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Iatrogenic Spinal Instability: Causes, Evaluation, Treatment, and Prevention

Introduction Instability in the lumbar spine is a well-recognized entity for both degenerative and traumatic processes. Less well defined is instability following an index decompressive or fusion procedure. This complex issue can exist as iatrogenic destabilization at either the same or adjacent level or could even be unrecognized preoperative instability in the setting of a patient who does not show improvement after their index procedure. During…

Pseudarthrosis/Nonunion

Introduction Degenerative disease of the lumbar spine is a common cause of disability and pain, with lumbar spondylolisthesis affecting 11.5% of the US population and lumbar stenosis affecting more than 200,000 adults in the United States. Spinal fusion surgery is indicated in select patients who have failed conservative medical management of symptomatic degenerative disease of the lumbar spine. The ultimate goal of surgery is to relieve…

Adjacent Segment Disease After Fusion

Definitions Adjacent segment disease (ASD) has been broadly and inconsistently defined in the literature. Other terms that have been used to describe ASD include junctional disease, junctional stenosis, or a transitional lesion. ASD has been applied to a plethora of radiographic findings suggestive of degeneration in a motion segment immediately adjacent to a spinal fusion construct with or without symptoms. Although the many symptoms included in…

Postoperative Considerations

Introduction Revision lumbar spine surgery comes with unique challenges and special considerations in the postoperative setting. In this chapter, we will cover some topics pertinent to postoperative care. Specifically, we will cover drains, antibiotic prophylaxis, venous thromboembolic prophylaxis, bracing, and physical therapy. Postoperative Drains Current literature does not strongly recommend for or against the use of postoperative drains following lumbar surgery. In particular, limited literature exists…

Revision Lumbar Deformity Surgery

Introduction The term “adult spinal deformity” generally refers to any major coronal, sagittal, or biplane malalignment of the spine in a patient over the age of 18. The revision rate for primary adult deformity surgery patients is approximately 9% to 25%. Moreover, the revision rate following a revision adult spinal deformity procedure has been shown to be as high as 21%. Despite improvements in technology, including…

Vertebral Column Resection

Introduction Vertebral column resection (VCR) is a challenging and lengthy procedure that is generally used as a last resort for the correction of severe rigid spinal deformities. Given VCR’s unique ability to translate the spinal column and provide truncal balance, the procedure is particularly well-suited for use in the thoracolumbar spine. VCR was originally described by MacLennan in 1922, and then more recently by Bradford in…

Pedicle Subtraction Osteotomy

Introduction Lumbar pedicle subtraction osteotomy (PSO) was first described by Thomasen in 1985 for the surgical treatment of 11 patients with severe disabling kyphosis secondary to ankylosing spondylitis. In this series, Thomasen performed posterior bony wedge resection (i.e., removal of the spinous process, neural arch, and posterior part of the index vertebral body) and subsequent osteotomy closure at the L2 vertebra to achieve the desired kyphosis…

Robotics for Revision Spine Surgery

Introduction Despite advances in our understanding of spinal pathologies, diagnostics, implant designs, and biological adjuncts, there is a significantly sized cohort of patients who fail to achieve resolution of pain following surgery or have recurrent symptoms after surgery. Revision spine surgery tends to have diminished odds for success that continues to decline with each additional surgery. These patients also present technical challenges for the spine surgeon…

Unilateral Versus Bilateral Strut Placement in Revision Spine Surgery

Introduction The concept of creating a fusion between two vertebral bodies as a solution to pain arising from lumbar spinal segments dates back to the 1930s when the first anterior lumbar interbody fusion (ALIF) was performed, using an autogenous tibial peg for the graft. The presumed mechanism involves both removing potentially pain-generating disc tissue and stabilizing the involved spine segments. In the 1940s, a posterior approach…

Anterior-Posterior Surgeries

Introduction There are many factors to consider in determining if a staged anterior-posterior (AP) lumbar procedure is the most appropriate for a given patient. These include the patient’s presenting symptoms (i.e., discogenic back pain, radiculopathy, myelopathy), bone quality, age, performance status, global alignment, coronal deformity, sagittal deformity, location, number of levels of the underlying pathology, and surgeon preference. The benefits of anterior column release, curve flexibility,…

Lateral Lumbar Interbody Fusion

Introduction An exponential rise in rates of spinal surgery over the past decade has been dominated by a concomitant increase in the utilization of intervertebral cages for spinal fusion. The modernized minimally invasive retroperitoneal transpsoas approach for lateral lumbar interbody fusion (LLIF) has congruently achieved growing surgeon adoption since it was initially reported by Ozgur et al. in 2006. Proponents of the lateral approach assert that…

Revision Transforaminal Lumbar Interbody Fusion

Introduction Degenerative disease of the lumbar spine has increased with the aging population and the number of elective lumbar spinal surgeries has also increased. Concurrently, the number of revision lumbar spinal surgeries has also increased as patients experience recurrence of symptoms or develop adjacent segment disease after their initial surgery. The transforaminal lumbar interbody fusion (TLIF) was developed as a technique to obtain an interbody fusion…

Anterior Lumbar Fusion

Introduction In 1969 and 1971, Coventry and Stauffer provided the first descriptions of anterior fusion for the treatment of failed posterior spine surgery, reporting overall good results. Since then, anterior lumbar interbody fusion (ALIF) has been used to treat a variety of pathologies, but controversy remains about the merits of ALIF compared with other approaches for interbody fusions, such as posterior (PLIF), transforaminal (TLIF), and lateral…

Minimally Invasive Surgery and Navigation

Introduction Revision surgeries are more common than ever in the spine surgeon’s practice. Each case is unique, and the diagnostic and treatment considerations are more complicated than their primary counterparts. In general, revision surgeries involve greater morbidity than primary surgeries, and depending on the indications, it may be more difficult to attain as good or better clinical outcomes. Accordingly, the decision to proceed with further surgery…

Autograft/Allograft/Cage/Bone Morphogenetic Protein

The Use of Autograft and Allograft in Revision Lumbar Spine Surgery One of the major contributors to a solid spinal arthrodesis is the use of bone grafts. In selecting the appropriate graft, there are three properties that receive consideration: osteoinductivity, osteoconductivity, and osteogenicity. Osteoinductivity describes the ability of the graft to stimulate migration of bone cell precursors that differentiate into osteoblasts and osteoclasts to lay down…

Disc Herniation (Primary, Recurrent, Residual)

Introduction Lumbar intervertebral discs are complex structures subjected to significant axial compressive forces. Because of biomechanical demands and the inability to remodel as a result of an avascular nature, lumbar disc herniation (LDH) is a relatively common cause of back pain and/or leg pain. The clinical course of LDH is often favorable and many patients improve with conservative treatment. Yet LDH can induce significant radicular symptoms…

Decompression

Introduction Lumbar spine disorders and the disabling pain associated with these conditions are associated with significant healthcare resource use and costs in the United States. Of these patients, an estimated 3% with back pain will require surgical intervention. Spine surgery in this patient population continues to be more prevalent, accelerated by the increasing number of aging patients. These patients are afflicted by a range of degenerative…

Dural Scarring and Repair Issues

Background A vast majority (up to 80%) of the US population are estimated to experience an episode of low back pain (LBP) during their lifetime. A subset of these individuals will go on to develop chronic LBP, which can limit their ability to perform activities of daily living (ADLs) and frequently, may hinder the ability to maintain gainful employment. This imposes a significant economic burden on…

Imaging Considerations (Magnetic Resonance, Computed Tomography, Myelography, Plain)

Introduction Regardless of the presence of lumbar instrumentation, recurrent symptoms after a lumbar decompressive surgery are not uncommon; for example, after undergoing microlumbar discectomy up to 12% of patients may have a recurrent disc herniation within the first year. The incidence of continued or new pain after lumbar fusion may be as high as 30%. Further, the incidence of repeat lumbar surgery following decompression alone ranges…