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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6013_Библиотеки_им_академика_М_И_Перельмана.pdf
X
- •Contributors
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4: Reduction of Unilateral Facet Dislocation
- •Step 5: Reduction of Bilateral Facet Dislocation
- •Foreword to the First Edition
- •Preface
- •Video Contents
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Procedure: Halo Application
- •Step 1: Crown and Pin Placement
- •Step 2: Vest Application
- •Step 3: Construct Alignment
- •Step 4: Follow-up
- •Procedure: Halo Application in the Child or Infant
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Disk Excision
- •Step 2: Decompression
- •Step 3: Strut Graft Preparation and Placement
- •Step 4: Internal Fixation
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Preparation of Disk Spaces and/or Cervical Corpectomy
- •Step 2: Takedown of OPLL
- •Step 3: Graft Placement, Anterior Plating
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Evidence
- •9 Occipital-Cervical Fusion
- •Indications
- •Examination/Imaging
- •Procedure
- •Step 1
- •Step 2: Exposure of Inion to C5
- •Step 3: Instrumentation and Fusion
- •Step 4: Closure
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Making the Entry Hole for the First Translaminar Screw
- •Step 2: Drilling the Contralateral Lamina
- •Step 4: Placement of the First Screw
- •Step 5: Placement of the Second Screw
- •Step 6: Connection of the C2 Laminar Screws to C1 Lateral Mass Screws
- •Step 7: Arthrodesis
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Step 6
- •Step 7
- •Postoperative Care and Expected Outcomes
- •Technique B: C1-2 Transarticular Facet Screws (Magerl Technique)
- •Indications
- •Examination and Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Step 6
- •Step 7
- •Step 8
- •Step 9
- •Step 10
- •Step 11
- •Step 12
- •Step 13
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy (Figure 12-2)
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Determining the Entry Point
- •Step 2: Drilling the Screw Hole
- •Step 3: Tapping and Screw Insertion
- •Step 4: Rod Insertion
- •Step 5: Placement of Screw Caps
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Overview
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Manual Screw Placement
- •Computer-Assisted Screw Placement
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Summary
- •Evidence
- •Indications
- •Procedure Notes
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 2: Transthoracic Retropleural Deep Exposure
- •Step 3: Diskectomy
- •Step 4: Hemicorpectomy and Spinal Cord Decompression
- •Step 5: Arthrodesis, Cage Preparation, and Insertion
- •Step 6: Screw/Plate Instrumentation
- •Step 7: Closure
- •Postoperative Care
- •Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Positioning
- •Portals/Exposures
- •Thoracic
- •Thoracolumbar
- •Lumbar
- •Procedure: Thoracolumbar Spine Fusion via an Open Approach Using Single-Rod Instrumentation
- •Step 1: Anterior Release and Diskectomy
- •Step 2: Placement of the Anterior Vertebral Body Screws
- •Step 3: End-Plate Ablation
- •Step 4: Placement of Anterior Interbody Structural Supports
- •Step 5: Rod Placement
- •Step 6: Placement of Chest Tube and Wound Closure
- •Procedure: Thoracolumbar Spine Fusion via an Open Approach Using Dual-Rod Instrumentation
- •Step 1: Anterior Release and Diskectomy
- •Step 2: Placement of the Anterior Vertebral Body Screws
- •Step 3: End-Plate Ablation
- •Step 4: Placement of Anterior Interbody Supports
- •Step 5: Rod Placement
- •Step 6: Placement of Chest Tube and Wound Closure
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Procedure
- •Step 1: Anterior Release and Fusion
- •Postoperative Care and Expected Outcomes
- •Step 2
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Postoperative Care and Expected Outcomes
- •Surgical Outcomes
- •Complications and Avoidance
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Insertion of Superior Rib Cradle for the Hybrid VEPTR
- •Step 2: Opening Wedge Thoracostomy
- •Step 3: The Hybrid VEPTR
- •Step 4: Implantation of the Hybrid VEPTR
- •Step 5: Hybrid VEPTR Attachment to Pelvis by Dunn-McCarthy Hook over Iliac Crest
- •Step 6: Addition of Second Rib-to-Rib VEPTR
- •Step 7: Closure
- •Postoperative Care and Expected Outcomes
- •Expansion of the Devices
- •Replacement Procedure
- •Evidence
- •Indications
- •Surgical Anatomy: Choosing Levels for Fusion
- •Examination/Imaging
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Facetectomies
- •Step 2: Release of the Spine
- •Step 3: Pedicle Screw Placement
- •Step 4: Rod Placement and Correction of Deformity, Including Vertebral Derotation
- •Step 5: Closure
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: En Bloc Laminectomy
- •Step 2: En Bloc Corpectomy
- •Step 3: Anterior Reconstruction and Posterior Stabilization
- •Postoperative Care and Expected Outcomes
- •Evidence
- •25 Sacropelvic Fixation
- •Indications
- •Biochemical Considerations
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure A: S1 Pedicle Screws
- •Procedure B: Sacral Alar Screws
- •Procedure C: Iliosacral Screws
- •Procedure D: Galveston Rods
- •Procedure E: Iliac Screws (Iliac Bolts)
- •Procedure F: Transilial Bar
- •Procedure G: S2 Alar Iliac Screws (S2AI)
- •Postoperative Care and Expected Outcomes
- •Complications of Pelvic Fixation
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Procedure A: Smith-Petersen Osteotomy
- •Step 1
- •Step 2
- •Step 3
- •Procedure B: Pedicle Subtraction Osteotomy
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Postoperative Care and Expected Outcomes
- •Evidence
- •29 Spondylolysis Repair
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Positioning
- •Step 2: Incision
- •Step 3: Preparing Interspace
- •Step 4: Implantation
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1: Diskectomy
- •Step 2: Remobilization
- •Step 3: Trial Insertion
- •Step 4: Keel Preparation
- •Step 5: Device Insertion
- •Postoperative Care and Expected Outcomes
- •Evidence
- •36 Kyphoplasty
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •General Aspects to Posterior Tubular Retractor Surgery
- •Procedure
- •Step 1
- •Step 2
- •Step 3: Instrumentation
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure A: Lateral-Posterior Lumbar Hemivertebra Resection and Correction with Segmental Anterior Instrumentation
- •Step 1
- •Step 2
- •Procedure B: Hemivertebra Resection and Fusion: Anterior and Posterior Approach
- •Step 1
- •Step 2
- •Procedure C: Posterior Hemivertebra Resection and Correction
- •Step 1
- •Step 2
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Indications
- •Surgical Anatomy
- •Positioning
- •Portals/Exposures
- •Procedure
- •Step 1
- •Step 2
- •Step 3
- •Step 4
- •Step 5
- •Postoperative Care and Expected Outcomes
- •Evidence
- •Introduction
- •Indications
- •Contraindications
- •Examination/Imaging
- •Surgical Anatomy
- •Positioning
- •Procedure
- •Step 1
- •Step 3
- •Step 4
- •Step 5
- •Step 6
- •Step 7
- •Step 8
- •Step 9
- •Additional Steps
- •Postoperative Care and Expected Outcomes
- •Case Illustration
- •Evidence

xii Contributors
Ishaq Syed, MD
Assistant Professor, Department of Orthopaedic
Surgery, Wake Forest University Baptist
Medical Center, Winston-Salem, North
Carolina
Posterior C1-C2 Fusion:
Harms and Magerl Techniques
Chadi Tannoury, MD
Orthopaedic Spine Fellow, Rush University
Medical Center and Midwest Orthopaedics at
Rush, Chicago, Illinois
Posterior Far Lateral Disk Herniation
Issada Thongtrangan, MD
Orthopedic Spine Surgeon, Orthopaedic and
Spine Institute, San Antonio, Texas
Kyphoplasty
Vincent C. Traynelis, MD
Professor, Department of Neurosurgery, Rush
University Medical Center, Chicago, Illinois
Spondylolysis Repair
Per D. Trobisch, MD
Spine Surgeon, Orthopädische Klinik Berlin,
Vivantes Klinikum im Friedrichshain,
Landberger Allee, Berlin, Germany
Operative Management of Scheuermann Kyphosis
Michael J. Vives, MD
Associate Professor and Chief of Spine Surgery,
Orthopedics, University of Medicine and
Dentistry-New Jersey Medical School, Newark,
New Jersey
Closed Cervical Skeletal Tong Placement and Reduction Techniques
Brian Walsh, MD
Staff Neurosurgeon, Madison, Wisconsin
Spondylolysis Repair
Christopher F. Wolf, MD
Orthopaedic Spine Surgeon, Christiana Spine
Center LLC, Newark, Delaware
Interspinous Process Motion-Sparing Implant
Kamal R.M. Woods, MD
Chief Resident, Neurosurgery, Loma Linda
University Medical Center, Loma Linda,
California
Transforaminal Lumbar Interbody Fusion
Neill M. Wright, MD
Herbert Lourie Professor in Neurological
Surgery, Neurological Surgery, Washington
University School of Medicine, St. Louis,
Missouri
C2 Translaminar Screw Fixation
Kene T. Ugokwe, MD
Associate Staff Neurosurgeon, Surgery,
St. Elizabeth Health Center, Youngstown,
Ohio
Lateral Extracavitary Approach for Vertebrectomy
Alexander R. Vaccaro, MD, PhD
Everett J. and Marion Gordon Professor of
Orthopaedic Surgery, Professor of
Neurosurgery, Thomas Jefferson University
and The Rothman Institute; Co-Director,
Delaware Valley Spinal Cord Injury Center,
Philadelphia, Pennsylvania
Anterior Odontoid Resection: The Transoral Approach
Anterior C1-C2 Arthrodesis: Lateral Approach of Barbour and
Whitesides
Anterior Resection of Ossification of the Posterior Longitudinal
Ligament
Occipital-Cervical Fusion
Cervical Spine: Lateral Mass Screw Fixation
Anterior Thoracic Diskectomy and Corpectomy
Posterior Far Lateral Disk Herniation
Transforaminal Lumbar Interbody Fusion
Vamshi Yelavarthi
Medical Student, Boston University School of
Medicine, Boston, Massachusetts
Anterior Resection of Ossification of the Posterior Longitudinal
Ligament
Cervical Spine: Lateral Mass Screw Fixation
Joseph M. Zavatsky, MD
Staff Orthopaedic Surgeon, Ochsner Medical
Center, Baton Rouge, Louisiana
Posterior C1-C2 Fusion:
Harms and Magerl Techniques
Lukas P. Zebala, MD
Associate Professor, Orthopedic Surgery,
Washington University School of Medicine,
Saint Louis, Missouri
Osteotomy Techniques (Smith-Petersen and Pedicle Subtraction) for
Fixed Sagittal Imbalance
Jack E. Zigler, MD
Orthopaedic Spine Surgeon, Co-Director of
Fellowship Program, Texas Back Institute,
Plano, Texas
Lumbar Total Disk Arthroplasty

To my previous fellows, who inspire me more than I can ever teach them
To Eli Baron, who typifies a physician of honor and dedication to patient care,
and who possesses a relentless drive for truth in spinal care research
To the graduates of the Thomas Jefferson spine fellowship—may they
continue to teach and inspire their teachers for years to come
Alexander R. Vaccaro
To my spine surgery instructors, colleagues, students, residents, and fellows,
who enlighten me on a daily basis regarding nuances in surgical decision
making and technique, and who also are my inspiration for continued
self improvement
Eli M. Baron

Foreword to the First Edition
It seems fair to say that the development of spine surgery over the past 50 years
has been nothing short of breathtaking. Advances in mechanical engineering and
biomaterials as well as increasing anatomic sophistication have led to a surge of
surgical treatment options for patients with spinal disorders. During this period,
the care of spinal disorders has matured from a peripheral possibility requiring
some improvisational management skills to a highly diversified specialty in its own
right. On the publications side, there has been a similar increase in the number
of textbooks and journals dealing with spinal disorders. Several of the classic
textbooks on the spine have blossomed into multivolume tomes containing highly
differentiated discussions on the many complex issues surrounding this subject.
The result, borrowing the words of Thomas De Quincey (1785-1859), is that
Worlds of fine thinking lie buried in the vast abyss…, never to be disentombed
“
or restored to human admiration
Lake Poets”). Indeed, the somewhat overwhelming plethora of spine publications
has led to frequently heard inquiries to the tune of “What should I read first?”
and “Where can I find a quick description of …?” by many involved in spine care.
It certainly is a privilege to have been asked to provide introductory words to
a refreshingly novel yet thorough approach toward presenting this increasingly
large body of knowledge in the world of spinal surgery to a widely differing audience. The editors of
Eli Baron, draw from an extensive clinical background across surgical specialty
lines and have a nearly unparalleled research background, as any Medline search
will readily demonstrate. They have taken the challenge of information overflow
head-on by providing a meaningful condensation of the myriad surgical techniques
available and presenting it in a well-structured and meaningful fashion. The reader
will find helpful the organization of each procedure into sections on Surgical
Anatomy, Positioning, Portals and Exposures, and step-by-step surgical plans,
accompanied by subsections on Pearls and Pitfalls. The open-ended questions of
spine surgery are addressed in straightforward fashion in the subsections on
Controversies. The latter will pique the interest of even seasoned spine surgeons
as they invite thought-provoking deliberations on how to further develop the field
of spine surgery. Key references are listed in an evidence-based bibliography, with
brief synopses of some of the most relevant publications. The quality of the stateof-the-art illustrations are in a way emblematic of this book, with their concise yet
eminently detailed depictions of anatomy providing meaningful assistance for a
brief review of a specific area of interest.
Undoubtedly this book will be an asset to a wide array of health providers
associated with spine care for the eminently approachable and resource-rich material that it provides.
Operative Techniques: Spine Surgery,
” (from Coleridge’s “Reminisces of the English
Alexander Vaccaro and
Jens R. Chapman
Professor
HansJörg Wyss Endowed Chair
Chief of Spine Service
Departments of Orthopaedic and Neurologic Surgery
University of Washington School of Medicine
Seattle, Washington

Preface
A plethora of textbooks on spinal surgery is available today. Most provide an
overview of the general science of spinal care or are intended as a reference text
for specific spinal procedures. They include the background on a particular topic,
its clinical presentation, treatment options, and outcomes. Alternatively, they may
provide a review of the nuances of a pathologic condition, including a discussion
of the nonoperative and operative treatments with case examples.
This book is intended to serve a much different purpose. Although some atlases
of spine surgery exist, none are meant to serve as an operating room companion.
We envision this text to function as an indispensable tool for spinal surgeons who
want to accent their knowledge and exposure to interesting and commonly performed surgical procedures encountered in daily practice. Within the pages of this
book, highly experienced practitioners present 40 of the most commonly performed
spinal procedures. Each chapter includes step-by-step illustrations of spinal procedures, along with practical expert advice. Many pearls of wisdom are conveyed by
the authors to assist in the learning curve and avoid the commonly experienced
pitfalls encountered by many practitioners.
We believe this text represents a source of information that will be used repeatedly by the busy spinal clinician. Surgeons will find they want to consult with this
text routinely before embarking on a particular procedure, to feel comfortable and
confident regarding their chosen techniques. A collection of videos that illustrates
master practitioners performing their trademark surgical procedures as they counsel
and guide the reader through each surgical step is available at expertconsult.com.
This addition wonderfully complements the overall appeal of this learning aid.
We hope this text serves as a valuable resource, not only to orthopaedic surgeons, neurosurgeons, and surgical trainees such as residents and fellows, but also
to physician assistants, nursing staff personnel, and anyone involved in the operative care of patients undergoing spinal surgery.
Alexander R. Vaccaro, MD
Eli M. Baron, MD

Video Contents
Section I
CERVICAL SPINE
Section II
THORACIC SPINE
Procedure 3 Anterior Odontoid Resection: The Transoral
Approach
Video 3-1 Anterior Odontoid Resection—
David Choi, H. Alan Crockard
Procedure 4 Odontoid Screw Fixation
Video 4-1 Odontoid Screw Fixation—
Ronald I. Apfelbaum, Daniel R. Fassett
Procedure 8 Anterior Cervical Disk Arthroplasty
Video 8-1 Lumbar Disk Arthroplasty—
Rick B. Delamarter
Procedure 14 Posterior Cervical Osteotomy Techniques
Video 14-1 Cervicothoracic Deformity Correction—
Neel Anand, Brian Perri
Procedure 18 Operative Management of Scheuermann
Kyphosis
Video 18-1 Correction of Scheuermann Kyphosis—
Thomas J. Errico
Procedure 19 Resection of Intradural Intramedullary or
Extramedullary Spinal Tumors
Video 19-1 Intramedullary Tumors—George Jallo
Procedure 20 Endoscopic Thoracic Diskectomy
Video 20-1 Endoscopic Thoracic Diskectomy—
J. Patrick Johnson, Stepan Kasimian
Section III
LUMBAR SPINE
Procedure 28 Osteotomy Techniques (Smith-Petersen
and Pedicle Subtraction) for Fixed
Sagittal Imbalance
Video 28-1 Smith-Petersen Osteotomy and Lumbar
Pedicle Subtraction Osteotomy—Keith H. Bridwell,
Lukas P. Zebala
Procedure 33 Transforaminal Lumbar Interbody Fusion
Video 33-1 Transforaminal Lumbar Interbody
Fusion—Neel Anand, Kamal R.M. Woods,
Eli M. Baron
Procedure 39 Lumbar Internal Laminectomy
Video 39-1 Unilateral Laminotomy with Bilateral
Microdecompression—Neel Anand, Sunil Jeswani,
Eli M. Baron

xxii Video Contents
MISCELLANEOUS
C1-C2 Posterior Cervical Fixation—Christopher
Ames, Jae Taek Hong
Minimally Invasive Deformity Correction and
Fusion—Neel Anand, Eli M. Baron

P R O C ED U R E 1
Closed Cervical Skeletal
Tong Placement and
Reduction Techniques
Michael J. Vives and Colin Harris
P I T F A L L S
• Patient must be awake, alert, and
cooperative.
• Coexistence of skull fractures in
the areas of pin placement may
contraindicate tong placement.
C O N T RO V E R S IE S
• Magnetic resonance imaging (MRI)
before closed reduction of dislocated
facets, to exclude an associated disk
herniation, is advocated by some.
• For awake, alert patients, closed
reduction may be attempted without
MRI. If closed reduction fails, MRI
should be obtained before operative
reduction under general anesthesia.
T R E A T M E N T OP T I O N S
• Open reduction by anterior or posterior
approach
• Anterior (or combined anteriorposterior) approach is commonly
recommended if MRI shows large
associated disk herniation at the level
of the dislocation.
Indications
n
Subaxial cervical fractures with malalignment
n
Unilateral and bilateral subaxial cervical facet dislocations
n
Displaced odontoid fractures, selected types of hangman’s fractures, and C1-2
rotary subluxations
Examination/Imaging
n
A thorough neurologic examination should be documented before the
procedure.
n
High-quality imaging of the cervical spine (including visualization of the
occipital-cervical and cervical-thoracic junctions) should be obtained before
the reduction attempts (Figure 1-1).
Surgical Anatomy
n
Correct pin placement site is 1 cm above the pinna, in line with the external
auditory meatus and below the equator of the skull (Figures 1-2 and 1-3).
n
The temporalis muscle and superficial temporal artery and vein are at risk if pins
are placed too anterior.
A N AT O M Y PE A R L S
• Posterior pin placement will apply a
flexion moment to the cervical spine.
• Anterior pin placement will apply an
extension moment to the cervical spine.
A N AT O M Y PI T F A L L S
• Placement of the pins too superior
(above the equator) increases risk of
pullout.
• Placement of the pins too anterior
may result in injury to the superficial
temporal vessels.
FIGURE 1-1

Procedure 1 | Closed Cervical Skeletal Tong Placement and Reduction Techniques 3
FIGURE 1-2
P O S I TI O N I N G PE A R L S
• Reverse Trendelenburg position or the
use of arm and leg weights can help
prevent the patient from sliding to the
top of the bed as weights are added.
P O S I TI O N I N G PI T FA L L S
• Frequent radiographs and close
monitoring are necessary during
reduction attempts; thus the emergency
room (trauma bay), the operating room,
or an intensive care unit are preferred
settings.
S T E P 1 P EA R L S
• Standing at the head of the bed during
tong placement facilitates symmetric
positioning of the tongs.
FIGURE 1-3
Positioning
n
The patient is positioned supine on the operative table, Stryker table, or Roto-
Rest bed.
Portals/Exposures
• The skin is prepped with a povidone-iodine solution.
• Shaving or skin incisions are not necessary with the use of tapered GardnerWells pins. Hair, however, can get wrapped around the pin during insertion.
Thoroughly soaking the area with the preparation solution facilitates parting
long hair in the area and helps prevent this.
• Local anesthetic is used to infiltrate the skin and down to the skull periosteum.
Procedure
Step 1
n
The pins are angled upward slightly and simultaneously tightened until the
spring-loaded force indicator (found on one of the two pins) protrudes 1 mm
above the flat surface of the pinhead (Figure 1-4).
S T E P 1 P IT FA L L S
• Overtightening can result in penetration
of the inner table of the calvarium,
leading to cerebral abscess or
hemorrhage.
• Check for all proper components before
starting the procedure. Occasionally, the
spring-loaded pin may be missing from
the set!
E Q U I PM E N T
• MRI-compatible graphite tongs and
titanium pins have lower failure loads
because of deformation. Stainless steel
tongs are therefore recommended if
greater than 50 lb of traction are
anticipated.
FIGURE 1-4

4 Procedure 1 | Closed Cervical Skeletal Tong Placement and Reduction Techniques
S T E P 2 P EA R L S
• Small doses of intravenous diazepam
can be administered to aid in muscle
relaxation. The patient should, however,
be kept awake and conversive
throughout.
S T E P 2 P IT FA L L S
• A small amount of weight (10 lb) is
used initially to avoid overdistraction of
unstable injury patterns, such as occult
instability at the occipital-cervical
junction.
S T E P 3 P EA R L S
• To reduce a facet dislocation that is
not associated with a fracture, a flexion
moment helps unlock the dislocated
facet(s) (Figures 1-5 and 1-6).
• This can be achieved by posteriorly
placed pins or by raising the height of
the pulley.
Step 2
n
An initial weight of 10 lb is applied.
n
The neurologic examination is repeated and a lateral radiograph is taken.
Step 3
n
Weights are increased at 5- to 10-lb increments at intervals of 20 to 30 minutes
to overcome muscle spasm and to obtain a soft tissue creep effect.
n
Serial neurologic examinations and radiographs are obtained after each increase
in weight.
S T E P 3 P IT FA L L S
• If overdistraction or neurologic
deterioration occurs, the weights
should be immediately removed.
E Q U I PM E N T
• In general, the amount of weight
required depends on the level of the
injury (5 kg per level).
• More weight is generally required to
reduce a unilateral facet dislocation
than a bilateral facet dislocation.
C O N T RO V E R S IE S
• Some authors have recommended
weight limits of 66 to 70 lb. Other
authors have reported use of up to
140 lb.
FIGURE 1-5
FIGURE 1-6

Procedure 1 | Closed Cervical Skeletal Tong Placement and Reduction Techniques 5
S T E P 4 P EA R L S
• Facets should be distracted to a
perched position before attempting
manipulative reduction.
S T E P 5 P EA R L S
• Facets should be distracted to a
perched position before attempting
manipulative reduction.
S T E P 5 P IT FA L L S
• An irreducible bilateral facet dislocation
is unstable and should be treated with
urgent open reduction (after MRI
evaluation is performed).
Step 4: Reduction of Unilateral Facet Dislocation
n
Manipulation may assist in the final reduction of dislocated facets.
n
An axial load is applied to the normal facet while the head is rotated 30 to 40
degrees past midline in the direction of the dislocated facet (Figure 1-7).
n
Stop the reduction once resistance is felt, and verify the reduction
radiographically.
Step 5: Reduction of Bilateral Facet Dislocation
n
An anteriorly directed force is applied just caudal to the level of the dislocation,
which is usually palpable as a stepoff in the spinous processes (Figure 1-8).
n
The head is rotated 30 to 40 degrees beyond midline toward one side, then the
maneuver is repeated toward the opposite side if successful.
30°–40°
FIGURE 1-8
FIGURE 1-7
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