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Rehabilitation and Recovery After Spinal Cord Injury

Summary of Key Points Severely disabled persons with spinal cord injury (SCI) who will require assistance from others to complete activities of daily living must learn adaptive and interpersonal strategies to obtain needed care. Early consultation with physical medicine and rehabilitation or SCI subspecialties when available is vital to initiate physician–patient relationships and patient education and to ensure appropriate referral to SCI-specific therapies and medical equipment.…

Surgical Approaches for Sacral Fractures and Sacropelvic Injuries

Summary of Key Points The ligamentous and musculotendinous connections of the lumbosacropelvic region are normally robust, and impart stability to the pelvic ring; because of this, injuries to this region are relatively uncommon and are usually associated with significant forces and/or weakened structures. A high index of suspicion is required, as these injuries are commonly overlooked in polytrauma patients. Multiple classification systems exist and can be…

Surgical Approaches to Thoracolumbar Trauma

Summary of Key Points At the thoracolumbar spine, a long and stiff kyphotic thoracic spine converts abruptly into a mobile lordotic lumbar spine, and this transition zone is susceptible to injury. All suspected spine trauma patients should be immobilized from the place of injury until a thorough and detailed evaluation can be performed. The instantaneous axis of rotation is located in the ventral vertebral body in…

Posterior Surgery for Cervical Trauma

Summary of Key Points Cervical spine trauma is common and often amenable to a posterior approach for surgical fixation. The role of surgical decompression and stabilization of the spine is determined by neural compression and stability of the spine. When determining need for surgical fixation versus nonoperative management of cervical spine injuries, it is important to consider if there is bony involvement, as a fractured bone…

Anterior Surgery for Cervical Trauma

Summary of Key Points Outcomes of cervical trauma can range from minor disability to total loss of function or life, and early management may have a major impact on clinical outcomes. Adherence to advanced trauma life support protocols, including proper spinal precautions, is imperative in preventing further damage after injury. Minor or structurally stable cervical injuries can generally be treated with spinal immobilization with a collar…

Medical Management of Fractures Without Spinal Cord Injury

Summary of Key Points All patients with injuries to the spinal column will require appropriate nonoperative management during their care. The majority of spine fractures can be managed nonoperatively with excellent long-term results. Those that require surgical treatment must be initially managed with appropriate, meticulous nonoperative techniques. The integrity of the posterior ligamentous complex can be key to deciding on operative vs. nonoperative care in the…

Spinal Traction

Summary of Key Points Spinal traction is an important treatment adjunct for cervical fractures, dislocations, destabilizing conditions, and deformity. Methods of spinal traction include head halter traction, Gardner–Wells tongs, and cranial halos. The most common indication for weighted traction is the treatment of cervical facet dislocation. When applying traction to a patient with a cervical injury, the patient must be followed with serial clinical examinations and…

Medical Management of Adult and Pediatric Spinal Cord Injury

Summary of Key Points Pediatric spinal cord injury (SCI) is rare and requires a review of the principles of medical management. The goals of pediatric SCI management are to optimize neurological recovery, minimize medical complications, initiate early mobilization, and facilitate rehabilitation. Methylprednisolone is not appropriate for pediatric SCI. Every organ system can be affected by SCI, thus requiring a multidisciplinary approach to treatment. The most common…

Timing of Surgery Following Traumatic Spinal Cord Injury

Summary of Key Points Although there is significant preclinical research supporting early surgery for traumatic spinal cord injury (tSCI), the timing of surgery remains a controversial topic among spine surgeons. The evidence supporting early surgery consists primarily of retrospective studies and case reviews, but is lacking in randomized controlled trials and high-quality prospective cohort studies. Large, prospective, multicentered spinal cord injury studies are needed to elucidate…

The Acute Management of Traumatic Spinal Cord Injury and Polytrauma

Summary of Key Points Avoiding hypotension after spinal cord injury (SCI) is a key pillar of modern SCI management. The concept of a complete SCI is outdated: no intervention (including surgery) should be delayed in the acute setting as a result of the clinical examination indicating a complete injury. A true complete injury is not possible to determine acutely after SCI, and thus should not be…

Radiosurgery for Spinal Tumors

Summary of Key Points Radiosurgery is safe and effective, with durable symptomatic response and local control for even radioresistant histologies, regardless of prior fractionated radiotherapy. The ability to deliver cytotoxic doses to the tumor while sparing normal tissue offers a better chance at significant palliation and durable tumor control for patients with spine tumors. Spine radiosurgery appears to provide better local tumor control than conventional radiation…

Sacral Tumors: Regional Challenges

Summary of Key Points Percutaneous computed tomography–guided biopsy should be performed in patients when diagnosis may influence the decision to proceed with surgery or the extent of surgery. It is critical that wide negative margins are obtained in tumor resection. Adjuvant therapy with proton beam or intensity-modulated radiation therapy is used for contaminated margins or incomplete resections. Optimal wound closure is critical, and the surgical team…

Thoracic and Thoracolumbar Spinal Tumors: Regional Challenges

Summary of Key Points Primary spinal tumors in the thoracic and lumbar region are uncommon, but they represent tumors that may have the potential for a cure. Metastatic tumors in this region, however, represent an advanced stage of primary cancer. Medical and adjunctive treatments have improved the quality of life and lengthened the survival of cancer patients. It is important for spine surgeons to collaborate closely…

Cervicothoracic Junction Tumors

Summary of Key Points The cervicothoracic junction (CTJ) is subject to unique biomechanical stresses because it is the transitional zone between the cervical and thoracic spine, and lesions in this area can lead to progressive instability, resulting in kyphosis and cord compression. Up to 80% of patients with CTJ tumors present with neurological symptoms caused by the narrow spinal canal size and tenuous blood supply to…

Tumors at the Foramen Magnum and Craniocervical Junction

Summary of Key Points A wide array of benign and malignant tumors can arise in the region of the foramen magnum and craniocervical junction. These can be intradural or extradural tumors. The most common symptoms of foramen magnum tumors are suboccipital or neck pain, dysesthesias of the extremities (more frequent in the upper than in the lower extremities), gait disturbance, and weakness (more frequent in the…

Staging, Classification, and Oncological Approaches for Metastatic Tumors Involving the Spine

Summary of Key Points The NOMS framework consists of four considerations (neurological, oncological, mechanical, and systemic) and facilitates decision making for patients with metastatic spine tumors. Conventional external beam radiation provides local tumor control in patients with radiosensitive tumors, whereas stereotactic radiosurgery (SRS) provides durable local control irrespective of tumor histology. The Spinal Instability Neoplastic Score facilitates diagnosis of mechanical instability of the spine in patients…

Oncological Approaches, and Outcomes for Primary Spine Tumors

Summary of Key Points Establishing histopathological diagnosis is critical to understanding the natural history, aggressiveness, and likelihood of the tumor to respond to chemotherapy, radiation, or other adjuvant treatments. Once accurate diagnosis is established, surgical planning requires knowledge of the oncological and surgical grade. When performing en bloc spondylectomy, there are anatomical challenges at different levels. En bloc resection results in lower local recurrence rate and…

Failed Back Surgery Syndrome

Summary of Key Points Failed back surgery syndrome is an evolving diagnosis characterized by chronic pain after surgical intervention. Pathophysiology is varied, but is based on abnormal pain signaling from damaged or dysfunctional nerves. Involvement of the limbic system in chronic pain can exacerbate the pain percept independently, as well as yield other comorbid psychological disorders. Core components of diagnosis include history, physical exam, imaging, neuropsychological…

Deformity Surgery for Ankylosing Spondylitis

Summary of Key Points Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease characterized by inflammatory back pain and potential progression to disability and deformity. Clinical characteristics of inflammatory back pain can be distinguished from other causes of chronic back pain. It is important to be aware of the bony disease complications of AS, such as early osteoporosis and occult fractures, in assessing and managing patients.…

Surgical Management of High-Grade Dysplastic Spondylolisthesis

Summary of Key Points Dysplastic spondylolisthesis is a developmental disorder of the spine that is associated with significant pain and disability. Sacropelvic and spinopelvic balance are important determinants of the impact of spondylolisthesis on health status. Reduction of high-grade dysplastic spondylolisthesis is most useful in patients with sacropelvic and spinopelvic imbalance. Surgical techniques for reduction of high-grade dysplastic spondylolisthesis include posterior-only or combined anterior and posterior…