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...

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...

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,...

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...

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...

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...

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...

D

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...

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 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 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...

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 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...

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...

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...

N

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...

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...

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 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 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 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 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 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 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 most common types of intraduralextramedullary spinal cord tumors

Eighty percent of the tumors in the intradural-extramedullary space are schwannomas, neurofibromas, or meningiomas (Fig. 62-3). Tumors of the intradural-extramedullary space account for 60 of all intradural spinal tumors in adults but are less common in children. Nerve sheath tumors (schwannomas, neurofibromas) arise from sheath cells covering the spinal nerve roots while meningiomas arise from meningeal cells localized at the spinal cord surface. Neurofibromas occur commonly in patients with...

What are the most common types of intramedullary spinal cord tumors

The most common types of intramedullary tumors (Table 62-3, Fig. 62-4) are ependymomas, astrocytomas, and hemangioblastomas. In children, astrocytomas are the most common tumor type, while in adults, ependymomas are most common. Ependymomas arise from the cuboidal ependymal cells that surround the ventricular system and central canal of the spinal cord. As the tumor enlarges in the central canal, the flow of CSF is obstructed and cystic cavities frequently develop above and below the lesion....

What are the most commonly used types of fullcontact TLSOs

Plastic jacket provides total body contact except over bony prominences. Available in one- or two-piece construction with anterior, posterior, or side-opening styles Indications. Immobilization of the spine between T8 and L4. Provides adequate rotational control for treatment of stable spine fractures in this region CUSTOM-MOLDED TLSO WITH CERVICAL EXTENSION (Fig. 18-16) Design. Custom-molded TLSO with attached chin and occiput support Indications. Immobilization of the spine between T1...

What are the surgical options for correction of the sagittal plane deformity in the previously fused spine

Smith-Petersen osteotomy (resection of a posterior column wedge to achieve correction through the disc space or through a prior anterior osteotomy) and pedicle subtraction osteotomy (resection of a three-column wedge hinging at the anterior longitudinal ligament) are powerful methods for correction sagittal deformity. Combined coronal and sagittal deformity may be corrected with a vertebral column resection procedure. See Figure 53-3. Figure 53-3. A, Preoperative lateral x-ray film of a...

What common medications may potentially interfere with healing of a spinal fusion

Certain medications have potential to impair fusion if used in the perioperative period because they inhibit or delay bone formation. Examples include nonsteroidal antiinflammatory drugs (e.g. ibuprofen, Toradol), cytotoxic drugs (e.g. methotrexate, doxorubicin), certain antibiotics (e.g. ciprofloxacin), and anticoagulants (e.g. Coumadin). Recent evidence has shown that the adverse effects of nonsteroidal antiinflammatory medications on spinal fusion are related to dose and duration of...

What is Social Security Disability SSD

According to the Social Security Administration (SSA), disability is defined as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. In addition, for a person under the age of 18, disability can exist if he or she has a medically determinable impairment(s) that is of comparable...

What is the difference between discitis and vertebral osteomyelitis

In the past, a distinction was made between discitis (infection involving the disc space) and osteomyelitis (infection in the vertebral body). Studies have shown that in children the vascular supply crosses the vertebral endplate from vertebral body to the disc space. As a result, discitis and vertebral osteomyelitis are considered to represent a continuum termed infectious spondylitis. Hematogenous seeding of the vertebral endplate leads to direct spread of infection into the disc space....

What is the most common pyogenic organism responsible for osteomyelitis involving the spine

Staphylococcus aureus is the most common organism and has been identified in over 50 of cases. However, infections due to a diverse group of gram-positive, gram-negative, and mixed pathogens may occur. Gram-negative organisms (Escherichia coll, Pseudomonas spp., Proteus spp.) are associated with spinal infections following genitourinary infections or procedures. Intravenous drug abusers have a high incidence of Pseudomonas infections. Anaerobic infections are common in diabetics and following...

What is the most common type of torticollis

Congenital muscular torticollis is the most common type of torticollis. It presents in the newborn period. Its cause is unknown, but it has been hypothesized to arise from compression of the soft tissues of the neck during delivery, resulting in a compartment syndrome. Radiographs of the cervical spine should be obtained to rule out congenital vertebral anomalies. Clinical examination reveals spasm of the sternocleidomastoid muscle on the same side as the tilt causing the typical posture of...

What is the typical pattern on technetium bone scan in a patient with acute vertebral compression fractures secondary

The typical appearance of osteoporotic compression fractures on a technetium bone scan (Fig. 13-3) consists of multiple transverse bands of increased uptake on a posteroanterior image. However, the etiology of the fracture (trauma, tumor, metabolic bone disease) cannot be definitively diagnosed based solely on a bone scan. Increased activity can be noted within 72 hours of fracture, and the average time for a bone scan to revert to normal following an osteoporotic vertebral compression fracture...

What is vertebroplasty

Vertebroplasty is the percutaneous injection of polymethylmethacrylate (PMMA) into a vertebral body to provide stabilization and relief of pain. The procedure was introduced in the 1980s, initially for treatment of vertebral hemangiomas. Currently, the procedure is most commonly used to treat acute and subacute osteoporotic vertebral body compression fractures. The procedure is performed with local anesthetic, with or without intravenous sedation, or with general anesthesia. The patient is...

What types of adverse reactions can occur during a CTmyelogram procedure

Initially patients may experience discomfort during intrathecal injection of the nonionic water soluble contrast agent. After injection, patients may experience an anaphylactoid (idiosyncratic) reaction (urticaria, facial and laryngeal edema, bronchospasm, hypotension) or a nonidiosyncratic reaction due to the adverse effect of contrast on a specific organ system (nephrotoxicity, cardiac arrhythmia, myocardial ischemia, vasovagal reaction). Specific treatment depends on the exact clinical...

When are combined anterior and posterior procedures indicated for the treatment of cervical myelopathy

Common indications for combined anterior and posterior procedures are 1. Postlaminectomy kyphotic deformities 2. Complex spinal deformities and instabilities 3. All three-level corpectomies and some two-level corpectomies (e.g. corpectomies ending at C7, patients with osteopenia) 4. Treatment of complex pseudarthroses See Figure 46-7. Figure 46-7. Circumferential cervical procedures. A, Anterior reconstruction following C5 and C6 corpectomy with fibula allograft and anterior plate combined with...

When is cervical TDR an appropriate option for treatment of cervical myelopathy

Cervical total disc arthroplasty has been shown to be successful for treatment of select patients with cervical myelopathy in whom spinal cord compression is localized to the level of the disc space (retrodiscal). This procedure is not appropriate for patients with severe facet joint degenerative changes at the operative level, severe loss of disc space height, myelopathy due to congenital spinal canal narrowing, and cervical stenosis due to retrovertebral cord compression (e.g. ossification of...

Who is at greatest risk of developing an osteoporotic vertebral compression fracture

The biggest risk factor for having a vertebral compression fracture is a prior osteoporotic fracture. A person who suffers a vertebral fracture is five times more likely to suffer an additional fracture, when compared with a control with no fracture. Because osteoporosis disproportionately affects older persons, age is a risk factor. In a large cohort of middle-aged individuals studied with serial radiographs over 2 decades, 24 of the women and 10 of the men sustained a vertebral fracture over...

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

What are the most common reasons for referral to evaluate the thoracic spinal region Pain and spinal deformity. The differential diagnosis of thoracic pain is extensive and includes both spinal and nonspinal etiologies. Spinal deformities (e.g., scoliosis, kyphosis) are generally painless in children but may become symptomatic in adult life. 2. What are some common spinal causes of thoracic pain Degenerative disorders spondylosis, spinal stenosis, disc herniation Fracture traumatic, pathologic...

Which anticonvulsant is most commonly used for neuropathic pain

Gabapentin (Neurontin) is currently used most often, although its use for pain is off-label. It may be useful for neuropathic extremity pain due to iatrogenic nerve injury, arachnoiditis, prolonged neural compression, and peripheral neuropathy. It has been shown to be useful in some patients with leg pain due to spinal stenosis. Gabapentin is started at 100 to 300 mg at night and then increased to 300 mg every 8 hours over the days to weeks, and then gradually titrated upward until there is...

When are antidepressants useful for patients with spine problems

Antidepressants have several potential uses in patients with chronic spinal problems, including the treatment of back pain, neuropathic pain, sleep disturbance, and depression. Only the antidepressants with primarily nonadrenergic activity are useful for pain. The data regarding efficacy of antidepressants for axial pain are equivocal. At best, isolated studies show about 30 reduction in pain in one third of patients. In addition, recent data suggest these drugs are not very effective for...

What is rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder of uncertain etiology. It is an immunologically mediated systemic disorder that affects articular and nonarticular organ systems. The articular involvement is a symmetrical peripheral joint disease affecting large and small joints. Axial involvement predominantly affects the cervical region, especially the upper cervical spine. The extra-articular involvement may affect the skin, eyes, and larynx, as well as the pulmonary,...

What problems have been associated with the use of halo orthosis

Complications associated with use of a halo orthosis include pin-loosening, pin-site infection, discomfort secondary to pins, scars after pin removal, nerve injury, dysphagia, pin-site bleeding, dural puncture (following trauma to the halo ring), pressure sores secondary to vest irritation, reduced vital capacity, brain abscess, and psychological trauma. Although the halo is the most restrictive of the various CTOs, significant motion may occur due in part to difficulty in fitting the brace...

Describe the prevalence and natural history of lumbar disc herniations How do they differ from the prevalence and

The lifetime prevalence of a lumbar disc herniation is approximately 2 . The natural history of sciatica secondary to lumbar disc herniation is spontaneous improvement in the majority of cases. Among patients with radiculopathy secondary to lumbar disc herniation, approximately 10 to 25 (0.5 of the population) experience persistent symptoms. These statistics are in sharp contrast to low back pain, which has a lifetime prevalence of 60 to 80 in the adult population. Although the natural history...

What is the incidence of recurrent disc herniation after microsurgical lumbar discectomy

The incidence of recurrent disc herniation following microsurgical lumbar discectomy is 5 to 10 . Higher rates of recurrence (up to 26 ) have been reported in patients in whom large annular defects were present at conclusion of discectomy. If symptoms are predominantly radicular in nature, repeat lumbar discectomy may be beneficial. If symptoms include a combination of radiculopathy and low back pain, discectomy combined with fusion may be considered in select patients with recurrent lumbar...

What is the role of chemotherapy in the treatment of a metastatic spinal lesion

Chemotherapy is used in patients with documented spinal metastases, patients at risk of developing spinal metastases, and patients with spinal lesions not amenable to surgical excision. The response to chemotherapy is determined by the tumor type. Tumors that are highly sensitive to chemotherapy include small-cell carcinoma of the lung, Ewing's sarcoma, thyroid carcinoma, breast carcinoma, lymphoma, germ cell tumors, and neuroblastoma. Tumors that are relatively resistant to chemotherapy...

What is a lipomyelomeningocele

A lipomyelomeningocele is a common congenital spinal anomaly in which herniation of a lipoma into the conus medullaris or the dorsal spinal cord occurs through an osseous defect and communicates with an adjacent subcutaneous fatty mass. It is a common cause of tethered cord syndrome. Symptoms may include constipation, urinary urgency, dyspareunia, lumbar pain, or cephalgia (headache) with defecation. The term lipomyelomeningocele is actually a misnomer, because abnormal neural tissue does not...

What guidelines exist to aid the practitioner in pursuing an effective and systematic approach to the child with back

An algorithm has been developed to guide patient assessment on data obtained from clinical history and physical examination (Figure 36-1). The algorithm takes into account three factors 1. Mechanism of injury Clear or unclear 2. Nature of symptoms physical findings Local vs. systemic vs. neurologic 3. Duration of symptoms Less than 1 month vs. greater than 1 month The patient may enter into the algorithm at any stage on findings noted in the history and physical examination. The patient may...

B

Complementary and alternative medicine treatments, 146-150 as indication for spinal surgery, 153 low assessment and management, 329-331 cardiovascular conditioning, role of, 108-109 common causes of lumbar pain, 106 complementary and alternative medicine treatments for, 146-150 discogenic, 337-341 lumbar spine exam, 41-44 in lumbar spine injuries in athletes, 417 orthosis for, 144 probability of recovery, changes in, 106 treatment plan for, 106 trunk strength deficits and, 110 pediatric,...

Which patients are less than ideal candidates for surgical treatment for lumbar DDD

Surgical treatment is associated with poor outcomes in patients with unresolved secondary gain issues, worker's compensation claims, litigation, multiple emergency department visits, high levels of opioid usage, abnormal psychometrics, chronic pain illness, and exaggerated pain behaviors. Patients off work greater than 3 months tend to have worse results. To have any sense that surgery might benefit the patient, the surgeon must get to know the patient. Overreliance on MRI or discography data...

What is the most important component of an exercise program for the treatment of low back pain due to lumbar DDD

The most important component of a low back exercise program is to address fear-avoidance behavior of the patient by reassuring the patient that it is safe to exercise despite the chronic pain he or she may experience. The appropriate exercise program is a supervised active physical therapy program that uses progressive, non-pain contingent exercise (i.e. the patient is encouraged to exercise despite their pain) to increase strength and endurance. Successful outcomes may be achieved with a...

What is the anatomic basis for EDX as it relates to the assessment of spinal disorders

Metatarsophalangeal Joint

The purpose of the EDX is to assess the motor and sensory function related to the spinal nerves. Each spinal nerve contains both motor and sensory fibers and contributes to the formation of the peripheral nerve. The cell bodies for the motor axons are situated within the anterior horn of the spinal cord. The cell bodies for the sensory axons are located within the dorsal root ganglion near its junction with the ventral root. There it forms the mixed spinal nerve in the region of the...

Define ankylosing spondylitis

Ankylosing Spondylitis Ray

Ankylosing spondylitis (AS) is a seronegative inflammatory arthritis of the spine of unknown etiology. It presents in the early stages with an inflammatory arthritic pain that typically involves the sacroiliac joints initially and later the other spinal regions. The classic feature of AS is enthesopathy (inflammation at the attachments of ligaments, tendons, and joint capsules to bone). Initially, range of motion is normal or mildly limited. Disease progression leads to spinal ossification,...

Explain how EMG is used to assess patients with spinal disorders for the presence of a radiculopathy

Specific muscles are selected for EMG assessment. Six upper limb muscles, including paraspinal muscles, consistently identify more than 98 of cervical radiculopathies that are confirmable by electrodiagnosis. For upper-limb EMG evaluation, a suggested screen includes deltoid, triceps, pronator teres, abductor pollicis brevis, extensor digitorum communis, and cervical paraspinal muscles. Six lower limb muscles, including paraspinal muscles, consistently identify more than 98 of...

Are anterior approaches commonly performed today for the treatment of adult scoliosis

As a result of the potential morbidity from an anterior approach and the fact that recent data suggest the same correction and similar fusion rates are achievable through a posterior-only approach, the enthusiasm for anterior fusions or combined anterior posterior fusions for adult spinal deformity has declined over recent years. A mini-open anterior retroperitoneal approach is, however, still commonly performed to achieve anterior column structural interbody grafting at caudal segments of a...

How is a PET scan performed

A positron-emitting radionuclide is injected into the body. As the positrons are emitted and travel through tissue they collide with electrons, resulting in production of gamma rays. A PET scanner records and analyzes these data and creates an image. CT or MRI may be combined with PET to maximize diagnostic potential. FDG is currently the most commonly used radiotracer. It is transported and becomes trapped intracellular as a result of phosphorylation by hexokinase. FDG accumulates at sites of...

How does RA affect the cervical spine

Rheumatoid Arthritis Anaesthesia Spine

The cervical spine is composed of 32 synovial joints. The occiput-C1 and C1-C2 articulations rely on soft tissue integrity for stability. In the subaxial cervical spine, the facet joints are true synovial joints. Rheumatoid pannus produces enzymes that destroy cartilage, ligaments, tendons, and bone. This synovitis leads to spinal instability, subluxation, and spinal deformity. Secondarily, the discs in the subaxial spine degenerate, which may result in additional facet joint subluxation and or...

What CAM treatments work best for the treatment of back pain

Popularity or personal testimonials do not prove or disprove treatment efficacy. CAM therapies are most frequently administered in combination with traditional therapeutic interventions for back pain using nonstandardized protocols. The medical evidence to support specific CAM treatments for back pain may be unavailable, insufficient, or conflicting depending on the specific intervention that is evaluated. Nevertheless, standardized reviews and randomized controlled trials have been published...

How is the clinical syndrome of lumbar DDD characterized

Lumbar DDD refers to a continuum of nonradicular pain disorders of degenerative origin. Specifically excluded are symptoms related to disc impingement on neural elements, facet-mediated back pain, and spinal deformities secondary to lumbar DDD (e.g. spondylolisthesis, degenerative scoliosis). Presenting symptom is primarily low back pain, which may radiate to the sacroiliac and or buttock region. Common physical examination findings include tenderness with palpation over the lumbar region and...

Describe the course of the vertebral artery in the cervical spine

The vertebral artery arises from the subclavian artery. It enters the transverse foramen at C6 in 95 of people and courses upward through the foramina above. At C1, the vertebral artery exits from the foramen, courses medially on the superior groove of the posterior ring of the atlas, and enters the foramen magnum to unite with the opposite vertebral artery to form the basilar artery. Figure 25-2. Vertebral artery. (From Winter R, Lonstein J, Denis F, et al. Posterior upper cervical procedures...

What are the different types of osteoporosis

Osteoporosis has been classified into two major types primary and secondary. Primary osteoporosis is further subdivided into type 1 or postmenopausal osteoporosis and type 2 or senile osteoporosis Type 1 osteoporosis is due to estrogen deficiency and typically occurs in women 5 to 10 years after menopause. It predominantly affects trabecular bone and is associated with vertebral fractures, intertrochanteric hip fractures, and distal radius fractures Figure 65-1. Specimen radiographs of 2-mm...

What is the degenerative cascade

The term degenerative cascade was introduced by Dr. Kirkaldy-Willis to explain the typical progression of lumbar spine degeneration. This process is conceptualized in terms of a three-joint complex composed of the intervertebral disc and two zygoapophyseal joints that comprise a functional spinal unit, the smallest anatomic unit of the spinal column that demonstrates its basic functional characteristics. The progression of degenerative changes involving the three-joint complex is conceptualized...

R

Radiation therapy, for metastatic spinal disease, 445 Radicular artery of Adamkiewicz, 22 Radiculopathy cervical computed tomography, 93 described, 36 disc replacement, 320 electrodiagnosis, 132 magnetic resonance imaging (MRI), 86, 93 natural history of, 104 nonsurgical treatment plan for, 105 provocative maneuvers for evaluation, 36 electrodiagnosis, 129, 130-131, 130t, 132-133 lumbar electrodiagnosis, 132 nonsurgical treatment plan for, 106 thoracic electrodiagnosis, 132-133 treatment plan...

Provide a brief description of the types of mindbody therapy that have been used to treat patients with LBP

Cognitive-behavioral programs are a component of many established pain treatment centers. These programs focus on educating patients and teaching coping skills in a highly structured group setting under the guidance of a clinical psychologist. They frequently incorporate hypnosis, meditation, and biofeedback techniques 2. The Alexander technique is a method of modifying chronic patterns of back and neck muscle tension through an instructor's verbal direction and awareness exercises. Patients...

What are the options for reconstruction of the anterior and middle spinal columns after resection of a metastatic

Options for reconstruction of the anterior and middle spinal columns include bone graft (autograft or allograft), methylmethacrylate, titanium mesh cages, and carbon fiber or polyether ether ketone (PEEK) cages. Expandable cages have been popularized for use in this setting. All of these intracolumnar implants are used in combination with anterior spinal instrumentation (plate systems, rod systems) and or posterior segmental spinal fixation. 29. What is the role of kyphoplasty and...

What is the crankshaft phenomenon

Crankshaft phenomenon refers to continued anterior spinal growth after posterior spinal fusion in a skeletally immature patient, resulting in increased spinal deformity. Risk factors include skeletal immaturity (Risser stage 0, premenstrual, open triradiate cartilage), surgery before the peak growth period (prior to 10 years of age) and large residual curves after initial surgery. The traditional approach for prevention of crankshaft phenomenon is to perform an anterior spinal fusion in...

Cervical Spine Injuries In Athletesi

Watkins, IV, MD, and Robert G. Watkins, III, MD O 1. What sports are associated with the highest risk for head and neck injuries The organized sports with the highest risk for head and neck injuries are football, gymnastics, wrestling, and ice hockey. Football is the sport associated with the highest risk of such injuries. Head and neck injuries also occur in a variety of nonorganized sports activities including diving, skiing, surfing, and trampoline use. 2. What types of cervical...

What is Pagets disease

Mitch Paget

Paget's disease is named after Sir James Paget, who described its clinical and pathologic aspects in 1876. Paget's disease is the second most common metabolic bone disease. It has been found in up to 5 of northern European adults older than 55 years. However, most affected individuals are asymptomatic. The cause is unknown, but viral infection and genetic factors are believed to be responsible. The disease causes focal enlargement and deformity of the skeleton. The pathologic lesion is abnormal...

What is lifting capacity

Lifting capacity assesses the spinal functional unit (extensor unit lumbar paraspinals, gluteals, and hamstrings) and its interaction with the body's other functional units in performance of activities of daily living. Patients with chronic low back pain have a 30 to 50 reduction in lifting capacity. Normal lifting capacity from floor to waist (lumbar lift) is approximately 50 of IBW for men and 35 of IBW for women. Normal lifting capacity from waist to shoulder (cervical lift) is 40 of IBW for...

Lumbar Spine Injuries In Athletesi

Watkins, V MD, and Robert G. Watkins, III, MD O 1. What is the differential diagnosis for an athlete who presents with symptoms of low back pain with or without radiculopathy Muscle strain ligament sprain Lumbar disc injury (annular tear, discogenic pain syndrome, disc herniation) Ring apophyseal injury (adolescents) Stress fracture (e.g. spondylolysis, sacral stress fracture) Minor lumbar fracture (e.g. transverse process fracture) Serious underlying spinal condition (discitis...