Ronald L. DeWald

Reconstructive spinal surgery as palliation for metastatic malignancies of the spine

Mestastatic tumors of the spine often cause severe pain and paralysis because of deformity and neural encroachment. As oncology now extends the life expectancies of these patients, spinal decompression and stabilization is necessary. We consider that prophylactic stabilization of the spine is analogous to prophylactic nailing of a femur with a pathologic lesion. Both the femur and spine are weight-bearing structures. The advent of segmental instrumentation makes this a feasible accomplishment with minimal morbidity. Seventeen patients with metastatic disease of the spine at Rush-Presbyterian-St. Lukes Medical Center, Chicago, were reviewed. All maintained spinal stability postoperatively. Eleven of the 17 had significant pain relief for 3 months or more. Five of 11 paralyzed patients had significant neural recovery. A classification for treatment purposes regardless of tissue type was developed. Once classified, the surgical goals for these patients were to decrease pain, to preserve or to improve neurologic function and to mobilize the patient without external orthosis.

Burst fractures of the thoracic and lumbar spine

A burst fracture may be defined as an unstable compression fracture of the posterior wall of the vertebral body that allows fragments to be retropulsed into the spinal canal. Computerized axial tomography evaluation of these injuries often reveals posterior element fracture heretofore not stressed in the literature. In surgical treatment for these injuries four important considerations must be met; (1) the coronal and sagittal alignment of the spine; (2) patency of the neural canal; (3) the two-column concept of spinal stability; and (4) bony vertebral body reconstitution. An algorithm for treatment may be developed with the aid of these principles. Distraction and the creation of spinal lordosis are necessary for reduction.

Controlled hypotensive anesthesia in scoliosis surgery.

In a retrospective study comparing normotensive (twenty-two patients) and controlled hypotensive (forty-four patients) anesthesia for spine fusion and Harrington instrumentation, the use of hypotensive anethesia was found to decrease the need for blood replacement and total blood loss by an average of 40 per cent and to reduce the average operating time by more than thirty minutes. No complications attributable to the anesthetic technique occured.

The pattern of vertebral involvement in metastatic vertebral breast cancer.

The spine is a common site of bony metastasis. To date, studies have not identified the initial site and pattern of vertebral metastasis in a homogeneous group of patients. Twenty-seven magnetic resonance imaging studies performed on 25 patients with metastatic vertebral breast cancer were reviewed retrospectively. The location and extent of metastatic vertebral involvement were determined. The vertebral body is the most frequent initial site of metastatic seeding. Although radiographically an absent pedicle is often the first sign of metastatic disease, involvement of the pedicle is by direct extension from either the vertebral body or the posterior elements and is therefore a late occurrence in the disease process.

Luque rod stabilization for metastatic disease of the spine

Instability of the spine caused by metastatic spread of primary tumors represents a serious risk for spinal cord or nerve root compression. In order to restore stability and relieve neural compression, a variety of surgical techniques originally used for reduction of nonpathologic spinal fractures have been applied to the problem of spinal metastases. Recently, we have utilized a technique developed primarily for correction of scoliosis to the treatment of metastatic spinal fractures. Six patients with spinal instability and neural compression secondary to metastatic tumors had segmental spinal stabilization with Luque rods, sublaminar wiring, and methyl methacrylate. Restoration of stability was successful in all cases with alleviation of preoperative pain and return to full activity. No evidence of instability occurred in this group of patients. As demonstrated by this experience and that of a few other small series, Luque rod stabilization provides a valuable addition to the techniques available for stabilization of metastatic fractures of the spine. Although the precise role of Luque rod segmental spinal stabilization in treatment of metastatic disease of the spine continues to be defined, thus far it has proved beneficial for cases of multiple vertebral body involvement or instability beyond one vertebral level.

An Evaluation of Spinal Deformity in Metastatic Breast Cancer

Between October 1984 and January 1988 31 magnetic resonance (MR) imaging studies were performed on 27 patients with metastatic vertebral breast cancer (MVBC). The MR images were reviewed to determine the extent and type of sagittal spinal deformity, and whether spinal canal compromise was present. Adjunct studies were compared to determine the pathogenesis of spinal deformity and the etiology of spinal canal compromise. An analysis of the data revealed that a consistent pattern of sagittal spinal deformity exists with MVBC, and a classification system was developed to describe the stages of vertebral deformity. Criteria are suggested for identifying metastatic spinal instability. A protocol is presented for treating patients with metastatic spinal involvement. By understanding the natural history of metastatic spinal deformity, instability and spinal canal compromise can be recognized and treated early, before the onset of progressive deformity and neurologic sequelae.

Spinal Deformities: The Comprehensive Text

I. Gross Anatomy: Surgical Anatomy of the Sacrum and Pelvis Surgical Anatomy of the Lumbar Spine Surgical Anatomy of the Thoracic Spine Surgical Anatomy of the Cervical Spine Muscles and Ligaments. II. Microanatomy: Development and Maturation of the Spine and Spinal Cord Microscopic Anatomy of Bone Macro and Microscopic Anatomy of the Disc and Endplate Nervous System and Muscle. III. Physiology: Physiology of Bone Nerve and Muscle Physiology Pulmonary and Chest Cage Physiology Electrophysiology Cerebral Spinal Fluid (CSF) Physiology. IV. Biomechanics: Biomechanics Biomechanics of the Intervertebral Disc Spine Testing Modalities. V. Pharmacology: Antibiotic Therapy in Spine Surgery Osteoporosis: Evaluation and Pharmacologic Treatment Pharmacologic Agents that Minimize Perioperative Blood Loss... Common Medications in Spinal Afflictions. VI. Pathology: Pathophysiology of Lumbar Degenerative Disc Disease Spinal Inflammatory Arthritides Spinal Neuroarthropathy (Charcots Spine) Pyogenic Vertebral Infection Coagulation Disorders in Spine Surgery Blood Conservation Strategies in Spine Surgery Management of Metastatic Disease to the Spine. VII. Clinical Evaluation: Evaluation of the Patient with Congenital Spine Deformity Clinical Evaluation of the Patient with a Spine Deformity Clinical Evaluation for Neuromuscular Scoliosis and Kyphosis Evaluation of Back Pain in the Spinal Deformity Patient. VIII. Neurology: Spinal Cord Injury, Reflexes, and Syndromes Anterior Horn Cell Disease: Poliomyelitis, Spinal Muscular Congenital and Developmental Spinal Cord Abnormalities The Spine in Friedrichs Ataxia, Charcot-Marie-Tooth Disease Cerebral Palsy, Myelodysplasia, Hydrosyringomyelia, Rett... IX. Anesthesia: Anesthetic Considerations for Spinal Surgery. X. Radiology: Radiology. XI. Rehabilitation: Rehabilitation. XII. Treatment of the Adult Spine: Degenerative Lumbar Stenosis Degenerative Disc Disease and Degenerative Spondylolisthesis of... Adult Spine Trauma Inflammatory Arthritis of the Spine Vertebral Osteomyelitis Neoplasms of the Spine. XIII. Surgical Techniques: Tables and Positioning Halo and Cranial Traction Approaches to the Cervical Spine Open Thoracic and Lumbar Spine Surgical Approaches Cervical Decompression Decompression for Lumbar Spinal Stenosis Spine Fusion Spine Osteotomy and Resection Staging Plus Complications of Approaches Thoracoplasty Endoscopic and Mini-Open Approaches to the Spine. XIV. Instrumentation and Complications: Basic Principles of Deformity Correction A Biomechanical Approach to Posterior Spinal Instrumentation Sacropelvic Fixation in Spinal Deformity Neurological Injury Complicating Surgery Postoperative Complications Revision Surgery. XV. Pediatric Spine: Etiology of Scoliosis Idiopathic Scoliosis: Prevalence and Natural History Congenital Scoliosis and Kyphosis Inflammatory and Infectious Disorders of the Childs Spine The Spine in Skeletal Syndromes and Dysplasias Neuromuscular Scoliosis Pediatric Spine Trauma Spine Tumors in Childhood and Adolescence. XVI. Deformities: Idiopathic Scoliosis: General Considerations, Natural History and... Bracing in Scoliosis Spinal Deformities Associated with Metabolic Diseases Perioperative Blood and Blood Product Management for Spinal... Scheurmann Kyphosis Spondylolysis and Spondylolisthesis Intraoperative and Immediate Postoperative Complications.

Long Structural Allografts in the Treatment of Anterior Spinal Column Defects

A retrospective study of 41 patients who had anterior spinal column reconstruction using long-segment allografts between 1983 and 1998 is reported. A long-segment allograft was defined as an allograft strut that replaces a vertebral body or approximates the height of the adjacent vertebral body for the thoracolumbar or lumbar spine, or more than two vertebral bodies for the cervical or cervicothoracic spine. Forty of the 41 patients had successful anterior strut grafting with radiographic evidence of allograft incorporation at the last followup with the majority of patients having radiographic evidence of incorporation by 6 months. There where three early complications related to the allograft (two end plate fractures and one repeated cervical spine allograft dislodgment) and one late complication associated with the posterior adjunct instrumentation unrelated to the allograft (degenerative lumbar stenosis). The only procedural complication was a deep venous thrombosis and a resultant nonfatal pulmonary embolus. No allografts fractured or collapsed. These data suggest that long-segment anterior allografts work exceptionally well in maintaining vertebral height and structural integrity in numerous pathologic deformities including traumatic and infectious etiologies.

Methylmethacrylate Reconstruction of Large Iliac Crest Bone Graft Donor Sites

Often full-thickness iliac crest grafts are necessary for various reconstructive procedures. Sometimes large defects remain in the donor ilium subsequent to their removal. Several complications have occurred as a result of these bony defects. Although several reports have been published regarding the repair of iliac herniae, little has been written about procedures to prevent these complications. A technique was devised to reconstruct the ilium with methylmethacrylate. After preparation of the defect, malleable retractors are bent to conform to the contour of the iliac crest. Methylmethacrylate is then packed into the mold made by the retractors. After hardening, the methylmethacrylate casting of the defect is trimmed and routine soft tissue closure is performed. This technique has been used in eight patients without any complications. The appearance of the waist and crests has been excellent; there have been no fractures or displacements of the mass of cement and there have been no infections. All these reconstructions have been mechanically stressed as all patients had well molded postoperative casts and/or braces. Reconstruction of the ilium with methylmethacrylate after removal of full-thickness grafts appears to be a reliable, safe, and easy technique based on a short-term follow-up of up to three years.

The treatment of severe scoliosis in osteogenesis imperfecta. Case report.

Surgical stabilization of the scoliotic spine in osteogenesis imperfecta (OI) is technically difficult owing to the mechanical weakness of the bone. Brittle bone makes instrumentation of the spine a procedure all too often associated with complications. Combining the instrumentation of the OI spine, both anteriorly and posteriorly, with the use of methylmethacrylate to augment the fixation may prove valuable as a surgical technique. This usage of methylmethacrylate in correcting severe scoliosis in OI has not been previously reported.