Alexander R. Vaccaro

Physical examination of the spine

General Introduction Anatomy of the Spine Vasculature of the Spine Basic neurology Upper / Lower motor neuron disease testing musculature reflex sensation, temperature, pain, vibration, and grading systems cervical eye examination thoracic spine examination lumbar examination

Role of Spinal Surgery in Pain Management

Low back pain, or spinal pain, is the second most common chief complaint in the adult population seeking medical care in the ambulatory care setting. Treatment is often initiated due to the high rate of concomitant degenerative pathology seen on magnetic resonance imaging in both symptomatic and asymptomatic adults. However, in the absence of radicular pain localizing to a compressive pathology, and clear evidence of the appropriate spinal pain generator, a more thorough work-up is warranted. The algorithm for localization of the appropriate lumbar level of disease can be complex and still leave the surgeon without a definitive answer. This is in part due to the complex innervation of the spine where in the case of the facets and disc space a mixed innervation from somatic peripheral and autonomic nerve system supply is seen. Additionally, chronic compression of the neural elements and inflammation of neural fibers may result in hyperexcitability of nociceptive neuronal pathways. In this case, neuronal excitability can be spontaneous or with a greatly lowered threshold, and surgical compression may not always provide pain relief. As a result, more patients are diagnosed with failed back surgery syndrome, a loosely defined term in the spinal literature referring to painful symptoms persisting beyond the expected postoperative time course. The authors highlight several pain generators of the spine and highlight potential nonsurgical interventions that should be considered in the spinal surgeon’s armamentarium as a means of addressing this problem in the clinic.

Anterior Corpectomy with Fixation, Thoracic

Because of the additional stability provided by the rib cage and the coronal orientation of their facet joints, the thoracic vertebrae are less susceptible to traumatic injury than the cervical or lumbar regions of the spine. While the majority of thoracic fractures may be adequately managed with a period of immobilization and early ambulation, anterior thoracic procedures performed through a thoracotomy may be preferable in certain cases because they allow for a thorough decompression of the neural elements and the placement of a load-sharing interbody implant within the vertebral column. In recent years, anterior instrumentation systems have also been developed that may confer even greater stability to the disrupted segment. This surgical approach is best suited for patients who demonstrate severe canal compromise or focal kyphosis; however, stand-alone anterior constructs may not be appropriate for fracture–dislocations or ligamentous injuries that may require supplementary posterior fixation.