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Intramedullary Spinal Cord Lesions

Summary of Key Points Intramedullary lesions of the spinal cord encompass a wide range of histopathology. The majority of these lesions are benign and amenable to surgical resection. Unlike primary intracranial tumors, most intramedullary spinal cord tumors are histologically benign and do not demonstrate progressive anaplasia. The primary goal of surgery for intramedullary tumors is long-term tumor control or cure with preservation of neurological function. Midline…

Intradural Extramedullary Spine Tumors

Summary of Key Points Intradural extramedullary spine tumors are rare entities that may present with nonspecific symptoms. Nerve sheath tumors (i.e., schwannomas and neurofibromas), meningiomas, ependymomas, and hemangioblastomas may present as part of a heritable clinical syndrome. Surgical decision-making should be tailored to the patient’s individual symptoms, medical conditions, and anatomy. For patients who are poor surgical candidates, stereotactic radiosurgery may represent a nonsurgical option for…

Metastatic Tumors of the Spine

Summary of Key Points Metastatic spine disease is the most prevalent form of spinal neoplasm, with an increasing incidence secondary to aging population demographics and increased survival in oncology patients. Appropriate management of metastatic spine disease requires a multidisciplinary team; a patient’s neurological, oncological, and medical status must be taken into account, in addition to spinal stability, for optimal treatment. Evidence supports circumferential decompression and stabilization…

Primary Tumors of the Spine

Summary of Key Points Primary tumors of the spine are far more rare than metastatic tumors. Management of spinal tumors is multidisciplinary, requiring a variety of treatment modalities. Treatment goals range from local disease control or cure to symptom palliation, prevention of neurological deterioration, and spinal stabilization. In the case of primary malignant bone tumors, long-term local control, survival, and potential cure are generally dependent on…

Secondary Infections of the Spine

Summary of Key Points Primary infection of the spine is an infection that spreads to the spine hematogenously, whereas a secondary infection is an infection that occurs following spine surgery (i.e., surgical site infection [SSI]). SSI is defined as an infection that develops within 30 days after the date of surgery if no implant is left in place or within 365 days if an implant is…

Primary Infections of the Spine

Summary of Key Points Spondylodiscitis is defined as infections involving various spinal elements, including vertebral bodies, intervertebral discs, the spinal canal, or paravertebral soft tissues. Spinal infections are broadly classified on the basis of etiology: pyogenic, granulomatous, and parasitic. Granulomatous conditions include tubercular, brucellar, and fungal spondylodiscitis. Infections reach the spine through one of the following routes: direct inoculation from the exterior, direct extension from local…

Ossification of the Posterior Longitudinal Ligament

Summary of Key Points The morbidity rate of cervical ossification of the longitudinal ligament (OPLL) is higher in East Asia than in Europe or North America. The ratio between men and women with cervical OPLL is 2:1, but the incidence of thoracic OPLL is 1.5 to 3 times higher in women than in men. Around half of the patients with cervical OPLL present with progression of…

Ankylosing Spondylitis and Related Disorders

Summary of Key Points Ankylosing spondylitis is a disabling seronegative spondyloarthropathy that results in progressively worsening deformity of the spine. Nonsteroidal antiinflammatory medications are first-line pharmacological therapy options, with antitumor necrosis factor agents used for refractory cases. The exact origin of ankylosing spondylitis is unknown, but there is a strong genetic connection in individuals with human leukocyte antigen–B27. Because of progressive fusion of the spinal segments,…

Rheumatoid Arthritis

Summary of Key Points The majority of operative interventions on the spine in rheumatoid arthritis patients occur at the C1–C2 level because of pannus formation, atlantoaxial instability, or potential vertical subluxation of the dens/cranial settling. Current use of disease-modifying antirheumatic drugs has decreased the need for surgical intervention in patients with rheumatoid arthritis. The indications for surgery include instability, intractable pain, deformity, myelopathy, or progressive neurological…

Spinal Injuries in Sports

Summary of Key Points The five steps for on-field management of spinal injuries in sports are: (1) preparation for any neurological injury, (2) suspicion and recognition, (3) stabilization and safety, (4) immediate treatment and possible secondary treatment, and (5) evaluation for return to play. Brachial plexus neurapraxia is characterized by pain and paresthesia in a single upper extremity following a blow to the head or shoulder.…

Spinal Cord Injury

Summary of Key Points Spinal cord injury results from both the primary injury and a subsequent secondary injury cascade. Understanding the secondary cascade of spinal cord injury has identified potentially modifiable components, and may translate to future treatment strategies in patients with acute spinal cord injury. Prognosis following spinal cord injury largely depends on the initial neurological deficits. Clinical manifestations of incomplete cord injuries are reflective…

Peripheral Nerve Injury

Summary of Key Points Whereas Schwann cells support peripheral nervous system (PNS) regeneration, oligondendrocytes fail to support long-distance axonal growth in the central nervous system (CNS). Common and different signaling pathways in both the CNS and the PNS, as well as sustained inflammatory responses or resolution of inflammatory responses, influence regeneration capacity. Seddon’s and Sunderland’s classification are useful pathoanatomical depictions of nerve injury and clinical guidance…

Thoracic and Lumbar Spine Injuries

Summary of Key Points Fractures of the thoracolumbar region are the most common injuries of the vertebral column, with the leading cause of significant thoracolumbar injury being high-energy and high-velocity trauma. Critical factors necessitating evaluation include: neurological status, stability of the spine, extent of deformity, and associated injuries. Four major classification systems for thoracolumbar injuries: the Denis three-column system, the Magerl AO system, the Thoracolumbar Injury…

Subaxial Cervical Spine Injuries

Summary of Key Points Cervical spine fractures must be treated from two perspectives: neural injury and spinal instability. Computed tomography is the first-line diagnostic test for suspected cervical spine injury. Rapid decompression of neural elements and restoration of spinal stability tend to maximize the chance of a good outcome. Aggressive intensive care unit care, including hemodynamic monitoring, blood pressure goals, respiratory monitoring, and prevention of deep…

Occipitocervical Injuries

Summary of Key Points Occipitocervical injuries should always be suspected and ruled out in patients with high-energy injuries to the head and neck. Occipitocervical injuries can be highly unstable, and great care should be taken to stabilize the patient during assessment and transfer to prevent neurological morbidity. Special attention should be paid to diagnosing pure transverse ligament injuries because they are not expected to heal with…

Lumbar Spondylolisthesis

Summary of Key Points Isthmic and degenerative lumbar spondylolisthesis are common lumbar deformities associated with a significant impact on the health status of affected patients. Surgery for symptomatic lumbar spondylolisthesis is supported by clinical trial evidence. Published guidelines support a surgical approach to symptomatic lumbar spondylolisthesis. There are a number of surgical approaches that are appropriate for the treatment of lumbar spondylolisthesis. Studies are being done…

Adult Degenerative Scoliosis

Summary of Key Points Adult degenerative scoliosis (ADS) is a debilitating condition, with a spectrum of clinical presentations and spinal misalignment. There has a significant trend toward higher demand for management of ADS (both surgical and nonsurgical) in recent years. A thorough history of main presenting complaints, onset and progression of the condition, and associated comorbidities, as well as a thorough neural examination and radiographic assessment,…

Deformity in the Cervical Spine

Summary of Key Points Cervical spine deformity is a leading cause of morbidity and poor patient quality of life in the adult spinal deformity population. Although a standardized classification system is yet to be validated, the most common qualitative radiographic parameters are C2–C7 sagittal vertical axis, C2–C3 angle, chin-brow vertical angle, and cervical lordosis minus T1 slope. Conservative management can be attempted for patients with mild…

Pathophysiology of Intervertebral Disc Degeneration and Pain

Summary of Key Points The disc has a complex organization that confers unique biomechanical properties. Disc subtissues (nucleus pulposus, annulus fibrosus, and end plate) have differing matrix structures and cell phenotypes. Poor vascular supply is an important factor affecting the disc’s healing capacity. Nonpainful, physiological disc degeneration is present in most adults. Advanced imaging tools may improve early localization of pain generators. Painful, pathological degeneration arises…

Pathophysiology of Thoracic Spondylosis, Radiculopathy, and Myelopathy

Summary of Key Points The thoracic spine has unique biomechanical and physiological features, creating a relatively rigid transition zone flanked by more mobile cervical and lumbar regions. The thoracic spinal cord is less prone to dynamic compression than the cervical spinal cord, but is also less tolerant to compression and vascular ischemia. Its limited dorsal mobility makes the thoracic spinal cord vulnerable to ventral compressive pathology,…