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Preoperative Evaluation of Psychosocial Aspects and Work-Related Issues

Summary of Key Points Psychological distress and psychiatric disease have been shown to be predictors for poor surgical outcomes. The presence of a workers’ compensation claim is also a predictor for poor surgical outcomes. Preoperative evaluation should include identification of each patient’s psychosocial and work-related risk factors. Several tools have been used to screen for psychological distress in spine surgery patients, such as the Beck Depression…

Evaluation of the Aging Patient

Summary of Key Points Age-related structural changes occur in the disc and facet joints. Older patients present with multilevel disease with complex pathology. Osteoporosis is common in the older population and commonly identified in patients undergoing spinal procedures; osteoporosis remains poorly treated. Assessment of function or frailty status of the older patient can determine risk. Age-related comorbidities like cognitive dysfunction, malnutrition, polypharmacy, renal impairment, and ischemic…

Patient Selection for Spine Surgery: Preoperative Optimization

Summary of Key Points Patients who are medically optimized before major spine surgery demonstrate improvements in self-reported satisfaction scores, decreased postoperative complications, and decreased hospital length of stay. There are several patient-specific, modifiable risk factors that could be targets for improvement before surgery: blood glucose control, smoking cessation, weight loss, osteoporosis treatment, opioid dependence, and treatment of comorbid mental health disorders. Active tobacco use is a…

Differential Diagnosis of Surgical Disorders of the Spine

Summary of Key Points The differential diagnosis for the patient with spine-related symptoms and/or signs can be extensive. An appropriate history and physical examination are the foundations for developing a differential diagnosis. The practitioner evaluating and treating patients with potential spine disease must be aware of similar signs and symptoms that are nonspine in origin. We call these conditions spinal masqueraders. Spinal masqueraders can arise from…

Electrodiagnostic Studies

Summary of Key Points Components of the electrodiagnostic (EDX) examination include (1) nerve conduction studies, (2) needle electrode examination (or electromyogram), and (3) special studies (e.g., H reflexes, F waves). Diagnosis is best facilitated when these components are used in combination. An EDX examination can facilitate localization, focus differential diagnosis, estimate lesion severity, and provide information useful for prognosis. Nerve conduction studies assess large myelinated nerve…

Overview of Imaging Procedures Available for Spinal Diagnosis

Summary of Key Points Imaging plays an important role in establishing spinal diagnosis by building upon the information gleaned from history and physical examination. Computed tomography offers superior resolution and has largely supplanted conventional radiography as the primary imaging modality for visualization of bony anatomy. The invasive nature limits the role of myelography in the evaluation of spine to instances where obtaining magnetic resonance imaging (MRI)…

Spinal Alignment: Significance and Preoperative Planning

Summary of Key Points Adult spinal deformity with sagittal plane imbalance is associated with poor health-related quality of life (HRQOL) scores. A correlation exists between certain radiographic parameters and disability. Reestablishing harmonious spinopelvic alignment is associated with significant improvement in HRQOL outcome measures and patient satisfaction. Rigid deformities often require major reconstructive procedures, including osteotomies. Appropriate standing posture is paramount to reducing musculature energy expenditure and…

Sagittal Spinal Alignment: An Evolutionary Perspective

Summary of Key Points The upright sagittal posture in bipedal humans is a unique evolutionary development that has allowed humans to free up their hands, carry their young, exploit food sources, increase their cognitive function, and travel efficiently across great distances with minimal energy expenditure and decreased oxygen consumption. There has been intense scrutiny of the sagittal alignment of the spine by researchers over the past…

Physical and Neurological Examination

Summary of Key Points The history and physical examination are best used to assess the function of the spine and nervous system, complementing the anatomic information from spine imaging. The physical and neurological examinations should include the following: Assessment of posture and range of motion of the spine and joints of affected limbs. Inspection and palpation of the entire spine. Focused neurological examination of tone, power,…

Proximal and Distal Junctional Kyphosis and Failure

Summary of Key Points The proximal and distal extents of long posterior fusions in adults with spinal deformity are considered “at risk” for failure because of increased loads and motion at the last instrumented vertebra and the unfused adjacent segment. Proximal junctional kyphosis (PJK) is defined as a postoperative proximal junctional Cobb angle 10 degrees or more between the lower end plate of the upper-instrumented vertebra…

Adjacent Segment Degeneration and Disease of the Lumbar Spine

Summary of Key Points Adjacent segment degeneration (ASDeg) refers to the development of asymptomatic degenerative changes on radiographic imaging adjacent to a fused spinal segment. Adjacent segment disease (ASD) describes the development of clinical symptoms associated with these radiographic changes. The etiology of ASD is unknown. Multiple risk factors have been described as possibly associated with the development of ASD, including sagittal imbalance, preexisting degeneration, fusion…

Adjacent Segment Degeneration and Disease of the Cervical Spine

Summary of Key Points Adjacent segment pathology is an umbrella term for adjacent segment degeneration, which refers to radiographic evidence of degenerative changes, and for adjacent segment disease, which refers to clinically symptomatic degenerative changes. Fusion leads to altered and increased kinematic motion, as well as increased intradiscal pressure at adjacent segments. Adjacent segment pathology is likely the result of the natural history of cervical spondylosis,…

Postoperative Spinal Deformity

Summary of Key Points Postoperative deformity is an important complication of surgery involving the cervical, thoracic, and lumbar spine. Postoperative deformity is a common and significant indication for revision spine surgery. Preoperative planning and intraoperative assessment of spinal alignment are important to avoid postoperative spinal deformity. Management of postoperative spinal deformity may require osteotomies for realignment of the spinal column. Deformity of the spine encompasses malalignments…

Postoperative Spinal Disorders—Cervical

Summary of Key Points The cervical spine is the most mobile region of the spine, leading to a propensity for instability in the setting of pathologies or iatrogenic destabilization during corrective surgeries. Disruption of key structures, including ligaments, vertebral bodies, intervertebral discs, muscles, and bones, during spine surgery can result in significant biomechanical instability if measures are not taken to stabilize the spine afterwards. Both anterior…

Neuromuscular Disorders in the Adult Spine

Summary of Key Points Neuromuscular disorders are an important and common cause of spinal deformity in the child and in the adult. Recognition of a neuromuscular etiology of spinal deformity is important for understanding the natural history of the deformity, and for defining appropriate management, including operative and nonoperative care. A rapid progression of an atypical, decompensated deformity is an important characteristic of neuromuscular deformity. Diagnostic…

Neuromuscular Disorders in the Pediatric Spine

Summary of Key Points Neuromuscular scoliosis represents an amalgamation of diagnoses that affect the neuromuscular system, leading to scoliosis. Cerebral palsy represents the most common pathological entity comprising neuromuscular scoliosis. Patients with neuromuscular scoliosis have a higher risk of perioperative complications after deformity correction compared with patients with idiopathic curves. Infection is the most common postoperative surgical complication associated with neuromuscular scoliosis. Within the subset of…

Vascular Malformations of the Spine

Summary of Key Points Spinal vascular malformations involve abnormalities of the arteries or veins that arise in the spinal column. These can occur in the intradural space, either in or around the spinal cord, or have abnormal arterial connections in the dura and extradural space. Dural and extradural vascular malformations account for approximately 80% of spinal vascular malformations. The spinal cord receives blood supply from one…

Osteoporosis, Osteomalacia, and Metabolic Bone Disease

Summary of Key Points Osteoporosis and consequent vertebral and nonvertebral fractures are a major source of mortality and morbidity in the elderly population. Screening for osteoporosis is based on risk factors and patient age, with routine screening recommended for all healthy women at age 65 years. Earlier screening is appropriate in the presence of risk factors. Laboratory evaluation for secondary causes is appropriate in patients with…

Spinal Disorders Associated With Connective Tissue Disorders

Summary of Key Points The structure and alignment of the spine are highly susceptible in connective tissue disorders. Early onset and severity necessitate early recognition of pathologies and treatment, which poses challenges for spine growth and visceral function. Deformity may progress rapidly in patients with connective tissue disorders. The burden of disease impacts the health status of affected patients beyond spinal involvement. Connective tissue disorders may…

Brachial Plexus Tumors Extending Into the Cervicothoracic Spine

Summary of Key Points Tumors of the brachial plexus can extend into the cervical and upper thoracic spine, presenting unique neurosurgical management challenges. Paraspinal neural sheath tumors have contiguous extra and intraforaminal components that may extend intraspinally. Tumors of the peripheral nerve can be of neural or nonneural sheath origin, benign or malignant. Initial symptoms depend on the level of the tumor, as well as the…