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Surgical Resection of Sacral Tumors

Tumors involving the sacral spine are rare lesions that can lead to significant morbidity and mortality. Symptoms may be minimal during the early stages of disease, and the clinical evaluation of these lesions is often delayed. Thus, sacral tumors are often far advanced at the time of diagnosis. Clinical management is dictated by the tumor type, the location of the lesion, and the tumor’s relationship to…

Surgery for Metastatic Spine Disease

Approximately 500,000 deaths occur per year from complications of metastatic disease. It is estimated that among living cancer patients, 10% experience symptomatic secondary metastases, with the most common sites of distant metastases being the liver, lungs, and skeleton. Within the skeleton, the spinal column has the highest incidence of metastasis, with as many as 90% of cancer patients affected on autopsy studies. The most prevalent lesions…

Surgical Approaches to the Cervicothoracic Junction

Surgical treatment of spinal disorders at the cervicothoracic junction is challenging because of the complex anatomy and biomechanical properties of this region. Access to the cervicothoracic junction is complicated by important vascular, visceral, and soft-tissue structures, and knowledge of these structures and surgical landmarks is essential for decompression and stabilization. Cervicothoracic pathologies are relatively uncommon but include bacterial and tuberculous infections, fractures from primary bone disease,…

Management of Primary Malignant Tumors of the Osseous Spine

Acknowledgments The author thanks Carlo Piovani for his most valuable assistance for imaging and documentation. Primary tumors of the spine are exceedingly rare. Owing to their rarity, few surgeons had gained enough experience and insight into their management until the 1970s when B. Stener first applied oncologic criteria in resecting spine tumors, previously submitted only to intralesional excisions (curettage). Stener was the first to plan and…

Management of Cauda Equina Tumors

Epidemiology and Pathology Cauda equina tumors (CETs) represent a distinct entity of spinal cord neoplasms that arise from the cauda equina, with an estimated prevalence rate is 0.03 per 100,000 persons (in the age-adjusted 2000 US population). According to 2004–07 data from the Surveillance, Epidemiology and End Results (SEER) database, CETs account for 3.5% of all primary spinal canal tumors in the United States, with benign…

Management of Spinal Cord Tumors and Arteriovenous Malformations

Introduction Although spinal cord tumor and spinal cord arteriovenous malformation (AVM) operations may appear to be unrelated, they are, in fact, closely linked. Both tumors and AVMs are space-occupying lesions, present challenging technical scenarios, and require an understanding of their natural history to pursue the wisest course of treatment. Addressing the mass lesion while preserving blood supply to the spinal cord is a goal in treating…

Surgical Management of Intradural Extramedullary Tumors

Introduction Tumors arising from the intradural extramedullary (IDEM) spinal canal reflect a wide variety of histopathologies. With few exceptions, however, these tumors are histologically benign and amenable to complete surgical resection. Long-term tumor control or cure with preservation or improvement in neurologic function can be achieved with surgery alone for most patients. This chapter focuses on direct surgical techniques and strategies for these largely benign tumors.…

Surgical Management of Intramedullary Spinal Cord Tumors in Adults

Introduction The neurosurgical literature on intramedullary spinal cord tumors (IMSCTs) contains many case reports and few large series, even for the tumors of glial origin, which are the most numerous. Despite occurring at any age group, these lesions are rare entities only accounting for 2% to 4% of all central nervous system tumors and 15% of all primary intradural tumors in adults. Ependymomas are the most…

Adult Thoracic and Lumbar Deformity

Introduction Scoliosis broadly refers to an abnormal curvature of the spine. The term scoliosis is commonly used to describe disease in children or adolescents with congenital or idiopathic curvature; however, the nomenclature of “spinal deformity” now encompasses congenital, idiopathic, degenerative, syndromic, neuromuscular, traumatic, or iatrogenic curvature. Historically, scoliosis was defined as a coronal curvature greater than 10 degrees. However, over the past 20 years a more…

Cervical Spinal Deformity

Historical Perspective The study of cervical spine deformity has increased tremendously during the past decade as multiple studies have demonstrated the important role cervical spinal alignment plays in quality of life. Furthermore, the relationships between quality of life and sagittal imbalance and increased pain and disability that were established in thoracolumbar deformity literature have also been identified in patients with cervical spine deformities. , Thus, understanding…

Management of Degenerative Scoliosis

Scoliosis refers to an abnormal curvature of the spine due to developmental, degenerative, idiopathic, or iatrogenic changes of subaxial biomechanics in the coronal, sagittal, and axial planes. Over much of this past century, the term scoliosis has generally referred to young patients with congenital or idiopathic curves that occurred during childhood or adolescence. A more comprehensive term, known as spinal deformity , likely encompasses the breadth…

Neurologic Problems of the Spine in Achondroplasia

Achondroplasia (“without cartilage formation”) is the most common form of dwarfism in humans and is characterized by disproportionately short stature with rhizomelic shortening of the extremities, macrocephaly, midface hypoplasia, and frontal bossing. , This skeletal dysplasia results from defective formation of endochondral bone, and affects approximately 1 in 25,000 births worldwide. Morbidity in achondroplasia results largely from bony compression of the neuraxis and respiratory failure. ,…

Management of Occult Spinal Dysraphism in Adults

The tethered cord syndrome (TCS) results from relative fixation of, most commonly, the caudal spinal cord owing to one of multiple pathologic entities. This fixation prohibits normal physiologic motion, can cause focal ischemia, and, in adults, most often manifests with back pain or a neurologic insult. TCS is generally diagnosed and treated during childhood, because most etiologies are congenital. The emergence of symptoms during adulthood has,…

Management of Chiari Malformations and Syringomyelia

Acknowledgment The authors and editors wish to thank Dr. Edward H. Oldfield and Dr. John Heiss for their contributions to this chapter in the previous edition. Definition and History In 1891, Hans Chiari described three types of cerebellar malformations that were associated with hydrocephalus. , He added a fourth type 5 years later. , The type I Chiari malformation was described as herniation restricted to the…

Craniovertebral Abnormalities and Their Neurosurgical Management

Craniovertebral junction abnormalities can be developmental, genetic, or acquired in origin. , To effectively treat these disorders when they are symptomatic, the clinician must have a knowledge of the embryology and the functional anatomy of the area. A myriad of abnormal neurologic findings may be present that are secondary to compression or ischemia of neural tissue. The surgical management of these disorders depends on precise identification…

Management of Penetrating Injuries to the Spine

Penetrating spinal injuries (PSIs) encompass a range of traumatic etiologies, from nonmissile injuries such as knife wounds to high-velocity missile injuries such as rifle shots. Historically, most literature on the treatment of PSIs came from the battle fields. However, with the rise of violence throughout the world, the incidence of PSIs in the urban population continues to increase. Injuries sustained from the direct path of the…

Management of Sacral Fractures

The sacrum is integral to the biomechanical and neuroprotective roles of the spinal column and pelvic ring. Although injuries to the sacrum have historically been relatively overlooked within the realm of spine trauma, sacral fractures may result in deformity, chronic pain, and loss of lower extremity, bowel, bladder, and sexual function. Treatment of sacral fractures must therefore address the sacrum’s structural and neurologic roles and requires…

Thoracolumbar Anterolateral and Posterior Stabilization

Background The thoracic and lumbar regions are the most common anatomic sites for vertebral fractures. The thoracolumbar area is especially susceptible to trauma, accounting for 52% of all thoracic and lumbar fractures. The most common fracture types in the thoracolumbar region are the vertebral body compression fractures (AO types A1 and A2), followed by burst fractures (type A3), then translation–rotation injuries (types B and C). Associated…

Stabilization of the Subaxial Cervical Spine

The cervical spine is the most mobile portion of the spinal column, and its stabilization has unique features. Cervical spine stabilization may be performed using anterior, posterior, or combined techniques. Fusions by anterior approaches have been widely used in cervical spine injuries, allowing anterior decompression of the spinal column. Anterior fusion techniques were first introduced in 1955 by Smith and Robinson and then popularized by Cloward.…

Atlantoaxial Instability and Stabilization

The atlantoaxial junction is a delicate anatomic complex that involves an intricate relationship between the atlas and the axis to allow flexion, extension, rotation, and lateral bending. The interrelation of osseous, ligamentous, neural elements, and articulations make the atlantoaxial junction vulnerable to instability and potentially devastating neurologic complications. A myriad of surgical treatment options exist, ranging from fixation with and without dorsal surgical fusion and/or internal…