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By the 1-year follow-up [lateral (d) and anteroposterior (e) X-rays], the patient had regained motor strength and was ambulating with a walker, but he still had a neurogenic bladder. The point where this line intersects the previously marked line denoting the axial plane is the site of the skin incision. This is on the ventral surface of the clivus at the symphysis between the basisphenoid and basiocciput. These systems have improved flexibility with regard to correcting/accommodating deformity and achieving immediate rigid internal fixation and high rates of fusion. Damage to the nerve eventually becomes permanent as the myelin sheath cannot be repaired and axonal damage occurs. Cutaneous findings are common and can include a sinus ostia dorsal to the spine, skin tags, hypertrichosis, abnormal skin pigmentation, angioma, and symptoms of a superficial infection such as erythema or induration. The rib is harvested as far posterior to the costotransverse junction to provide adequate exposure and can be used as graft material. It has been theorized that "equal drainage" for the ventricular and cranial subarachnoid spaces would lessen the risk of subdural hematoma, but this has not been demonstrated by any clinical study. Compared with the transoral approach, this approach provides broader, more extensive exposure. A 20-year-old woman has had bouts of pancreatitis twice a year for the past 5 years. Ependymomas of the filum terminale in childhood: report of four cases and review of the literature. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. We prefer to use a Kerrison punch with a curved tip; when inserted into the foramen it targets the superior facet while preserving the pars interarticularis. Renal dysgenesis occurs 40 times more often in patients with Klippel-Feil syndrome than in the general population and may predispose these patients to uremia. Biomechanical and clinical outcomes studies have shown that pedicle screw fixation enables high fusion rates with preservation of height and lordosis and lower rates of instrumentation failure and pseudarthrosis. Upon closure of the neural tube, the redundant membranes are discarded, but recontamination occurs due to the additional neural folds. The exposed tumor surface should be visualized, including the rostral and caudal tumor poles. More recently, topical antibiotic powder administered throughout the wound prior to closure has been shown to reduce the incidence of postoperative wound complications. The line of incision for diaphragmatic detachment is marked with monopolar cautery. Conclusion the retropharyngeal approach to the occipitocervical junction is predicated on careful and complete dissection of sequential layers of cervical fascia investing the submandibular triangle. The root in the lateral recess is called the traversing root, whereas the root in the foramen is called the exiting root. After a large cavity is created in the middle of the vertebral body, the posterior portions of the body adjacent to the thecal sac can be removed by using curettes to push the fragments to ward the empty cavity, making sure to direct all forces away from the thecal sac. A dose of intravenous antibiotics is administered, and the lumbar region is widely prepped and draped. An equally important surgical landmark, the carotid sheath, should be given attention at this time. Once symptoms commence, then surgery is offered, before the onset of any significant neurologic deficit, because surgery is usually not effective in reversing neurologic deficits. It may be necessary to widen this in the case of very calcified disks or those that have migrated behind the vertebral body. Patients who were treated via direct posterior midline approaches for thoracic disk herniation often had poor results.

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Therefore, it is best to use an angled curette to dissect the superior aspect of the ligamentum flavum from the dura in the midline. Surgical correction of the bony deformity by direct means, such as wedge osteotomy, is not recommended. The overall risk of the procedure in patients with suspected gallstones is 2% to 7% for diagnostic Box 39. Similarly to how this is performed in the cervical spine, these uncovertebral joints can be identified by the upward course of the end plates and will demarcate the lateral borders of the decompression. If extensive lumbosacral exposure is required or if arterial or venous anatomy prevents the interiliac approach, the common iliac vessels are reflected to the right. Both types of ports attempt to put minimal compression on the intercostal nerve bundle running on the caudal aspect of each rib, thus decreasing postoperative intercostal pain. Primary tumors of the spine are far more rare; they account for only 10% of spinal tumors3 and can be either benign or malignant. Exposure As one proceeds more caudally and encounters the segment overlying L5S1, this becomes even more apparent and can be a helpful landmark in the very obese patient in whom precise localization can be problematic. Because this is a transpedicular approach, this trajectory may be utilized to rescue fixation with a pedicle fracture using a conventional pedicle screw approach. Multidisciplinary care is needed for continued welfare of the child, as many children have associated congenital anomalies with occipitocervical encephalocele. External neurolysis, in which dissection is performed around the epineurium, and internal neurolysis, in which an interfascicular dissection is performed, are options to decompress the injured neural elements. The initial diskectomy is performed by removing the disk material that clearly lies away from the ventral canal. Briefly, the patient is positioned prone with gel bolster chest support and appropriate padding of pressure points, and the head is immobilized with the Mayfield three-point skeletal fixation device. According to Schwab et al,57 there are varying degrees of destabilization through an osteotomy based on the amount of bony resection, with six grades of potential destabilization: Grade 1: partial facet release. Approach A muscle-splitting approach involves division of the abdominal skeletal musculature along anatomic planes. Dissection of the subcutaneous tissues can be completed with either the scalpel or the monopolar electrocautery. The exposure is limited by the amount of manubrium resected, as further resection can result in a larger manubrial defect and a higher risk of sternal nonunion. Although the inciting cause of inflammation is unclear, the inflammatory process itself is well described. Although there have been reports of reabsorption of calcified thoracic disks associated with resolution of the clinical symptoms,53,62 some authors believe that this type of disk herniation does not usually regress and should be always treated surgically if symptomatic. As with bone tumors in other areas, night pain is frequently associated with neoplasm. In an axonotmetic injury, both the myelin sheath and axon are disrupted, resulting in distal wallerian degeneration. As a further confirmatory measure, contrast can be injected into the corpectomy defect, and a lateral fluoroscopic image can confirm that there are no filling defects, thus providing confirmation that all compression has been addressed. For thoracic lesions, ventral decompression and fusion via a ventrolateral or dorsolateral approach is generally recommended. Plain film evaluation is repeated with the patient upright in an orthosis to again verify the integrity of the construct and ensure that no kyphosis has occurred. Advantages and Disadvantages Perhaps the primary advantage of the transcervical approach over the transoral and endonasal alternatives is the avoidance of the contaminated nasopharyngeal and oral mucosa. In the lumbar spine (particularly for a singlelevel lumbar diskectomy), the level is initially approximated from the plain X-rays, realizing that the iliac crest usually passes through the L4-5 interspace. In the majority of series, the most common site of fusion is between the second and third cervical vertebrae, with fusion of the fifth and sixth cervical vertebrae seen next most commonly. This exposure provides access to the lumbosacral spine and superior sacrum medial or lateral to the iliac vessels. The surgeon will feel the posterior lateral wall of the abdomen and the quadratus lumborum that leads directly to the psoas muscle.

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Successful treatment with stand-alone arterial embolization has also been reported. Although they are benign, their rapid enlargement can lead to neurologic compromise due to spinal instability or cord impingement. Clinical Presentation In sacral agenesis it is estimated that one fifth of the patients are not diagnosed before the age of 3. This exposure provides direct access for the relief of compression from basilar impression, the resection of neoplastic lesions, and the repair of chronic fractures and pannus with broader and safer latitudes than those available via the transoral route. A large Leksell rongeur can be used for the initial portion of the laminectomy, with the lower blade placed just beneath the leading inferior edge of the lamina 30 degrees from the vertical or 60 degrees to the long axis of the spine. In selected cases, adjustable valves are used, but with the knowledge that it will likely be difficult to change the settings once the system is implanted. Cervicothoracic Pedicle Screws Pedicle screw fixation of C7 and the upper thoracic vertebrae is a good option in most cases of posterior instability, but it is technically challenging for several reasons: (1) the pedicles are narrow and routinely more tall than wide. Adjacent vertebral bodies are held together by an intervertebral disk and anterior and posterior longitudinal ligaments. Care is taken to ensure that the eyes, axillae, ulnar grooves, breasts, genitals, and bony prominences are free from compression, with foam padding placed as needed. Cells located next to the segmental arteries proliferate faster than those located farther away. Our preference for performing the endoscopic thoracic sympathectomy is to create a sympathectomy using either monopolar cauterization scissors or a harmonic scalpel. If the patient has a stable cervical spine, a shoulder roll is placed to aid neck extension. If an expandable cage is to be used, the proper-sized footplates are attached to the cage. Therefore, additional exposure can be gained with the median labiomandibular glossotomy approach. Blunt finger dissection of the mediastinal contents from the inner table of the sternum is then performed. Adhering to strict perioperative guidelines regarding antibiotics, systemic as well as topical, can minimize wound infections. The minimally invasive microscopic transoral approach was later modified with endoscopic applications. Of these patients, 15 received proton therapy as adjuvant therapy and six as first-line treatment; overall survival at 10 years was 62. Preoperative Imaging and Planning Imaging studies of the thoracic and lumbar spine should be obtained to determine the level of surgery and confirm the number of ribs. Although true radiculopathy occurs infrequently, children may complain of radiation of pain into the buttock or legs. Ultimately, the exact location of the incision should be based on the initial intraoperative image and should allow the surgeon a perpendicular access to the pathology. If a rise in temperature is not seen, the sympathetic chain ganglia must be inspected for accessory connections that could be transmitting sympathetic tone to the arm. The neck is flexed as needed to obtain adequate exposure of the encephalocele, and the occipitocervical region is prepped and draped in sterile fashion. The mucosa is incised over the hard palate slightly off the midline, continuing posteriorly through the soft palate, staying on one side of the uvula. Multiple biomechanical and clinical studies have demonstrated that percutaneous facet screws are a suitable alternative to pedicle fixation as an adjunct to interbody fusion. During the anterolateral dissection of the vertebral body, a wrapped sponge in the form of a cylinder is used to progressively separate the great vessels from the spine. Paralysis of both arms from injury of the upper portion of the pyramidal decussation: "cruciate paralysis". Thus the roots corresponding topographically to the muscles harboring "harmful" spasticity are identified prior to sectioning decision. As with the other types, fractures pattern and ligamentous injury should be classified and noted in addition to the type C injury.

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We are not convinced that this adds any protection against recurrent disk herniation, and we do not perform this as a routine practice. The goals of a minimally invasive approach are laudable, with reduced pain, disability, blood loss, and infection. For positioning the patient, awake traction reduction with either Gardner-Wells cervical tongs or a halo ring is safe and usually effective. Patients who have a significant nociceptive component to their pain (such as many patients with malignancies) may not obtain as much relief from the procedure. In patients with malignant processes (life expectancy < 1 year) a bony fusion would be inhibited by the use of adjunctive radiation or chemotherapy as well as the generally poor systemic health and nutritional status of these patients. Impact of spinopelvic alignment on decision making in deformity surgery in adults: A review. Inclusion of the vertebrae adjacent to the level of the injury is essential if the disk spaces adjacent to the vertebral body fracture have been injured. A good understanding of the retroperitoneal anatomy is critical for this approach to avoid ureter, vascular, or peritoneal violation. Pathological fracture, progressive deformity, and tumor invasion may cause neural canal or foramen compromise, resulting in neurologic symptoms from root or cord compression. More cephalad exposure can be achieved by wanding the tubular retractor upward and removing more of the superior lamina. Moreover, with the exception of cranial applications and true basilar invagination (osteogenesis imperfecta), the transcervical operation precludes a resection of the C1 ventral arch for upper cervical lesions. Depending on the graft used (lordotic or parallel), the end plates can be milled to facilitate a press-fit construct with either a cage or allograft spacer. Although the procedure does not require an arthrodesis, it is limited to solely foraminal pathology. In the direct extension variation of terminal lipoma, the lipoma is easily identified as adipose tissue due to its inherent yellow color versus the pink, velvety appearance of the spinal cord. The disk ratio of nucleus to annulus is 2:1, which is greater than that of more cephalad disks, whose ratio is closer to 1:1. In patients who have previously placed pedicle screw instrumentation, exposure of the previous instrumentation to enable removal of the set screws and rods and interrogation of the pedicle screws is often done more expeditiously through an open approach. Flexion and extension of the cervical spine may exacerbate this relationship between the vertebrae. Potential need for long-term antiplatelet or blood thinning agents if vertebral dissection is encountered should also be discussed. Trilator measurements taken from this rod determine the lengths of the L5 and the S1 segments of the device; the device is assembled before insertion. Furthermore, because many spinal conditions are self-limited or improve with nonoperative modalities, surgery is generally considered only if symptoms persist despite 6 weeks of conservative management including oral pain medication, physical therapy, and epidural steroid injections. An avascular plane is created with the esophagus and trachea retracted medially, and the carotid sheath is retracted laterally, as described above. The incision should center over the anterior iliac tuber cle where the quantity of corticocancellous bone is greatest, as discussed above. Disadvantages the treatment could potentially prolong death if the child is terminally ill. Immediate hypotension is seen, and an emergent call to general surgery for open or endovascular repair must be done expediently. Spinal decompression is performed using longer and bayoneted versions of the typical instruments (drills, suctions, curettes, nerve hooks, and rongeurs).

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The diameter of the common bile duct is normally 3 to 6 mm, and it may increase with advancing age. Often after freeing of the neural tissue from the healthy epithelium, the placode inherently rolls into its natural tube-like structure, especially at the rostral end of the defect. If a calcified fragment is identified, then a larger trough is made extending into the vertebral body for its delivery. As supporting data continue to accumulate, conclusions will eventually be drawn to guide treatment decisions. Of the 11 patients who initially presented with lower extremity symptoms (pain or weakness), nine ultimately required surgical decompression (82%). A gel roll or rolled blanket may be placed ventrally to elevate and support the pelvis, permitting relaxed hip abduction, such that the abdomen is relaxed and not in contact with the operating table. Pillows are placed between the legs, and the up leg is flexed at the hip and knee to relax the psoas muscle on the approach side. Longlasting curarization, as well as narcotics or analgesics that could influence neural activities, should be avoided so as not to affect muscular contraction responses to stimulation. This should include a contrasted sequence if a mass lesion such as a tumor or abscess is determined to be the primary pathology. The stimulator probe is used to confirm that the lumbar plexus is sufficiently remote from the entry point. Iniencephaly is characterized by a short immobile neck with a hyperextension deformity of the head. A majority have physical or mental impairment, although a minority with minimal brain tissue involvement in isolated small defects may attain a normal level of development and function. A 65-year-old woman with an unremarkable medical history complains of vague, infrequent right upper quadrant discomfort. For this reason, the spinal axis (spinal cord and brainstem) needs to be evaluated in all patients with a congenital spine deformity. Embryologically, the caudal eminence, a mass of pluripotent cells that is continuous with the primitive streak, gives rise to the caudal spine, hindgut, and genitourinary system. Surgical treatment of Chiari malformation with and without syringomyelia: experience with 177 adult patients. Sandhu Anterior exposure of the upper lumbar spine is challenging due to the critical structures located in the abdominal cavity and thorax. Injury isolated to a nerve root or a complete spinal cord injury is assigned 2 points, whereas an incomplete injury, conus medullaris, or cauda equina syndrome is assigned 3 points (Table 87. Cytokines and growth factors in the protruded intervertebral disc of the lumbar spine. Pain is well controlled postoperatively given that a large percentage of patients experience lower back or leg. Spondylolysis and Spondylolisthesis in Children 533 technique that we typically use. Objective For diskectomy, the objective is removal of the pathological disk fragment through a ventral approach. The intima pia is densely adherent to the underlying glial outer limiting membrane of the spinal cord. Anterior approach to the cervicothoracic junction by unilateral or bilateral manubriotomy. This defines the medial edge of the platysma muscle and initiates vertical access to allow easier retraction of deeper structures. Enzymes taken before or after a meal are not as effective as enzymes taken during the meal. Routine imaging should be ordered to evaluate hardware placement if stabilization was performed. Surgical Procedure Patient preparation and placement in a "chin tuck" position is performed as described in Chapters 17 and 19. This ensures visualization of the complete segmental anatomy as well as exposing an appropriate bony bed for fusion.

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These two features are often interpreted with caution in the grading of ependymomas. In addition, the sternohyoid and sternothyroid muscles are dissected and reflected medially. Because many patients progress over a considerable period of time before a diagnosis is made, it can be argued that the delay in diagnosis rather than the degree of neurologic impairment is the major reason for incomplete recovery. The sublabial gingival mucosa is reapproximated with interrupted absorbable sutures. Separate tumors of different sizes tend to develop on multiple fascicles; occasionally, a predominant mass may occur in the setting of innumerable smaller tumors. In the event that the dura is opened, broad-spectrum intravenous antibiotics and spinal drainage are maintained 52 8 Transoral Closure 53 a b c. The early construct failure rate dramatically increases with multilevel constructs. Surgical management of these lesions is a complex feat, and further research into less invasive and more effective treatment methods is necessary. These mesh cages are implanted in a vertical orientation between the vertebral end plates of a corpectomy defect. In addition, connective tissue scar within the site of regeneration impedes regenerating nerve fiber growth. As some patients may present with 11 or 13 ribs, it is recommended to count in both the rostral and caudal directions, so counting is confirmed from T1 caudally as well as from L5 rostrally. Although this is higher than what is usually used, it provides a "cushion" that theoretically would increase safety. Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise Treatment of traumatic thoraco lumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment. But many centers worldwide perform these surgeries, with different degrees of expertise and surgical skills, varying amounts of equipment, and varying results, despite the steep learning curve. Conclusion Facet fixation is a well-described technique with over 50 years of use. The free-hand technique relies on the proper identification of anatomic landmarks and on surgeon experience. Wherever possible, in segments adjacent to the laminectomy, transosseous reattachment of muscles to the spinous processes should be undertaken, followed by careful midline suturing of the fascial and dermal layers. The abdomen should hang free to avoid increased pressure in the epidural veins, which can lead to increased bleeding during the procedure. For classic lesions located at the nerve root sleeve, a laminectomy or laminoplasty is completed eccentric to the side of the lesion. The central port is accessed using a noncoring (Huber) needle, any excess drug within the pump is drawn off, and the pump is filled with a full volume of medication. Abnormal neurologic signs such as hyperreflexia and Babinski responses were presents in 80% of patients. The use of Ray-Tec sponges can help dissect the soft tissue in a subperiosteal manner. Neurologic Problems No specific symptoms can be attributed directly to congenital fusions in the cervical spine. A fixed retractor and endoscope are mounted on the side of the table that is contralateral to the surgeon and caudal to the surgical field. For pedicle screws, the commonly used methods are discussed in the following subsections. The patient is then placed in the prone position, with small gel rolls on the chest and hip.

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Often the height of the iliac crest prevents a direct lateral approach to the disk space, especially at the L4-L5 level. Standard diskectomy is performed using curettes and pituitary and Kerrison rongeurs, used with care to remove only the cartilaginous end plates. Therefore, the anteriorly situated carotid arteries and accompanying sympathetic nerves have a decreased risk of injury. Loupe magnification or an operating microscope is essential for identification of the fascicles coursing over the tumor. Biopsy can be either closed or open, but a closed biopsy is recommended as the first-line treatment. Restoration of the musculotendinous gluteal and abdominal attachments over some type of solid support. The alar ligaments limit lateral rotation, and, similar to the transverse atlantal ligament, they also resist posterior translation of the dens. If a "shallow docking" (described below) technique is used to directly visualize and split the psoas muscle and genitofemoral nerve, rather than blindly placing sequential dilators, then the retractor should target zone 3. The diagnosis is often made early because of unaesthetic disfigurement (shoulder asymmetry) or functional difficulties (limited abduction). Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. Using an electrocautery device, the paraspinous muscles are removed from their C1 attachment to expose the arch of C1. The atlantoaxial complex depends on the transverse and alar ligaments and to a lesser degree on the apical ligaments for stability. A 0-degree endoscope with an irrigation sheath in placed in the right nares and the surgical instruments in the left nares. This exposes the position of the rostral and caudal vertebral bodies for eventual placement of a ventral stabilization plate. Still, some common postoperative sequelae should be avoided, including poor wound healing or infection, especially of sural nerve harvest incision sites. Posteriorlateral foraminotomy as an exclusive operative technique for cervical radiculopathy: a review of 846 consecutively operated cases. This approach poses less risk to the peritoneal organs and great vessels, while providing unilateral visualization of the vertebral body and intervertebral disk space. Because of the angle of approach to the lamina, a drill is required for this step to remove this portion of the lamina. At the level of the lesion, the cord is displaced anteriorly and its borders ill-defined. Indications the high anterior retropharyngeal approach is an effective surgical option for treating basilar impression, occipitocervical osseous anomalies. Note the proximity and displacement of the distal conus medullaris along with the prominent draining veins on the spinal cord surface. Ossification of the vertebral column in human foetuses: histological and computed tomography studies. New Developments Surgery is a dynamic specialty that fosters innovation and the never-ending search for less aggressive and more effective techniques or equipment to treat diseases. When the fascial defect is identified, the fat lateral and dorsal can be removed with scissors and bipolar cautery. It should be noted that radiographic evaluation of fusion does not always correlate with intraoperative findings in a subsequent "second look" surgery. Surgical management of spinal cord hemangioblastomas in patients with von HippelLindau disease. The size and material of the rod is also important in choosing the best construct for a specific patient. The lamina may then be removed either manually or using a high-speed drill and bone punch (such as a Kerrison), and any residual ligamentum flavum trimmed back.

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The transpedicular approach is ideal for centrolateral to lateral disk herniations that are soft and extradural. Indeed, an acute or subacute onset of a significant neurologic deficit with little or no spinal cord en- largement is nearly always associated with a medical myelopathy rather than an intramedullary tumor. One-stage posterior decompression and reconstruction of the cervical spine by using pedicle screw fixation systems. The prevalence and characteristics of thoracic magnetic resonance imaging findings in men. Adherence to these guidelines will ensure that the patient has the highest chance for cure and will minimize postoperative complications. Effectiveness of cervical spinal cord stimulation for the management of chronic pain. Intermittent nasogastric suction may reduce nausea in the early postoperative period, but the nasogastric tube should be removed as soon as possible to prevent sinus infection. Once a cavity is created (by performing the initial diskectomy and adjacent bone removal), the remaining disk can be reduced into this cavity, thereby directing all force away from the spine. However, for a vertebrectomy, rib resection is still necessary to obtain adequate exposure, with the skin incision made as for a retropleural approach. Pterygium Colli Patients with Klippel-Feil syndrome may have pterygium colli, which is various degrees of webbing of the skin from the side of the neck to the shoulders. The influx of combined fluid and inflammatory mediators produces the pain, swelling, and erythema that characterize rheumatoid synovitis. The goal is to access intradurally the contralateral root, with its ventral and dorsal components, at exit to the corresponding dural sheath. Its strengths are its ability to provide the surgeon with a wide field of vision within the thoracic cavity, as well as the ability to operate on multiple thoracic spinal segments. Peritoneal laceration should be repaired primarily, and perforation of bowel requires the expertise of a general surgeon. Transverse Ligament Disruption C1-C2 subluxation can occur with or without the disruption of the transverse atlantal ligament. Nerve grafting was first introduced by Seddon32 in 1963 and remains the most commonly employed technique in nerve reconstruction surgery. An anterior cervical procedure necessitating manipulation of the esophagus may result in severe dysphagia. Recent studies suggest that microlithiasis may account for an unexplained attack of acute pancreatitis in as many as 75% of patients with a gallbladder in situ. Many of these patients were made worse following surgery (combined results from multiple series demonstrated that 28% of patients worsened and 11% showed no improvement), presumably from inadequate decompression of the ventral force, spinal cord retraction for those attempting to access a ventral disk, "watershed" blood supply, general smaller diameter of thoracic canal versus lumbar/cervical, and the absence of modern microsurgical instruments and techniques. Tight fascial and skin closure along with intra-wound vancomycin powder can reduce the risk of wound infection. Carson and colleagues11 reported on an alternate posterolateral approach with total removal of the facet complex accomplished through a T-shaped incision. The validity of the Tokuhashi and Tomita scores, however, has yet to be established. Central calcified disks are better treated through an anterior or a far-lateral approach, whereas soft lateral disks can be successfully managed through posterolateral approaches. During removal, the surgeon should be careful not to apply excessive tension to the fatty stalk, as it is firmly attached to the spinal cord. Also, both the superior and inferior lamina should be undercut to provide adequate room for the neural elements when the osteotomy is closed. Gentle pressure on the cottonoid with a suction tip in one hand will protect the dura as ligament and bone are removed with a Kerrison in the other hand. The long-term results of kyphectomy and spinal stabilization in children with myelomeningocele. Serial examinations can be critical in distinguishing complete from incomplete injuries, which may have dramati cally different treatment implications. Additionally, in the case of prenatal myelomeningocele repair, the patient risks include low birth weight and neonatal respiratory distress syndrome. The defects are covered by skin; unlike myelomeningoceles, they are less readily apparent on clinical examination and may not be noted until later in life.

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Coccygectomy at this level is recommended in all cases, as it has been reported to prevent recurrence. The variable trajectory systems may also be easier to use when working in the high cervical spine or near the cervicothoracic junction, where the jaw or the clavicle, respectively, may make standard instrument placement. Percutaneous screw insertion minimizes the skin incision and dissection of the paraspinal muscles. However, care should be taken between the C2 transverse process and the C2-3 interspace, where the anatomy can be variable. Hsieh et al concluded, "We also need to improve our ability for spinal reconstruction after aggressive tumor excision to provide patients with long-term fusion and stability of the spine. The imaging may also demonstrate compression of the nerve root from a disk herniation or less commonly compression from a synovial cyst arising from the facet joint. Surgical Procedure the tubular retractor approach is performed as described in Chapter 95, with the inferior laminar edge in the center of the field. Intertransverse process lumbar arthrodesis with allogeneic fresh-frozen bone graft. Incision the incision is planned to enable primary skin closure at the end of the surgery, such as longitudinally, or a vertical ellipse if needed. The tract can then be marked by injecting sterile methylene blue, although this is not our practice. A higher rate of leg dysesthesias has been reported in patients receiving internal fixation, and up to 15% of instrumentation systems have been removed secondary to so-called hardwarerelated pain. Likewise the facet joints should be exposed only when needed, and when they must be exposed care, should be taken to avoid injury to facet capsules not included in a fusion to reduce the risk of destabilizing the spine. Instrumentation and improved graft options have led to increased success rates and reduced morbidity. Pain may be radicular, ischemic, related to injury of the peripheral nerves, or a part of a complex regional pain syndrome. Potential Complications and Precautions Complications inherent to any posterior cervical instrumented arthrodesis may occur, including, but not limited to , vertebral artery injury, incidental durotomy, neural element injury, and C5 palsy. The definitive treatment of rheumatoid cranial settling is dorsal occipitocervical fusion. Approach A standard anterior cervical approach to the C5-C6 level should be performed, either from the left or right side. A method for calculating the exact angle required during pedicle subtraction osteotomy for fixed sagittal deformity: comparison with the trigonometric method. The dura rostral to the lipoma is then opened in the midline and retracted to expose the spinal cord. A review of three studies with a total of 380 patients with chondrosarcoma of the skull base treated with proton beam therapy reported a 5-year progression-free survival of 95%, which was observed to be no different than the results of conventional therapy. Because the wire is placed at the midline, it provides less rotational stability than bilaterally applied lateral mass fixation. These elements distribute forces evenly over the inferior and superior vertebral body end plates. In cases of pathological fracture and the need to decompress the canal with reversed curettes or a power drill, a pedicle or a portion thereof may have to be removed for access. C2 is characterized by the odontoid process (dens), which projects upward from the body between two lateral masses. A retrospective study of 113 consecutive cases of surgically treated spondylodiscitis patients. Infectious complications of intrathe cal baclofen pump devices in a pediatric population. Then a clamp is placed on the spinous process, and a single fluoroscopic image is taken. Because the levels above and below the fracture are autofused, forming a large level arm, multiple points of fixation above and below the fracture are recommended, to provide op timal biomechanical stability and to prevent failure and screw pullout. This direct access is created by disruption or resection of bony anterior thoracic structures (sternum, manubrium, clavicle) and ligamentous structures.

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On the other hand, the lateral and ventrolateral approaches (costotransversectomy, lateral extracavitary, thoracotomy) enable greater ventral exposure. Finally, it obviates the need for the assistance of an approach surgeon for the thoracotomy. This approach can be performed on two sides to facilitate complete spondylectomy if necessary. They also found evidence of vertebral subluxation > 5 mm on the radiographs in five of their 20 patients. Because it is positioned superficial to the segmental and intercostal vessels, the sympathetic chain can be transected without sacrificing any of these vessels. For major spinal reconstructive procedures the intraoperative administration of antifibrinolytics (aprotinin, tranexamic acid, e-aminocaproic acid) has been gaining increasing popularity. Arrows mark the vertebral end plate, and asterisks indicate anterior direction in sagittal sections. Differential diagnosis and surgical treatment of primary benign and malignant neoplasms. During weeks 3 to 4, the neuroectoderm undergoes thickening, narrowing, and elongation with the aid of microtubules regulated by the mesoderm. The anterior chest wall should have adequate room for expansion during the surgery. They are the thinnest in the cervical spine and make traditional techniques for lateral mass screw placement more difficult and more likely to result in a fracture. Thus, a significant proportion of injuries require surgical decompression and open stabilization. Finally, the apical ligament arises from the tip of the dens and attaches to the foramen magnum and is considered a notochordal remnant. Without closure of the pial layer, there may be an increased risk of tethered cord syndrome later in life. Edema, epineural fibrosis, and further thickening of the nerve occur with chronic compressive lesions. Posterior cervical arthrodesis and stabilization: an early report using a novel lateral mass screw and rod technique. The type I kyphotic deformity is the most common and the most likely to progress rapidly and cause neurologic deterioration. Cervicothoracic junction kyphosis: surgical reconstruction with pedicle subtraction osteotomy and Smith-Petersen osteotomy. This technique has been almost completely replaced with other methods, but it is still found in the literature and so it is appropriate to understand the procedure. Hemostasis is obtained via careful bipolar cautery and packing with topical hemostatic agents in the deeper spaces. Alternatively, the epidural space can be accessed more inferiorly by separating the fibers of the ligamentum flavum with a Penfield No. Cordotomy is indicated more frequently for patients with extremity pain rather than pelvic pain. The middle column included the posterior half of the vertebral body, annulus, and disk, in addition to the posterior longitudinal ligament. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. A biomechanical evaluation of graded posterior element removal for treatment of lumbar stenosis: comparison of a minimally invasive approach with two standard laminectomy techniques. A transverse process extends from each lateral mass, and each transverse process has a foramen that contains the vertebral artery. Hensinger1 has cautioned that cosmetic treatment of the torticollis posture has been met with limited success. The superior oblique muscles span the transverse processes of the atlas and attach to the suboccipital bone. Before the osteotomy is begun, pedicle screws should be placed cephalad and caudad to the intended osteotomy site, as they will be used to help secure and stabilize the spine after the osteotomy. Dissection is carried down to the level of the thoracodorsal fascia, and self-retaining retractors are placed. Reversal of longstanding neurological deficits after a late release of tethered spinal cord.