and Andrew P. White Elderly patients are at increased risk of neurological injuries, including central cord syndrome, due to degenerative stenosis, spondylotic stiffness, and changes in spinal cord morphology and vasculature. Spinal ankylosis increases the risk of unstable fractures, which may not be diagnosed on initial imaging studies such as plain radiographs. For historical reasons, central cord syndrome has traditionally been treated nonoperatively or...

Basic Science

The pathogenesis of lumbar stenosis is an interesting degenerative cascade that eventually leads to the pathognomonic signs and symptoms. In brief, the degenerative cascade begins at the level of the intervertebral disc, which consists of an inner nuclear core called the nucleus pulposus and an outer supporting layer of the disc called the annulus fibrosus. Beginning early in life, the nucleus pulposus loses its vascular supply and depends on diffusion for its nutrient base, which slowly...

Case Studies

Minimally invasive scoliosis surgery relies on three main technologies (1) DLIF XLIF, (2) posterior MIS TLIF, and (3) percutaneous pedicle screw instrumentation. Using a combination of these techniques, deformities of the thoracolumbar spine spanning T10 to the pelvis can be treated. The most common and most straightforward problem is a degenerative scoliosis from L2 to L5 with back pain and neurogenic claudication (Figure 60-8). Using a lateral interbody approach, much of the stenosis can be...

Pharmacologic Treatment

Osteoporosis has been divided into two categories, high-turnover and low-turnover osteoporosis. The pharmacologic agents currently available are commonly divided into antiresorptive and anabolic groups. Antiresorp-tive agents have been developed to address the high-turnover state. These include estrogen, selective estrogen receptor modulators (SERMs), cal-citonin, and bisphosphonates. The anabolic agent, parathyroid hormone, provides active building of bone mass and has been suggested to treat...

Clinical Practice Guidelines

Operative indications for stenosis in the thoracic spine are similar to those in the cervical spine symptoms recalcitrant to nonoperative measures and cases in which myelopathy develops. A 58-year-old woman with no significant past medical history presented to an outside hospital with progressive bilateral lower extremity weakness, right greater than left, and decreased sensation below the nipple line. In addition, she reported 5 out of 10 pain in the midthoracic area, urinary retention, mild...

L5 Dorsal Ramus

Nerve Ganglion

The L5 dorsal ramus is longer than the L1-L4 dorsal rami. It courses the superior border of the ala of the sacrum, lying in the groove formed by the junction of the ala and the superior articular process of the sacrum. It divides into medial and intermediate branches, lacking a lateral branch. The medial branch curves medially around the caudal aspect of the lumbosacral facet joint and ends in the multifidus muscles. The intermediate branch innervates the longissimus thoracis and communicates...

Facet Arthropathy

Diffuse Disc Bulge

Degenerative changes of the facet joints in the spine resemble that of other synovial joints in the rest of the body. Although radiography can demonstrate the bone changes associated with osteoarthritis, including joint space narrowing as a result of thinning of articular cartilage, subchondral sclerosis, marginal osteophyte formation, facet hypertrophy, and hyperostosis, these findings are best demonstrated on CT (see Figures 16-2 and 16-3). Very often, gas from vacuum phenomenon can also be...

References

Winlove, Pathophysiology of the intervertebral disc and the challenges for MRI, J. Magn. Reson. Imaging 25 (2007) 419-432. 2. C.Q. Zhao, L.M. Wang, L.S. Jiang, et al., The cell biology of intervertebral disc aging and degeneration, Ageing Res. Rev. 6 (2007) 247-261. 3. A.G. Hadjipavlou, M.N. Tzermiadianos, N. Bogduk, et al., The pathophysiology of disc degeneration a critical review, J. Bone Joint Surg. Br. 90 (2008) 1261-1270. 4. I. A. Stokes, J.C. Iatridis, Mechanical...

Degenerative Mechanics

Osteoarthritic changes at the facet joints can have a cascading effect on a patient's overall spinal health. The facet joints function as the posterolateral articulation between vertebral segments. As such, they bear weight, restrict anterior and posterior movement of the anterior column, and restrict axial rotation. Arthritic changes in these joints can promote abnormal spine mechanics, increasing degeneration. It is commonly held that facet joint arthrosis is a sequela of disc degeneration.4...

Patients with Poor Indications for Dorsal Ramus Rhizotomy

Endoscopic Dorsal Rhizotomy

Patients with lumbosacral radiculopathy whose debilitating leg pain is 1. Multiple-level disc disease with confirmed severe concordant disco-genic pain by evocative diskography, and minimal relief with medial branch blocks 2. Significant motion segment instability or hypermobility 3. Pseudarthrosis following failed fusion 4. FBSS with more leg pain than back pain without known etiology 5. Patients with multiple debilitating painful conditions severe multilevel stenosis including foraminal...