Operative and Post-Operative Management of Spine Conditions

What are the two main goals of surgery?

decompression and stabilization

What are the indications for surgical management of radiculopathy?

- > 3 months of persistent or recurrent pain (referral to extremity)

- neurological deficit interferes with function

- failed non-operative care (PT, pharmacoogy)

What are the indications for surgical management of myelopathy?

- moderate to severe symptoms impacting QOL and function

- ataxic gait

- hand dysfunction

- neurogenic bowel and bladder

- spinal stenosis on imaging

progressive disease

True or false: the surgical outcomes for axial cervical pain are unpredictable

true

True or false: axial cervical spine pain can radiate

false

What are the three most commonly performed surgical interventions for single level resulting from disc herniation?

anterior cervical discectomy and fusion, cervical disc arthroplasty, foraminotomy

Anterior cervical discectomy and fusion

- disc and end plate cartilage removed to uncovertebral joints with a contoured graft placed into disc space

- internal fixation is performed to aid in stabilization and to increase fusion rate

True or false: a laminotomy with foraminotomy is a surgical procedure used to treat unilateral radiculopathy

true

True or false: with a laminotomy with foraminotomy, surgeons ideally want to preserve 75% of the facet joint to reduce segmental instability

true

laminotomy with foraminotomy

remove part of the lamina and then excise the disc fragment

What is the surgical goal of cervical myelopathy?

halt neurological progression and reduce pain

True or false: surgical approaches for cervical myelopathy are usually posterior

false

For a spinal cord compression due to a disc that causes cervical myelopathy, what type of surgery can be performed?

a. laminotomy with foraminotomy

b. anterior cervical discectomy and fusion (ACDF)

b

corpectomy

removal of central portion of the vertebral body and the discs above and below

What is the principle posterior procedure for surgical treatment of cervical myelopathy?

laminectomy with or without fusion and laminoplasty

What is a relative contraindication for surgical treatment of cervical myelopathy>

kyphosis (spinal cord posterior movement is less likely with presence of kyphosis)

laminectomy

SP and lamina removed as a block held together by ligamentum flavum and the facet joints are left intact

True or false: with a laminectomy, there is a change for an increase in instability due to how much was removed

true

What is the intent of a laminoplasty?

decompression of the spinal canal while preserving the posterior bony and ligamentous structures

What are red flag findings after surgery?

- change in neurological examination findings of symptoms

- worsening pain

- difficulty swallowing

- erythema/fever/wound drainage

What are the indications for surgical internventions for the thoracic spine?

- progressive myelopathy

- lower extremity weakness

- unremitting pain after conservative care (PT and pharmacological)

True or false: a transthoracic procedure offers the widest exposure to the thoracic disc

true

Why is a left-sided approach preferred for transthoracic procedures?

to avoid the inferior vena cava and liver

What is the indication for a costotransversectomy?

posterolateral and lateral disc herniation

costotransversectomy

posterior medial portion of the rib resected, TP and pedicle excited, disc fragment and often the posterolateral portion of adjacent vertebral body removed

What is the indication for transpedicular procedures?

only posterolateral or foraminal herniation

transpedicular procedure

lamina, facet joint, and pedicle removed

What are the indications for lumbar spine surgery?

failed conservative care for 6-8 weeks, severe or worsening motor deficit

What are the indications in performing a discectomy for unilateral radicular leg pain?

- imaging confirms correlating lumbar disc herniation

- failure of conservative care for 6-8 weeks

- severe or worsening motor deficits

open discectomy

removal of posterior annulus and PLL

True or false: an open discectomy utilizes a 2-3cm incision

false - microdiscectomy

What are the indications for a posterior lumbar interbody fusion (PLIF)?

persistent and disabling pain following prolonged non-operative care

posterior lumbar interbody fusion

portion of lamina and superior and inferior facets are removed, removal of disc material

What are the indications for an anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF)?

DDD, chronic LBP, degenerative spondylolisthesis, failed posterior surgery

What levels are most common for an ALIF?

L4/L5 and L5/S1

What is a contraindication for ALIF?

neural compression - decompression of spinal canal and foramen is safer via posterior procedures

What are the contraindications for a lateral lumbar interbody fusion (LLIF)?

L5/S1 level due to iliac crest barrier

What are the indications for a lumbar disc arthroplasty?

- failed >6 months of conservative care

- single-level DDD confirmed by imaging

- no previous lumbar fusion

- no instability

- no extruded disc material

True or false: lumbar laminectomies have a very high success rate in eliminating neurogenic claudication

true

What are the indications to perform a lumbar laminectomy?

intractable pain recalcitrant to non-operative care, neurological deficits significantly impairing lifestyle and function

What are the indications for a posterolateral fusion of the lumbar spine?

trauma, tumor, infection --> spine is unable to support physiological loading; ishmic spondylolisthesis

True or false: it is important for ambulation to begin as soon as possible after surgical treatment of scoliosis

true