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Postoperative Medical Complications

Summary of Key Points Medical complications following spine surgery are common. Complications can involve essentially every organ system. Thromboembolic complications such as deep venous thrombosis (DVT) and pulmonary embolism can occur in up to 31% and 13% of spine surgery patients, respectively, depending on how you measure them. The rate of symptomatic DVT is much lower, and asymptomatic screening is typically not recommended. Prevention includes early…

Common Complications in Spine Surgery: Pseudoarthrosis

Summary of Key Points Pseudoarthrosis of the spine is defined as a failure of bony union. Symptoms include persistent pain, failure of instrumentation, and instability. Diagnosis of pseudoarthrosis remains a challenge and requires high clinical suspicion, as well as utilization of various imaging modalities. There are numerous patient factors, as well as surgical techniques, that can influence the risk of symptomatic pseudoarthrosis. Treatment of symptomatic pseudoarthrosis…

Osteointegration: The Bone and Implant Interface

Summary of Key Points Osteointegration of a spinal implant implies both a mechanical and a morphological bond at the bone–implant interface. The biological process of osteointegration involves three phases: clot formation and initial mesenchymal cell differentiation, initial bone formation, and finally bone remodeling. Implant material composition, surface topography, and surface chemistry influence the biological process of osteointegration. Titanium implants have excellent biocompatibility and osteointegration. Polyetheretherketone (PEEK)…

Biologics in Spine Fusion Surgery

Summary of Key Points Spinal biologics can alter the existing biological environment to enhance specific cellular/molecular activity to further a clinical goal by facilitating osteoinduction, osteoconduction, and/or osteogenesis. Autograft can be taken from the iliac crest or locally from the spinous processes and lamina; its trabecular surface area serves as a scaffold and allows vascular/cellular ingrowth. Autograft contains growth factors such as bone morphogenetic proteins, insulin…

Intraoperative Crisis Management in Spine Surgery: What to Do When Things Go Bad

Summary of Key Points A crisis requires swift and decisive action by the healthcare team. In the unlikely event of cardiac arrest, the patient in the prone position will require closed or reverse cardiopulmonary resuscitation or, rarely, a last-resort open thoracotomy. During dorsal lumbar spine surgery, risk of vascular injury is very low. The common iliac artery is the most commonly injured vessel. Should iatrogenic spinal…

Blood Management and Complex Spine Surgery

Summary of Key Points Blood transfusion is no longer driven by the “10/30 hemoglobin/hematocrit rule,” because as little as one unit of homologous blood transfusion can increase postoperative complications. Therefore, a more restrictive transfusion protocol has become the standard of care. More than 50 drugs are approved that interfere with either the coagulation cascade or platelet function. Table 84.1 lists many of these drugs and gives…

Intraoperative Monitoring in Routine and Complex Surgery

Summary of Key Points Intraoperative neurophysiological monitoring is useful in detecting neurological deficits during major deformity corrective spinal surgeries. Somatosensory-evoked potential monitoring evaluates the functioning of the dorsal aspect of the spinal cord. Transcranial electrical stimulation motor-evoked potentials can monitor the corticospinal pathways via myogenic motor-evoked potentials, as well as via direct recordings from the spinal cord. Triggered electromyography monitoring can help ensure accurate pedicle screw…

Anesthesia for Spine Surgery and the Prevention of Complications

Summary of Key Points Preoperative evaluation of the patient scheduled for spine surgery most commonly focuses on functional capacity, neurological assessment, and upper airway examination. In patients with significant spinal cord compression or an unstable cervical spine undergoing cervical spine surgery, awake fiberoptic intubation may be the safest technique for upper airway management. Increased intraocular pressure during spine surgery may compromise the ocular perfusion pressure. Maintaining…

Intraoperative Imaging Protocols

Summary of Key Points Intraoperative imaging is an essential component of effective and safe spinal surgery. Common indications for intraoperative imaging include anatomic localization, placement and evaluation of spinal instrumentation, tumor resection, and assessment of decompression. Plain film radiography and fluoroscopy are the most widely used intraoperative imaging modalities. Radiation exposure, especially with the use of intraoperative fluoroscopy, is a growing concern. Image-guided spinal navigation promises…

Surgical Incisions, Positioning, and Retraction

Summary of Key Points Surgical positions, incisions, and retractors are reviewed for cervical, thoracic, lumbar, and sacral operations. Technical details of various surgical approaches are outlined. The anatomy of ventral, dorsal, and combined approaches and how to avoid complications are discussed. Minimally invasive techniques are also outlined. Ventral approaches to craniocervical junction include the transoral approach, the endoscopic transnasal approach, median labiomandibular glossotomy, the transmandibular and…

Perioperative Management Protocols: Enhanced Recovery After Surgery

Summary of Key Points With an ageing and more infirm population, coupled with health economic pressures and an evolving opioid crisis, never has there been a greater need for more effective perioperative management strategies to mitigate the physiological and psychosocial impact of spine surgery on the patient. Beyond the specific technical aspects of spine surgery and anesthesiology, enhanced recovery after surgery (ERAS) represents a paradigm shift…

Fundamentals of Spine Surgery

Summary of Key Points The overarching objective of spine surgery is to restore patients’ functional capacity and independence. Key goals in spine surgery include neural decompression, spinal stabilization, arthrodesis, and restoration of alignment. Treatment decision-making should be centered on each patient’s values and expectations rather than purely on radiographic measures. Patient–physician communication throughout diagnosis, treatment, and the follow-up period is essential. The aim of this chapter…

Pain Management: Opioids and Alternatives

Summary of Key Points Many medication options exist for the management of chronic spinal and back pain disorders, including nonsteroidal antiinflammatories, acetaminophen, oral steroids, antidepressants, anticonvulsants, opioids, cannabinoids, and topical ointments. Muscle relaxants, oral steroids, opioids, and nonsteroidal antiinflammatories can be used effectively in such certain acute situations, such as sprains, strains, and herniated discs. Muscle relaxants, oral steroids, nonsteroidal antiinflammatories, and opioids are not known…

Neuromodulation and Rehabilitative Interventions for the Spine

Summary of Key Points Spinal cord stimulation (SCS) has traditionally been clinically used to treat chronic pain; however, the indications for spinal neuromodulation are growing. It recently has been used to treat paralysis after spinal cord injury, spinal instability, and other applications. Closed-loop stimulation for SCS may further expand the role for neuromodulation. Spine–machine interfaces have several advantages over brain–machine interfaces, and will likely be the…

Regenerative Strategies and Intervertebral Disc Degeneration

Summary of Key Points Cell-based therapy for intervertebral disc degeneration has the potential to restore the physiological function of the spine and improve back pain and disability. Cell sources explored to date include mesenchymal stem cells, notochordal cells, induced pluripotent stem cells, and disc cells, with or without a scaffold. Therapeutic cells can be administered via simple percutaneous injection under fluoroscopic guidance. Well-designed preclinical studies and…

Cognitive Behavioral Therapy and Back Pain

Summary of Key Points Pain is a multifaceted and complex experience, with both sensory and emotional components. When pain persists beyond the expected time of healing, chronification of pain occurs and is best treated within a biopsychosocial framework. National physician treatment guidelines recommend nonpharmacological treatments, such as exercise therapy and psychological therapies (cognitive behavioral therapy [CBT] and mindfulness-based therapy), as the first-line approaches to chronic low…

Spine Injections

Summary of Key Points There are numerous types of spine injections used to diagnose and treat pathophysiology of the spine. To accurately diagnose and treat the underlying pathophysiology with an injection, correct diagnosis based on history, physical exam, and imaging if needed is necessary to guide treatment planning, whether it be for pain control or surgery. Epidural steroid injections have been effective in treating patients with…

Rehabilitation and Interventions in Management of Spinal Disorders

Summary of Key Points Exercise is important for the prevention of back pain and recurrent episodes. Acute low back pain is common and has an excellent short-term prognosis, which should be explained to patients. Serious causes of low back pain (i.e., cancer, infection, fracture, spondylitis) are uncommon (affecting <5% of patients with back pain). Imaging is not indicated in patients with acute back pain in the…

Measuring Preoperative Health-Related Quality of Life: What Metrics Matter

Summary of Key Points Measurement of health-related quality of life (HRQOL) is an integral part of healthcare. HRQOL measures are a subset of patient-reported outcomes that measure common ways in which health or healthcare impact wellbeing over time. HRQOL surveys allow us to more closely measure patient perceptions of health and the effects of interventions for spinal disorders. Measures can be generic health–related or condition-specific, although…

Preoperative Evaluation of Patients With Tumors Affecting the Spine

Summary of Key Points Many different types of tumors may involve the spinal column, spinal cord, or nerves. Overall survival of the patients with metastatic spinal tumors has improved because of continued advances in systemic cancer therapies. The use of multimodal imaging is essential for evaluating tumors affecting the spine and for planning surgery. Preoperative embolization may help decrease intraoperative bleeding in highly vascular tumors. Prognostic…