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The authors found that the surgical patients had increased satisfaction with their treatment and that maintaining patient comfort in the nonoperative group was imperative to their willingness to continue with nonoperative therapy medicine 8162 trusted 500 mg duricef. The usefulness of diskography in evaluating low back pain patients is controversial,37 and extensive debate regarding the efficacy of diskography is beyond the scope of this chapter. Diskography is probably most useful as an ancillary procedure and should be used to eliminate surgical candidates rather than include additional candidates. Patients with progressive neurological deficits, including loss of antigravity strength in the affected dermatome or loss of bowel, bladder, or sexual function, are typically referred for more urgent surgical intervention. Physical therapy and core stabilization exercises are often included as initial management. If pain complaints persist, further nonsurgical treatment with epidural or transforaminal injections is indicated. Varying success is seen with other nonsurgical interventions, including manipulations, acupuncture, and trigger point injections. Nonoperative treatment is aimed at returning the patient to activities of daily living in as expedient a manner as possible. In some patients, physical restrictions may be warranted initially, but most patients eventually benefit tremendously from physical therapy and controlled exercise. Thus, pain management is one of the most important aspects of successful nonoperative treatment. Technique A typical symptomatic disk herniation may be treated with a minimal unilateral approach under magnification and the patient under general or spinal anesthesia. The nerve root is decompressed and the risk for recurrent disk herniation reduced by performing annular fenestration, curettage, and removal of loose, degenerated disk material from the disk space with a rongeur. In all cases, the goal of surgery is to remove compression and adequately decompress any affected nerve roots while avoiding injury to any neural structure or retroperitoneal structures on the other side of the disk space. Spinal fusion procedures are used for the treatment of several different degenerative disorders, including degenerative disk disease, disk herniation, spondylolisthesis, and stenosis. Spinal fusion procedures are indicated when increased stability and restoration of normal anatomy are required. Disk replacement may be considered for individuals with degenerative disk disease and herniation without radicular pain. Disk replacement preserves motion and is not associated with increased stress at adjacent vertebral segments, in contrast to vertebral fusion procedures. The best results are achieved in younger patients and when only one vertebral level is affected. The complicated pathophysiology of the degenerative cascade often mandates an initial nonsurgical approach to management. Once the pain becomes lifestyle limiting and is refractory to nonsurgical intervention, surgery is often considered a reasonable option. A prospective evaluation of the role for intraoperative x-ray in lumbar discectomy. Long-term outcomes of surgical and non-surgical management of sciatica secondary to lumbar disc herniation: 10 year results from the Maine Lumbar Spine Study. A gold standard evaluation of the "discogenic pain" diagnosis as determined by provocative discography. Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3,183 consecutive degenerative lumbar cases. Lumbar disc degeneration: correlation with age, sex, and spine level in 600 autopsy specimens. Complications One of the most common intraoperative complications is negative exploration or wrong-level spine surgery. Although a recent survey suggested that wrong-level lumbar surgery occurs at a rate of just 4. Other intraoperative complications include violation of the dura or retroperitoneal injury. Most can be managed by repair of the defect and placement of a temporary subfascial drain, although some patients will require a return to the operating room. Epidural scarring is an unavoidable consequence of any procedure in the epidural space. In most patients this scarring is clinically silent, but a few experience significant pain. The pathogenesis of this pain is postulated to be tethering of a nerve root in the foramen by scar tissue. Worsening back pain often accompanied by paravertebral muscle spasm may be an indication of infection. Both the erythrocyte sedimentation rate and C-reactive protein level are elevated, with C-reactive protein being a more specific indicator of infection. Epstein Verbiest1-4 was one of the first to define central lumbar spinal stenosis, noting that laminectomy alone relieved radiculopathic symptoms for patients with narrowed spinal canals. He defined congenital stenosis, characterized by shortened pedicles and a shallow sagittal diameter, in two ways: absolute stenosis (10 mm) or relative stenosis (>10 to 12 mm). Single and multilevel stenosis is variously attributed to thickened laminae, arthrotic facets, exaggerated lordotic curvatures, laminar shingling, infolding of the hypertrophied yellow ligament, and ossification of the posterior longitudinal ligament, all of which contribute to central, lateral, or foraminal stenosis. In descending order, these are L5 root syndromes (L4-5 disease), L4 root syndromes (L3-4), L3 root syndromes (L2-3), and S1 root pathology (L5-S1). Patients averaging 71 years of age and undergoing two- to four-level laminectomies for severe lumbar stenosis exhibited a significant degree of both preoperative and postoperative bladder compromise. Radiography Plain anteroposterior radiographs demonstrate the number of lumbar vertebrae and help determine whether there is a lumbosacral bony anomaly (frequency, 7%). Although congenital benign Tarlov cysts (small or large) may occasionally balloon into neural foramina, they are not considered pathologic and rarely require surgery. It does not, however, directly demonstrate calcific or ossific changes often associated with disk or limbus fractures, spondylosis, and ossification of the posterior longitudinal or yellow ligament. In one series of patients older than 60 years, herniated disks (36%) and spinal stenosis (21%) were symptomatic in only one third of patients. Unilateral or bilateral radiculopathy may be associated with neurogenic claudication, characterized by leg pain, numbness, tingling, and weakness, that is exacerbated by walking specific distances (measured in blocks). When 100 consecutive patients with disk disease, lateral recess stenosis, and central stenosis were evaluated, all three groups of patients demonstrated comparable complaints of pain at rest, pain at night, and pain on coughing. Of 50 patients entered in the study, 28 (55%) had facet fluid; 23 (82%) were unstable, and 5 (18%) were not. In one study it documented foraminal stenosis that was surgically confirmed in 35 of 990 patients. For patients with relative stenosis and a canal depth of 11 to 13 mm correlated with radiculopathy rather than myelopathic symptoms, lumbar surgery often takes precedence over cervical intervention. For the former patients, preliminary cervical decompression often results in improvement of seemingly "lumbar" complaints in more than one third. In another series, 8 of 230 patients with lumbar stenosis were also found to have cervical stenosis. Although tandem cervical-lumbar stenosis occurs in only 10% of patients, it should be anticipated in patients older than 65 years, and these individuals should undergo more stringent screening for tandem cervical disease. These typically include ependymomas, neurofibromas, meningiomas, and metastatic lesions. In one study, a patient with an unresolved right footdrop following lumbar surgery was found to have a left-sided parasagittal convexity meninigoma; resection resulted in complete resolution of the deficit. In one series, amyloidosis and its characteristic crystals contributed to hypertrophy of the yellow ligament in 12 of 97 patients undergoing lumbar surgery for stenosis. Of note, among diabetics with lumbar stenosis, only 39% exhibited good or excellent outcomes, compared with 95% good or excellent results for those without diabetes. These fragments are typically extremely large, include both cortical and cancellous elements, and warrant more extensive resection to afford access for adequate decompression.

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A translational deformity can occur with two-rod constructs because of an intrinsic bending moment between the rods medications resembling percocet 512 buy duricef 500 mg otc. Some of the newer constructs avoid a parallelogram configuration by offsetting the screws in the sagittal and coronal planes within a single vertebral body. Distraction and compression are applied to the screws before and after the graft is inserted. Excessive distraction across the defect can cause neurological injury from stretch and vascular compromise. Particular care with distraction should be taken if the anterior or posterior longitudinal ligament is incompetent. Screw-rod constructs generally consist of vertebral body plates, cancellous screws, paired rods, and a method of fixing the rods to the screws, either directly or through vertebral body plates. The screws provide a means for distraction across the defect during insertion of an interbody strut graft. A transverse coupler or parallel connector can be used to increase the stability of the construct against both rotatory and flexion-extension forces. With earlier plating systems, distraction across the corpectomy site was obtained with a separate instrument because the plate provides no anchor for distraction. Once the graft is in place, compression is applied through a separate set of screws, which can provide a limited degree (typically up to 3 mm) of compression. An interbody device may be used when intervertebral support is desired following a diskectomy or corpectomy, particularly if an appropriate structural bone graft, either autologous or allogeneic, is not available. Compared with more traditional posterior fusion constructs, anterior interbody fusion has some surgical and biomechanical advantages. InterbodyGraftsandDevices the initial interbody grafts were human allograft, typically obtained from the femur or humerus. These are osteoconductive, have biomechanical properties similar to the vertebral bodies, and are customizable in the operating room. Vertically oriented titanium cages have the advantage of being able to be cut to a specific size to custom-fit an interbody space or corpectomy defect. There have been some reports of adjacent level vertebral body fractures using expandable cages, owing to the forces used to expand the cages. Biomechanical data indicate that most of these devices increase stability beyond that of the normal intact spine, but no conclusive studies have demonstrated the superiority of one device over another. Complications related to the graft and instrumentation include pseudarthrosis, graft or construct dislodgment, and instrumentation failure. The cumulative incidence of complications for anterior spinal fusion has been reported to be as high as 40%. Vascular injuries have been reported to follow anterior lumbar fusion in up to 15% of cases. The screw-rod and screw-plate constructs can be fixed either in a direct anterior or anterolateral position. The left-sided approach is favored because arterial structures are easier to mobilize than venous structures and also because hemorrhage from an arterial vessel is usually easier to control. Inflammatory, neoplastic, or degenerative processes or adjuvant therapy for neoplastic disease, such as radiation or chemotherapy, may increase scarring around the vessels, making dissection more difficult. Temporary hemostatic clamps can also be placed to control bleeding and to allow repair of the defect. Excessive lateral retraction of the iliac vessels can lead to spasm or thrombosis. If a thrombus occurs, the assistance of a vascular surgeon may be required to perform a thrombectomy. Close communication with the anesthesiologist and ensuring the patient is hemodynamically optimized before performing a part of a procedure with an anticipated risk of significant blood loss will minimize the risks to the patient. Preoperative embolization may also be used to reduce the risk of hemorrhage associated with the resection of a vascular neoplasm. Bowel perforations, most often encountered with a transperitoneal approach, should be repaired by a general surgeon. A functional ileus is common after intra-abdominal surgery and typically resolves spontaneously within 2 to 3 days. Failure to recognize a mechanical obstruction can compromise blood flow and lead to the devastating consequences of bowel ischemia. The ureter is frequently manipulated during a retroperitoneal approach but is usually lateral to the transperitoneal exposure. If mobilization is required, particularly with a rostral lumbar exposure, a generous cuff of soft tissue should be left surrounding the ureter to preserve blood flow. The preaortic sympathetic plexus forms the superior hypogastric plexus distal to the aortic bifurcation ventral to the L5-S1 intervertebral disk space, which provides innervation to the sphincter urethrae muscle. Deinnervation of this muscle causes retrograde ejaculation in men, a significant complication that can result in functional sterility. If a ventral approach to L5-S1 is planned in a male patient, this potential complication is discussed frankly and the advisability of sperm banking explained to him. Penile erection is mediated through the parasympathetic plexus and should not be injured when standard anterior approaches are used. Injury to the lumbosacral plexus and to the femoral and genitofemoral nerves is possible during dissection or retraction of the psoas muscle; ipsilateral leg weakness or paresthesias result. Decompression and graft insertion can injure the exiting nerve roots and cauda equina, producing lower extremity or bowel and bladder deficits. The decision to use instrumentation and the choice of construct should be approached logically and judiciously. A thorough understanding of the appropriate indications, biomechanics, and surgical techniques is required before these implants are used. Practicing surgeons should always consider several questions when contemplating the use of instrumentation constructs: (1) What is the indication for a spinal implant With these considerations in mind and a treatment plan developed for each patient based on established treatment principles, optimal clinical outcomes can be achieved. Vertebral body reconstruction with a modified Harrington rod distraction system for stabilization of the spine affected with metastatic disease. A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine. Anterior lumbar interbody fusion: indications for its use and notes on surgical technique. The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults: a review of 1223 procedures. Anterior discectomy and interbody fusion for lumbar disc herniation: a review of 350 cases. Anterior fixation for fractures of the thoracic and lumbar spine with or without neurologic involvement. Anterior spinal cord decompression for lesions of the thoracic and lumbar spine: techniques, new methods of internal fixation, results. Tumors of the thoracic and lumbar spine: surgical treatment via the anterior approach. Anterolateral decompression for metastatic epidural spinal cord tumors: results of a modified costotransversectomy approach. Extreme lateral interbody fusion: a novel surgical technique for anterior lumbar interbody fusion. The influence of fracture mechanism and morphology on the reliability and validity of two novel thoracolumbar injury classification systems. Unstable thoracolumbar fractures: a comparative clinical study of conservative treatment and Harrington instrumentation. Shaffrey Posterior lumbar instrumentation is intended to promote spinal stabilization. Lumbar instability warranting instrumentation may be encountered in a variety of disorders, including trauma, degenerative disease, infection, and tumor. Rapid advances in technology and techniques have provided the surgeon with a wide array of instrumentation and applications. Although widely used, the clinical indications for posterior lumbar instrumentation remain a matter of considerable debate, highlighting the need for further high-quality clinical studies. The purpose of this chapter is to provide an overview of the indications for posterior lumbar instrumentation, to discuss the types of instrumentation available as well as the techniques for placement, and to summarize available outcomes data. Although the indications for these devices are still being clarified, many of the applications are related to degenerative disease. Multiple classification systems have been developed for spinal fractures, including those of Denis,1 McAfee and colleagues,2 Gertzbein and associates,3 and Magerl and coworkers.

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These implants may be constrained in terms of motion, or they may be semiconstrained or unconstrained medications containing sulfa duricef 250 mg with mastercard. As such, classification is based on the following criteria: articulation, material, design, fixation, and kinematics. These trials appear to suggest that the advantages of maintenance of motion and the potential improved clinical outcome of arthroplasty outweigh the putative disadvantages of wear debris, material fatigue, and joint failure. The cervical disk arthroplasties maintained segmental sagittal angular motion averaging greater than 7 degrees. It is important to note that there were no cases of implant failure or migration in the arthroplasty group. Similar to the Prestige trial, the functional outcome and radiographic results of this prospective, randomized trial for patients with onelevel cervical disk disease were determined. With further long-term follow-up of cervical arthroplasty, clinicians will be able to determine the ultimate benefits and drawbacks of this technology. Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: A randomized controlled clinical trial. Spinal implants improved fusion rates significantly while minimizing morbidity, such as iliac crest donor site pain. In the next 50 years, spine surgeons may witness the emergence of a new philosophy centered around the maintenance of motion when treating spinal segmental disease. Cervical arthroplasty is a promising new option for the management of degenerative cervical disease. Anterior cervical discectomy and fusion involving a polyetheretherketone spacer and bone morphogenetic protein. Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: singlelevel and bi-level. Long-term results after anterior cervical fusion and osteosynthetic stabilization for fractures and/or dislocations of the cervical spine. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. Intractable headache and cervico-brachialgia treated by complete replacement of cervical intervertebral discs with a metal prosthesis. Artificial disc versus fusion: a prospective, randomized study with 2-year follow-up on 99 patients. Cervical arthroplasty in the management of spondylotic myelopathy: 18-month results. Influence of an artificial cervical joint compared with fusion on adjacent-level motion in the treatment of degenerative cervical disc disease. The advent of increasingly sophisticated spinal instrumentation and implants have consistently increased fusion rates. Partial disk replacement dates back to the 1960s, when Fernstrom implanted stainless steel balls into the cervical and lumbar spine. Constrained devices have a mechanical stop within the range of physiologic motion, while semiconstrained devices have a mechanical stop outside the range of physiologic motion. Nucleus replacement devices represent an even more heterogeneous group of devices and are earlier in the developmental process. Functionally, nucleus replacement devices can be divided into two broad classifications: elastomeric and mechanical. Advantages of nucleus replacement include minimally invasive and multiple approach options, including anterior retroperitoneal, lateral, and posterior approaches. A standard anterior retroperitoneal approach is followed by exposure of the anterior disk. In the United States, exposure is generally accomplished with an access surgeon, either general or vascular. The midline should be preliminarily identified and marked using anatomic landmarks before extensive dissection. Proper identification and verification of the midline is crucial to proper artificial disk placement. It is imperative to mobilize the iliac vessels to visualize the lateral margins of the anterior disk. Disk removal is accomplished with standard technique using variously sized and angled curets and pituitary and Kerrison rongeurs. Care is taken to remove the cartilaginous end plates while preserving the bony end plates to minimize the risk of implant subsidence. Attention is paid to complete disk removal, retaining only the lateral annulus bilaterally. Special care must be taken with lateral disk resection where any retained disk material can be pushed into the foramen during artificial disk placement. These initial designs were limited to placement via the anterior retroperitoneal approach. Second- and third-generation devices have incorporated novel materials with the potential for an elastomeric component to the artificial disk function. Newer designs also allow for more flexibility in surgical approach, incorporating the standard posterior and lateral transpsoas approaches to the lumbar spine. Prodisc-L Artificial Disk (Synthes Spine) the Prodisc-L has cobalt chrome end plates with a semiconstrained, polyethylene core and keel fixation and a threepiece design with a two-stage application. Charite Artificial Disc (Depuy Spine) Cobalt chrome endplates with an unconstrained, polyethylene floating core and spike fixation. They have a three-piece design with a two-stage application and endplates followed by core placement. InMotion Artificial Disc (Depuy Spine) the next-generation Charite device has redesigned end plates and a no-impaction application technique. The reconfigured cobalt chrome end plates and spike fixation have the same unconstrained, polyethylene floating core. FlexiCore Artificial Disk (Stryker Spine) the FlexiCore has a cobalt chrome, metal-on-metal design with a constrained domed core and spike fixation. Injectable nucleus replacements are delivered in liquid form into the nucleotomy void and cure in situ. A central challenge involved in the use of preformed devices is implant extrusion because of their inherently deformable nature. For injectable devices, biocompatibility, longterm durability, and avoidance of leakage are of crucial importance. It is implanted dehydrated and expands anisotropically to conform to the nucleotomy defect. The concept of comparing different surgical techniques and attempting to assess superiority is, at best, a theoretical exercise and, at worst, counterproductive to patient care. A more pragmatic, and potentially successful, approach lies in using a spectrum of surgical treatments to match an inherently heterogenous disease process. Nucleus replacement remains investigational, but early clinical results have been encouraging. The potential of nucleus replacement must be tempered by the lack of long-term clinical results. These devices reliably maintain motion while concomitantly decreasing stresses on adjacent levels compared to fusion. The techniques and devices associated with lumbar arthroplasty continue to evolve, providing a widening array of motion preservation treatment options to address the spectrum of pathophysiologic processes affecting the lumbar spine. Change of disc height, radial disc bulge, and intradiscal pressure from discectomy: an in vitro investigation on human lumbar discs. Adjacent-segment degeneration after lumbar fusion: a review of clinical, biomechanical, and radiology studies. Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature: results of a multicenter, prospective, randomized investigational device exemption study of Charite intervertebral disc.

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Pedicle fixation began to be widely used in North America as an adjunct to fusion in the 1980s and 1990s treatment room buy discount duricef line. Dwyer and coworkers described a device for the anterior correction of scoliotic deformity in 1969. Oroszco and Llovet60 first applied plates to the anterior cervical spine, followed by Caspar61 and others. During the 1970s and 1980s, implants for posterior cervical fixation with plates with screws inserted into the lateral masses were also undergoing development by several clinical investigators. These techniques have permitted progression from segmental immobilization in situ to active correction of most cervical deformities. Advances in instrumentation with active correction of deformity have reduced the need to perform procedures such as transoral odontoid resection for basilar impaction caused by rheumatoid arthritis. The continued dramatic expansion in the use of internal fixation for the gamut of spinal disorders is further testament to its utility. Building on previous developments in spinal instrumentation and improvements in intraoperative imaging, many traditional spine surgery procedures can now be performed with minimally invasive techniques to decrease muscle injury and potentially reduce complications and improve outcomes. Chapter 307 details the progressive advances in surgical technique over the past decade and discusses future trends in treating a greater spectrum of clinical pathology with minimally invasive techniques for lumbar disorders. Over the past 100 years, progress in all areas relevant to the management of spinal disorders has been observed. Through the chapters in this section of the textbook, we have sought to provide an overview of current neurosurgical spinal practice that reflects the recent and ongoing revolutionary changes in the field. In each of these areas of study, key concepts emerge that have a direct impact on the quality of surgical decision making. Spinal cord injury is among the most devastating of injuries because it robs the individual of neurological function and offers limited prospect for recovery. Advances in basic neurobiology and neurophysiology have altered the historical view that the spinal cord has no potential for neural plasticity. Chapters 267 and 268 discuss the spectrum of theoretical and practical pharmacologic and physiologic treatments undergoing laboratory and clinical evaluation and how these treatments are having an impact on current management of spinal cord injury. The recent literature cited in these chapters provides current information on the benefits and risks of early and delayed surgical intervention for spinal column injury with associated neurological deficits. Chapters 265 and 266 provide an extensive overview of spinal biomechanics for all current forms of spinal instrumentation, including arthroplasty. Concepts such as load sharing, cantilever bending, and forces leading to implant failure are discussed. The current understanding of the effect of various biomaterials on implant durability and wear and their role in lumbar and cervical arthroplasaty is also detailed. As the surgical techniques for managing spinal disorders have become more powerful and greater forces are used for spinal realignment, the concept of intraoperatively monitoring the physiologic status of the neural elements during operative manipulation has become more important. Procedures that decompress the spinal cord or cauda equina, reduce fractures or subluxations, or correct deformity all have the potential to alter neurological function through direct or indirect injury to the neural elements. The goal of continuously assessing the status of the cord and nerve roots in nearly real time is now feasible. Chapter 269 describes the role of intraoperative physiologic monitoring as applied to spine surgery and discusses the reliability and validity of such measurements. A surgeon who routinely performs spinal instrumentation, treats fractures, or manages spinal disorders in the elderly must understand normal bone metabolism, its hormonal regulation, and the impact of aging on bone density. Chapters 271 and 321 describe normal and pathologic bone metabolism, the challenges of patients with reduced bone mineral density, and treatment strategies to best manage these challenging cases, including the use of vertebroplasty and kyphoplasty. Chapters 289 and 290 discuss the evaluation and management of congenital and developmental abnormalities of the craniocervical junction and thoracolumbar spine. Although many of these conditions are present from infancy, they frequently become evident only after skeletal maturity. These chapters discuss the latest surgical techniques for reducing complications and improving outcomes in these often demanding cases. Chapter 270 describes the physiologic concepts of disk degeneration and current laboratory techniques under development to either slow degeneration or promote disk regeneration. Managment of chronic lower back pain is a substantial burden to the surgeon and society. The treating physician must maintain an organized, methodical but individualized approach. Most patients referred to a spine surgeon with complaints of low back pain are best treated by medical management, and it is therefore essential to remain abreast of current medical treatments. Patients who have failed previous operative interventions represent a particularly difficult group for whom surgery must be considered only with extreme caution and attention to strict operative indications. Chapters 272, 273, and 274 provide useful insight into the evaluation and management of spine patients in general and those with intractable spine-related pain in particular. Surgeons must remain aware of a variety of other nondegenerative causes of low back pain and other medical conditions that may initially be manifested as pain in the spinal area. Multiple studies have detailed generally poorer outcomes with revision spine surgery than with primary surgery. Chapter 275 discusses evaluation, appropriate patient selection, and differences in technique for patients who have failed a primary surgical intervention. Multimodality management is typically optimal; it combines antimicrobial therapy with decompression of the neural elements, removal of necrotic tissue, and spinal stabilization, followed by physical rehabilitation. Chapters 276 and 277 address these issues with respect to a spectrum of pyogenic, fungal, and tubercular causes. Chapters 279 and 280 review these topics and describe the evaluation and general surgical options. Chapter 293 describes in detail the indications, contraindications, results, and operative technique for cervical arthroplasty. Ankylosing spondylitis and other spondyloarthropathies pose unique problems for the surgeon, as does ossification of the posterior longitudinal ligament. The special issues related to these disorders are reviewed in Chapters 281 and 282. Nonetheless, these herniations can be associated with considerable neurological morbidity. An expanding surgical armamentarium of open and thoracoscopic approaches is available to manage thoracic disk herniation. Chapters 283 and 306 describe the range of surgical procedures currently used for the management of these conditions and discuss the need to individualize the approach based on factors such as thoracic disk location, calcification, and size. Chapter 306 also discusses the increasing range of thoracic pathology that can be successfully managed with thoracoscopic approaches with potentially less morbidity than seen with traditional thoracotomy. Degenerative conditions of the lumbar spine consist primarily of disk herniations, spondylosis and stenosis, spondylolisthesis of multiple origins, and deformity. Chapters 284, 285, and 287 review the clinical and physical findings, evaluation, and therapeutic options for these common conditions. More recently, the introduction of newer techniques such as lumbar arthplasty, nucleoplasty, dynamic stabilization, and other motion-sparing techniques has gained increased interest. Chapters 288 and 289 provide a history of the development of these devices, detail the results of recently completed and ongoing clinical trials, and discuss the current indications for the use of these devices. The topic of evaluation and management of adult thoracolumbar deformity is not typically included in most neurosurgical texts. With the trend toward subspecialization in spine surgery, however, both neurosurgical and orthopedic spine surgeons are increasingly being exposed to progressively more complex cases. Aging of the population and the consequences of previous surgical interventions have increased the overall incidence of adult spinal deformity. Most neurosurgeons treating degenerative spinal conditions will encounter patients with spinal deformity. Chapter 287 discusses the clinical findings, diagnosis, and management of adult thoracolumbar scoliosis. Chapter 288 details the evaluation and management of sagittal spinal deformites, including iatrogenic flat back, which has been increasing recognized as a major cause of failure in management of deformity. Chapter 290 discusses the indications and fixation techniques for spinopelvic instrumentation.

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Intraoperative biopsy can be useful in certain circumstances but should not be used as the sole criterion dictating the surgical objective medications used for bipolar disorder discount 500 mg duricef otc. First, interpretation of tiny biopsy fragments on a poor-quality frozen section is often inaccurate or nondiagnostic and may consist of only peritumoral gliosis that can be erroneously interpreted as an infiltrating astrocytoma. However, intraoperative frozen sections can be helpful when they indicate positive histologic features. Malignant features such as vascular proliferation or necrosis, for example, usually signal an end to the procedure because most surgeons believe that aggressive resection of malignant intramedullary neoplasms is not beneficial. Surgical Technique After intubation and perioperative administration of steroids and antibiotics, the patient is turned to the prone position. Subdural and epidural motor evoked potentials can be monitored in 60% of patients and provide real-time feedback. A 50% decline in the amplitude of motor evoked potentials can be an indication of a new, permanent postoperative weakness. A standard laminectomy, which should extend at least one segment above and below the solid tumor component, is performed. In adults, delayed instability rarely follows laminectomy for intramedullary tumor removal. For tumors spanning high-risk regions such as the cervicothoracic junction, laminoplasty or hemilaminar exposures may be reasonable options, particularly in children. Strict hemostasis must be secured before the dura is opened to prevent ongoing blood contamination of the dependent microsurgical field. A hemostatic agent such as thrombin-soaked Gelfoam is spread generously over the lateral gutters to prevent contamination of blood in the operative field. The dura is opened in the midline and tented laterally to the muscles with sutures, and the operating microscope is brought Treatment Surgery is the most effective treatment of the majority of intramedullary tumors,52,56,63,71 including most ependymomas and hemangioblastomas. The benefits of aggressive surgical resection of astrocytomas are more controversial. Because most intramedullary spinal cord neoplasms are low-grade lesions and well circumscribed, long-term tumor control or cure with preservation of neurological function can be achieved in most patients by microsurgical removal alone. This interface can be assessed accurately only through an adequate myelotomy that extends over the entire rostrocaudal extent of the tumor. Although the presence of a syrinx may improve the chances of achieving gross total resection, it cannot be used as an independent predictor of outcome. Some benign astrocytomas possess a clear gross morphologic boundary with respect to the cord parenchyma, thereby permitting safe, gross total radiographic resection. The arachnoid is opened separately and the spinal cord inspected for surface abnormalities. Occasionally, the overlying spinal cord may be thinned or even made transparent by a large or eccentrically located tumor or polar cyst. Ultrasonography is useful to localize the tumor and ensure adequate bony exposure. Most hemangioblastomas arise from the dorsal half of the spinal cord and have a visible pial attachment. The dorsal midline can be estimated accurately by noting the midpoint between the dorsal nerve root entry zones bilaterally. Spreading the posterior columns gently with microforceps or dissectors deepens the myelotomy. The tumor is first encountered in the area where the spinal cord is enlarged maximally. Dissection continues on the surface of the tumor until the entire rostrocaudal extent has been identified. Once the entire dorsal extent of the tumor has been identified, 6-0 pial traction sutures are placed. The technique of tumor removal is determined by the surgical objective and by the gross and histologic characteristics and size of the tumor. If no plane is apparent between the tumor and surrounding spinal cord, the tumor is probably infiltrative. A biopsy specimen is obtained to provide some additional information for intraoperative decision making. If an infiltrating or malignant astrocytoma is identified and is consistent with the intraoperative findings, further tumor removal is probably unwarranted. In most cases, however, a reasonably well-defined benign glial tumor is identified. Ependymomas have a smooth, reddish gray glistening tumor surface that is sharply demarcated from the surrounding spinal cord. Variable blood vessels cross the surface of the tumor, thus distinguishing these tumors from astrocytomas, which rarely display these surface characteristics. Traction on the surface of the tumor is used against the countertraction provided by the pial sutures to allow the dissection plane to be developed. Small feeding blood vessels and fibrous adhesions between the spinal cord and tumor are cauterized and divided. Although en bloc resection is preferred, large tumors may require internal decompression with an ultrasonic aspirator or laser. Once the tumor has been debulked significantly, the lateral and ventral margins can be dissected. The ventral tumor margin is developed by applying traction to a tumor pole, perpendicular to the long axis of the spinal cord. Feeding arteries from the anterior spinal artery are easily identified, cauterized, and divided. About a third of adult patients have benign, infiltrative tumors without an identifiable tumor mass. Occasionally, an astrocytoma may be so well developed that it mimics an ependymoma. Nevertheless, astrocytomas rarely have a plane as well defined as that of ependymomas. Dissection on the surface of an astrocytoma usually develops laminated pseudoplanes. Decompression is achieved with an ultrasonic aspirator or laser and proceeds systematically from the center of the tumor radially to the surface. Although most astrocytomas do not have a clean plane, the tumor is frequently a different color than the spinal cord. Removal of hemangioblastomas is facilitated by excising the pial attachment as part of the tumor mass. After the surface vessels have been cauterized, a circumferential incision is made around the pial base. The portion of the tumor buried within the spinal cord is easily dissected and delivered by applying traction to the pial base. These neoplasms cannot be decompressed internally, but cauterizing the surface shrinks the tumor to a more manageable size. After an intramedullary tumor has been removed, the resection bed is inspected and bleeding points are controlled with warm saline or oxidized cotton. The pial traction sutures are removed to allow the spinal cord to assume its normal position. The dura is usually closed primarily, although a dural patch graft may prevent dorsal tethering of the spinal cord at the operative site-a potential cause of postoperative morbidity. During this period, aggressive prophylaxis for deep venous thrombosis and frequent use of incentive spirometry can help avoid complications related to bed rest. Orthostatic hypotension occasionally occurs after upper thoracic and cervical intramedullary neoplasms have been removed. This problem is usually self-limited and can be managed with liberalization of fluids and gradual mobilization.

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In vitro biomechanical comparison of pedicle screws, sublaminar hooks, and sublaminar cables medicine you can overdose on duricef 500mg mastercard. Expandable cage placement via a posterolateral approach in lumbar spine reconstructions. Inserting pedicle screws in the upper thoracic spine without the use of fluoroscopy or image guidance. The use of an expandable cage for corpectomy reconstruction of vertebral body tumors through a posterior extracavitary approach: a multicenter consecutive case series of prospectively followed patients. Thoracolumbar fracture: posterior instrumentation using distraction and ligamentotaxis reduction. Angevine Biomechanical insufficiency of the ventral lumbar spine is a common clinical problem encountered by spinal surgeons. Its effective management requires a comprehensive understanding of the indications for ventral surgical intervention, spinal biomechanics, anterior spinal anatomy, ventral surgical approaches, and techniques for spinal stabilization. Loss of the structural integrity of the anterior and middle columns of the spine may be caused by the pathologic destruction of the vertebral body secondary to neoplastic, traumatic, infectious, and degenerative processes, or it may occur as an iatrogenic consequence of surgical decompression. Additionally, correction of spinal deformity may require anterior stabilization of the lumbar spine. A variety of anterior fixation techniques and devices provides the spinal surgeon with several options when planning anterior lumbar surgery. Anatomic factors place constraints on surgical approaches to the upper, mid, and lower lumbar regions and also, to some degree, on the type of instruments that may be used. Selection of the approach and type of construct depend, among other factors, on the specific indications for surgery, the levels involved, and whether any posterior procedure has been performed or is planned. Numerous series have reported the successful treatment of spinal neoplastic disease with a ventral or ventrolateral approach. Trauma Compared with fractures of the thoracolumbar junction, fractures of the lumbar spine distal to L2 are relatively uncommon, with less than 4% of all fractures involving L3-5. Falls from a significant height that produce a substantial axial load may result in unstable burst fractures. Passengers wearing lower abdominal seat belts during motor vehicle accidents may sustain flexion or flexion-distraction injuries to the lumbar or thoracolumbar spine, with the seat belt acting as a fulcrum. The decision to treat a lumbar spine trauma patient operatively is based on multiple factors. In addition to the presence of a neurological deficit, the extent of spinal canal encroachment or compromise, loss of vertebral body height, degree of local kyphotic deformity, and fracture pattern may guide treatment decision making. Surgical decompression is the first-line treatment for a patient with an acute partial neurological deficit due to neural compression following trauma. Emergent decompression is recommended for a progressive neurological deficit and a grossly unstable spine. The indications for operative treatment of patients with fixed neurological deficits are less clear. Advocates who favor delaying surgery believe that there is a reduced risk of neural injury and intraoperative blood loss with surgery after the acute period. Patients may also be mobilized early after surgery, thereby avoiding the complications of prolonged bed rest. When the stability of the anterior column is in jeopardy or when ventral spinal arthrodesis is desired, an anterior approach may be necessary to ensure proper stabilization and bony fusion. Midline or bilateral ventral decompression of the spinal canal, when necessary, is best accomplished through an anterior approach. Finally, anterior stabilization is indicated in cases where ventral correction of a deformity is preferred or necessary to restore proper spinal alignment. A clear understanding of the surgical indications based on the specific pathology and cause of instability is essential to planning appropriate surgery and achieving optimal outcomes. Neoplasm the spinal column is the most frequent site of bony metastases1; up to two thirds of these arise from breast, prostate, lung, and hematopoietic cancers. By far the most common symptom produced by either primary or metastatic lesions is pain,9-12 stereotypically a constant pain that is not relieved by rest and intensifies at night. Progression of the tumor beyond the confines of the vertebral body may produce myeloradiculopathy because of direct compression of neural elements or compromise of vascular supply. Acute partial loss of neurological function may be an indication for urgent surgical intervention because studies have shown improvement in neurological function following early surgical treatment in such circumstances. In cases of severe degenerative destruction of vertebral bodies, or a significant local spinal deformity, multisegmental ventral instrumentation constructs may be necessary, either alone or in conjunction with posterior fixation. Infection Bacterial organisms, usually Staphylococcus aureus, are the most common causes of spinal infections, and most spinal infections are treated with intravenous antibiotics and immobilization before the onset of a neurological deficit or spinal deformity. This often involves discectomies and a corpectomy of the involved vertebral body followed by a fusion. Over the years, several ventral approaches for access to the anterior lumbar spine have been developed and refined. For instance, exposure of the thoracolumbar junction for access to L1 requires a thoracoabdominal approach and release of the diaphragm. Lesions located between L2 and L5 can be addressed through a flank or paramedian incision and a retroperitoneal approach. If midline exposure of L2 to L5 is required, a transperitoneal approach is often most direct. The side of the approach is ultimately dictated by the location and nature of the pathology, but a left-sided approach is usually preferred because the liver is avoided and the aorta is easier to mobilize and less susceptible to injury than the vena cava. Our practice is to use a general or vascular surgeon for anterior approaches to the lumbar spine to ensure a safe and adequate exposure. We scrub in, however, as assistants, to gain experience with the approaches and to help tailor the exposure to the requirements of the individual case. An incision is marked using fluoroscopy and is made from the lateral border of the paraspinal musculature along the 10th rib to the junction of the rib and the costal cartilage. The rib is divided posteriorly at the angle of the rib and at the junction of the rib and costal cartilage. The rib is removed, the remaining costal cartilage is divided lengthwise with a knife or scissors, and the flaps of cartilage are retracted. The retroperitoneal space is identified with blunt dissection deep to the costal cartilage and the peritoneum is dissected off the inferior surface of the diaphragm. The peritoneum is then retracted medially, and the abdominal musculature is divided in layers, revealing the diaphragm. The endothoracic fascia within the rib bed is divided along with the parietal pleura, which is deep to it. The soft tissue is swept off the thoracic and abdominal surfaces of the diaphragm, which is then incised circumferentially leaving a cuff of muscle of approximately attached to the chest wall. Alternatively, the diaphragm is bluntly stripped from the chest wall with a Cobb elevator or sponge stick. This technique obviates the necessity of reapproximating the diaphragm at closure. A large Deaver retractor is used to retract the peritoneal sac anteromedially, and a large rib retractor opens the 10th rib space to reveal the thoracolumbar junction. In the lumbar spine, the psoas must be elevated dorsolaterally off the vertebral bodies to allow full visualization as far distally as the lesion dictates, taking care not to injure the lumbar plexus that runs within the muscle or the genitofemoral nerve that runs on its surface. A table-mounted retractor with multiple adjustable arms is used to maintain exposure during the procedure. Before closure a chest tube is inserted and tunneled out through a separate incision located distal to the main incision. The costal cartilage is carefully approximated, which reestablishes the separate retroperitoneal and thoracic spaces and helps to define the layers of the abdominal musculature. The rib bed is closed with interrupted permanent sutures, and the skin incision is closed in standard fashion.

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The position of the portals are triangulated over the region of the pathology and ideally evenly spaced rostral and caudal to the surgical target medications with acetaminophen duricef 500 mg for sale. If needed, a fan retractor can be placed between the anterior and middle axillary lines, rostral or caudal to the working portals. Flexible portals are used in thoracoscopic spinal procedures to prevent injury to the intercostal nerves. Before the portals are placed, the skin is infiltrated and an intercostal nerve block is administered with a local anesthetic (1% bupivicaine [Marcaine] with epinephrine). The skin is incised parallel to the superior surface of the rib to prevent injury to the neurovascular bundle. A hemostat is passed through the intercostal muscles and parietal pleura directly adjacent to the superior surface of the rib. A finger can be inserted to check for lung adhesions that would preclude the introduction of a portal at that site. Portals are placed over a rigid trocar, which is immediately removed after the portals have been placed. The proximal end of the portal is stapled or sutured to the skin to anchor it to the chest wall during surgery. Small adhesions can be addressed with sharp or blunt dissection techniques; however, dense, diffuse adhesions usually preclude thoracoscopic access and require conversion to a thoracotomy. Initial Spinal Exposure As the lung is deflated, the thoracoscope is inserted to visualize the thoracic cavity. If necessary, the operating room table is rotated 30 to 40 degrees anteriorly to allow the lung to fall away from the spine to minimize the need for retraction. When present, pleural adhesions can be detached with cauterization and scissors to mobilize the lung. Wound Closure and Postoperative Management At the conclusion of the procedure, after hemostasis has been obtained, the contents of the thoracic cavity are inspected carefully with the thoracoscope. The fan retractors are removed, and the surface of the lung is inspected for air leaks or contusions as it is inflated. One or two chest tubes are placed through separate, preexisting portal incisions under direct thoracoscopic visualization to ensure proper positioning. A B plastic causes and have failed efforts at medical management with topical and anticholinergic agents. In clinical series, the success rate of sympathectomy for permanent relief of palmar hyperhidrosis ranges from 90% to 100%. Medical therapy tends to be ineffective in terms of both the degree and duration of relief. Patients who experience symptomatic relief after percutaneous blocks of the stellate ganglion with local anesthetic agents are considered candidates for surgical sympathectomy. After a small incision is made parallel to the superior surface of the rib and access to the thoracic cavity with a hemostat has been obtained, a flexible portal is inserted with a trocar. The skin entry sites for the chest tubes are sealed with an occlusive dressing and nylon suture material. The second, third, and sometimes fourth sympathetic ganglia are thought to be the primary mediators of these disease processes. Traditionally, the second thoracic ganglion is considered to be the key ganglion for sympathetic denervation of the upper extremity. The autonomic tissue can be resected or the connections between the ganglia and the autonomic chain can be disrupted using sharp transection or thermal methods. Our practice has shifted from en bloc excision of these neural structures (ganglia with the interval sympathetic chain) to sharp transection of the ganglia and sympathetic chain with cauterization and scissors. While this procedure is performed, the accessory innervations to the sympathetic chain must be addressed. The accessory nerve Surgical Indications Several major groups of disorders can be treated by thoracoscopic sympathectomy (Table 306-4) and contraindications for the procedure are few. Idiopathic (essential) palmar hyperhidrosis is the most common indication for thoracoscopic sympathectomy. It must be transected to optimize the chances of the sympathectomy being effective. Patient Positioning With the patient in the lateral decubitus position, the bed is rotated approximately 40 degrees toward the surgeon, which allows gravity to retract the lung and brings the thoracic vertebral column within view. A mild reverse Trendelenburg position allows the lung to fall away from the apex of the pleural cavity. The first 5-mm diameter portal is placed in the middle or posterior axillary line within the fourth or fifth intercostal space. A second 5-mm portal incision is placed in the anterior axillary line within the third intercostal space. The 5-mm-diameter endoscopic monopolar scissors are passed into the thoracic cavity. Gently patting the deflated lung with an endoscopic dissection tool produces further atelectasis and improves the visualization of the spinal column. The first rib can be palpated, and the second through fourth ribs can be visualized directly. The stellate ganglion is located directly over the head of the first rib and typically is surrounded by a fat pad within the thoracic outlet, adjacent to the subclavian vasculature. On the right side, tributaries of the second, third, and fourth intercostal veins merge to form the superior intercostal vein, which then empties into the azygos vein. On the left side, the subclavian artery and intercostal vessels are adjacent to the region of dissection. Because the sympathetic chain is positioned superficial to the segmental and intercostal vessels, it can be transected without sacrificing any of these vessels. For a right-sided approach, the patient is similarly positioned on the opposite side. We routinely isolate the T2 ganglia for palmar hyperhidrosis by transecting the sympathetic chain over the second and third rib heads, and include the T3 and T4 ganglia for axillary hyperhidrosis. In our experience, outcomes with this technique are comparable to those obtained following an en bloc resection of the sympathetic chain. Because the sympathetic chain does not have to be dissected away from the vertebral column, this modified procedure Brachiocephalic artery Internal mammary a. The first rib and overlying stellate ganglion can be palpated; they are rarely visualized. Electrical or mechanical stimulation of this structure causes pupillary dilation that can be observed by the anesthesiologist. The scissors are used to hook and elevate the sympathetic ganglia away from the rib head. Centering the dissection directly over the rib head protects the intercostal nerve. The effectiveness of the sympathectomy is judged intraoperatively by monitoring palmar skin temperature. If palmar skin temperature fails to increase, the presence of an aberrant accessory sympathetic supply that is still functional must be sought. Another possibility is that the inferior third of the stellate ganglion is contributing sympathetic input that needs to be addressed. The indications include symptomatic calcified or noncalcified central or centrolateral disk herniations, and all types of infectious, traumatic, degenerative, or neoplastic processes of the ventral thoracic spine. The thoracoscopic approach provides access to the anterior and anterolateral vertebrae (the vertebral bodies, ipsilateral pedicles, and ipsilateral transverse processes), disk spaces, and ventral aspect of the dura. This exposure cannot access posterior spinal elements (laminae, spinous processes, facets), the contralateral pedicle, or the contralateral transverse process. The extent of exposure and visualization ventrally is identical to the exposure achieved with thoracotomy. Unequivocally, this anterior approach provides full visualization of the anterior spine and spinal cord, a view that cannot be achieved with posterolateral approaches. If a contralateral sympathectomy is to be performed, the chest tube is left in place with an occlusive dressing. This strategy protects against difficulties with oxygenation or ventilation related to the deflation of both lungs.

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This identifies the relationship of the cervical spine to the contained cervicomedullary junction and cervical spinal cord symptoms by dpo buy cheap duricef. There is atlantoaxial dislocation with ventral compression on the cervicomedullary junction. Dynamic views in the flexed and extended positions identify the instability as well as the manner of compression. With joint effusions, Stiskal and coworkers57 found a low signal intensity on unenhanced T1-weighted images and a high signal intensity on T1-weighted enhanced images, with a rim-like zone at the periphery in all lesions; this was redistributed with delayed images. In hypervascular pannus, T2-weighted graded images showed high intensity, as did contrast-enhanced images. In the case of fibrous hypovascular pannus, craniocervical immobilization with fusion does not result in disappearance of the ventral mass. However, active pannus with hypervascular tissue, like active synovitis, resolves with dorsal stabilization. Cranial settling is irreducible in individuals who exhibit odontoid penetration through the foramen magnum greater than 15 mm, large pannus, fracture of the odontoid process, or cranial settling complicated by lateral or rotational dislocation in addition to the primary phenomenon. Likewise, the identification of abnormal pathology without attempted reduction in potentially reducible lesions has led to an increased incidence of ventral decompression and dorsal occipitocervical fusion. The gadolinium-enhanced T1-weighted image shows a rim-like zone at the periphery of the lesion, with ventral cervicomedullary compression. B, Composite of midsagittal magnetic resonance images of the craniocervical junction with T1 (left) and T2 (right) weighting 3 months after dorsal occipitocervical fusion with titanium loop instrumentation and rib grafts. Operative Indications There is wide variation among natural history studies, including the results. B, Three-dimensional reconstruction of the skull and cervical spine in the patient in A. C, Composite of axial computed tomography scans through the upper (left) and lower (right) rims of the atlas arch. There is an odontoid fracture, with the superior segment adjacent to the odontoid stub. Boden,63 in a 1994 publication, showed that a posterior atlantodental interval greater than 14 mm (on plain films) was generally safe. This does not include the presence of pannus or other tissues that reduce the effective diameter of the subarachnoid space. If the posterior atlantodental interval was greater than 14 mm, there was a 94% chance the patient would have no paralysis. Unfortunately, a patient with a posterior atlan- todental interval of 13 mm could have a much smaller available space for the spinal cord, depending on the thickness of pannus. When the spinal cord area was less than 44 mm2, a poor outcome was more likely; this also correlated with patients who had an increased degree of vertical translocation. B, Midsagittal T1-weighted image of the craniocervical junction in the same patient 48 hours after halo traction. There is reduction of the vertical odontoid penetration into the foramen magnum and relief of the cervicomedullary compression. B, Composite of axial computed tomography scans made 1 cm (left) and 3 cm (right) above the plane of foramen magnum. The tip of the odontoid process is anchored into the ventral medulla at the formation of the basilar artery and the two vertebral arteries. Boden63 likewise recognized that when the posterior atlantodental interval was less than 10 mm preoperatively, the prognosis for return of motor function was poor. In contrast, significant motor recovery could be appreciated after surgery in patients who had preoperative intervals of 14 mm or more. In irreducible lesions, the basic tenet is decompression in the manner in which encroachment occurred before dorsal fixation. All patients who require surgical attention must first be evaluated for articular and extra-articular involvement by the rheumatoid process. Nutritional status is best evaluated with a total lymphocyte count and liver function tests. During this time it is imperative to maintain drugs such as methotrexate and steroids for the symptomatic relief of pain. The senior author strongly believes that before patients undergo any other treatment for rheumatoid involvement of the craniocervical junction, an attempt should be made to align the osseous anatomy to relieve the neural compression. Traction is contraindicated only when there is a complex rotary luxation or posterior occipitoatlantoaxial dislocation. Dorsal occipitocervical fusion with plate and screws and iliac crest bone graft had been performed previously to treat ventral pontomedullary compression with cranial settling, without addressing the ventral pathology. B, T2-weighted magnetic resonance image in the midsagittal plane of the craniocervical junction reveals odontoid penetration into the foramen magnum, compressing the ventral pontomedullary junction. Note the position of the vertebrobasilar arterial tree and the acquired hindbrain herniation. The odontoid process is posterior to the vertebrobasilar system and compresses the ventral and right lateral medulla. This is started at 5 to 7 pounds and gradually increased to a maximum of 10 to 11 pounds, achieved at 36 hours. Periodic radiographic evaluation is essential to identify the degree of reduction and to adjust the vector of force for distraction. If reduction is not achieved in 4 to 5 days, this should be considered an irreducible state, especially in the conditions previously described. Dorsal fusion in the face of ventral irreducible pathology can have adverse results. Internal fixation obviates the need for postoperative halo immobilization and similar measures. Dorsal occipitocervical fusion is necessary in all individuals with rheumatoid cranial settling and in those who have had resection of the rheumatoid pannus. In a few individuals with active pannus, dorsal fixation allows stabilization and reduction of the ventral soft tissue mass because the active process abates immediately with stabilization (as with active effusion in other joints). Dorsal occipitocervical stabilization necessitates the placement of bone to anchor the cervical spine to the occiput as far laterally as possible; this prevents lateral rotation as well as flexion and extension and provides for axial loading. This is handled with a custom-contoured threaded titanium loop fixed to the skull and the upper cervical spine. Use of calvarial bone in a disabled rheumatoid patient does not add to morbidity or mortality, as questioned by several authors. This custom-molded orthosis is similar to a modified Minerva brace and has a high degree of patient acceptance and compliance. Transarticular screw fixation between C2 and C1 requires satisfactory width of the pars interarticularis at C2 and integrity of the lateral mass of C1-that is, no compromise by atrophy, compression, or significant osteoporosis. Note the transarticular screw fixation and bone obtained from the calvaria for dorsal occipitocervical fusion. There is failure of the reduction, and the subsequent fusion mass has added to the cervicomedullary compression. B, T1-weighted magnetic resonance image of the patient in A demonstrating ventral and dorsal compression of the cervicomedullary junction. C, Reformatted computed tomography reconstruction of the craniocervical region through the plane of the odontoid process. The atlantoaxial dislocation is still present, and the fusion mass has slipped ventral to the posterior arch of C1. The patient required ventral odontoid resection as well as dorsal bony decompression and fusion. For instance, with a bedridden patient who is not mobile, one must weigh the ideal treatment (transoral odontoid resection) against the practicalities of the situation. Such an individual would have a poor outcome, so the operative procedure should be tailored to his or her needs. Pain may be handled with fusion; however, significant ventral pathology would need to be addressed first. Likewise, the fusion may not take owing to the quality of recipient bone, tissue vascular changes, and the inability to achieve satisfactory postoperative immobilization. Following occipitocervical or cervical arthrodesis, careful follow-up is required. In this study, age and postoperative complications were associated with higher mortality. In addition, patients with horizontal atlantoaxial subluxation fared better than those with other forms of atlantoaxial subluxation. In these conditions the anatomic site of involvement in the ligament is the tendinous insertion into bone-the enthesis.