What patient psychosocial factors may negatively influence the decision to proceed with a spinal operation

Substance abuse (alcoholism, drug dependence), severe depression or other psychologic disturbance (e.g. borderline personality), secondary gain (litigation, financial, social), chronic pain, as well as childhood developmental risk factors (physical abuse, sexual abuse, abandonment, neglect, chemically dependent parents). 6. What is the role of Waddell signs in deciding whether or not to proceed with a lumbar spine operation A brief screening for nonorganic signs as described by Waddell is...

Which organisms are associated with nontuberculous granulomatous spinal infections

Atypical mycobacteria (Actinomyces, Nocardia, and Brucella spp.), as well as fungal infections (coccidioidomycosis, blastomycosis, cryptomycosis, candidiasis, aspergillosis), are potential pathogens. Immunocompromised patients are at high risk for developing infections with atypical mycobacteria. Fungal infections can occur following use of broad-spectrum antibiotics in combination with central venous catheters for parenteral nutrition. Sarcoidosis can involve the spine and cause lytic,...

What are some of the side effects of opioids

Most patients taking opioids experience side effects. The type and intensity of side effects vary greatly. The most common are somnolence and diminished mental acuity. Interestingly, severe pain can itself cause alteration of cognitive abilities and, when opioids relieve pain, cognitive abilities actually improve. Sedation is common, particularly at initiation of treatment or when medication doses are raised, but it usually improves with time. If the opioid is effective, but there is excess...

Describe the presentation of an anterior sacral meningocele

An anterior sacral meningocele is a rare congenital spinal anomaly in which herniation of dura mater and or neural elements through a defect in the ventral spine is identified. The anomaly contains CSF and may contain neural elements. Unlike the myelomeningocele, this anomaly is not associated with hydrocephalus or Chiari malformation. Associated findings include the triad of sacral bony anomalies, a presacral mass, and anorectal anomalies (Currarino syndrome). Symptoms may include...

What is amyotrophic lateral sclerosis ALS

Amyotrophic lateral sclerosis (ALS) is a progressive degenerative disorder of motor neurons in the spinal cord, brainstem, and motor cortex manifested clinically by muscular weakness, atrophy, and corticospinal tract involvement. Clinical presentation typically includes atrophic weakness of hands and forearms, slight spasticity of the legs, and generalized hyperreflexia. Other findings may include hand and finger stiffness, cramping, fasciculations, and atrophy and weakness of tongue,...

What is the tethered cord syndrome

Tethered cord syndrome presents with signs and symptoms that result from excessive tension on the spinal cord. At birth, the conus is usually located at the L2-L3 level and ascends to the L1-L2 level by 3 months of age. Spinal dysraphism is responsible for the majority of cases. A constellation of signs and symptoms is associated with this syndrome including neurologic deficits, back pain, cutaneous abnormalities, spinal deformities, bowel and bladder dysfunction, gait abnormalities, and...

A

Abdominal assessment, after spine fusion, 234 Achondroplastic thoracolumbar kyphosis, 282 Acupressure, 148 Acupuncture, 149 Acute respiratory distress syndrome (ARDS), 232-233 ADA Amendments Act of 2008, 62 Adams test, 53 Addiction, 114 Adolescent idiopathic scoliosis anterior spinal instrumentation and fusion for, 275-276, 276f bracing, use of, 273 characteristic features of, 269 consequences of untreated, 273 evaluation of, 269-270 orthoses, spinal, 143, 143f, 144f pain associated with, 253...

A 70yearold woman complains of increasing low back and upper sacral pain A technetium bone scan was obtained Fig 134

The scan shows increased radionuclide activity above the bladder in the sacral area in a H-shaped pattern (Honda sign). Bilateral increased radionuclide uptake in the sacral ala in association with a transverse region of increased radionuclide activity is typical of a sacral insufficiency fracture, most commonly due to osteoporosis. Figure 13-3. Technetium bone scan demon- Figure 13-4. Increased radionuclide uptake in strates acute two-level osteoporotic compression an H-shaped pattern (Honda...

And Complications After Spine Surgery J Ss

Devlin, MD, and William O. Shaffer, MD 1. What types of complications may present in the early postoperative period following spinal procedures The spectrum of spine procedures ranges from outpatient lumbar discectomy to complex anterior and posterior multilevel fusion procedures. Health care providers must be knowledgeable regarding Procedure-specific complications (e.g. problems related to the surgical approach, neural decompression, or spinal instrumentation)...

And Lumbar Spine

Musser, DO, and Richard T. Holt, MD 1. What are the indications for an anterior surgical approach to the thoracic and lumbar spine Anterior spinal decompression and stabilization (e.g. tumor, infection, fracture) Anterior correction of spinal deformity (e.g. scoliosis) To enhance arthrodesis (e.g. for treatment of posterior pseudarthrosis) Anterior release or destabilization to enhance posterior spinal deformity correction (e.g. for treatment of severe, rigid...

Anesthesia And Related Intraoperative a Considerations In Spine Surgeryj

Devlin, MD, and William O. Shaffer, MD 1. What are the top 10 areas of concern in relation to perioperative anesthesia care for spinal surgery patients 1. Assessment of patient-specific risk factors 2. Assessment of procedure-specific risk factors 5. Intraoperative neurophysiologic monitoring 8. Fluid management (crystalloid, colloid, transfusion, autotransfusion) 9. Preparation for potential intraoperative disasters 10. Postoperative assessment and coordination...

Are there any techniques that can be used to decrease the risk of construct failure when cervical corpectomies are

Depending on the pattern of neurologic compression, a hybrid corpectomy-discectomy construct may be a feasible option and can increase the stability of the construct by increasing the number of screw fixation points below the corpectomy (Fig. 46-6). Figure 46-6. A corpectomy-discectomy construct. This patient with cervical myelopathy from three disc level disease was treated with C5 corpectomy and a C6-C7 anterior discectomy and fusion. This construct allowed for additional fixation into the...

Are there easily defined subtypes of DDD

A variety of terms have been applied to patients with nonradicular lumbar pain disorders of a degenerative origin including discogenic pain syndrome, annular tear syndrome, dark disc disease, internal disc disruption (IDD), isolated disc resorption, and lumbar spondylosis (LS). Currently there is no level I evidence to support subsegregation of DDD, and no universally accepted classification exists. Patients with chronic low back pain of discogenic origin with tall discs and normal radiographs...

Instrumentation And Fusion Of The Spine 301 To The Sacrum And Pelvis

Margulies, MD, PhD, and William O. Shaffer, MD 1. When is fusion across the L5-S1 motion segment indicated Symptomatic degenerative disorders involving the L5-S1 level Tumor, infection, or fractures involving the lumbosacral junction Spinal deformities (e.g. neuromuscular scoliosis with pelvic obliquity, adult idiopathic or de novo scoliosis with associated L5-S1 degenerative changes) Revision salvage situations (e.g. distal extension of a prior scoliosis fusion...

Can psychosocial factors influence a patients perception of axial pain associated with degenerative spinal disorders

A variety of factors have been shown to influence a patient's perception of axial pain associated with degenerative spinal disorders. When pathologic processes stimulate pain sensitive structures in the lumbar spine and pelvis, neural signals are transmitted through the dorsal root ganglion (DRG) to the spinal cord and ultimately to the brain for processing. Perception of these stimuli may be modulated by a variety of factors along the pathway of signal transmission. Psychologic and social...

Can spinal stenosis occur in the thoracic region

Spinal stenosis can occur in the thoracic region although it is much less common than cervical or lumbar spinal stenosis. Thoracic spinal stenosis occurs most commonly in the T10 to T12 region due to acquired degenerative changes superimposed on preexisting developmental canal narrowing. Hypertrophic spondylosis and ossification of the posterior longitudinal ligament and ligamentum flavum may lead to circumferential narrowing of the lower thoracic spinal canal. A wide range of neurologic...

Cervical Spine Instrumentationi

Devlin, MD, Justin Munns, MD, Alexander R. Vaccaro, MD, PhD O 1. What are the indications for use of cervical spinal instrumentation To immobilize an unstable segment To correct spinal deformity To promote bony union To decrease the need for external immobilization To improve soft tissue healing 2. How are the various types of cervical spinal implants classified No universal classification exists. Cervical spinal implants may be classified descriptively by Location of...

Compare and contrast the presentation of neurogenic claudication and vascular claudication

Patients with neurogenic claudication report tiredness, heaviness, and discomfort in the lower extremities with ambulation. The distance walked until symptoms begin and the maximum distance that the patient can walk without stopping varies from day to day and even during the same walk. Patients report that leaning forward relieves symptoms. These patients may not experience symptoms during activities performed in a flexed posture such as riding a bicycle or walking uphill. In contrast,...

Contributors

Clinical Professor, Orthopedics, University of California-San Diego Medical Director, San Diego Center for Spinal Disorders, La Jolla, California Richard Rothman Professor and Chair, Orthopaedics, and Professor, Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Associate Professor, Department of Orthopaedic Surgery, Thomas Jefferson University Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Professor, Department of Orthopedics...

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Decompression in athletes, 420 for C5-C6 disc herniation, 167 Decompression (Continued) before cervical osteotomy, 485 classification of problems after procedure, 240t complications of, 345 computed tomography following, 95, 96f in degenerative spondylolisthesis, 363, 364f indications for, 152 interlaminar, 345 before lumbar osteotomy, 486-487 for lumbar spinal stenosis, 343-344, 344f, 345 pain-free interval following procedure, 238 procedures for, 165-170 revision surgery after prior, 239 for...

Define nonunion following a spinal fusion procedure

Nonunion or pseudarthrosis is defined as the failure of an attempted fusion to heal within 1 year after surgery. Table 24-1. Anterior Column Reconstruction Options after Corpectomy Combination of cancellous bone (promotes osseous union) and cortical bone (provides structural support) Low initial strength Curved geometry Donor site morbidity Straight geometry High initial strength Slow osseous incorporation Donor site morbidity Can be harvested during surgical exposure Low initial strength...

Define pseudarthrosis

Pseudarthrosis is defined as failure to obtain a solid bony union after an attempted spinal fusion. The time between initial surgery and diagnosis of pseudarthrosis is variable. One year following initial surgery is a reasonable and accepted interval for determining fusion success for short segment cervical and lumbar fusions. In certain cases, a patient's symptoms and imaging studies suggest the diagnosis of pseudarthrosis as early as 6 months following initial surgery. However, in patients...

Describe common indications for posterior spinal instrumentation and fusion procedures

Posterior spinal decompression and stabilization. Symptomatic spinal stenosis is most commonly decompressed from a posterior approach. Concomitant posterior fusion and spinal instrumentation can restore posterior spinal column integrity and prevent future spinal deformities. A wide range of pathology (e.g. fractures, tumors, spondylolisthesis) requiring decompression and fusion may be treated from a posterior approach Posterior correction of spinal deformities. A wide spectrum of spinal...

Describe key points to consider in the evaluation of a patient with a suspected osteoporotic compression fracture

Vertebral compression fractures may present as acute, subacute, or chronic deformities. Statistics show that approximately 25 of radiographically detectable vertebral compression fractures are recognized clinically. The diagnosis of a vertebral compression fracture can often be made by history and physical examination. Important elements of the history would include acuity of pain onset, history of antecedent trauma, and prior fractures. Query of medical conditions that affect bone mineral...

Describe prolotherapy and its use in LBP

Prolotherapy treats back pain that is related to motion and due to weakened or incompetent ligaments and tendons. The injury-repair sequence is initiated by scraping the tissue or adjacent periosteum with a needle and then injecting a dextrose solution to induce fibroblast proliferation and scarring repair of tissue. Prolotherapy can increase tendon size and strength. Success (less pain, less tenderness) in patients with chronic LBP who have not responded to conventional treatment is reported.

Describe the clinical presentation of an epidural abscess

Epidural abscess can result from hematogenous spread, local extension, or direct inoculation. This condition is usually found in adults risk factors include intravenous drug abuse, diabetes mellitus, prior spine trauma, renal failure, and pregnancy. The majority of cases are located in the thoracic spine. The initial presentation includes localized pain and fever with elevation of the ESR, CRP, and leukocyte count. Blood cultures are positive in 60 of patients. Without treatment, significant...

Describe the normal sagittal contour of the adult spine

In the sagittal plane, the normal spine possesses four balanced curves (Fig. 53-1). The kyphotic thoracic and sacral regions are balanced by the lordotic cervical and lumbar regions. In the normal state, the sagittal vertical axis (determined by dropping plumb line from the center of the C7 vertebral body) passes anterior to the thoracic spine, through the center of the L1 vertebral body, posterior to the lumbar spine, and through the lumbosacral disc. A positive sagittal vertical axis (SVA) is...

Describe the presentation and management of a child with discitis

The presentation of childhood discitis is highly variable. Spinal infection should be considered when children present with back pain, refusal to bear weight, or a flexed position of the spine. Children may also complain of nonspecific abdominal pain. Infants are more likely to become systemically ill, whereas nonspecific findings are more common in children older than 5 years. Less than 50 present with fever. After several weeks radiographs may demonstrate disc space narrowing, which is the...

Describe the sequence of ordering spinal imaging studies in terms of an algorithm

Plain radiographs are generally the first imaging study obtained in the evaluation of patients with a spinal problem. If radiographs do not provide sufficient information, MRI is generally the next best study to evaluate most clinical conditions because it provides the greatest amount of information regarding a single spinal region. CT may be obtained to complement the information obtained with MRI, especially when additional information is required about osseous anatomy. CT-myelography and...

Describe the standard radiographic evaluation of a patient with suspected Scheuermanns disease

Standing long cassette posteroanterior (PA) and lateral views of the spine are examined for excessive thoracic kyphosis, vertebral wedging, endplate changes, narrowing of the disc spaces, and scoliosis. The PA view should include the iliac apophyses and triradiate cartilages for evaluation of skeletal maturity. The patient should stand with his or her hips and knees fully extended. The elbows are flexed and the hands supported in the supraclavicular fossa so the arms neither flex nor extend the...

Describe the surgical treatment for flatback syndrome

Fixed sagittal plane imbalance, or flatback syndrome, refers to symptomatic loss of sagittal plane balance primarily through straightening of the normal lumbar lordosis. Symptoms include pain and inability to stand upright with the head centered over the sacrum without bending the knees. Patients typically report a sense of leaning forward, thoracic pain, neck pain, and leg fatigue. Surgical treatment options include osteotomies (Smith-Petersen type or pedicle subtraction type), combined...

Describe the two main types of pulse generators

The two main types of pulse generator systems are totally implantable pulse generators and radiofrequency-driven pulse generators. Totally implantable pulse generators utilize an internal power source (lithium battery). Following activation, these pulse generators are controlled by transcutaneous telemetry and can be switched on-off with a magnet. The battery requires replacement in 2 to 5 years. Despite this disadvantage, totally implantable pulse generators are the most common type of system...

Describe the typical clinical presentation of a patient with spinal osteoporosis

The clinical presentation can be quite variable. In general, patients with osteoporosis are asymptomatic until a fracture occurs. However, not all patients with spinal fractures are symptomatic, and the initial presentation may be a significant loss of height associated with development of an exaggerated thoracic kyphosis (dowager's hump). Many patients present with acute severe pain after minimal trauma. Paravertebral muscle spasm is common, and tenderness can often be elicited at the fracture...

Describe the typical presentation of a patient with thoracic Scheuermanns kyphosis

A male or female approaching the end of skeletal growth (12-15 years old) presents with complaints of thoracic deformity and or back pain. The patient has an increased thoracic kyphosis, which is accentuated with forward-bending. Patients are not able to correct the kyphotic deformity by active extension. Thirty percent of patients have mild scoliosis in addition to increased kyphosis. A compensatory increase in cervical lordosis causes the head to translate forward. Patients often have tight...

Describe treatment options for congenital lordosis

When congenital lordosis is diagnosed early in life, surgical treatment consists of anterior spinal fusion to eliminate anterior growth potential. Patients presenting later in life require more complex surgery. Moderate deformities may be treated with wide posterior release followed by segmental instrumentation and fusion. Severe deformities require anterior and posterior spinal surgery. Anterior closing wedge osteotomies and posterior segmental spinal fixation are required. Rib resections may...

Describe what is involved in a typical open decompression for L4L5 degenerative spondylolisthesis Does decompression

A typical open decompression for L4-L5 spondylolisthesis involves removal of the inferior one-half of the lamina of L4 and the superior one-half of the lamina of L5 to decompress the central spinal canal. Next the L5 nerve roots are decompressed by removing the medial one-half of the L4-L5 facet joints and accompanying ligamentum flavum. The decompression of the L5 nerve root is continued until the L5 nerve root is mobile and a probe passes easily through the neural foramen. The L4 nerve root...

Discuss advantages and disadvantages of cervical laminectomy combined with posterior fusion and screwrod instrumentation

The addition of instrumentation and fusion can prevent postlaminectomy instability and improve neck pain. In addition, patients with flexible kyphotic deformities can undergo correction of their deformities following laminectomy by surgical repositioning and fusion in a more lordotic posture. Laminectomy and fusion provides a good alternative for select patients who require multilevel treatment for myelopathy associated with mechanical neck pain. Disadvantages of this approach include a higher...

Discuss and contrast the general approach to treatment of intraduralextramedullary spinal cord tumors versus

Intradural-extramedullary spinal cord tumors tend to be histopathologically benign and can be successfully resected in the majority of patients, most commonly through a posterior surgical approach. Tumors in an anterior location and dumbbell-shaped tumors are more challenging to treat surgically. Radiotherapy or chemotherapy is generally reserved for tumors with malignant histologic characteristics and for recurrent tumors. Intramedullary spinal cord tumors are typically treated with open...

Discuss key points to consider in the initial assessment of a patient with AS following a traumatic spinal injury

Spinal pain in the AS patient represents a spinal fracture until proven otherwise. A spine fracture in an AS patient is a high-risk injury with an associated mortality rate reported as high as 30 . These fractures are frequently three-column spinal injuries and are highly unstable due to the long, rigid lever arms created by fused spinal segments proximal and distal to the level of injury. Neurologic injury is common and may be due to initial fracture displacement, subsequent fracture...

Discuss the indications and results of posterior foraminotomy and discectomy for a herniated cervical disc

Patients who have acute radiculopathy without long-standing chronic neck pain and posterolateral or intraforaminal soft tissue disc herniation are excellent candidates for posterior foraminotomies. The disc space height should be well preserved, and there should be no associated spinal instability. The advantages of this technique are avoidance of fusion and early return to function. The disadvantages are difficulty in removing pathology ventral to the nerve root, especially an osteophyte, and...

Discuss the indications for and results of cervical laminoplasty

Laminoplasty increases the midsagittal diameter and cross-sectional area of the spinal canal. This procedure directly decompresses dorsal aspect of the spinal cord. It also allows posterior displacement of the cord, which indirectly decompresses its ventral surface. Accepted indications for laminoplasty are a straight or lordotic cervical spine, a stable spine, and multilevel cord compression. It is the preferred technique when only dorsal cord compression is present. Long-term improvement is...

Discuss the side effects of corticosteroids

Adverse effects may be associated with spinal corticosteroid injections. Fortunately, the amount of steroid used and the frequency of injection are limited. For this reason, fewer complications occur following spinal injections compared with chronic steroid use. Dose-dependent side effects of corticosteroids include nausea, facial flushing, insomnia, low-grade fever (usually < 100 F), and nonpositional headache. Corticosteroid-related immune suppression can mask an existing infection or...

Distinguish among laminotomy laminectomy and laminoplasty

All three procedures are performed through a posterior approach and are intended to provide posterior decompression of neural structures. A laminotomy consists of partial lamina or facet joint removal to expose and decompress the nerve root and or dural sac (see Fig. 23-1B). A laminectomy consists of removal of the spinous process and the entire lamina to achieve decompression (see Fig. 23-1C). Figure 23-1. Lumbar decompression. A, Preoperative. B, Laminotomy. C, Laminectomy. Figure 23-1....

Do patient age and medical history play a role in selection of the appropriate graft material

The bone of skeletally immature patients has an inherent osteogenic potential, and high rates of arthrodesis are reported regardless of whether the autograft, allograft, composite grafts, or ceramics are utilized. Lower fusion rates are encountered in the adult population and healing rates have been shown to decline with increasing age. Additional factors that negatively impact fusion rates in adults include endocrine disorders (e.g. diabetes), medications (e.g. corticosteroids), and...

Explain why spinal deformities develop in the aging thoracic and lumbar spine

As an individual patient's spine passes through the degenerative cascade, the rate of degeneration may exceed the patient's ability to autostabilize the spinal column by formation of osteophytes around the facet joints and intervertebral disc. Risk factors remain incompletely understood but include osteoporosis, female sex, poor connective tissue quality, diabetes, and obesity. Disc height loss, facet subluxation, and asymmetric disc space collapse may occur. These changes may lead to deformity...

For a left lumbar scoliosis if exposure is desired from T10 to the sacrum is it better to do the approach from the left

It is generally best to approach a curve on the convexity of the curve. In most left lumbar curve patterns, the major curve has an apex between T12 and L2 and extends from T10 or T11 to L4. From L4 to the sacrum, there is usually a fractional curve that extends the other way to the right side. Generally exposure can be accomplished from the left side behind the aorta and vena cava from L4 to L5. Exposure at L5-S1 is variable from patient to patient. Sometimes it is possible to expose L5-S1 from...

For which common disorders can a PET scan provide useful diagnostic information

PET scans are most commonly used in the evaluation of cancer for diagnosis, staging, and assessment of treatment effectiveness. Utility in head and neck tumors, colorectal tumors, melanoma, lymphoma, multiple myeloma, lung cancer, and metastatic breast cancer have been reported. The role of PET scans in the diagnosis of spinal infections is evolving. 1. A technetium-99m bone scan can detect regions of increased blood flow or osteoblastic activity. 2. A gallium scan or indium-labeled white blood...

How are NCS obtained For what diagnoses are NCS most likely to be helpful

NCS are obtained by application of an electrical impulse at one point, resulting in an action potential (motor or sensory) that is recorded at a second point at a predetermined distance along the course of the nerve. The NCS measures the time (latency) required to travel between the stimulating and recording site as well as the velocity (nerve conduction velocity NCV ) and amount of potential conducted (amplitude). Sensory responses (sensory nerve action potential SNAP ) are picked up over a...

How are postural kyphosis and kyphosis due to Scheuermanns disease distinguished clinically

Postural kyphosis (postural roundback) and Scheuermann's kyphosis are common causes of abnormal sagittal plane alignment in teenagers (Fig. 7-3). They can be distinguished on clinical assessment by performing a forward-bend test and observing the patient from the side. With postural kyphosis, the sagittal contour normalizes because the deformity is flexible. In kyphosis due to Scheuermann's disease, the deformity is rigid (structural) and does not normalize on forward bending. Table 7-1. Causes...

How are trial spinal cord stimulation electrodes placed

Most trial spinal cord stimulation electrodes are placed into the epidural space through epidural needles utilizing fluoroscopic guidance. The procedure is performed under mild sedation and local anesthetic, as the patient must be awake during electrode placement and testing. The wires from the trial electrode may be left protruding through the skin for direct connection to a trial stimulator. Alternatively, a small incision is made around the epidural needle insertion site and dissection is...

How do I fill out the forms from the SSA

Social Security forms frequently cross a physician's desk. They are often multipaged documents asking many questions. They can be daunting for those who do not understand the process of how the SSA determines disability. The completed forms are intended to provide background information to the impairment and disability evaluator in the Social Security system. An independent impairment examination also may be performed on such patients. The attending physician's report is used to provide...

How do interspinous process distraction devices improve spinal stenosis symptoms

A device is inserted between adjacent spinous processes to create segmental flexion at the operative level. This indirectly increases the cross-sectional area of the spinal canal and neural foramina. Appropriate candidates for this type of device are patients with mild to moderate spinal stenosis whose symptoms are relieved with sitting and flexion maneuvers. These devices are appealing to patients because the procedure for insertion is less invasive than a laminotomy or laminectomy procedure....

How does a lumbar disc herniation present in children

Lumbar disc herniation is less common in children than adults. In contrast to adults, children commonly have a history of acute injury or chronic repetitive injury. The child may present with back pain and or radicular leg pain. Physical examination may reveal reduced lumbar range of motion and a positive Lasegue's sign. Neurologic changes and bowel and bladder compromise are rare in adolescents. Initial treatment includes activity reduction, NSAIDs, ice, and physical therapy. Surgery is...

How does a pedicle subtraction osteotomy PSO differ from a vertebral column resection VCR

Both a PSO and VCR can be performed in the thoracic and lumbar spine however, most commonly for fixed deformity, a PSO is performed in the lumbar spine and a VCR is carried out in the thoracic spine. The most distinguishing feature that differentiates a PSO from VCR is correction mechanics. In a PSO, there is a fixed angle of closure determined by the size of the wedge resection. In a VCR, the spine is dissociated in two separate segments and the arc of correction falls anterior to the spinal...

How does one stabilize the spine to the pelvis after complete sacrectomy

Spinopelvic fixation is required in this setting. Interconnection of anchors in the ilium is utilized to form a foundation that allows stabilization of the ilium to the spine and opposite ilium. See Fig. 63-7. Figure 63-6. Resection of the posterior arch. A, The en bloc excision of a tumor to achieve an oncologically appropriate surgical margin is possible if tumor extent is limited between zones 3 and 10. The pedicles must be uninvolved by tumor. B, Surgery is performed through a posterior...

How does the physician treat a patient with acute LBP

Generally, the offending structure is not known and the natural history is to improve regardless of (or despite) treatment. Few treatments have been proven to be beneficial, but several things may hasten the recovery process. Reassurance is vitally important. Advise the patient that the process is benign and unlikely to lead to long-term impairment, and major intervention is not anticipated. First-line medication options to consider include acetaminophen and nonsteroidal antiinflammatory...

How is BMD measured

The most widely accepted method of determining BMD is dual-energy x-ray absorptiometry (DEXA) at the hip. BMD is reported in terms of two absolute values T-score (units of standard deviation compared with the bone density of a healthy 30-year-old) and Z-score (units of standard deviation compared with age- and sex-matched controls). The World Health Organization has defined osteoporosis in terms of the T-score. See Table 65-3. The T-score can be used to predict fracture risk. A one-point...

How is DISH different from AS

DISH stands for diffuse idiopathic skeletal hyperostosis. It is also known as Forestier's disease. The disease affects the ligaments along the anterolateral aspect of the spine, which become ossified. DISH typically affects four or more vertebrae, is most common in the thoracic region, and typically spares the lumbar spine and sacroiliac joints. The radiographic hallmark of DISH is the presence of asymmetric nonmarginal syndesmophytes, which appear as flowing anterior ossification originating...

How is lumbar spinal stenosis defined and described on CT and MRI

Lumbar spinal stenosis refers to any type of bone or soft tissue pathology that results in narrowing or constriction of the spinal canal, nerve root canal, or both Central spinal stenosis refers to compression in the region of the spinal canal occupied by the thecal sac Lateral stenosis involves the nerve root canal and is described in terms of three zones, using the pedicle as a reference point (Fig. 12-5). Spinal stenosis may involve a single spine segment or multiple spinal segments. It may...

How is spinal impairment evaluated

The practitioner can evaluate spinal impairment by quantifying spinal range of motion, assessing trunk strength and endurance, evaluating balance and motor control, and determining aerobic fitness. Techniques for measuring spinal range of motion include inclinometer, goniometer, modified Schober test, and finger-to-floor distance. There are three basic approaches for testing trunk extensor strength and lifting capacity isometric (velocity is zero), isokinetic (velocity is constant), and...

How is spondylolysis diagnosed

History and physical examination are important indicators of spondylolysis. A history of hyperextension activities should alert the clinician to the possibility of the diagnosis. Patients typically present with back pain radiating into the buttocks. Physical examination may reveal tenderness to palpation, hamstring tightness, decreased forward flexion of the lumbar spine, a positive single-leg hyperextension test, or a stiff gait. Lateral radiographs may reveal a pars defect. Oblique views can...

How is the F wave elicited What is its value in the assessment of radiculopathy

The F wave is a compound action potential evoked from a muscle by a supramaximal electric stimulus to its related peripheral nerve. This procedure results in an antidromic activation of the motor neuron. The F wave has variable configuration, latency, and amplitudes. Amplitudes generally range between 1 and 5 of the M wave. F waves are abnormal immediately after nerve root injury, even when the needle EMG is normal. However, an F-wave study has low utility for diagnosing a radiculopathy because...

How is the halo skeletal fixator applied

The patient is placed supine with the head position controlled by the physician in charge (Fig. 18-10). The correct ring size (permits 1-2 cm of circumferential clearance around the skull) and vest size are determined. Critical measurement to determine correct vest size include 2. Chest circumference at level of xiphoid 3. Distance from shoulder to iliac crest Pin sites are identified. The skin is cleaned with Betadine, and pin sites are injected with 1 lidocaine. The patient is instructed to...

Is meperidine Demerol ever useful for longterm treatment

Meperidine should rarely, if ever, be used long-term because it is poorly absorbed, provides unreliable analgesia, and may be associated with an unacceptably high level of toxic neurologic side effects. Table 15-1. Opioid analgesics most useful for chronic pain Multiple dose sizes convenient expensive ER, extended release IR, immediate release RCT, randomized controlled trial. ER, extended release IR, immediate release RCT, randomized controlled trial.

IThoracic And Lumbar Spine Fractures

Greg Anderson, MD, Todd J. Albert, MD, and Vincent J. Devlin, MD 1. Why is it important to assess radiographically the entire spinal axis when a significant spine fracture is identified in one region of the spine There is a 5 to 20 chance that a patient has a second fracture in a different region of the spine. Factors that increase the risk of missed spine fractures on initial evaluation include head injuries, intoxication, drug use, and polytrauma. 2. What factors...

Ito The Thoracic And Lumbar Spine

Describe the options for patient positioning for posterior surgical approaches to the thoracic and lumbar spinal regions. Typically patients are positioned prone on a radiolucent operative frame for posterior approaches to the thoracic and lumbar spine. An exception is the use of a lateral decubitus position during simultaneous anterior and posterior surgical procedures. 2. What are the basic types of positioning frames for posterior spinal procedures Four-post frame Proximal pads are placed...

During Spinal Procedures

Vaughan, PhD, DABNM, and Vincent J. Devlin, MD 1. What is intraoperative neurophysiology monitoring Intraoperative neurophysiology monitoring refers to the various neurophysiology techniques used to assess functional integrity of the nervous system during surgical procedures that place these structures at risk. 2. What neurologic structures are at risk during spinal surgery Spinal cord and or nerve roots at the surgical site Spinal cord and or nerve roots remote from the surgical site...

John Steinmann DO and Gina Cruz DO

What are the incidence and leading causes of spinal cord injuries It is estimated that 12,000 new cases of spinal cord injury occur each year in the United States. This equates to approximately 40 cases per million population. There is a distinct predominance of male patients, representing 81 of patients enrolled in the spinal cord injury database. The average age of spinal cord injury in the United States for the years 2000 through 2005 was 37.6 years with the past 30 years showing a slow...

L

Laminectomy cervical, 167-168, 321 described, 165, 165f electrodiagnosis after, 133 lumbar, 169-170 for lumbar spinal stenosis, 343-344, 344f, 345 for metastatic spinal disease, 446 postlaminectomy kyphosis, 282 thoracic disc, 327f for thoracic disc herniation, 168 Laminoplasty cervical, 167-168, 322 described, 165, 166f morbidities, 323 Laminotomy cervical, indications for, 167 described, 165, 165f lumbar, 169-170 for lumbar spinal stenosis, 343, 345 Lateral decubitus position, 183-184, 183f,...

Lower Cervical Spine Injuries

Steinmann, DO, and Paul A. Anderson, MD 1. Describe the initial evaluation of a trauma patient with respect to potential lower cervical spine injury. The cervical spine is immobilized in the blunt trauma patient until the spine has been cleared Initial evaluation and management is carried out according to the elements of the Advanced Trauma Life Support (ATLS) protocol The posterior cervical region is palpated for tenderness, and the patient is log rolled to...

M

Magnetic resonance imaging (MRI), 80-91 abnormal disc morphology, 84, 85-86f, 85f Magnetic resonance imaging (Continued) advantages of, 67 in cervical abnormalities, 86, 87f cervical stenosis, 94 in children with back pain, 251 computed tomography (CT) compared, 93-94 contraindications for, 81 contrast agent use, 84 in degenerative spondylolisthesis, 362, 362f disadvantages of, 67 in discitis osteomyelitis, 89, 89f lumbar disc herniation, 333 lumbar spinal stenosis, 88, 88f, 94 in metastatic...

Match each cervical MR image in Figure 116AF with the appropriate description Each image depicts a patient who presents

Cervical kyphosis is associated with posterior spinal cord compression at C2 to C4 and anterior spinal cord compression C4 to C6. 2. Severe multilevel cervical spinal stenosis due to anterior and posterior cord compression. 3. Single-level cervical disc extrusion associated with severe spinal cord compression. 4. Multilevel cervical spondylosis superimposed on developmental stenosis. The anteroposterior diameter of the central spinal canal is narrowed on a...

Match each MR image of a disc abnormality in Figure 115AE with the appropriate description 1 annular tear 2 disc bulge

Answers (1) annular tear, B (2) disc bulge, E (3) disc protrusion, C (4) disc extrusion, A (5) disc sequestration, D. Figure 11-5. Lumbar disc abnormalities A from Herzog RJ. State of the art imaging of spinal disorders. Phys Med Rehabil State Art Rev 1990 4 239. B from Gundry CR, Heithoff KB, Pollei SR. Lumbar degenerative disk disease. Spine State Art Rev 1995 9 151. Figure 11-5. Lumbar disc abnormalities A from Herzog RJ. State of the art imaging of spinal disorders. Phys Med Rehabil State...

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Neckline asymmetry, 55 Neck pain causes of, 317 surgical indications, 317 Nerve block, spinal, 66 Nerve conduction study, 128, 131 Nerve root compression, 29 decompression procedures for, 165-170 dorsal, 15 exiting, 29, 29f injury after surgery, 168 testing in cervical disorder evaluation, 36t transversing, 29, 29f ventral, 15 Nerve root tension signs, 332 Nerves, spinal, 15, 15f Neural anatomy cervical, 14-15 lumbar, 29-30, 29f, 30f thoracic, 21-22, 21f Neural pathway testing, in cervical...

Outline a treatment plan for patients with thoracic radiculopathy

Thoracic radiculopathy may be due to disc herniation or metabolic abnormalities of the nerve root (i.e. diabetes). Patients present with bandlike chest pain. Thoracic radiculopathy is not a common diagnosis, and other possible serious pathology should be excluded (malignancy, compression fracture, infection, angina, aortic aneurysm, peptic ulcer disease). Nonsurgical treatment options for thoracic radiculopathy include medication (NSAIDs, analgesics, oral steroids), modalities, TENS, spinal...

OWinston Fong MD Scott C McGovern MD and Jeffrey C Wang MD

How does the evaluation of a patient with a spine complaint begin A complete history and physical exam are performed. The purpose of the history and physical exam is to make a provisional diagnosis that is confirmed by subsequent testing as medically indicated. 2. What are some of the key elements to assess in the history of any spine problem Chief complaint Pain, numbness, weakness, gait difficulty, deformity Symptom onset Acute vs. insidious Symptom duration Acute vs. chronic Pain location Is...

Sacral Fracturesp

Schildhauer, MD, and Carlo Bellabarba, MD O 1. What is the role of the sacrum The sacrum connects the lumbar spine and the left- and right-sided iliac wings by means of well-developed ligaments with little inherent bony stability. The sacrum is kyphotically aligned in the sagittal plane in a variable dimension ranging from 0 to over 90 . The sacrum distributes the torso load from the lumbar spine mainly through its S1 segment into the sacroiliac joints and...

Spinal Cord Injury

Which of the following terms are currently favored to describe impairment or loss of motor and or sensory function due to damage of neural elements within the spinal canal (1) tetraplegia, (2) paraplegia, (3) quadriplegia, (4) quadriparesis, and or (5) paraparesis Tetraplegia refers to the impairments resulting from damage to neural elements within the cervical spinal canal, whereas paraplegia refers to the impairments resulting from damage to neural elements within the thoracic, lumbar, or...

Spondylolysis and spondylolisthesis in regard to classification clinical presentation radiographic workup and treatment

Contemporary classifications (Wiltse, Marchetti, and Bartolozzi) do not distinguish between pediatric and adult patients with spondylolisthesis. However, the degenerative type of spondylolisthesis is seen only in adult patients. Degenerative spondylolisthesis is covered in this chapter while basic principles regarding spondylolisthesis with emphasis on isthmic spondylolisthesis are covered in detail in Chapter 38. In pediatric patients, back pain is the most common presenting symptom. Pain is...

Thoracic And Lumbar Spine Instrumentation

Greg Anderson, MD, and Vincent J. Devlin, MD 1. Summarize the functions of spinal instrumentation in thoracic and lumbar fusion procedures. Enhance fusion. Spinal implants immobilize spinal segments during the fusion process and increase the rate of successful arthrodesis Restore spinal stability. When pathologic processes (e.g. tumor, infection, fracture) compromise spinal stability, spinal implants can restore stability Correct spinal deformities. Spinal...

Upper Cervical Spine Trauma

Bransford, MD 1. What are the major types of injuries involving the upper cervical (occiput-C2) region The major types of injuries can be classified according to location 1. Occipitocervical articulation 3. Axis (C2) Occipital condyle fractures Odontoid fractures Atlanto-occipital dislocation Hangman's fractures Transverse ligament injuries 2. How are upper cervical spine injuries diagnosed Any patient with a suspected cervical spine injury requires a...

Vincent J Devlin MD and Darren L Bergey MD

Describe the bony landmarks of the occiput. The occiput forms the posterior osseous covering for the cerebellum. The foramen magnum is the opening through which the spinal cord joins the brainstem. The anterior border of the foramen magnum is termed the basion (clivus), and the posterior border is termed the opisthion. The inion or external occipital protuberance is the midline region of the occiput where bone is greatest in thickness. The superior and inferior nuchal lines extend laterally...

What anatomic structures should be routinely assessed on an MR study of the lumbar spine

Normal cervical spine anatomy. The sagittal T1 -weighted image (A) provides excellent anatomic delineation of the vertebral bodies (curved black arrows), intervertebral discs (straight black arrows), and spinal cord (white arrows). On the sagittal cardiac gated T2-weighted image (B), a myelographic effect is created by the increased signal intensity in the cerebrospinal fluid (CSF). There is an excellent interface between the posterior margin of the discovertebral joints (curved...

What are flexion exercises Williams exercises When are they appropriate

Examples of flexion exercises include knee-to-chest exercises (Fig. 14-1), abdominal crunches, and hip flexor stretches. Flexion exercises are commonly prescribed for facet joint pain, lumbar spinal stenosis, spondylolysis, and spondylolisthesis. Flexion exercises increase intradiscal pressure and are contraindicated in the presence of an acute disc herniation. Flexion exercises are also contraindicated in thoracic and lumbar compression fractures and osteoporotic patients. Flexion exercises...

What are important points to assess on physical examination in the patient being evaluated for possible revision spine

A general neurologic assessment and regional spinal assessment are performed. The presence of nonorganic signs (Waddell signs) should be assessed. Global spinal balance in the sagittal and coronal planes should be assessed. The physical examination is tailored to the particular spinal pathology under evaluation. For cervical spine disorders, shoulder pathology, brachial plexus disorders, and conditions involving the peripheral nerves should not be overlooked. For lumbar spine problems, the hip...

What are nerve root tension signs

Tension signs are maneuvers that tighten the sciatic or femoral nerve and in doing so further compress an inflamed nerve root against a lumbar disc herniation. The supine straight leg raise test (Lasegue's test) and its variants (sitting straight leg raise test, bowstring test, contralateral straight leg raise test) increase tension along the sciatic nerve and are used to assess the L5 and S1 nerve roots. The femoral nerve stretch test (reverse straight leg raise test) increases tension along...

What are potential treatment options for osteoporotic compression fractures

The goal of treatment is rapid return to baseline functional status, while limiting possible complications. Traditionally, osteoporotic compression fractures were treated nonoperatively except in unusual cases where the fracture was associated with neurologic compromise or extreme spinal instability. Rationale for this approach included the finding that a certain percentage of these fractures were associated with mild symptoms that improved over time. In addition, surgical treatment in this...

What are signs to look for in identifying the disability syndrome

The most common associations that indicate disability from an injury are not physical ones. The best predictors are history of prior injury with time off work, high Minnesota Multiphasic Personality Inventory (MMPI) scale 3 (hysteria), and high work dissatisfaction scales. History and physical examination features that may help identify this syndrome include past episodes of back pain that led to disability, a long history of tests and surgical procedures, and a very detailed description of the...

What are some emerging techniques for treatment of osteoporotic fractures

Investigational techniques include use of bioactive cements and implantation of devices in combination with PMMA into the fractured vertebral body. Hybrid surgical procedures have been reported that combine vertebral body augmentation procedures with traditional open surgical techniques. In patients with spondylolisthesis or kyphotic deformity, posterior pedicle screw-rod fixation has been performed in combination with posterior surgical decompression and cement augmentation. Although...

What are some predictions regarding future therapeutic strategies for intervention in patients with degenerative spinal

With increased understanding of the interplay of mechanical, biochemical, and genetic factors in the development of spinal degeneration, strategies that permit earlier intervention in the degenerative cascade will evolve. Current surgical technologies including instrumented spinal fusion will remain an option for treatment of the severe end-stage degenerative pathology. Clinical and basic science research efforts will lead to development of new treatment strategies that specifically target...

What are spinal stabilization exercises When are they used

Strengthening exercises for a dynamic corset of muscle control to maintain a neutral position are known as spinal stabilization exercises. Recently, there has been a special focus on the role of the transversus abdominis and lumbar multifidi muscles in enhancing spinal stability. The goal of stabilization exercises is to reduce mechanical stress on the spine. Spinal stabilization exercises can be prescribed for most causes of low back pain. Key concepts of spinal stabilization exercise program...

What are the accepted therapies for patients with AS

Treatment of AS is based on current disease manifestations and level of symptoms. Half of patients are able to control joint and spine pain stiffness with a nonsteroidal antiinflammatory drug while half require stronger agents, such as a tumor necrosis factor a (TNF-a) inhibitor. Up to 30 of patients develop uveitis, which is treated with corticosteroid eye drops. Regular exercise and group physical therapy have been proven helpful. Total hip arthroplasty is considered for severe hip joint...

What are the basic components of an electrodiagnostic examination

EDX is an extension of the history and physical examination. Its goal is to help in distinguishing among the variety of causes for numbness, weakness, and pain. The standard EDX examination consists of two parts electromyography (EMG) and nerve conduction studies (NCS). EMG (needle electrode examination) uses a needle antenna to detect and record electrical activity directly from a muscle. The four standard components of the examination assess The distribution of abnormalities identifies the...

What are the different types of basilar impression

There are two main types of basilar impression primary and secondary. The primary type is most common. It is frequently associated with other vertebral defects, including atlanto-occipital fusion, odontoid abnormalities, Klippel-Feil anomaly, and hypoplasia of the atlas. Vertebral artery abnormalities may also be present. Secondary basilar impression arises as the result of softening of osseous structures at the base of the skull. Diseases associated with secondary basilar impression include...

What are the different types of peripherally acting analgesics

The peripherally acting analgesics are acetaminophen and the NSAIDs, including aspirin. They are useful for mild to moderate pain and may also act synergistically with centrally acting analgesics. The NSAIDs have two mechanisms to relieve pain, an antiinflammatory effect and a pure analgesic action. Empiric support for this includes the fact that analgesia can begin in less than an hour, long before any antiinflammatory activity could occur, and NSAIDs may relieve pain even when there is no...

What are the indications for singlestage posterior instrumentation and fusion for Scheuermanns kyphosis

Traditionally, kyphosis correcting to less than 50 on hyperextension lateral radiographs is treated with posterior instrumentation and fusion. The instrumentation should include the entire kyphotic area proximally and extend distally to include one lordotic disc. Pedicle screws in the distal thoracic and lumbar spine provide better anchors and more powerful correction than hook fixation. Dual rods are secured proximally with claw hook configuration or pedicle screws. The deformity is corrected...

What are the indications for surgical treatment for a lumbar disc herniation

Occasionally an acute massive disc herniation can result in cauda equina syndrome, which is best managed by emergent surgical treatment. However, most patients undergo elective surgical treatment due to failure of radicular pain to improve with nonsurgical treatment. Surgical treatment is directed at improving the patient's leg pain. When the predominant symptom is back pain, symptom relief is unpredictable, and discectomy is not advised. Appropriate criteria for surgical intervention include...

What are the limitations of DEXA scans for predicting fracture risk

DEXA scans do not convey all the necessary information to predict a specific patient's fracture risk. This is highlighted by the finding that up to half of all osteoporotic-related fractures occur in patients with BMD values classified as osteopenia. Thus, factors in addition to BMD require consideration in the assessment of fracture risk. The FRAX tool (http www.sheffield.ac.uk FRAX ) has been developed by the World Health Organization to integrate important clinical risk factors and bone...

What are the limitations of needle EMG in the diagnosis of radiculopathy

Needle EMG detects recent motor axon loss but does not detect sensory axon loss, demyelination, or conduction block 2. False-negative studies can occur in instances of focal demyelination secondary to root compression, when axon loss involves only sensory root fibers, when only a few motor fibers are injured by root compression, during the early postinjury period before denervation potentials appear, or several months after the onset of a radiculopathy (late postinjury period) when significant...

What are the mechanisms by which spinal cord stimulation exerts its effect

The mechanism of spinal cord stimulation is conceptualized based on the gate control theory of pain. In simplistic terms, this theory states that peripheral nerve fibers carrying pain to the spinal cord may have their input modified at the spinal cord level prior to transmission to the brain. The synapses in the dorsal horns act as gates that can either close to keep impulses from reaching the brain or open to allow impulses to pass. Small-diameter nerve fibers (C-fibers and lightly myelinated...