Examples: Young adult female with scoliosis (A), and a progressive neurological deterioration.
She has a split-cord deformity, or diastematomyelia, with a tethering band (yellow arrow, B) passing through the defect in the cord (green arrow)
effects of spinal arthritis, also known as spondylosis. Examples include herniated disks, spinal stenosis, spondylolisthesis, some forms of scoliosis, and many causes of back pain.
Intervertebral (between two spinal bones) joint consists of a soft, gelatinous nucleus pulposis and thick fibrous ring called annulus fibrosus. It acts as a shock absorber, and a restrictor of the joint surface to allow normal movement but prevent abnormal movement. Pieces of the nucleus pulposus may herniate in the direction of nerves or the spinal cord to cause compression.
When pain is difficult to manage with medications alone and no clear surgical lesion exists, electrical stimulators create an electric field that dampens the pain fibers that are traveling near the electrode. These can be placed over the spinal cord or peripheral nerves.
the percutaneous process of using a catheter in the artery leading to a lesion or area to be treated whereby something (small particles, glue, or other substances) is injected into the blood vessels that feed the lesion area. This is often used to reduce the bleeding at the time of surgery, or can be used as a primary treatment option in certain cases.
Use of an endoscope, or a device that allows the surgeon to view the operative area from a different perspective than that of looking straight down. This allows the surgeon to look around objects and view things from a different angle.
Injection into the space around nerves and their covering, called the dura (thus epi-, around, dural). Can be a local anesthetic to reduce pain, an anti-inflammatory steroid to reduce swelling, or both.
Posterior joint of the spine, reduces motion and allows for control of movement. When joints degenerate, they may swell and compress nerves or spinal cord, or they can cause pain by direct arthritic inflammation.
Infections that involve the spine can be in the bone (osteomyelitis), the disk space (diskitis), the epidural space outside the dura (epidural abscess) or inside the dura around the spinal cord or nerve roots (subdural empyema). Infections can be very fast-growing, from aggressive bacteria, or slow-growing, such as with tuberculosis. In addition, infections of the spinal fluid are called meningitis (thus, not all meningitis cases involve the infectious kind that closes schools when an outbreak occurs).
Diseases that result from abnormal function of the immune system, resulting in the patient attacking their own tissues. This may result in masses appearing like tumors, or like infections. There may be erosion or thickening of the bones as a result.
The use of implanted devices to provide temporary or permanent stability to the spine, often to compensate either for instability from the patient’s condition, or from the surgery to treat the condition.
Placement of a catheter into the spinal fluid for direct delivery of medication to the spine and nerves. Medications used include narcotics for pain management, baclofen for spasticity management, local anesthetics for pain management, and others for various aspects of pain management.
A kyphosis is any curve of the spine forwards. There are parts of the spine that are normally kyphotic, including the thoracic spine and the sacrum and coccygeal region. A kyphoscoliosis is an abnormal forward curve, usually one that exceeds the normal amount of curve, making the spine more sharply curved forward, which often creates strain on the spnal cord as well as creating an abnormal position for the body, such as a “gibbous deformity” or “dowager’s hump”.
Laminoplasty is a less invasive and less restrictive way of decompressing the spine, predominately in the cervical spine, when there is significant spinal stenosis. It is a specialized procedure, which requires special training to perform, and is limited to a certain subset of patients (ie, not all patients can have this procedure). When appropriate, this approach can preserve most of the range of motion in the neck, as well as preserving most of the inherent anatomy but essentially double the size of the spinal canal. This typically provides many years or permanent relief from the symptoms the patient was suffering from. It is important to know that this procedure is an option for some patients who might be offered a laminectomy and fusion by a surgeon who does not know how or is not comfortable performing the laminoplasty.
The procedure consists of making two cuts on the back of the spine (the lamina), one full thickness, one partial thickness. The side with the full thickness cut is elevated, and the partial thickness cut is used as a hinge, essentially causing a “green-stick” fracture to make the hinge, but keeping the spine otherwise intact. This way the back of the spine is essentially opened like opening a door, which widens the canal without removing the bones that the muscles of the neck need to attach and maintain normal movement with.
Ligament that connects one spinal level to another that is located behind the dura and nerves, in front of and in between the lamina of one level and the next.
Any spinal curve that goes “backwards”.
One brand of minimally invasive “port-hole” system that provides for approaches to the cervical and lumbar spine, produced by Medtronic/Sofamor-Danek. The system consists of a series of dilators, retractors and working channels that reduce the incision length and OR time but provide equivilant exposures to open techniques. Can be used for a wide variety of conditions and surgical procedures. Can be used with the microscope or endoscope.
Use of an operating microscope to greatly enhance visibility, lighting, magnification, and allows for binocular (full 3-dimensional) viewing of the area in question, instead of just looking at a flat screen as in endoscopic procedures. This requires special training, which not all spine surgeons have. It also requires that the facility where the procedure is being performed has a modern operating microscope.
A general heading for any technology that reduces the incision length, and/or impact on the patient of a given procedure. This can include approaches that are percutaneous, use a port-hole to gain access to an area, use a mini-open technique, or a standard type of opening that is different than the technique used in the past when a procedure was first introduced but now causes less tissue damage, resection, or removal.
“Through the skin”, or as it relates to spine surgery, any technique, either with needles or over guide-wires that are places like a needle, that does not require or allow direct visualization of the part of the spine being operated upon.
the incisions are much smaller, and require much less muscle retraction which may correlate with reduced post-operative pain.
the spine is not visualized, so all the direction of the procedure is done under X-ray or stereotactic guidance, so there is a reliance upon the imaging or computer to ensure the procedure is going well, rather than seeing the procedure directly.
It is very difficult to combine two procedures, such as performing a fusion as well as doing instrumentation with a percutaneous technique, so usually one procedure is sacrificed and not performed (often the fusion is not performed in the above example when compared to either a classic, mini-open, or port-hole technique for instrumentation and fusion).
After nerves have left the spine, they are called peripheral nerves. These can include major or minor nerves of the arms, legs, and other parts of the body. Examples of diseases that may require surgery include tumors of the peripheral nerves, carpal tunnel syndrome, syndromes of sympathetic nervous system dysfunction (like reflex sympathetic dystrophy and hyperhidrosis), trauma, and others.
Use of precisely focused radiation therapy designed to maximize delivery of destructive radiation and minimize exposure of normal tissue by having the beams come from several different directions with the focal point being the region of interest.
Abnormal curvature of the spine. This can be forwards (kyphosis) or backwards (lordosis), side to side, or a combination of the two. There can be just one abnormal curve, one with compensation, or two separate pathological curves. Many, but not all, examples of scoliosis are caused by an underlying deformity or condition that may also need to be treated at the time of surgery.
Injection to the outside of the nerve that results in reduction in pain and partial numbness in one particular spinal root distribution. Can be used as a diagnostic tool (is this the nerve root involved?) as well as a therapeutic tool (to treat the pain directly).
(AKA slip) Abnormal orientation of the spine where one bone has slid forward or sideways on the next one. This is usually caused by loss if integrity of the joints of the disk and/or the facet joints, or loss of integrity of the bone that makes up the spine connecting the disk to the facet joint, known as the pars interarticularis. The later instability is known as a spondylolysis.
(AKA isthmic spondylolisthesis) Defect of the pars interarticularis, either congenital or traumatic, that results in a disconnect between the front part of the spine (the vertebral bodies and disks) from the back (the facet joints) at one or more levels. This results in instability of the spine, although the instability may only be symptomatic from time to time, as there is often scar and adhesions that hold the spine together pretty well until something tears the scar (some minor or moderate trauma, often) which unmasks the instability. This results in differential movement of the front of the spine from the back, and often results in widening of the spinal canal at that level as the disk and facet drift slowly apart.
Use of computer guided navigation that makes surgery safer by comparing visible landmarks with preoperative imaging studies to “see” where items are that are not on the surface of the exposed tissue. Uses include telling which part of brain is involved with tumor, where the best path to place screws is, and other forms of computer-assisted surgery.
Injury arising out of accident or violence. Examples include falls, stab wounds, gunshot wounds, car accidents, injuries at work, etc. Many patients with trauma are young and otherwise healthy, but trauma can occur to anyone.
Young male after motor vehicle accident. The patient did not survive long after arrival at hospital. Note the complete separation of the second from the third cervical vertebra.
Cancerous or benign masses that occur where they do not belong. Some require surgery, some can be treated with radiation, chemotherapy, immunotherapy, and other modalities. Many will cause weakness in the bones and collapse, some cause overgrowth and compression of neural or other structures.
Benign tumor – a simple growth that does not respond to the normal signals to stop growing but does not represent a cancerous growth that can spread
Malignant tumor – growing without control and with the potential to spread to other areas of the body either through the blood stream or through local aggressive spread and growth
Metastatic tumor – Metastatic cancer is cancer that has spread from the place where it first started to another place in the body.
A patient with tumor involving the L1 and L3 bodies, and radiation changes at T12, L2, and L4. The L1(image B) and L3(image C) bodies have collapsed, with the collapsed fragments at L1 compressing the spinal cord and nerves. The spine is unstable. This patient underwent resection of both vertebral bodies via retroperitoneal approach and stabilization anteriorly and posteriorly.
A patient with tumor involving the thyroid gland that eroded through the spine and compressed the spinal cord and nerve roots of the arm. She presented with loss of leg function and sensation, as well as loss of right arm function except at the shoulder. She underwent a posterior debulking procedure with instrumentation. She woke up and over the next several days regained the use of her arm and legs.
40 year old female with progressive back pain, radiating leg pain, and subtle bladder dysfunction. She had a benign lesion of the dura called a meningioma that was completely removed via laminectomy. She is doing well with no recurrence.
Two similar techniques, usually using a percutaneous technique, to put a large bore needle into the back of the spine through to the vertebral body.
In Vertebroplasty, the empty space in the bone (and often in between fracture fragments in the case of a compression fracture) is filled with a bone cement to provide extra stability and prevent further compression, fixing the bone where it is at that moment without inducing any change in the shape or size of the bone.
In Kyphoplasty, once the needle is in place, a balloon is blown up in the space to try to reinflate the vertebral body back to a taller height, as well as create a well defined cavity to fill with cement. The balloon is then removed and the cavity is then filled with cement, in an attempt to restore some lost height to the vertebral column.