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128 III Degenerative Spinal Conditions
d. One- or two-level spondylotic myelopathy
e. Kyphotic sagittal alignment
2. Anterior cervical discectomy and fusion
a. Tricortical iliac crest bone is used for interbody fusion (Smith–Robinson
anterior fusion technique) and 6 weeks of neck brace.
b. Allograft may be used for one-level fusion with instrumentation.
(1) No graft site morbidity
(2) Heavy smoking is a relative contraindication.
c. Use of anterior instrumentation (plating)
(1) Single-level interbody fusion is quite stable, and fusion rates
are excellent with the use of autograft alone without instru-
mentation.
(2) Instrumentation is recommended in the following
(a) Single-level fusions with allograft
(b) Avoid postoperative bracing.
(c) Multiple-level interbody fusions
(d) High-risk patients
B. Revision fusion
C. Smokers
1. Anterior cervical corpectomy and fusion
a. The plate is most commonly used for corpectomy and strut fusion.
(1) Avoids postoperative halo vest
(2) Improves fusion rates
D. Posterior cervical surgery
1. Indications
a. Unilateral soft disc herniation or foraminal stenosis in patients with
radiculopathy and no axial symptoms
b. Cervical spondylotic myelopathy (3 levels of pathology)
c. Ossification of the Posterior Longitudinal Ligament (OPLL)
d. Neutral or lordotic sagittal alignment
e. Laminoforaminotomy (Fig. 11–5)
(1) Motion-preserving procedure
(2) Treatment of cervical radiculopathy with minimal axial symp-
toms
f. Laminoplasty (Fig. 11–6)
(1) Becoming more popular because of the lower incidence of com-
plications as compared with laminectomy and fusion
(2) Motion-preserving procedure
(3) Same indications as laminectomy and fusion
(4) Technique with or without instrumentation
(a) French door
(i) Midline opening
(ii) Bilateral hinges
(b) Open door
(i) Opening side
(ii) Hinge side
g. Laminectomy and fusion with instrumentation
Chapter 11 Degenerative Cervical Spine Disorders 129
Figure 11–5 Step-by step methodology for performing a posterior cervical foraminotomy. (A) A cut-
ting burr is used to thin the lamina (labeled I) at the junction of the lateral mass-lamina. (B) Twenty-five
percent of the lateral mass is removed exposing the lamina (II), superior articular process of the inferior
lamina (V), the facet joint (IV), and ligamentum flavum (VI). (C) A curette is used to remove the supe-
rior articular process overlying the nerve root.
(1) Stabilization is recommended when performing laminectomy
to prevent postlaminectomy kyphosis.
(a) Lateral mass screw fixation
(b) Pedicle screw (C2, C7, T1)
VII. Complications
A. Anterior cervical surgery
1. Pseudarthrosis
2. Graft dislodgement, resorption, or collapse
3. Dysphagia
4. Hoarseness
5. Vertebral or carotid artery injury
6. Dural tears
7. Esophageal or tracheal injury
8. Nerve injury
130 III Degenerative Spinal Conditions
B. Posterior cervical surgery
1. Neurological deficit
2. C5 nerve root palsy
a. Believed to occur secondary to posterior cord migration and stretch
injury to the C5 nerve root
VIII. Postoperative management
1. Hard collar recommended for noninstrumented single-level fusions
Figure 11–6 (A) Preoperative cervical MRI demonstrating spinal stenosis extending from
C3–C7. (B) A laminoplasty from C3–C7 was performed (postoperative lateral radiograph
demonstrating the placement of titanium cervical plates and allograft). (C) Postoperative axial
image (computed tomography) demonstrating placement of the titanium plate. (D) Postopera-
tive axial image (computed tomography) demonstrating placement of the machined allograft.
A
B
C
D
Chapter 11 Degenerative Cervical Spine Disorders 131
A. For anterior approaches, the head of the hospital bed should be elevated
30 degrees for the first 24 hours to prevent hematoma formation.
B. Rigid collars may be discontinued by 6 weeks after the operation.
C. No rigid collar is needed after instrumented laminoplasty.
1. May begin range of motion exercises in the immediate postoperatively
period.
Suggested Reading
Bartolomei JC, Theodore N, Sonntag VK. Adjacent level degeneration after anterior cervical fusion: a clin-
ical review. Neurosurg Clin N Am 2005;16:575–587
Christe A, Laubli R, Guzman R, et al. Degeneration of the cervical disc: histology compared with radiog-
raphy and magnetic resonance imaging. Neuroradiology 2005;47:721–729
Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the conse-
quences of spinal fusion? Spine J 2004;4:190S–194S
Lopez–Espina CG, Amirouche F, Havalad V. Multilevel cervical fusion and its effect on disc degeneration
and osteophyte formation. Spine 2006;31:972–978
12
Degenerative Thoracic Spine
Conditions
I. General considerations
A. Thoracic pain may be due to several different etiologies (Table 12–1).
1. Incidence is 15%.
2. Frequently presents in the fourth to sixth decade of life
3. Clinical presentation
a. May be either radicular or myelopathic
(1) Thoracic canal is relatively small.
(2) Subtle myelopathic symptoms are significant.
(3) Radiculopathy involves radiating pain around the associated rib.
B. Diagnosis
1. Thoracic disk herniation is frequently seen on magnetic resonance
imaging (MRI).
a. MRI is most useful because of the wide field of view.
(1) Provides information regarding the status of disk degeneration
and spinal canal impingement (Fig. 12–1)
(2) High false-positive rate
(3) Also useful in ruling out infections and tumors
b. Myelogram/computed tomography (CT) scan
(1) More accurate assessment of spinal cord impingement (Fig. 12–2)
2. Thoracic stenosis
a. Ossification of posterior longitudinal ligament
(1) Common in Asian populations
b. Ossification of ligamentum flavum
(1) Posterior spinal cord compression
(2) Treated with posterior thoracic decompression
c. Spondylosis
132
Chapter 12 Degenerative Thoracic Spine Conditions 133
II. Treatment of thoracic disk disease
A. Conservative modalities
1. Nonsteroidal antiinflammatory drugs
2. Exercise program
Table 12–1 Differential Diagnosis of Thoracic Pain
Category Etiologies
Cardiovascular • Angina pectoris
• Myocardial infarction
• Mitral valve prolapse
• Pericarditis
• Aortic aneurysm
Pulmonary • Pneumonia
• Carcinoma
• Pneumothorax
• Pulmonary embolus
• Pulmonary effusion
Mediastinal • Esophagitis
• Tumors
Intra-abdominal • Hepatitis
• Abscess
• Cholecystitis
Gastrointestinal • Peptic ulcer disease
• Hiatal hernia
• Pancreatitis
Retroperitoneal • Pyelonephritis
• Ureteral stone
• Aneurysm
Neurological • Intraspinal cyst/tumor
• Demyelinating disease
• Transverse myelitis
Infectious • Osteomyelitis
• Discitis
• Epidural abscess
• Tuberculosis
Traumatic • Compression fractures
• Rib fractures
Neoplastic • Metastatic disease
• Multiple myeloma
• Intradural tumors
Metabolic • Osteoporosis
• Osteomalacia
• Paget’s disease
Miscellaneous • Herpes zoster
• Inflammatory disease
• Polymyalgia rheumatica
134 III Degenerative Spinal Conditions
Figure 12–1 (A) T2–weighted sagittal MRI shows a herniated disk at T12–L1. (B) A T2–weighted
axial MRI demonstrates a left paracentral disk herniation with foraminal impingement.
A
B
Chapter 12 Degenerative Thoracic Spine Conditions 135
3. Muscle strengthening and cardiovascular fitness
4. Physical therapy and modalities as necessary
5. Conservative treatment should be tried at least 6 months in patients
without myelopathy.
B. Surgery
1. Indications
a. Thoracic disk herniation with myelopathy
b. Thoracic radicular pain without myelopathy that becomes unrelent-
ing and resistant to conservative treatment for at least 6 months
2. Surgical techniques
a. Laminectomy is usually contraindicated.
b. Costotransversectomy
(1) An option in posterolaterally herniated disk cases
c. Most cases require anterior approach with or without fusion
(1) Fusion is advocated in patients with
(a) Significant back pain
(b) Evidence of spinal instability
Figure 12–2 A CT-myelogram of the above disk herniation, demonstrating effacement of the
spinal cord.
136 III Degenerative Spinal Conditions
(c) Iatrogenic instability secondary to removal of bone/disk for
decompression
(d) Kyphotic deformity
d. Anterior instrumentation may be used in kyphotic cases.
e. Thoracoscopic discectomy is an option that may decrease surgical
morbidity.
(1) Very surgeon dependent
(2) Sharp learning curve
Suggested Reading
Otani K, Yoshida M, Fujii E, Nakai S, Shibasaki K. Thoracic disk herniation: surgical treatment in 23
patients. Spine 1988;13:1262–1267
Ross JS, Perez–Reyes N, Musaryk TJ, Bohlman HH, Modic MT. Thoracic disk herniations: MR imaging.
Radiology. 1987;165:511–515.
Simpson JM, Silveri CP, Simeone FA, Balderston RA, An HS. Thoracic disk herniation. Reevaluation of the
posterior approach using a modified costotransversectomy. Spine 1993;18:1872–1877
13
Lumbar Disk Disease:
Pathogenesis and Treatment
Options
I. General considerations
A. Incidence
1. Eighty percent of the population will experience back pain.
2. Two to 3% will experience lower extremity radiculopathy.
B. Age
1. Mean age of onset is 35 years.
2. Unusual under 20 years and over 60 years of age
3. Herniated disk in children is rare.
a. Slippage of an entire disk and vertebral end plate or “slipped verte-
bral apophyses” may mimic herniated disk.
4. Herniated disk in the elderly is also uncommon.
a. May be associated with spinal stenosis
C. Gender ratio is approximately equal.
1. Females typically present a decade later.
D. Natural history of low back pain and sciatica
1. Low back pain resolution
a. Fifty to 60% recover in 1 week.
b. Ninety-five percent recover in 3 months.
2. Sciatica resolution
a. Fifty percent recover in 1 month.
b. Seventy-five percent recover in 1 year.
3. Surgical results are better after 1 year but no significant difference
after two years when compared with nonoperative management.
E. Epidemiological factors
1. Occupational
a. Heavy lifting
b. Vibrational exposure
137