We have compiled 30 clinical facts about spinal surgery, including concepts, principles and details of spinal disorders.
The thoracic medulla of T4-T9 has the least blood supply. This area is called the critical blood supply area of the spinal cord and corresponds to the narrowest area of the spinal canal.
The posterior muscles of the spine maintain the normal sagittal sequence of the spine with back tension against the force of the intact anterior spinal column (tension band principle), and the musculature of the posterior spine acts as a tension band when the anterior column structure is intact.
The median thoracic thrust has the smallest arch size (T4-T6), with a slight widening of the arch in the upper thoracic thrust (T1-T3) and a significant widening in the lower thoracic thrust (T10-T12), and in general the thoracic arch is slightly larger than that in the upper lumbar spine. L1 is usually the narrowest lumbar arch, with a progressive increase in arch size from L2 to S1.
One of the main goals of examination in patients with axial pain is to determine the presence of chronic spinal disease, such as nonspecific axial pain, spondylolisthesis, etc., and to differentiate it from serious disease such as spinal infection, spinal tumor, or spinal cord injury.
Spinal cord cervical spondylosis is the most common cause of spinal cord dysfunction in patients over 55 years of age, and the diagnosis is based on the presence of clear signs of spinal cord impairment on physical examination and imaging confirmation of spinal cord compression.
The straight leg raise and strengthening test pulls the sciatic nerve and is commonly used to examine the L5 and S1 nerve roots. The reverse straight leg raise test pulls on the femoral nerve and is used to examine the L2, L3, and L4 nerve roots.
The use of evoked discography in the management of axial pain syndrome is controversial. Patients with psychological pain problems, chronic pain syndromes, ruptured annulus fibrosus, and those involved in litigation or workers’ compensation have been reported to have a high rate of false-positive discogenic angiography results.
The thoracolumbar orthosis is effective in limiting motion from T8 to L4, but increases motion at both the L4-L5 and L5-S1 segments. The orthosis can be added to the cervical spine if restriction of motion is required above T8, or to the L4-L5 or L5-S1 if restriction is required down to the thigh sleeve.
Dysfunction of the C1 nerve root is most likely to occur after laminectomy or vertebroplasty and is often detected immediately or 1 to 5 days after surgery.
Cervical vertebroplasty or laminectomy is a contraindication for patients with cervical kyphosis.
Acute lower back pain and chronic lower back pain are two distinct conditions that require different treatment strategies.
The nerve root outlet of the lumbar spine is located below the corresponding vertebral body’s pedicle and above the inferior intervertebral disc; the L4-L5 disc protrudes posteriorly and laterally to compress the L5 nerve root (nerve root that passes inferiorly through the L4-L5 motion segment), while the L4-L5 disc protrudes through the foramen or very laterally to compress the L4 nerve root (nerve root that exits through the L4-L5 motion segment).
Patients with neuropathic walking often complain of fatigue and heaviness in the lower extremities, and the distance walked at the onset of symptoms and the maximum distance the patient can walk continuously vary from day to day. Patients complain that symptoms are relieved when leaning, but are exacerbated by stretching activities (e.g., going downhill). Patients with vascular claudication experience spasticity and calf muscle tension with activity, and the distance walked before the onset of symptoms is often fixed and not affected by posture.
Radiculopathy often occurs in the exiting nerve roots of the isthmus of the arch and in the descending nerve roots of degenerative lumbar spondylolisthesis.
In patients with degenerative lumbar spondylolisthesis, posterior decompression spinal fusion is more effective than decompression alone.
The most commonly used posterior spinal fixation device is the nail bar system. Screws can be placed in the dentate process, the C1 lateral block, the C2 pedicle, or the lamina. In the lower cervical spine, lateral block screws are most commonly used to fix C3-C6, while pedicle screws are used to fix C7 or more distally in the thoracolumbar spine.
For high fusion rates in the sacrum, the most reliable procedure is bilateral S1 screw fixation to the ilium with structural intravertebral support.
The choice of spinal revision surgery relies on a comprehensive assessment of the reasons for the patient’s poor clinical outcome. Poor outcomes due to surgical strategy or technique can be improved by revision surgery; however, failure due to diagnostic error rarely improves symptoms. In the absence of a specific anatomical and pathological basis, pain alone is not an indication for revision surgery.
Spinal cord electrical stimulation is a minimally invasive treatment modality for pain relief, mainly for patients with persistent postoperative spinal pain, chronic regional pain syndrome, and other injurious pain syndromes. Implantable drug delivery devices may be considered for patients with injurious or neuropathic pain for whom medications, spinal cord point stimulation, and nerve disruption methods have failed.
Incomplete spinal cord syndromes include: central spinal cord syndrome; anterior spinal cord syndrome; Brown-sequard syndrome; spinal cone syndrome; cauda equina syndrome.
Traction repositioning of lower cervical synovial dislocations should be performed carefully with the patient awake. The patient should be able to cooperate, and the patient’s neurological status can be monitored. MRI should be performed prior to resetting in uncooperative or unconscious patients, and cervical MR1 should be performed prior to closed resetting of lower cervical synovial dislocations.
Children under 8 years of age are susceptible to upper cervical thrust injury due to the high head to body length ratio and the horizontal orientation of the articular processes.
The assessment of C1-C2 instability should include solid tooth spacing (AD1) and spinal extracranial clearance (SAC).
Idiopathic scoliosis is classified according to age at diagnosis into three types: infantile (from 0-3 years), juvenile (3-10 years) and adolescent (10 years and older), and another different typology into two categories: early-onset (birth to 5 years) and late-onset (5 years and older) Both classifications reflect the physiological period of thoracic thrust development, as the first 5 years of Life Thoracic development is most important.
The prognosis of congenital spinal deformities is based on 3 factors: the type of deformity, the age of the patient, and the location of the lesion. In congenital spinal deformities with extensive intraspinal and extraspinal abnormalities, a thorough examination and whole spine MRI is critical.
Primary spinal tumors can originate from bone, cartilage, nerve and ligamentous structures in the spine and can be classified as intradural or extradural. Secondary tumors or tumors that have metastasized to the spine or surrounding structures (e.g., supraspinal sulcus tumor) are the most common type of spinal tumor, accounting for approximately 95% of all spinal tumors.
Spinal tumors have different diagnoses depending on their anatomic location, including extradural tumors, intradural extramedullary tumors, and intramedullary tumors, with metastatic tumors being the most common type of extradural tumors in the spine. The most common intradural extramedullary tumors are nerve sheath tumors, neurofibroblastomas, or meningiomas. The most common intramedullary tumors are ventricular meningiomas, astrocytomas, and angiogenic tumors.
Vertebral compression fractures are the most common type of fracture caused by osteoporosis and are two to three times more common than hip or wrist fractures. Patients who have had a vertebral compression fracture are 5 times more likely to have a re-fracture than those who have not had a vertebral fracture.
Initial treatment of septic vertebral osteomyelitis includes antibiotic therapy guided by bacterial Culture and brace immobilization. Indications for surgical treatment: failure of pharmacologic therapy; incisional biopsy following an undiagnosed closed biopsy; clinically definite abscess drainage; neurologic symptoms; progressive spinal deformity.
Disseminated primary osteomalacia (DISH or Forestier disease) presents with ossification of the ligaments involving the anterolateral aspect of the spine. Imaging of DISH is characterized by asymmetric unmarginal bands of ligamentous osteophytes in the location of the anterior longitudinal ligament.
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