Symptoms and Signs

• Paraplegia (incomplete or complete)
• Diminished control/dysfunction of bowel/bladder (including urinary retention) and external genitalia (men: problems with erection and ejaculation; women: problems with lubrication)
• Moderate/severe numbness in lower extremities and perianal area (saddle anesthesia)
• Paresthesia in lower body extremities
• Lower back/hip/pelvis/butt pain and loss of mobility due to the pain
• Muscle weakness in legs (paresis) or paralysis
• Radicular pain extending into legs
• Difficulty maintaining balance and walking
• Positive Babinski sign (in adults or children over 2 years old)
• Myelopathy
• Bruising of the lower back
• Hypotonia or flaccidity within 24 hours of injury
• Herniated disk(s)

Surgical Pathology

• Lumbar spine benign/malignant trauma

Diagnostic Modalities

• CT of lumbar spine without contrast
• CT myelography of lumbar spine
• MRI of lumbar spine without contrast
• X-ray of lumbar spine (to test for fractures; anterior–posterior and lateral views)
• CT or X-ray of hip/pelvis (not typically necessary)

Differential Diagnosis

• Blunt trauma (complete and incomplete spinal cord injury [SCI])
• Penetrating trauma (complete and incomplete SCI)
• Wedge/Compression fracture
• Burst fracture
• Chance fracture
• Fracture-dislocation
• Compression fracture (most common of lumbar fractures)
• Ligamentous injury
• Musculoskeletal injury

Treatment Options

• Acute pain control with medications and pain management
• Physical/Occupational/Rehabilitation therapy and rehabilitation
• If symptomatic with cord/nerve root compression:
  • Surgical decompression with or without fusion over implicated segments if deemed suitable candidate for surgery
    • If poor surgical candidate with poor life expectancy, medical management recommended
    • Surgery may be done anteriorly or posteriorly, or combined two-stage approach for added stabilization (typically only one stage needed posteriorly)
    • Foraminotomy (expanding space of neural foramen by removing soft tissues, small disk fragments, and bony spurs in the locus) (see ▶Fig. 3.1)
      

      

    • Diskectomy (removal of section of herniated disk)
    • Endoscopic lumbar approach is minimally invasive and reduces complications (see ▶Fig. 3.2)
      

      

Indications for Surgical Intervention

• No improvement after nonoperative therapy (physical therapy, pain management)
• Residual spinal compression
• Unstable patterns of fracture
• Sufficient disruption of supporting ligaments
• Lumbar compression with posterior wall involvement and/or significant kyphosis
• Significant canal narrowing and/or significant kyphosis
• Neurologic dysfunction and/or instability resulting from lumbar trauma
  • Paresis or paralysis

  • Numbness in lower extremities and perianal area

  • Bowel/Bladder dysfunction
• Clinical or radiographic instability

Surgical Procedure for Posterior Lumbar Spine (Endoscopic Approach)

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist (endotracheal delivery preferred)
3. Patient placed prone in neutral alignment on radiolucent table, enabling use of C-arm fluoroscope
4. Neuromonitoring not needed
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Perform midline lumbar incision and dissect to lamina
7. Dissect lamina using lamina dissector through the working portal, under fluoroscopic guidance
8. Once the vertebrae of interest are exposed, it is best to localize and verify them via X-ray or fluoroscopic imaging and confirming with at least two people in the room
9. Perform foraminotomy:
   1. Dissect additional lamina and hypertrophied part of facet using endoscopic burr to expose the ligamentum flavum, controlling bleeding using radiofrequency coagulators
   2. Remove ligamentum flavum, thickened foraminal ligament, and bone spurs using micro punches and forceps, successfully exposing the exiting nerve root
   3. Coagulate the redundant disk and soft tissues compressing the nerve root using bipolar radiofrequency to relieve pressure from foraminal stenosis
10. Perform Diskectomy (if indicated in procedure):
    1. Retract the visible interfering nerve roots
    2. Incise through the indicated disk to expose large herniated disk fragment(s)
    3. Use a nerve hook to free them for removal
    4. Break adhesions between the herniated disk fragment(s) and surrounding structures to facilitate removal
    5. Using a grasper through the endoscopic apparatus, pull out the herniated disk fragment(s)

11. Remove lingering fragments as required

12. Ablate tissue debris using a side-firing laser
13. Remove remaining bone and ligament tissues using endoscopic punches
14. Mobilize exiting nerve root and dural sac under endoscopic visualization
15. Remove the endoscopic apparatus
16. Perform spinal fusion with instrumentation:
    1. Place open or percutaneous pedicle screws over segments involved with bone grafting to fuse these segments
    2. Insert small drainage catheter to reduce likelihood of postoperative epidural hematoma (can be removed after 2–3 days)
17. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion

Pitfalls

• Reduction in range of motion and mobility of fused spinal segments
• Intraoperative cerebrospinal fluid (CSF) leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord (especially thecal sac injury and dural tear)
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Loss of sensation
• Progressive kyphosis
• Residual spinal compression
• Problems with bowel/bladder control
• Epidural hematoma

Prognosis

• Typically, no hospitalization (outpatient procedure), but hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• Pain medications for postsurgical pain
• Physical therapy and occupational therapy will be needed postoperatively, immediately and as outpatient to regain strength
• Brace placed after discharge to immobilize to increase rate of healing

Symptoms and Signs

• Degenerate spondylolisthesis
• Radiculopathy
• Neurogenic claudication
• Moderate numbness in lower extremities and perianal area (saddle anesthesia)
• Paresthesia in lower body extremities
• Lower back/hip/pelvis/butt pain and discomfort derived from consistent nerve irritation and loss of mobility due to the pain
• Muscle weakness in legs (paresis)
• Leg pain (sciatica)
• Difficulty maintaining balance and walking
• Muscle weakness and reduction of mobility from pain (as opposed to from nerve impairment, which typically requires emergent treatment, particularly if it relates to bladder function)
• Spinal instability

Surgical Pathology

• Lumbar spine benign/malignant trauma
• Lumbar spine benign/malignant tumor
• Lumbar vascular benign/malignant lesion

Diagnostic Modalities

• Clinical examination
• CT of lumbar spine with and without contrast
• CT myelography of lumbar spine
• MRI of lumbar spine with and without contrast
• CT or X-ray of hip/pelvis
• Angiography
• PET scan (search for tumor foci)
• Biopsy to examine tissue sample to determine whether tumor is benign or malignant, and what cancer type resulted in the tumor if malignancy is determined

Differential Diagnosis

• Lumbar disk herniation
• Spinal stenosis (narrowing of the spine)
• Bulging lumbar disk
• Presence of synovial cyst or bone spurs (see ▶Fig. 3.3)
  

  

• Tumor:
  • Metastatic (malignant, requiring emergent treatment)
  • Primary (benign or malignant)

• Vascular lesion (typically requiring supplemental embolization):

  • Fibromuscular dysplasia (FMD)
  • Spinal arteriovenous malformation (AVM)
  • Spinal dural arteriovenous fistula (AVF)
• Vertebral trauma:
  • Blunt trauma (incomplete SCI)
  • Penetrating trauma (incomplete SCI)
  • Wedge/Compression fracture
  • Burst fracture
  • Chance fracture
  • Fracture-dislocation
  • Compression fracture
  • Ligamentous injury
  • Musculoskeletal injury

Treatment Options

• Acute pain control with medications and pain management
• Physical/Occupational/Recreational therapy and rehabilitation
• If asymptomatic or mildly symptomatic with lumbar cord/nerve root compression and failed conservative routes:
  • Surgical decompression and fusion over implicated segments if deemed suitable candidate for surgery
    • If poor surgical candidate with poor life expectancy, medical management recommended
    • Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization
    • May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Diskectomy (removal of section of herniated disk), synovial cyst removal
    • Endoscopic lumbar approach is minimally invasive and reduces complications

Indications for Surgical Intervention

• Lumbar spinal stenosis (LSS)
• No sufficient improvement of pain and other symptoms after nonoperative measures (physical therapy, medications/injections, pain management)
• Disruption of supporting ligaments
• Lumbar compression

• Spinal condition isolated to specific locus of the body

• Significant reduction in everyday activities due to symptoms
• Expected postsurgical favorable outcome

Surgical Procedure for Posterior Lumbar Spine (Endoscopic Approach)

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist (endotracheal delivery preferred)
3. Patient placed prone in neutral alignment on radiolucent table, enabling use of C-arm fluoroscope
4. Neuromonitoring not needed
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Perform midline incision over the appropriate level of interest based on X-ray and dissect to the spine
7. Confirm location on X-ray
8. Dissect lamina using lamina dissector through the working portal, under fluoroscopic guidance
9. Perform Laminotomy (see ▶Fig. 3.4):
   

   

   1. Make small openings of the lamina, above and below the spinal nerve, using a drill
10. Perform Diskectomy:
    1. Retract the visible interfering nerve roots
    2. Incise through the indicated disk to expose large herniated disk fragment(s), under microscopic guidance
    3. Use a nerve hook to free them for removal
    4. Break adhesions between the herniated disk fragment(s) and surrounding structures to facilitate removal
    5. Using a grasper through the endoscopic apparatus, pull out the herniated disk fragment(s)
11. Perform synovial cyst resection:
    1. Resect the remaining visible interfering bone and ligamentum flavum, exposing the synovial cyst
    2. Sharply and bluntly dissect the synovial cyst, separating it from the dura
    3. Resect the synovial cyst
    4. Decompress the traversing nerve root medially and laterally
12. Perform “clean-up” as necessary:
    1. Remove lingering fragments as required
    2. Ablate tissue debris using a side-firing laser
    3. Remove remaining bone and ligament tissues using endoscopic punches
13. Once the exiting nerve root and dural sac are mobilized, under endoscopic visualization, remove the endoscopic apparatus
14. Perform spinal fusion with instrumentation if instability or listhesis is present:
    1. Perform lumbar fusion if multiple vertebrae are involved, recurrent herniations occur, or spinal instability is significant
    2. Place percutaneous or open pedicle screws over segments involved with bone grafting, to fuse these segments
    3. Insert small drainage catheter to reduce likelihood of postoperative epidural hematoma (can be removed after 2–3 days)
15. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion

Pitfalls

• Reduction in range of motion and mobility of fused spinal segments
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord (especially thecal sac injury and dural tear)
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Loss of sensation
• Progressive kyphosis
• Residual spinal compression
• Problems with bowel/bladder control
• Recurrent disk herniation
• Epidural hematoma

Prognosis

• Typically, no hospitalization (outpatient procedure), but hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities; hospitalized patients are typically discharged after 1 to 2 days
• Pain medications for postsurgical pain
• Catheter placed in bladder and removed 1 to 2 days after surgery
• Physical therapy and occupational therapy will be needed postoperatively, immediately and as outpatient to regain strength
• Brace placed after discharge to immobilize to increase rate of healing

Symptoms and Signs

• Moderate lower back/hip/pelvis/butt pain and reduction of mobility due to the pain
• Muscle weakness in legs (paresis)
• Difficulty maintaining balance and walking
• Spinal instability

• Muscle weakness and reduction of mobility from pain (as opposed to from nerve impairment, which typically requires emergent treatment, particularly if it relates to bladder function)

Surgical Pathology

• Lumbar spine benign/malignant trauma
• Lumbar spine benign/malignant degenerative condition
• Lumbar spine benign/malignant postsurgical complication

Diagnostic Modalities

• CT of lumbar spine without contrast
• MRI of lumbar spine without contrast
• X-ray of lumbar spine (to test for fractures; anterior–posterior and lateral views)
• CT or X-ray of hip/pelvis (not typically necessary)

Differential Diagnosis

• Spondylolisthesis
• Degenerative disk disease
• Adjacent segment degeneration (ASD)
• Recurrent disk herniation
• Cage migration
• Pseudarthrosis

Treatment Options

• Acute pain control with medications and pain management
• Physical/Occupational/Recreational therapy and rehabilitation
• If asymptomatic or mildly symptomatic with lumbar cord compression:
  • Surgical decompression and fusion over implicated segments if deemed suitable candidate for surgery
    • If poor surgical candidate with poor life expectancy, medical management recommended
    • Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization
• If asymptomatic or mildly symptomatic without lumbar cord compression:
  • Surgical fusion over implicated segments if deemed suitable candidate for surgery
    • Posterior, anterior, and anterolateral approaches

Indications for Surgical Intervention

• No sufficient improvement of pain and other symptoms after nonoperative measures (physical therapy, medications/injections, pain management)
• Spinal condition isolated to specific locus of the body
• Significant reduction in everyday and recreational activities due to symptoms
• Expected postsurgical favorable outcome

Surgical Procedure for Anterior Lumbar Spine (Anterior Lumbar Interbody Fusion; ALIF)

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Preoperative antibiotics delivered via IV injection
3. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist (endotracheal tube and ventilator-assisted breathing)
4. Patient placed in supine position on radiolucent table, enabling use of C-arm fluoroscope
5. Place sterile drapes after properly cleansing the abdominal region
6. Neuromonitoring not needed
7. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
8. Make 3 to 8 cm transverse or oblique incision to the left of the belly button
9. Spread abdominal muscles apart without cutting them
10. Retract the peritoneal sac (including the intestines) and large blood vessels to the side
11. Visualize the anterior aspect of the intervertebral disks using retractors
12. Once the bone of interest is exposed, it is recommended to localize and verify it via fluoroscopic imaging and confirming with at least two people in the room
13. Remove the intervertebral disk using Pituitary rongeurs, Kerrison rongeurs, and curettes
14. Restore normal height of disk using distractor instruments and determine the size required for cage using fluoroscopy
15. Implant metal, plastic, or bone cage (with bone graft material) into the intervertebral disk space, under fluoroscopic guidance
16. Confirm that the location is correct using fluoroscopy
17. Add stability by adding instrumentation (a plate or pedicle screws to hold the cage in place) (see ▶Fig. 3.5 and ▶Fig. 3.6)
    

    

    

18. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion