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Internal Fixation

Internal Fixation of Tibial Plateau Fractures Fixation constructs depend largely on fracture patterns and on patient factors such as associated injuries and functional status. Classification systems discussed in Chapter 2 can aid in the determination of definitive treatment for tibial plateau fractures. Many commercially available plating systems specific to the tibial plateau are available, with innovations constantly being brought to market. These provide treatment options with…

External Fixators for the Treatment of Proximal Tibia Fractures: Ringed and Standard

Introduction Tibial plateau fractures come in many forms from the senile nursing home patient falling on the way to the bathroom to the young motorcyclist driving into a tractor-trailer. Similarly, external fixators range from simple uniplanar large pin frames to complex ring fixators that take hours to construct and “fine tune.” This chapter is a guide to fitting the frame to the problem. The treatment of…

Nonoperative Treatment of Tibial Plateau Fractures

Introduction Tibial plateau fractures have been documented in the literature as early as the 1820s, and the mainstay of treatment was nonoperative until the 1950s. Many reports in the 1970s and beyond suggest that open reduction and internal fixation is indicated for most displaced tibial plateau fractures. With modern advances in fracture treatment principles, techniques, imaging methods, and implants, operative intervention has become the standard treatment…

Mechanism, Evaluation, and Temporary Fixation

Introduction Demographics Fractures involving the tibial articular surface account for a little over 1% of all long bone fractures, 56.9% of all proximal tibia fractures/dislocations, and 8% of all fractures in the elderly. These fractures have an annual incidence of 10.3 per 100,000. The combined incidence of a patient having a tibial plateau fracture with associated polytrauma on admission has been estimated at 16% to 40%.…

Anatomy and Surgical Approaches

Introduction The anatomy of the proximal tibia involves a complex interaction between bone, ligaments and their attachment sites, cartilage, and muscles. The knee is an intricate hinge joint consisting of the tibia, femur, and patella. Ligamentous and muscular attachment sites also include the proximal fibula. Rather than being a purely rotational motion around a fixed axis, the tibiofemoral articulation involves posterior translation of the femoral condyles…

Nonunions and Implant Failures of the Cervical Spine

Chapter Preview Chapter Synopsis Nonunions and implant failures of the cervical spine indicate a failure to stabilize the spine biomechanically. The most difficult failures to reconstruct are multilevel corpectomy procedures. The assessment and reconstructive methods that are needed are discussed in this chapter. Important Points The goals of revision surgery should be to obtain adequate decompression, restore sagittal balance, and achieve solid fusion. The failure rate…

Adjacent Segment Disease

Chapter Preview Chapter Synopsis Adjacent level disease is a relatively frequent clinical finding in cervical spine surgery. An overall rate of approximately 3% per year can be expected in patients who have undergone cervical surgical procedures. Whenever possible, nonoperative treatment should be attempted, but it may be less successful than in de novo cervical spondylotic syndromes. Anterior cervical diskectomy and fusion at the adjacent level or…

Wound Complications

Chapter Preview Chapter Synopsis Wound complications, namely infection and dehiscence, are some of the most common adverse events following spinal surgical procedures. These complications can incur substantial morbidity and financial burden. Risk factor modification and prevention represent a burgeoning paradigm. Yet evidence-based guidelines for diagnosing and treating these problems are few. A working knowledge of wound healing physiology, proper surgical technique, a high index of suspicion,…

Dural Tear

Chapter Preview Chapter Synopsis Dural tear is not uncommon in cervical spine surgery, and the incidence varies depending on the disorder addressed and the procedure performed. Because the potential complications associated with a persistent cerebrospinal fluid (CSF) leak can be devastating, surgeons must have both intraoperative and postoperative treatment options available to them. Repair should involve appropriate measures to promote healing of the dural tear. Although…

Tracheoesophageal Injuries

Chapter Preview Chapter Synopsis The anterior approach to the cervical spine has gained worldwide acceptance by spine surgeons to address a variety of pathologic conditions of the cervical spine. Injuries to the trachea and esophagus are rare, but they can result from direct or indirect injury and manifest with early or late clinical findings. Radiographic imaging such as plain radiography, computed tomography or magnetic resonance imaging,…

Spinal Cord and Nerve Injuries in the Cervical Spine

Chapter Preview Chapter Synopsis Nerve injuries and spinal cord injuries following cervical spine surgery can be devastating to the patient, family, and surgeon, but with adequate counseling preoperatively and appropriate management postoperatively, the impact can be lessened. Surgical technique can help to minimize these complications, but even the best surgical techniques do not entirely prevent serious complications. Promptly recognizing a neurologic complication and managing it accordingly…

Vascular Injuries

Chapter Preview Chapter Synopsis Vertebral artery injury during cervical spine surgery is a rare but devastating complication. The vertebral artery is most susceptible to injury anteriorly at C7, laterally from C3 to C7, and posteriorly at C1 and C2. A thorough understanding of normal arterial and osseous anatomy, as well as common aberrancies, can reduce the risk of injury. Despite taking all possible precautions, inadvertent injury…

Intervertebral Disk Transplantation

Chapter Preview Chapter Synopsis The current gold standard for treatment of disk degeneration is spinal fusion. Although effective in controlling pain, spinal fusion leads to restricted spinal motion and potentially to adjacent level degeneration. The goal of management should be to restore the functional spinal unit. This can be done with artificial or biologic disk replacements. Artificial total disk replacements are gaining popularity, and early results…

Biologics for Spinal Fusion

Chapter Preview Chapter Synopsis Biologics in cervical spine surgery include demineralized bone matrix (DBM), ceramics, allografts containing mesenchymal stem cells, and growth factors. Each of these biologics has different characteristics and different degrees of osteoconductivity, osteoinductivity, and ostegenicity. This chapter reviews the key basic science principles, preclinical studies, and clinical studies that guide the surgeon in the appropriate use of biologics in the cervical spine. Important…

Biologics for Intervertebral Disk Regeneration and Repair

Chapter Preview Chapter Synopsis Neck and low back pain is common, and intervertebral disk degeneration is thought to be one of the primary sources for pain generation. Although therapeutic techniques including surgical and non-surgical modalities have been applied, current therapies for disk degeneration may address symptoms but do not restore structure and function. In this chapter, we will review the advancement of biologic therapeutic options for…

Image-Guided Navigation for Cervical Spine Surgery

Chapter Preview Chapter Synopsis Image-guided spinal navigation is a computer-based surgical technology designed to improve intraoperative orientation to the nonvisualized anatomy during both conventional and minimally invasive spinal procedures. This chapter covers the principles of image-guided spinal navigation, current types of navigation systems, and the concept and process of registration. Its clinical application, specifically to C1-C2 transarticular screw fixation, C1-C2 segmental screw fixation, and transoral surgery,…

Minimally Invasive Techniques for the Cervical Spine

Chapter Preview Chapter Synopsis The goals of individual minimally invasive surgery (MIS) approaches in the cervical spine are to minimize disruption of the normal anatomic structures, to diminish soft tissue disruption, and to prevent both short-term and long-term morbidity while achieving the aims of the surgical procedures. MIS approaches have been shown to be safe for cervical foraminotomies, diskectomies, decompression for stenosis, resection of spinal tumors,…

Interspinous Wiring

Chapter Preview Chapter Synopsis Interspinous wiring techniques were developed as a means of stabilizing traumatic cervical injuries. Although increasingly replaced by newer technologies, such as lateral mass screws and pedicle screws, interspinous wiring remains a useful supplemental or alternative means of posterior cervical fixation. The purpose of this chapter is to review the indications, surgical technique, and postoperative management for cervical interspinous wiring. Important Points Wiring…

Lateral Mass Screws

Chapter Preview Chapter Synopsis Lateral mass screw–based instrumentation is a well-established technique for cervical spine fusion. Screw placement is constrained by the course of the vertebral artery, the nerve roots, and the anatomy of the facet joints. Many screw trajectories have been described, each with advantages and disadvantages. This chapter provides an overview of pertinent factors and describes the technique of placing cervical lateral mass screws.…

Cervical Pedicle Screws

Chapter Preview Chapter Synopsis Cervical pedicle screws offer a biomechanical advantage over other types of posterior cervical instrumentation, but at the expense of increased risk of iatrogenic neurovascular injury. Careful preoperative planning with evaluation of three-dimensional imaging and meticulous surgical technique, however, leads to a low incidence of complications, particularly in experienced hands in high-volume centers. The purpose of this chapter is to review the preoperative…