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Minimally Invasive Approaches to Spinal Deformity

Summary of Key Points The minimally invasive spinal deformity 2 algorithm guides patient selection for a minimally invasive surgery (MIS) procedure or an open deformity correction operation. Meticulous preoperative assessment of the patient’s spinopelvic parameters and the amount of correction needed to address the patient’s pathology is required to select the appropriate MIS operation for a given patient. Three-dimensional image navigation and robotics are useful adjuncts…

Posterior-Based Management of Spinal Deformity

Summary of Key Points Rigid deformities require an osteotomy to rebalance the spine. Mild sagittal plane deformity with mobile discs can be treated with posterior column osteotomies. Severe, rigid sagittal and coronal plane deformities require three-column osteotomies to restore spinal balance. Pedicle subtraction osteotomies can provide 25 to 35 degrees of sagittal correction. Vertebral column resections are reserved for the most severe deformities. Intraoperative neuromonitoring is…

Anterior Column Release in Deformity

Summary of Key Points The amount of lordosis gained from the anterior column release (ACR) procedure depends on the extent of bony removal, with the addition of the posterior column osteotomies allowing for placement of hyperlordotic grafts with maximal end plate–to-cage apposition. Preoperative measurement of sagittal parameters, intended lordotic goals, and anticipated correction, combined with intraoperative intradiscal angle assessment, allows the surgeon to avoid under- or…

The Role of Anterior Surgery for Thoracolumbar Deformity

Summary of Key Points There is significant variability in the surgical approaches to adult deformity. Advantages of anterior surgery include mobilization of the spine circumferentially, restoration of physiological lordosis, implementation of indirect decompression, and enhancement of fusion rates and loading of interbody grafts. Disadvantages of anterior surgery include morbidity of the anterior approach and staging of surgery. Specific cases examples for anterior surgery are postlaminectomy deformity,…

Cervical and Cervicothoracic Deformity Correction: Posterior-Based Osteotomies

Summary of Key Points Moderate to severe adult cervical deformity has a significant impact on disability and quality of life. Surgical correction of cervical spine deformities can be technically challenging, especially for rigid cases. Correction of adult cervical deformity improves quality of life and can be effectively and safely performed with careful surgical planning and experience. Corrective surgical strategies should consider a variety of factors related…

Cervicothoracic Deformity: The Role of Anterior Surgery

Summary of Key Points Surgical correction of deformity in the cervicothoracic junction (CTJ) can be challenging; anterior approaches, in particular, are complicated by the complex anatomy of this region. Anterior approaches to the CTJ require careful clinical and radiographic evaluation, as well as familiarity with the different options for anterior access to this region. Anterior approaches to the CTJ offer superior visualization of the ventral vertebral…

An Approach for Treatment of Complex Pediatric Spinal Deformity

Summary of Key Points Pediatric spinal deformity can be a complex condition involving and affecting other physiological systems along with the spine. Obtaining a thorough prenatal and perinatal history, performing a detailed examination, assessing for other associated conditions, and assessing pulmonary function are important for the diagnosis of, treatment planning for, and prognosis of pediatric spinal deformity. Skeletal maturity may be predicted with greater accuracy by…

An Approach for Treatment of Complex Adult Spinal Deformity

Summary of Key Points Decision-making in complex spinal problems can be made easier by a systematic approach to the problems. “Problem, Goals, Tools, Plan” is one way to approach the problems. The primary driver of a good clinical outcome in deformity surgery is a stable spine in neutral sagittal balance. Pelvic parameters, in particular pelvic incidence, determine lumbar lordosis. Numerous operative techniques are available, and each…

Surgical Principles for Spinal Deformity

Summary of Key Points Spinal deformity has many different causes and affects patients of all ages. Depending on the patient’s symptomatology and magnitude of deformity, surgical intervention may be necessary. Iatrogenic spinal deformities, such as lumbar flatback syndrome and proximal junctional kyphosis, are increasingly common causes of adult spinal deformity. Preoperative patient selection and identification and reduction of risk factors for perioperative complications are paramount before…

Sacroiliac Joint Pain

Summary of Key Points The sacroiliac (SI) joint is responsible for symptoms in up to 30% of patients presenting with lower back pain. SI joint pain symptoms include low back, buttock, and radiating lower extremity pain and can be easily mistaken for lumbar spine or hip pathology. SI joint pain lacks pathognomonic clinical examination findings or radiographic hallmarks. SI joint pathology cannot be ruled out by…

Degenerative Spondylolisthesis

Summary of Key Points Randomized controlled trial evidence supports the use of surgical treatment of degenerative lumbar spondylolisthesis. There are a variety of surgical approaches for treating these patients. Lumbar fusion is associated with more complications and greater cost when compared with decompression alone as the surgical strategy. Although lumbar fusion is often performed, recent evidence suggests that fusion may not be necessary in all cases.…

Thoracic Discectomy

Summary of Key Points Symptomatic thoracic disc herniation is rare and may have a wide variety of symptoms, which delays diagnosis. The relative surgical inexperience of surgeons and the complex unique anatomy of the thoracic spine has hampered the development of a universally accepted gold standard. The choice of thoracic discectomy technique is mostly based on the location and characteristics of the hernia, the clinical presentation,…

Lumbar Intervertebral Disc Herniation

Summary of Key Points Lumbar disc herniation is a common cause of back pain with sciatica. Although most cases improve with conservative management, many other cases require surgical decompression, specifically microdiscectomy. Recurrent lumbar disc herniations following microdiscectomy are not uncommon, occurring at a rate of 2% to 25%. The clinical presentation in a patient with a recurrent disc herniation typically includes a period of clinical improvement…

Cervical Disc Herniation

Summary of Key Points Cervical disc herniation is a common cause of neck pain, radiculopathy, and cervical myelopathy. Risk factors include male gender, increasing age, white race, cigarette smoking, heavy lifting, and occupation. Disc herniations results from traumatic, overuse, or age-related weakening of the annulus fibrosus and subsequent herniation of the nucleus pulposus through the injured annulus. This can cause compression of the posteriorly based neural…

Indications for Spine Fusion for Axial Pain

Summary of Key Points Axial low back pain is a common clinical problem with a significant healthcare impact. The pathophysiology and underlying etiology of axial low back pain remain poorly defined. The diagnosis of axial low back pain is largely based on clinical symptoms in combination with various findings on imaging studies. Lumbar fusion surgery has been shown to improve pain and disability in select patients…

Spinal Augmentation for Vertebral Compression Fractures

Summary of Key Points The percutaneous vertebral augmentation procedures vertebroplasty and kyphoplasty are indicated for painful vertebral compression fractures refractory to conservative medical management. Vertebroplasty involves injection of the bone cement, polymethylmethacrylate (PMMA), into a fractured vertebral body, typically using a transpedicular approach. Kyphoplasty is the addition of inflatable bone tamps to a vertebroplasty procedure allowing for cavity creation before PMMA injection. Extravasation of cement (PMMA),…

Complex Lumbosacropelvic Fixation Techniques

Summary of Key Points Diseases of the sacrum and lumbosacral junction lead to clinically complex problems for surgical treatment and biomechanical stabilization. The lumbosacral pivot point, the axis of rotation at the lumbosacral junction, is marked by the intersection of the middle osteoligamentous column and the lumbosacral (L5‒S1) disc. In constructs that cross the sacroiliac joint, only those devices that pass ventral to the lumbosacral pivot…

Anterior and Anterolateral Lumbar Spine Decompression and Fusion: Minimally Invasive Surgery Approaches

Summary of Key Points Patient positioning is paramount for a successful procedure. Triggered directional electromyography findings should guide retractor placement anterior to the femoral nerve for the transpsoas approach. Open (expanded) retractor time should be minimized as much as possible during transpsoas surgery to minimize ischemia to the surrounding muscles and nerves. Preoperative evaluation of vascular structures on magnetic resonance imaging can potentially avoid catastrophic complications.…

Anterior Lumbar Interbody Fusion

Summary of Key Points Anterior lumbar interbody fusion (ALIF) provides a biomechanically sound structural intervertebral arthrodesis with a large fusion surface area. ALIF may indirectly decompress the exiting nerve roots by increasing the neural foraminal height. ALIF allows for improved sagittal plane alignment with restoration and/or improvement of lumbar lordosis. Clinical success rates may be lessened with each additional fused level. The most common complication is…

Posterior Approaches to the Lumbar Spine: Minimally Invasive Fusion

Summary of Key Points Minimally invasive fusion options have been shown to have similar complication rates compared with their open counterparts while providing similar or improved clinical outcomes, such as decreased postoperative pain, operative times, length of hospitalization, and blood loss. Midline lumbar interbody fusion utilizing cortical screw placement is a reasonable alternative to more traditional minimally invasive interbody fusion techniques. Fully endoscopic transforaminal lumbar interbody…