Does kyphoplasty or vertebroplasty increase the risk of an adjacent level fracture

This complication has been reviewed in multiple studies, and the data are conflicting as to whether or not placing cement in a vertebral body poses an independent increased risk of fracture in the adjacent bodies. Following kyphoplasty, the risk of adjacent-level fracture seems to be highest in the first 2 months following the procedure (Fig. 66-6). Evidence suggests that patients with steroid-induced osteoporosis are more likely to refracture than patients with primary osteoporosis. It is...

Match each lumbar MR image in Figure 117AD with the appropriate description Each image depicts a patient who presents

Ligamentum flavum hypertrophy causing stenosis of the central spinal canal and lateral recess. 2. Hypertrophy of the superior articular process at L5-S1 associated with thickened ligamentum flavum and resulting in front-to-back narrowing of the L5-S1 intervertebral nerve root canal with compression of the L5 ganglion. 3. Synovial cyst arising from the L4-L5 facet joint, resulting in compression of the left side of the thecal sac and left L5 nerve root. 4. Degenerative spondylolisthesis...

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...

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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 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 opioids misused by patients

There are some patients who misuse opioids. Several patterns of misuse have emerged. Perhaps the most serious is drug diversion, obtaining prescription opioids and subsequently selling them. Another serious problem is the use of illegal drugs, such as cocaine or methamphetamine in addition to the opioids. Unsanctioned dose escalation is common and can be due to tolerance, poor pain control, or using opioids to treat psychological or other symptoms. Additional aberrant behaviors include seeking...

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 really no detectable abnormalities in people with socalled nonspecific LBP

There are many spinal abnormalities in patients who present with LBP. However, there is no conclusive evidence that these abnormalities are responsible for the patient's complaints. Clinical studies have shown a poor correlation between spinal radiographic abnormalities and LBP. More recently, as computed tomography (CT) and magnetic resonance imaging (MRI) of the spine evolved, additional abnormalities became visible including facet arthrosis, disc desiccation, and anular tears. In an attempt...

At which level should a thoracotomy be performed for a transthoracic disc resection

A chest radiograph can be used to determine the slope of the ribs in the thoracic spine. Usually, a thoracotomy is performed one or two levels above the target disc space. This strategy allows a parallel approach to the disc space, thus permitting the use of a microscope if desired. Alternatively, a minithoracotomy can be performed to attempt to decrease approach-related morbidity. The posterior portion of the rib leading to the target disc space is removed (e.g. remove the posterior portion of...

Can posterior spinal instrumentation be utilized in the setting of an acute spinal infection without an increased rate

Experimental and clinical evidence supports the concept that bone infections are better controlled with antibiotics and bone stabilization than with antibiotics alone in an unstable osseous environment. In this setting, advantages of posterior spinal instrumentation include 1. Preservation of spinal alignment and restoration of spinal stability following radical debridement 3. Ability to correct kyphotic deformities 4. Avoidance of graft collapse or dislodgement 5. Rapid patient mobilization...

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...

What is diastematomyelia

Diastematomyelia is a congenital spinal anomaly in which splitting of the spinal cord is identified. Two separate hemicords divided by a septum are present. Variations exist including two separate hemicords separated by a septum (osseous or cartilaginous) and contained in separate dural coverings or two separate hemicords (fibrous septum) in one dural covering. There is a female predominance and the condition most commonly presents in the lower thoracic or upper lumbar spine. Patients present...

Compare and contrast laminectomy and laminotomy for treatment of lumbar spinal stenosis

Laminectomy is the traditional procedure for surgical decompression for lumbar stenosis. It involves removal of the midline osseous and ligamentous structures including the lamina, spinous processes, interspinous ligaments, and portions of the facet joints. It provides excellent visualization of neural structures and facilitates complete decompression of involved neural structures. However, spinal instability is not uncommon following laminectomy and often requires treatment with spinal...

Compare and contrast the healing potential of the anterior spinal column and posterior spinal column with respect to

Biomechanical factors are different in the anterior and posterior spinal columns. In the lumbar region it is estimated that 80 of the body's load passes through the anterior spinal column, and 20 passes through the posterior spinal column. Thus, bone graft placed in the anterior column is subjected to compressive loading, which promotes fusion. In the anterior spinal column, the wide bony surface area combined with the excellent vascularity of the fusion bed creates a superior biologic milieu...

Compare the utility of CTmyelography and MRI for assessment of cervical stenosis presenting with myelopathy

After plain radiographs are obtained, MRI is usually the next test obtained in the imaging workup for cervical myelopathy. MRI provides a noninvasive means of visualizing the entire cervical spine, including the discs, vertebra, spinal cord, and nerve roots, in multiple planes. CT-myelography plays a role when MRI is contraindicated or when osseous pathology contributes to spinal canal encroachment. In the presence of complex cervical stenosis problems, CT-myelography continues to play a...

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 cervical spinal instability

Instability is present when the spine is unable to withstand physiologic loads, resulting in significant risk for neurologic injury, progressive deformity, and long-term pain and disability. Instability is not common in patients with cervical spondylosis except in those with stiffness in the middle and lower segments who develop compensatory hypermobility at C3-C4 or C4-C5. This condition can result in degenerative spondylolisthesis and lead to symptomatic cervical myelopathy. Cervical spinal...

Define cervical spondylosis What causes it

Cervical spondylosis is a nonspecific term that refers to any lesion of the cervical spine of a degenerative nature. Cervical spondylosis results from an imbalance between formation and degradation of proteoglycans and collagen in the disc. With aging, a negative imbalance with subsequent loss of disc material results in degenerative changes. Factors such as heredity, trauma, metabolic disorders, certain occupational exposures, and other environmental effects (e.g. smoking) can influence the...

Define chiropractic medicine and chiropractic manipulation

Chiropractic medicine is a holistic approach to patient care that focuses on the normal relationships among the spinal column, nervous system, and soft tissues. Imbalance or misalignment of the spinal column is considered to be responsible for impaired or abnormal nerve function, resulting in subsequent disease and pain. Chiropractic manipulation is a realignment or balancing of the spine or extremities to restore normal relationships and health. This goal is achieved by movement of body parts...

Define gibbus

The term gibbus derives from the Latin word for hump. It refers to a spinal deformity in the sagittal plane characterized by a sharply angulated spinal segment with an apex that points posteriorly (Fig. 7-2). Figure 7-2. A, Congenital kyphosis with gibbus. B, Magnetic resonance imaging demonstrates sharply angulated kyphotic deformity secondary to congenital kyphosis. Figure 7-2. A, Congenital kyphosis with gibbus. B, Magnetic resonance imaging demonstrates sharply angulated kyphotic deformity...

Define lumbar disc degeneration

Lumbar disc degeneration has been defined by the North American Spine Society Consensus Committee on Nomenclature in terms of morphologic changes involving the anatomic components of the lumbar disc. These changes may include Desiccation, fibrosis, vacuum changes, or cleft formation in the nucleus Fissuring, mucinous degeneration, or calcification in the annulus Defects and sclerosis of the vertebral endplates Osteophytes at the vertebral apophysis

Define myelomeningocele and describe the pertinent clinical findings

Myelomeningocele is a neural tube defect in which the dorsal neural structures are open through the skin due to failure of the neural tube closure. This is the most common significant spinal birth defect. The incidence of this defect varies based on geography (worldwide 1 1000 live births United States 0.6 1000 live births Ireland 4 1000 live births). Prevalence has diminished since the 1980s due to the utilization of perinatal folate and elective termination of the pregnancies upon...

Define nonstructural curve structural curve major curve minor curve full curve and fractional curve

Patients typically present with a combination of fixed and flexible spinal deformities. Side-bending radiographs are used to assess the flexibility of curves that comprise a spinal deformity. Curves that correct completely when the patient bends toward the convexity of the curve are termed nonstructural curves. Nonstructural curves permit the shoulders and pelvis to remain level to the ground and permit the head to remain centered in the midline above the pelvis. For this reason, nonstructural...

Define os odontoideum and explain its likely etiology

Os odontoideum is an anomaly of the odontoid process that appears as an ossicle with smooth cortical margins separate from the body of the axis. The atlantoaxial joint becomes unstable as the odontoid becomes unable to function as a peg. Associated symptoms range from mild neck pain to myelopathy and sudden death secondary to minor trauma. Surgery is considered in the presence of neurologic deficit, C1-C2 instability greater than 10 mm on flexion-extension radiographs, or persistent neck pain....

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...

Define segmental spinal dysgenesis and describe treatment of this deformity

Segmental spinal dysgenesis is a congenital spinal deformity characterized by focal dysgenesis or agenesis of the lumbar or thoracolumbar spine and a focal abnormality of the underlying spinal cord and nerve roots. The bony defects include canal stenosis, hypoplastic vertebrae, and spinal column subluxation and instability. Neural pathology includes narrowing of the thecal sac and absent nerve roots. Early spinal stabilization, usually by anterior and posterior arthrodesis, is required to...

Define the surgical goals in terms of curve correction and balance for Scheuermanns kyphosis

The goal of surgical treatment is restoration of normal and harmonious thoracic kyphosis and lumbar lordosis while relieving pain through successful arthrodesis. Approximately 50 correction is desired. Overcorrection of the deformity can lead to proximal or distal junctional kyphotic deformities, which may require additional surgical procedures for correction. Appropriate selection of fusion levels is critical for achieving long-term correction of sagittal deformity and a successful spinal...

Describe a paraspinal approach for removal of a foraminal lumbar disc herniation

The muscles attached to the midline bony structures are left intact. An incision is made in the fascia lateral to the midline. Blunt dissection is carried down to the transverse processes. The transverse processes are identified, and the intertransverse membrane is exposed. A radiograph is obtained to confirm that the correct spinal level has been exposed. The intertransverse membrane is then released, the nerve root is identified and retracted medially, and the disc herniation is removed.

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 basic components of the clinical assessment of a patient with spinal deformity

What is the presenting complaint (deformity pain neurologic symptoms impaired function in activities of daily living cardiorespiratory symptoms ) When was the deformity first noticed Is there a family history of spinal deformity Were there any abnormalities during development What is the patient's maturity and growth potential Has prior treatment been performed Are there any associated general medical problems Inspection. The patient must be undressed to fully assess the trunk and extremities....

Describe the clinical presentation of a symptomatic thoracic disc herniation

Peak incidence occurs in the fifth decade. Males and females are equally affected. Degenerative changes are considered to be the major factor responsible for thoracic disc herniation. An association between Scheuermann's disease and thoracic disc herniation has been reported. Trauma plays a role as a precipitating or aggravating factor in a small percentage of cases. The clinical presentation is variable and can include axial pain, radicular pain, and or myelopathy. Axial thoracic pain is...

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 clinical presentation of pyogenic vertebral osteomyelitis

The most consistent symptom is back or neck pain, which is noted in 90 of patients. In contrast with pain due to degenerative spinal problems, pain is typically unrelated to activity. Fever is documented in approximately 50 of patients. Neurologic deficits are present in up to 17 of patients at presentation. Radicular pain occurs in 10 of patients. Weight loss is common and occurs over a period of weeks to months. Spinal deformity may be a late presenting finding. A delay in diagnosis is...

Describe the components of a halo vest orthosis

The halo vest orthosis (Fig. 18-9) stabilizes the cervical spine by fixing the skull in reference to the chest through an external mechanical apparatus. A rigid ring is fixed about the periphery of the skull. A snug-fitting fleece-lined plastic vest immobilizes the chest. Adjustable rods and bars stabilize the ring and vest with respect to each other. This orthosis provides the most effective restriction of cervical motion, especially for the upper cervical region. Traction may be applied to...

Describe the different periods of spine growth during childhood

The growth of the immature spine can be conceptualized in terms of three phases Early phase (0-5 years) A phase of early rapid growth. Average height gained is 2 cm per year. By age 5, two thirds of sitting height is achieved. Thoracic volume grows from 5 of adult lung volume to 30 (six-fold increase) at age 5 years Middle phase (5-10 years) A phase of slow to moderate growth. Growth slows to 0.9 cm per year and thoracic volume reaches 50 by age 10. By age 8, most alveolar growth is complete...

Describe the H wave and its clinical use

The H reflex is a monosynaptic spinal reflex first described by Hoffmann in 1918. It is the electrical equivalent of the triceps surae reflex when recorded from the gastrocnemius soleus muscle. An abnormal H reflex localizes the lesion to the S1 root or any points along this neural pathway. Prolonged latency and reduced amplitude may indicate an S1 radiculopathy. However, H-reflex studies are neither highly sensitive nor specific. H reflexes demonstrate approximately a 50 sensitivity for S1...

Describe the key points in the physical examination of a patient with LBP

Examination should assess the lumbar spine, pelvis, and lower extremities. Key examination points include Lumbar range of motion (ROM), for asymmetric movement, re-creation of pain, and areas of limited or guarded motion (spasm) Tenderness, especially percussion tenderness over bony areas in the back and pelvis, palpate for tenderness over the sacroiliac joint and greater trochanter Gait and balance, include heel-toe walking and squatting and returning to the upright position. Evaluate for...

Describe the nonoperative treatment of pyogenic vertebral osteomyelitis

Nonoperative treatment includes antibiotic administration, treatment of underlying disease processes, nutritional support, and spinal immobilization with an orthosis. Antibiotic selection is based on identification and sensitivity testing. Consultation with an infectious disease specialist is recommended. Intravenous antibiotics generally should be continued for 6 weeks, provided that satisfactory clinical results and reduction in ESR and CRP occur. In the setting of a broadly sensitive...

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 presentation of coccidioidomycosis of the spine

The patient with spinal coccidioidomycosis typically presents with a low-grade fever and an abscess with a draining sinus. Imaging findings include a paraspinal mass and multiple vertebral lesions with sparing of the disc spaces in combination with involvement of the ribs and posterior spinal elements. 1. Spinal infection should be considered as a potential diagnosis when spinal pain is severe and unrelated to activity (e.g. present at rest or at night). 2. In general, antibiotic therapy should...

Describe the principles of surgical treatment for posttraumatic kyphosis

Posttraumatic kyphosis is most commonly a short-radius kyphotic deformity that may be either flexible or rigid. Factors to consider in the surgical treatment of posttraumatic kyphosis include the magnitude of deformity, the number of involved levels, global sagittal balance, effects of prior surgical procedures, the presence or absence of neurologic deficit, and the stability of the anterior and posterior spinal columns. Isolated anterior surgical procedures are often insufficient because 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 three basic steps involved in performing a thoracic or lumbar corpectomy after the exposure has been

The discs above and below the target vertebral body are removed. This procedure facilitates removal of the vertebral body by providing reference landmarks for the depth and position of the spinal canal. 2. The vertebral body is then removed. The anterior two thirds of the vertebral body is rapidly removed with a rongeur, osteotome, or burr. The remaining posterior wall of the vertebral body is thinned with a burr. This procedure facilitates the more delicate removal of the posterior vertebral...

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 history reported by a patient with acquired degenerative spinal stenosis

The typical patient reports the gradual onset of low back, buttock, thigh, and calf pain. Patients may report numbness, burning, heaviness, or weakness in the lower extremities. The lower extremity symptoms may be unilateral or bilateral. Symptoms are exacerbated by activities that promote spinal extension such as prolonged standing or walking (neurogenic claudication). Maneuvers that permit spinal flexion such as sitting, lying down or leaning forward on a shopping cart tend to relieve...

Describe the typical radiographic and imaging findings associated with cervical spondylotic myelopathy

A variety of spinal pathologies may result in cord compression and lead to subsequent development of myelopathy. Spinal pathology may occur at a single level or, more commonly, involve multiple spinal levels. Patterns of cord encroachment vary and include anterior-based compression, posterior-based compression, or circumferential compression. Many patients with myelopathy have a congenitally small spinal canal with a mid-sagittal diameter measuring less than 10 mm. Associated imaging findings...

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 a technetium bone scan for diagnosis of spine infections

Advantages of a technetium bone scan include the ability to detect a pyogenic infectious process long before plain radiographs demonstrate any abnormality. A technetium bone scan has a high sensitivity in the diagnosis of spinal osteomyelitis in the absence of prior spine surgery or medical comorbidities. Disadvantages of a technetium bone scans is related to its lack of specificity, especially in patients with a history of recent spine surgery, spinal implants, Paget's disease, fracture, or...

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 limitations associated with traditional surgical treatment options for degenerative spinal problems

Procedures for neural decompression violate the structural integrity of the spine and may lead to segmental spinal instability unless fusion is performed. Spinal fusion procedures increase stress at adjacent spinal levels and may accelerate the degenerative process leading to adjacent level degeneration, instability, and spinal stenosis. An initial fusion procedure may generate the need for further procedures, such as implant removal or pseudarthrosis repair. In addition, bone graft harvest for...

Discuss the controversy surrounding provocative discography

Discography remains a controversial test. Proponents of discography opine that disc morphology on MRI cannot be used to distinguish a painful disc from asymptomatic age-appropriate degenerative changes as justification for this test. Opponents of discography cite a high percentage of false-positive results in patients with psychological distress, chronic pain syndromes, increased somatic awareness, anular disruption, and individuals involved in litigation or workers' compensation cases. In...

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 issue of adjacentlevel problems in the cervical spine following nonfusion and fusion procedures

Adjacent segment degeneration and adjacent segment disease are common findings when patients are evaluated over time following cervical spine surgery. The annual incidence of adjacent segment disease requiring additional cervical surgery following an initial cervical spine procedure (ACDF or a posterior cervical foraminotomy) is 3 per year. Because the rates of adjacent segment problems are similar following fusion and nonfusion procedures, it remains uncertain whether adjacent segment...

Discuss the problem of adjacentlevel degeneration following lumbar fusion

Lumbar fusion results in load transfer to unfused proximal and distal spinal segments resulting in increased intradiscal pressure and increased intersegmental motion at neighboring spinal segments. This may result in radiographic degenerative changes in the adjacent spinal segments (adjacent segment degeneration) and symptoms requiring additional surgical intervention (adjacent segment disease). It has been estimated that the rate of adjacent segment disease (development of symptoms...

Discuss the relative value of different laboratory tests in the diagnosis of pyogenic vertebral infection

The ESR is elevated in more than 90 of patients with infection but is nonspecific and may be normal in the presence of low virulence organisms. CRP is typically elevated in pyogenic infections and is considered more specific than ESR. The leukocyte count is a less reliable indicator of spinal infection with elevation greater than 10,000 noted in less than half of cases. Blood cultures, although helpful if positive, yield the causative organism in only one quarter to one half of cases.

Discuss the role of physical agents in the treatment of spinal pain

Physical agents utilize physical forces (thermal, acoustic or radiant energy) to promote healing reduce pain, swelling, and inflammation or modulate muscle tone. These agents should not be used in isolation but rather as supplements to a therapy program. Heat and cold provide analgesia and muscle tone reduction in superficial structures. Ultrasound increases deep soft tissue extensibility, blood flow, and healing. Hydrotherapy uses agitated water to produce convective heating and massage....

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....

Does the presence of a nonunion after an attempted spinal fusion always cause symptoms

Although many patients who develop a nonunion report pain symptoms, this is not always the case. Fusion success does not always correlate with patient outcome. However, many studies support a strong positive correlation between successful arthrodesis and positive patient outcomes. 1. Graft options for spinal arthrodesis include autograft bone, allograft bone, synthetics, and bone morphogenetic protein (BMPs). 2. Successful posterior fusion is dependent on meticulous preparation of the graft...

E

80-20 rule of Harms, 214 Ejaculation, retrograde, 188 Elastic binder, 142, 142f Electrodes epidural, 243, 244f trial spinal cord stimulation, 245 Electrodiagnosis in spinal disorders, 128-133 anatomic basis of exam, 128-129, 129f components of exam, 128 of radiculopathy, 129, 130-131, 130t, 132-133 for sacral fractures, 399-400 Electromyography (EMG) burst, 222 described, 128 electrically elicited EMGs, 222 mechanically elicited EMGs, 222 monitoring during spinal procedures, 222 needle EMG...

Explain how to safely access the thoracic and lumbar spine with a Jamshidi needle to perform a vertebroplasty or

The most common approach utilized is the transpedicular approach. Anteroposterior (AP) and lateral fluoroscopy is mandatory, and use of two C-arms is ideal, to permit simultaneous AP and lateral views of the target vertebra. The level of the fracture is localized on the AP view. The skin is marked at the lateral border of the pedicle on the AP view. A small incision is made and the needle is advanced to contact bone at the 10 o'clock position on the left pedicle and 2 o'clock position on the...

Explain the basic steps involved in a laminectomy procedure performed to treat central spinal stenosis between L4 and S1

A skin incision is made between L3 and S1. The paraspinal muscles are elevated from the lamina between L3 and S1. The L4 and L5 spinous processes are resected. The pars interarticularis is identified at each level to ensure that bone removal does not compromise its integrity. The hypertrophic lamina of L4 and L5 are thinned with a motorized burr to facilitate removal with angled Kerrison rongeurs. Adhesions between the dural sac and surrounding tissue are released with a Penfield elevator....

Explain the difference between a facet joint injection and a medial branch block

A painful facet joint can be blocked by injecting into the joint itself or by blocking the nerves that supply the painful joint. The medial branch of the posterior primary ramus of the spinal nerve innervates the facet joint. The medial branch of the adjacent dorsal rami carries the nociceptive fibers supplying the facet joint. Because each facet joint is dually innervated by the medial branch above and below the joint, it can be blocked by injecting the medial branch above and below the joint....

Explain the difference between nonstructural and structural bone grafts

Bone grafts placed in the anterior spinal column may be classified as Nonstructural grafts (also termed morselized grafts) typically consist of particles of cancellous bone (e.g. from the iliac crest) placed into a defect in the anterior spinal column (e.g. after discectomy). This type of graft is intended to promote arthrodesis between adjacent vertebral bodies. The graft itself does not restore structural stability to the anterior spinal column. Use of adjunctive spinal instrumentation is...

Explain the principles involved in placement of percutaneous lumbar pedicle screws and rods

The percutaneous technique is dependent on ability to accurately visualize pedicle anatomy with fluoroscopy or surgical navigation technology. A Jamshidi needle is placed with its tip at the lateral border of the pedicle on a true anteroposterior (AP) view of the vertebra to be instrumented. The depth from the entry point of the needle into bone to the pedicle vertebral body junction is approximately 20 mm (Fig. 70-2A). Therefore, if at an insertion depth of 20 mm the tip of the needle remains...

Explain the rationale and evolution of growing rod surgical techniques

Harrington formulated the concept of instrumentation without fusion for children younger than 10 years. Moe and colleagues pioneered the technique utilizing a single Harrington rod placed subcutaneously through small incisions. Patients were immobilized in a brace and underwent periodic rod lengthenings until definitive fusion was indicated based on curve magnitude and patient age. The dual rod technique was introduced and popularized by Akbarnia to address problems encountered with use of a...

Explain the Weinstein tumor zone system

This zone system was developed to guide the selection of the most appropriate approach to the spine for excision and stabilization of primary bone tumors (Fig. 63-2). Four zones (I IV) are identified and tumor extension is denoted as Figure 63-2. Weinstein's zones. A, Axial view. Zone I is composed of the spinous process, inferior articular process, and the lamina. Zone II is composed of the superior articular process, pedicle, and transverse process. Zone III is the anterior column. Zone IV is...

Explain what is involved in a posterior spinal instrumentation and fusion procedure for adolescent idiopathic scoliosis

The posterior surgical approach is applicable to all idiopathic scoliosis curve types. During the surgical procedure the posterior spinal structures are exposed, the facet joints are excised, and graft material is packed into the facet joints and over the decorticated posterior spinal elements. Posterior spinal instrumentation is placed and utilized to realign and stabilize the spinal deformity. A typical instrumentation construct consists of two parallel rods attached to the spine at multiple...

Explain what is involved in an anterior spinal instrumentation and fusion procedure for adolescent idiopathic scoliosis

Anterior spinal instrumentation and fusion procedures (Fig. 39-7) are most commonly indicated for single thoracic, thoracolumbar, or lumbar curve types. The convex side of the curve is exposed. The thoracic spine is approached via an open thoracotomy or minimally invasive thoracoscopic approach. The disc, annulus, and cartilaginous vertebral endplates are excised over the levels undergoing fusion. The disc spaces are packed with nonstructural bone graft. Structural spacers are placed in the...

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...

F

Facet joint injection, 123, 123f, 124f Facet joints bilateral dislocation, 383, 383f closed reduction of dislocations, 383-384 lumbar, 27 as pain generator, 120 subaxial cervical, 13 unilateral dislocation, 382, 382f unilateral injuries, 381 Facial artery, 181 Facial nerve, marginal branch of, 180 Failed back surgery syndrome, 237 Fascia cervical, 17 dissection through pretracheal, 182 lumbar, 31-32 thoracic, 23 Feldenkrais method, 148 Femoral nerve stretch test, 43, 43f Fentanyl, transdermal,...

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...

Have MIS procedures been proven safer or more effective than traditional open spine procedures

Despite the fact that MIS procedures are performed through smaller skin incisions, the potential for serious and life-threatening complications is not eliminated. All spine procedures are maximally invasive because neural, visceral, and vascular structures remain at risk for serious injury. Claims that MIS procedures are more effective than traditional spine procedures remain unproven in the current medical literature. This may change in the future depending on technologic advances, surgeon...

How are graft materials classified

Autograft bone has been considered the gold reference standard for bone graft materials for spinal fusion. Alternative graft materials may be classified according to their intended use Extender This type of graft material is indicated for use in combination with autograft bone. The material permits use of a lesser volume of autograft without compromising fusion rates. Alternatively, the material may permit a finite amount of autograft to be utilized over a greater number of spinal segments...

How are indications for spinal surgery prioritized

Indications for spinal surgery are prioritized based on the physician's responsibility to prevent irreversible harm to the patient as a result of spinal pathology and the window of time within which surgical intervention is effective. Although there is no universally accepted classification, surgical indications can be separated into three broad categories 1. Emergent indications. Patients in this category are likely to experience a negative outcome if surgery is not performed emergently....

How are neuromuscular spinal deformities diagnosed

Diagnosis is based on clinical examination and confirmed with long cassette radiographs. Upright radiographs are obtained in patients who are able to stand. Patients who are able to sit without hand support are assessed in the sitting position. Patients who are unable to sit are evaluated with recumbent anteroposterior (AP) and lateral radiographs. The examiner should assess curve magnitude, curve progression, spinal balance, pelvic obliquity (if present), and curve flexibility. Spinal magnetic...

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 spinal orthoses classified

Orthoses have been described according to location of origin (e.g. Milwaukee brace, Charleston brace), inventor (e.g. Knight, Williams), or appearance (e.g. halo). The most universally accepted classification system describes spinal orthoses according to the region of the spine immobilized by the orthosis Cervical orthosis (CO) e.g. Philadelphia collar Cervicothoracic orthosis (CTO) e.g. SOMI brace Cervicothoracolumbosacral orthosis (CTLSO) e.g. Milwaukee brace Thoracolumbosacral orthosis...

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 can a pain clinic assist in the treatment of spinal disorders

The pain clinic provides an interdisciplinary program for patients with chronic spinal pain syndromes. The Commission on Accreditation of Rehabilitation Facilities (CARF) pain management guidelines require that the team include a physician, nurse, physical therapist, and psychologist or psychiatrist. Interdisciplinary chronic pain treatment uses the strength of specialists working together. The pain clinic is ideal for the following goals Providing medical management, physical therapy,...

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 I know whether I am looking at a T1 or T2weighted image

One method is to look at the TE (time to echo) and TR (time to repetition) numbers on the scan (Table 11-2). A simpler method is to recall the signal characteristics of water. Locate a fluid-containing structure (e.g. CSF surrounding the spinal cord). If the fluid is bright, the image is probably a T2-weighted image. If the fluid is dark, the image is probably a T1-weighted image. The above criteria refer to the most basic pulse sequence, spine echo (SE). In other pulse sequences, contrast...