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Instrumentation Complications

Introduction The evolution of spinal instrumentation from simple wiring, to segmental, rigid fixation, to motion-preservation and dynamic implants has been powered by an improved understanding of spinal disease and its impact on the biomechanics of the spine. Coincident with that understanding have been improvements in metallurgy, perioperative spinal imaging, and a wealth of clinical outcomes data. Technical advances have also improved surgeons' ability to place implants…

Vascular Complications in Spinal Surgery

Introduction A vascular complication may be defined as an injury to a blood vessel and the sequelae of that injury, which may be the direct or indirect result of the procedure, surgical approach, or operative technique. For the purposes of this chapter, a vascular complication may arise directly from vascular injury or indirectly as a consequence of the injury. Mechanisms of blood vessel injury include laceration,…

Spinal Dural Injuries

Anatomy and Pathophysiology The meninges cover the brain and spinal cord. They consist of dura mater, arachnoid, and pia mater. The dura has three distinct layers: a fibroelastic outer layer, a fibrous middle layer, and a cellular inner layer. Although there is controversy regarding the orientation of dural fibers, there is substantial evidence that they run longitudinally, as evidenced by their higher ultimate stress in this…

Intraoperative Spinal Cord and Nerve Root Injuries

Introduction Neurologic injury is one of the most dreaded complications associated with spine surgery. Depending on the location, injury can be relatively minor (nerve root) to completely debilitating (spinal cord injury). Luckily, the frequency of devastating neurologic complication is rare. Nonetheless, increasing complexity of surgery is typically associated with increased risk of neurologic injury. Injury can occur at any stage in the operative procedure. Only with…

Syringomyelia

Syringomyelia, or cavitation within the substance of the spinal cord without an ependymal lining, has been recognized for more than 300 years as a pathologic entity. Etienne is credited for the first pathologic description in 1564 in La Dissection du Corps Humain ; he described a cystic lesion in the spinal cord that contained a “fluid, reddish, like the fluidity of that of the ventricles.” Portal,…

Vascular Anatomy of the Spine, Imaging, and Endovascular Treatment of Spinal Vascular Diseases

Normal Vascular Anatomy of the Spine An accurate and thorough understanding of the normal vascular anatomy of the spine and spinal cord is vital for the safe and appropriate performance of spinal angiography and endovascular intervention. Learning these skills is challenging because diagnostic spinal angiography is less commonly performed than cerebral angiography and is being gradually replaced by magnetic resonance angiography (MRA). In this section, we…

Pediatric trigger digits

There are two types of pediatric trigger digit procedures: trigger thumb release and trigger finger release. Pediatric trigger thumb release Indications Trigger thumbs are one of the most common hand conditions affecting the pediatric population. They typically present in children between 1 to 4 years of age. Timing for surgical intervention is debated because symptoms will resolve in an uncertain percentage of children. A period of…

Capsulotomy for metacarpophalangeal contracture

Indications Metacarpophalangeal (MCP) joint stiffness can usually be prevented or corrected with nonoperative management, such as edema control, splinting, and early joint mobilization. About 90% of patients with MCP contractures are successfully treated nonoperatively. MCP capsulotomy is indicated in motivated patients with persistent contracture and hand dysfunction after several months of therapy. Surgery is one part of the treatment plan for MCP contracture. Postoperative hand therapy…

Capsulotomy for proximal interphalangeal contracture

Indications Proximal interphalangeal (PIP) joint capsulotomy is indicated for patients with decreased range of motion (ROM) and functional limitations who have failed nonoperative management (active joint mobilization, dynamic and/or static splinting, and passive stretching). Patients must understand that recurrence is common and postoperative therapy is mandatory. Clinical examination In rheumatoid arthritis, synovitis within the joint stretches the extensor mechanism and causes a boutonniere deformity. In osteoarthritis…

Thumb adductor release

Indications Cerebral palsy patients may develop spastic contracture of thumb adduction and flexion muscles, which causes a characteristic thumb-in-palm deformity ( Fig. 102.1 ). House described four types of thumb-in-palm deformity: Type 1: First ray adduction across the palm from contracture of the adductor pollicis (AdP). Type 2: First ray adduction with flexion of the metacarpophalangeal joint (MCP) from contracture of flexor pollicis brevis (FPB). Type…

Flexor-pronator slide

Indications Indications include established Volkmann ischemic contracture of the flexor-pronator muscles of moderate severity and a sustained functional impairment of the spastic upper extremity (resulting from central nervous system disorders such as cerebral palsy, traumatic brain injury [TBI], or cerebrovascular accident [CVA]) with fixed forearm pronation, wrist flexion, and finger flexion deformities. Contraindications Contraindications include complete absence of voluntary motor control of forearm supination, wrist extension,…

Step-cut fractional lengthening of flexor tendons and flexor digitorum superficialis to flexor digitorum profundus transfer

Indications An indication is patients with spastic wrist and finger flexion contractures resulting in functional limitations in activities of daily living, poor hygiene, and undesirable hand appearance. Patients should have exhausted nonoperative treatments, including splinting, occupational therapy, serial casting, and pharmacologic agents (e.g., botulinum toxin A, baclofen). Indications may vary based on the patient’s cognitive ability and baseline function. For patients with little voluntary control and…

Biceps and brachialis lengthening

Indications One indication is a spastic elbow contracture from upper motor neuron injuries (which are frequently the result of cerebral palsy, stroke, or traumatic brain injury). Any neurologic injury should be stable. In patients with volitional control, flexion contractures of 40 degrees may benefit from surgical lengthening. Without volitional control, surgery is reserved for contractures over 100 degrees, principally to facilitate hygiene care. The goals of…

Surgical and nonsurgical treatment of dupuytren contracture

Indications It is important to take a patient-centered approach and implement shared decisionmaking when treating patients with Dupuytren disease because indications for intervention vary widely based on patients’ subjective functional limitations and needs. Intervention for Dupuytren disease is most successful in instances when a cord develops and causes metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint contractures with functional consequences, including: Difficulty grasping objects. Difficulty performing fine…

Ulnar artery to superficial arch bypass with a vein graft

Indications The ulnar artery bypass procedure with a vein graft is used to reconstruct an ulnar artery damaged from occlusion caused by Raynaud phenomenon or repetitive trauma to the hand known as hypothenar hammer syndrome. For Raynaud phenomenon, the indications are similar to those in Chapter 96 , but there must be proximal and distal targets amenable to microsurgical anastomosis for this procedure to be indicated.…

Sympathectomy of radial, ulnar, and common digital arteries for raynaud phenomenon

Introduction Raynaud phenomenon (RP) is an exaggerated vascular response to cold temperature or emotional stress, which manifests clinically as color changes in the fingers from white to blue to red. Primary RP (“Raynaud disease”) occurs in the absence of associated conditions; secondary RP (“Raynaud syndrome”) is associated with conditions such as scleroderma (systemic sclerosis), systemic lupus erythematosus, and an extensive list of other conditions, medications, and…

Toe to thumb transfer

Indications One indication is loss of the thumb because of a traumatic injury ( Fig. 95.1 ). Although replantation of the amputated thumb is always considered first, there may be instances where the amputated digit is not viable or replantation is not possible. For these cases, toe to thumb transfer is an excellent option for replacing the lost digit. Traumatic amputation at the level of the…

Revascularization and replantation of digits and hand

Replantation refers to the reattachment of a completely amputated part of a digit, whereas revascularization is defined as repair of an incompletely amputated part that is nonviable and will experience necrosis without vascular repair. Indications The aim of digit replantation is not only to restore vascularity but also regain useful function. There are many factors that influence the final decision, including the type of injury; level…

Venous flap

Introduction The venous flap is a thin, pliable flap consisting of skin, subcutaneous tissue, and veins. It differs from conventional flaps in that it is not an arterial afferent and venous efferent flap ( Fig. 93.1A ). Instead, inflow and outflow occur through the venous system of the donor tissue (see Fig. 93.1B ). These flaps can be well shaped to fit different wounds and provide…