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Endoscopic Surgical Approaches to the Lumbar Spine

Summary of Key Points Endoscopic surgery of the lumbar spine is an advanced form of minimally invasive surgery that is gaining worldwide popularity. Several studies have shown endoscopic surgery of the lumbar spine to be just as effective as and have enhanced postoperative recovery compared with conventional minimally invasive surgery. With technological advancements, endoscopic spine surgery has evolved, and its clinical indications range from microdiscectomy in…

Endoscopic Approaches to the Cervical Spine

Summary of Key Points Fully endoscopic surgical approaches to the cervical spine include anterior and posterior approaches. Anterior endoscopic cervical spine surgery approaches include anterior cervical discectomy and anterior transcorporal discectomy. Posterior endoscopic cervical spine surgery approaches include posterior cervical unilateral laminectomy and bilateral decompression and posterior cervical foraminotomy. Working-channel endoscopes for endoscopic cervical spine surgery vary in diameter and length. Cervical disc herniation is common…

Posterior Approaches to the Lumbar Spine: Minimally Invasive Decompression

Summary of Key Points The fundamentals of minimally invasive surgery (MIS) techniques involve minimal muscle dissection and soft tissue trauma, and avoidance of detachment of the osteoligamentous structures, which may help preserve stabilizing structures; while reducing operative time, blood loss, and hospitalization times and improving clinical outcomes. MIS posterior lumbar techniques include the MIS foraminotomy, MIS discectomy, and MIS laminectomy. The MIS laminectomy is the most…

Minimally Invasive Spinal Decompression and Stabilization Techniques I: Philosophy and Rationale

Summary of Key Points Minimally invasive spine surgery has gained popularity. It may be used for decompression and stabilization of all segments of the spine and spinal cord. The evolution of minimally invasive spine techniques includes more historical surgical approaches, such as thoracoscopic and endoscopic techniques. Modern procedures include minimally invasive transforaminal lumbar interbody fusion, mini-open retroperitoneal interbody fusion, extreme lateral interbody fusion, oblique lateral interbody…

Lumbar Total Disc Arthroplasty

Summary of Key Points Lumbar total disc replacement (TDR) has been studied extensively since its initial use in the 1980s in Europe. Results of long-term follow-up studies in Europe as well as multiple prospective, randomized trials in the United States have found TDR to produce good outcomes that are noninferior or superior to fusion. TDR function depends on biomechanical factors such as articulation, degrees of freedom,…

Dorsal Semirigid Stabilization

Summary of Key Points Semirigid spine stabilization system refers to a class of spinal fixation strategies that promote segmental load-sharing while controlling abnormal motion, thereby theoretically reducing the risk of adjacent level degeneration and pseudoarthrosis. Semirigid systems may be subdivided into flexible systems that augment spinal fusion and dynamic, nonfusion systems that reproduce physiological spinal motion. Flexible pedicle screw– and/or rod-based systems, interspinous spacers, and facet…

Transforaminal Lumbar Interbody Fusion

Summary of Key Points In minimal access surgery, there is a temptation to rely more on fluoroscopy than direct visualization of the pedicle screw entry point. Such reliance quickly drives an upsurge in radiation exposure. The “mini-open” approach allows direct visualization of the pedicle screw entry point. Harness that advantage. Percutaneous placement of pedicle screws mandates fluoroscopy (or image guidance) at every step. Direct visualization of…

Midline Lumbar Interbody Fusion With Cortical Bone Trajectory Pedicle Screw Placement

Summary of Key Points Traditional posterior lumbar interbody fusion techniques allow direct neural decompression and placement of interbody graft bilaterally or unilaterally and the use of pedicle screws, but are associated with increased length of stay, blood loss, and postoperative pain as compared with more minimally invasive surgery (MIS) spinal techniques, such as percutaneous or mini-open posterior spinal arthrodesis. Midline lumbar interbody fusion (MIDLF) is an…

Posterior Thoracic and Lumbar Universal Spine Instrumentation

Summary of Key Points Dorsally applied universal spinal instrumentation (USI) systems increases the rate of bony fusion after surgery for traumatic, neoplastic, or degenerative conditions of the spine. Various biomechanical forces and properties imparted by thoracic and lumbar spinal implants are fundamental aspects of USI systems. Multiple systems are now available that differ in coupling mechanisms, metallurgic composition, screw and hook design, and even placement technique.…

Posterolateral Thoracolumbar Fusion

Summary of Key Points The technique of posterolateral fusion is an essential part of a surgeon’s armamentarium. Meticulous preparation of the fusion bed and placement of bone graft are important intraoperative steps for a successful fusion. Pseudoarthrosis is a significant concern with noninstrumented fusions, occurring in 14% to 55% of these procedures. Pseudoarthrosis appears to occur less frequently with instrumented fusions (0%–18%). Degenerative spondylolisthesis is one…

Thoracoscopic Corpectomy and Reconstruction

Summary of Key Points Thoracoscopic access to the anterior thoracic spine should be considered as a minimally invasive alternative to traditional open and mini-open procedures. Thoracoscopy can be used along the entire thoracic spine (T1 to T12) and can be extended via transdiaphragmatic incision to the upper third of L2 in the retroperitoneal space. However, the chest cavity gets smaller at the cranial end, which can…

Minimally Invasive Lateral Thoracic Decompression

Summary of Key Points Patient selection is paramount when choosing a lateral approach for a thoracic decompression. Fluoroscopy or stereotactic navigation is critical to define the anteroposterior and lateral axes before incision. Mastery of the lateral anatomic constraints of the thoracic spine is critical to avoid complications and limit morbidity. Stand-alone single- and multilevel lateral interbody fusions are still under investigation, and many surgeons still advocate…

Anterior and Lateral Approaches to the Thoracic Spine

Summary of Key Points Transpedicular approaches can provide excellent access to ventral pathology and provide the option for a partial or complete corpectomy. Minimally invasive transpedicular extracavitary options are increasingly used. Retropleural thoracotomy provides a short surgical approach to the ventral thoracic and thoracolumbar spine and spinal canal. Avoidance of pleural entry reduces postoperative pain and morbidity and obviates the need for a chest tube in…

Posterior Approaches to the Thoracic Spine

Summary of Key Points Posterior approaches are the cornerstone of thoracic spine surgery and are associated with decreased morbidity relative to anterior approaches. The four primary approaches are: midline, transpedicular, costotransversectomy, and lateral extracavitary. The optimal surgical approach depends upon lesion location, surgeon expertise, and surgical goals. A standard posterior midline approach is ideal for dorsal pathologies; however, ventral decompression is challenging because of the natural…

Thoracic and Lumbar Spine Construct Design

Summary of Key Points Construct design is an essential part of the planning process when addressing instability or deformity of the spinal column. Spinal implants provide internal stabilization until bony fusion occurs. The goals of spinal instrumentation are to immediately restore stability, withstand biomechanical forces and loads, and correct deformity. Creating a preoperative plan or blueprint ensures a definitive plan and saves time in the operating…

Combined Ventral-Dorsal Surgery

Summary of Key Points Cervical spine trauma, malignancy, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, kyphotic deformity, and cervical spondylotic myelopathy are all pathologies for which a combined surgical approach may be biomechanically advantageous when both ventral and dorsal elements are involved. When circumferential surgery is necessary, it has been shown that performing both the dorsal and ventral portions in a single setting is beneficial. This is…

Cervical Total Disc Arthroplasty

Summary of Key Points Cervical disc arthroplasty is a safe and effective alternative to anterior cervical discectomy and fusion in selected patients with symptomatic cervical radiculopathy or myelopathy related to cervical degenerative disc disease. The advantages of cervical arthroplasty include maintenance of segmental stability and mobility and reduction of adjacent segment degeneration. The indications for cervical arthroplasty are not synonymous with those for cervical fusion, and…

Anterior Subaxial Cervical Fixation and Fusion Techniques

Summary of Key Points Anterior subaxial fixation techniques have greatly evolved since first being described in the 1950s. Current fixation techniques involve a combination of modular interbodies, titanium plates, and screws. The composition of the interbodies (titanium, allograft, etc.) and plates (dynamic or rigid) can vary based on surgeon preference and indications. Compared with traditional titanium, polyetheretherketone interbodies have a modulus of elasticity closer to that…

Management of Soft Cervical Disc Herniation: Controversies and Complication Avoidance

Summary of Key Points Cervical soft disc herniation can lead to a variety of presentations Nonsurgical management is often successful. Anterior cervical discectomy and fusion, cervical total disc replacement, and posterior cervical laminoforaminotomy are all safe and efficacious procedures with a good evidence basis for treatment of cervical soft disc herniation. Surgeons should be aware of strategies for avoiding and managing common complications of anterior and…

Anterior Cervical Discectomy and Corpectomy

Summary of Key Points Anterior cervical discectomy provides rapid relief from radicular arm pain and halts progression of myelopathy. Corpectomy is indicated for anterior spinal cord compression between the disc spaces. Completeness of discectomy and corpectomy is based on intraoperative identification of the pedicles. Subsequent spinal reconstruction involves implantation of autograft or allograft, usually contained in titanium or polyetheretherketone cages and stabilized with internal fixation. Anterior…