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Transoral Approaches to the Cervical Spine

Introduction Multiple anterior approaches to the craniocervical junction have been described to allow exposure to the midline and lateral aspects of both the cranial base and upper cervical spine. The transoral-transpharyngeal approach, a technique well known to many spine surgeons, provides surgical access to the anterior clivus, C1, and C2. Transoral approaches provide the fundamental techniques upon which the more extensive approaches are based. Although it…

Management of Injuries of the Cervical Spine and Spinal Cord

Epidemiology The most recent demographic update provided by the National Spinal Cord Injury Statistical Center in 2016 estimates that there are approximately 17,000 new cases of spinal cord injury (SCI) every year. Motor vehicle accidents are the cause of nearly 40% of cases, and almost 70% of cases are incomplete injuries. The societal cost is immense: mean hospital stay is 11 days from the time of…

Vertebroplasty and Kyphoplasty

Vertebroplasty and kyphoplasty are minimally invasive, percutaneous procedures in which a fast-setting polymer is injected into a pathologic vertebral body with the goal of relieving pain or disability. These treatments have been applied to painful osteoporotic compression fractures, painful neoplasms, and structurally compromised vertebrae. They represent an evolving set of technologies for treating a common and important problem with limited medical and open surgical treatments. Before…

Lateral Transpsoas and Anteropsoas Interbody Fusion Indications and Techniques

Stabilization and arthrodesis of the lumbar spine may be achieved through a variety of surgical approaches. Traditionally, direct anterior or posterior surgical approaches have been employed that take advantage of natural tissue planes and midline orientation. However, today’s surgeons have the option of additional approaches, specifically the lateral transpsoas interbody fusion (LTIF) and lateral anteropsoas interbody fusion (LAIF) techniques. A lateral approach to the lumbar spine…

Anterior Lumbar Interbody Fusion: Indications and Techniques

Overview Anterior approaches to the lumbar spine have been utilized to treat lumbar degenerative disc disease for over a century. The approach evolved from a transperitoneal approach to using a retroperitoneal surgical corridor. , The retroperitoneal approach became a favored approach, given the higher complications associated with direct manipulation of intra-abdominal contents when using the transperitoneal approach. An anterior lumbar interbody fusion (ALIF) provides a robust…

Minimally Invasive Transforaminal Lumbar Interbody Fusion

Introduction Traditional transforaminal lumbar interbody fusion (TLIF) is performed through a large midline open incision on the back. With this approach the surgeon must dissect and retract the paraspinal musculature in order to access the target level This can lead to significant intraoperative blood loss, postoperative pain, muscle impairment, and longer hospital stays. With the integration of minimally invasive surgical techniques to the field of spine…

Transforaminal Lumbar Interbody Fusion: Indications and Techniques

Lumbar fusion is an accepted treatment for spinal deformity, degenerative instability, and iatrogenic instability following decompressive procedures. Lumbar interbody fusion yields certain advantages over posterolateral fusion alone, particularly because of higher rates of fusion. Segmental motion still exists with posterolateral fusion alone, but this motion is significantly reduced with fusion techniques through the intervertebral disc space. , Biomechanically, the disc contributes significantly to anterior column stability,…

Posterior Lumbar Interbody Fusion

The first successful report of a posterior lumbar interbody fusion (PLIF) dates to 1940 when Cloward performed this operation using a shaped spinous process autograft. Since Cloward’s original report, many surgeons have modified this technique using various grafts, implants, and cages. The application of pedicle screws to augment arthrodesis , and minimally invasive spine (MIS) percutaneous techniques have refined the PLIF procedure. In recent years, expandable…

Dynamic Stabilization of the Lumbar Spine: Indications and Techniques

Fusion remains the standard method of controlling pain from lumbar spinal instability and is commonly performed in conjunction with decompression procedures. However, unintended consequences of otherwise successful lumbar fusion procedures may occur, including transfer of forces to adjacent segments, possibly resulting in expedited lumbar spondylosis, stenosis, and further instability at adjacent segments and potentially requiring reoperation. Less invasive surgical fusion techniques may reduce associated surgical trauma…

Percutaneous Placement of Lumbar Pedicle Screws: Indications and Techniques

Introduction The use of pedicle screws for spinal stabilization has become increasingly popular worldwide since their introduction in the 1970s by Roy-Camille, largely replacing spinal hook and laminar wire systems. Pedicle screw systems engage all three columns of the spine and can resist motion in all planes. Pedicle screw fixation is a safe and effective treatment for many spinal disorders. , Open techniques for pedicle screw…

Posterior Lumbar Fusion by Open Technique: Indications and Techniques

Introduction Successful fusion is known as arthrodesis; nonunion is referred to as pseudoarthrosis. The goal of arthrodesis is to produce a solid fusion mass connecting one vertebra to another. The first fusion was described in 1911 by two independent surgeons, both of whom were treating patients with spinal instability that resulted from tuberculosis, using different sources of bone graft: Albee used a tibial graft and Hibbs…

Management of Degenerative Lumbar Stenosis and Spondylolisthesis

Lumbar Spinal Stenosis The surgical management of lumbar spinal stenosis and degenerative spondylolisthesis is critically shaped by whether a spinal arthrodesis (instrumented or noninstrumented) is performed along with the decompressive procedure. Although the conditions under which these choices are made have not been fully and absolutely defined, the literature provides positive guidelines once the disorders are definitively diagnosed. Differentiation of these conditions is therefore a first…

Lumbar Spinal Arthroplasty: Clinical Experiences of Motion Preservation

Lumbar spinal arthroplasty was first reported in clinical settings in 1994 by Griffith and colleagues. This early experience was acquired with the first lumbar artificial disc, the Charité I, in patients with degenerative disc disease (DDD). Since that time, a randomized, controlled trial comparing arthroplasty with the Charité III Artificial Disc versus anterior lumbar interbody fusion (ALIF) with the Bagby and Kuslich (BAK) titanium Cage (BAK;…

Management of Far Lateral Lumbar Disc Herniations

Far lateral disc (FLD) herniations account for between 6.5% and 12% of lumbar disc herniations. Operative resection techniques include minimally invasive procedures or microendoscopic alternatives, laminotomy, hemilaminectomy, and laminectomy with or without fusion ( Figs. 147.1 to 147.9 ). The latter alternatives require differing degrees of facet resection depending on the location and complexity of the FLD and the accompanying degree and extent of spondylosis and stenosis.…

Minimally Invasive Lumbar Discectomy: Indications and Techniques

Introduction The first accurate clinicopathologic descriptions of lumbar disc herniation, by Dandy and Mixter and by Barr, date as far back as 1929 and 1934, respectively. , The technique for open discectomy as practiced today is a modification of the technique described by Love in 1938. , The current “gold standard” for surgical intervention, microdiscectomy (MD), involving the use of the operative microscope to optimize visualization…

Lumbar Microdiscectomy: Indications and Techniques

Introduction Sciatica and back pain are two of the most common reasons for referral to spine specialists and are a leading cause of physical disability in the United States. Sciatica is characterized by radiating pain in an area of the leg typically served by one nerve root in the lumbar or sacral spine, often associated with sensory and motor deficits, and commonly caused by a herniated…

Anterior and Lateral Approaches for Thoracic Discectomy: Endoscopic and Mini-Open Techniques

Introduction Thoracic disc herniation (HTD) was first described by Key in 1838 and has since proven to be challenging to both diagnose and treat properly. The surgical management of HTDs has evolved over the past 50 years. Symptomatic HTD is a disease of middle to late adult life and is often not the result of a traumatic event. , HTDs occur in approximately 12% to 37%…

Posterior and Posterior Lateral Techniques for Thoracic Disc Herniations

Acknowledgments We thank Mr. James Postier, who is a medical illustrator at Mayo Clinic in Rochester, Minnesota and created the illustrations used in this chapter. Background Thoracic disc herniation (TDH) is a rare form of degenerative intervertebral disc disease, making up approximately 1% of all disc herniations. Although autopsy studies find an incidence rate ranging from 7% to 15%, symptomatic disease is still rare compared to…

Video-Assisted Thoracoscopic Discectomy: Indications and Techniques

History Thoracic Disc Disease The surgical management of disorders of the thoracic spine began in 1814 when H. J. Cline attempted to treat a fracture of the thoracic spine by laminectomy. In 1911, Middleton and Teacher attempted the first surgical procedure for a thoracic disc herniation, which was later described by Benjamin. In this case the patient was paraplegic and subsequently died. Historically, the diagnosis of…

Surgical Techniques in the Management of Thoracic Disc Herniations

The management of thoracic disc herniations presents a paradox to the casual observer. One of the most accepted features of thoracic disc disease is its infrequency in comparison with the more common cervical and lumbar disc herniations. Given such a low incidence, one might assume that only a limited number of operative procedures are available to treat the condition. Yet for such a “rare” entity, a…