Spine: Essential Neurosurgery For Medical Students

ESSENTIAL NEUROSURGERY FOR MEDICAL STUDENTS
Faiz U. Ahmad, MD∗

Erica F. Bisson, MD, MPH‡
Stephen Shelby Burks, MD§
Jason J. Chang, MD¶
Spine
A. Jessey Chugh, MD||
Ian Côté, MD§
A
mong the wide spectrum of diseases tumors, trauma, and emergencies that they are
Jason M. Frerich, MD, MSc∗
Zachary C. Gersey, MD, MS# treated by neurosurgeons, few are as likely to see during their neurosurgical rotation
Benjamin K. Hendricks, MD∗∗ gratifying as a good outcome like in the clinics and wards. This is geared towards
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Michael Karsy, MD, PhD‡ freedom from pain or disability in a well-selected students in their third and fourth years of school,
Manish Kasliwal, MD‡‡ patient with a spinal problem. Spinal surgery irrespective of their ultimate choice of residency
Katie L. Krause, MD, PhD¶ comprises a major part (often up to 70%-80%) specialty later.
Glen R. Manzano, MD§
Clinton D. Morgan, MD∗∗ of the practice of most general neurosurgeons Each subsection has a video, case presen-
Laura A. Snyder, MD∗∗ currently practicing in the USA. The number tation with multiple-choice questions and subse-
Christian C. Swinney, MD§§ of spinal operations performed per year in the quent explanations, a short didactic text, pearls,
Khoi D. Than, MD¶ USA has risen continuously and rapidly over and suggested reading. We are confident that
Christian B. Theodotou, MD§
Anand Veeravagu, MD§§ ||
the last 3 decades. With our growing and aging this will provide the students with the basic
Jacqueline Ventura§§ population, this number is almost certain to knowledge of spinal pathologies and treatment
grow further. Older population means more options, stimulate their interest to ask more
∗
Department of Neurosurgery, Emory people with falls and fractures, more tumors in questions, and hopefully consider neurosurgery
University, Atlanta, Georgia; ‡ Department patients who will live longer due to advances as their career option. This manuscript and the
of Neurosurgery, University of Utah,
Salt Lake City, Utah; § Department of
in oncology treatment, more degenerative content there within is an educational reference
Neurological Surgery, University of pathologies, and, consequently, more demand text. No research was conducted and no data
Miami Miller School of Medicine, Miami, to perform procedures to help these patients were collected or analyzed. Institutional Review
Florida; ¶ Department of Neurosurgery,
improve their quality of life. Board/ethics committee approval and patient
Oregon Health & Science University,
Portland, Oregon; || Department of While tremendous advancements have been consent were not required.
Neurosurgery, Case Western Reserve made in all subspecialties of neurosurgery,
University, Cleveland, Ohio; # Department this is particularly true in the field of spinal
of Neurological Surgery, University of
surgery, where new innovations and techniques
CHAPTER 1: EPIDURAL ABSCESS
Pittsburgh, Pittsburgh, Pennsylvania;
∗∗
Department of Neurosurgery, Barrow have totally transformed the landscape over the AND OTHER SPINAL INFECTIONS
Neurological Institute, St. Joseph’s last 2 decades, helping us take care of more
Hospital and Medical Center, Phoenix, Case Presentation and Questions
complex problems with shorter hospital stays
Arizona; ‡‡ Department of Neurosurgery, A 45-yr-old male who reports no prior medical
University Hospitals Cleveland Medical and less morbidity. The discussion of cutting-
Center, Cleveland, Ohio; §§ Department of edge technologies like robotics, osteobiologics, problems presented to the ER with fever, malaise,
Neurosurgery, Stanford University School navigation, and neuromodulation is not the severe lumbar back pain, and sudden onset
of Medicine, Stanford, California
purpose of this section. The purpose of this bilateral foot drop within the past 3 h. Magnetic
section is to introduce medical students to the resonance imaging (MRI) of the lumbar spine
Given constraints of this publication
exciting world of spinal pathologies, and cover shows a contrast enhancing lesion just anterior
modality (ie, a book rather than journal
articles), the citations and bibliography a breadth of topics like degenerative conditions, to and causing a significant mass effect on the
are not to the level of detail of a journal thecal sac at L5-S1. There does not appear to be
articles. Readers are directed to the any significant bony involvement.
suggested reading lists, which contain
references to subsequent references and ABBREVIATIONS: ACDF, anterior cervical
derivatives of the article content discectomy and fusion; ASIA, American Spinal 1. Which of the following may be risk factors of
Injury Association; CES, cauda equina syndrome; the patient’s condition?
Correspondence: CSM, cervical spondylotic myelopathy; DDD, a. Osteoporosis
Faiz U. Ahmad, MD, degenerative disc disease; HGS, high-grade spondy-
1365-B Clifton Road, Suite 6200,
b. Rheumatoid arthritis
lolisthesis; ISCNCSCI, International Standards for
Atlanta, GA 30322. c. Intravenous drug abuse
Neurological Classification of Spinal Cord Injury; IV,
Email: [email protected]
intravenous; JOA, Japanese Orthopedic Assessment;
d. Ankylosing spondylitis
MAP, mean arterial blood pressure; MPSS, methyl- e. All of the above
Received, March 5, 2019.
prednisolone sodium succinate; MRI, magnetic 2. Primary management in this patient will be to
Accepted, March 5, 2019.
Published Online, May 17, 2019. resonance imaging; NASCIS, National Acute a. Initiating empirical antibiotics
Spinal Cord Injury Studies; NSAIDs, nonsteroidal b. Immediately decompressing the neural
Copyright
C 2019 by the anti-inflammatory drugs; SCI, spinal cord injury; elements
Congress of Neurological Surgeons STASCIS, Surgical Timing in Acute Spinal Cord Injury
c. Obtaining percutaneous biopsy
Study
d. Fusing the spine
OPERATIVE NEUROSURGERY WWW.CNS.ORG VOLUME 17 | NUMBER 2 | AUGUST 2019 SUPPLEMENT | S153

AHMAD ET AL
3. What is the role of instrumented fusion in this crobials, which will be started empirically until either biopsy
patient? or culture identifies a causative organism. Empirical coverage
a. Absolute contraindication should include agents for both gram-positive and gram-negative
b. Relative contraindication; placement of foreign bodies in a organisms as these constitute the majority of all epidural abscesses.
contaminated field increases the risk of hardware infection However, if patients have risk factors or are suspected to have
c. Not contraindicated; unnecessary other causes such as HIV or tuberculosis, appropriate treatment
d. Not contraindicated; necessary to correct instability with antivirals or antifungals, respectively, should be added as
well. There is no established length of treatment; however, antimi-
crobial therapy is often implemented for 6 to 8 wk.

Section Content
In patients who fail medical management or have a neuro-
Spinal Infection logical compromise, surgical treatment may become necessary
Infections of the spine can take several forms. They can (Figure 1 and Video 1). Laminectomy will allow for decom-
present as an epidural abscess, discitis, osteomyelitis, or menin- pression of the neural elements, debridement with the removal of
gitis. The most common etiology of spinal infections is a pyogenic infected material, and accurate biopsy. Depending on the extent
bacterial infection, less commonly a granulomatous infection of disease, the spine may have become unstable and may warrant a
from tuberculosis or other fungi, and rarely from parasitic causes. fusion procedure. If necessary, fusion techniques incorporate bone
Medical therapy is organism-dependent and may require biopsy, graft and occasionally metal instrumentation. Bone autograft is
which may be negative in up to 30% of cases. While some preferred over allograft to decrease the infection risk, and although
patients respond to antibiotic and antifungal therapy, more metallic instrumentation is not used by some surgeons, titanium
aggressive surgical options may be necessary in some circum- rather than stainless steel hardware is also used to decrease the
stances. Neurological deficits either with or without mass lesions, risk of infection. To further reduce infection in some cases, the
bony deformities, severe unremitting pain following conservative fusion is staged after the decompression to prevent the exposure of
care, and biomechanical instability are all indications for surgical the instrumentation to infected tissue or the hardware is removed
intervention. after a radiological documentation of adequate fusion.
Epidural spinal abscesses have an incidence of up to 2 per
10 000 hospital admissions. Risk factors include intravenous (IV)
drug use, diabetes mellitus, obesity, immunocompromised state,
and spinal procedures. The most common causative organisms Spondylodiscitis
are bacteria with Staphylococcus aureus responsible for 50% to Infection of the intervertebral discs can also occur, with
66% of all epidural abscesses. However, other organisms such as Staphylococcus aureus and Enterobacter constituting the
Haemophilus influenza, Escherichia coli, Mycobacterium tubercu- majority of cases. Infection can occur via a variety of routes,
losis, and Pseudomonas (particularly in IV drug users) can also be including a hematogenous spread of an existing infection or a
isolated. nonhematogenous spread via direct introduction of pathogens
due to surgical procedures, trauma, or preexisting wounds. The
Epidural Abscess presentation of these cases is similar to epidural abscesses with
Patients with epidural abscesses generally present with signs of general signs of infection, including fever, malaise, and tenderness
local infection, including fever, back pain, and tenderness over and focal neurological signs if there is an epidural spread of the
the spine. They may or may not present with focal neurologic infection.
signs or deficits, including weakness, parasthesias, radiculopathy, Imaging is critical for the diagnosis of spondylodiscitis. Nuclear
bowel/bladder dysfunction, or paralysis. A recent history of spinal scans, including technetium and gallium, can detect discitis;
operation may also indicate the possibility of an infection. however, these are also sensitive for bone remodeling, reducing
After identifying a patient with a possible infection based on their specificity. Increased activity seen in these modalities does
history and physical examination, imaging is required to localize not definitively diagnose an infective process. MRI is again
the disease process. Plain X-rays and computed tomography (CT) the modality of choice in these patients. Spondylodiscitis will
are inadequate. MRI with contrast is the ideal modality for the appear hyperintense on T2 imaging, hypointense on T1 imaging,
evaluation of most spinal infections, including epidural abscesses and will be contrast-enhancing. Spondylodiscitis can easily be
(although CT can be useful in diagnosing bony infections). T1- confused radiologically with metastatic disease. However, metas-
weighted sequences will characteristically show hypointensity in tases generally do not compromise disc height and will not cross
the area of infection, while on T2-weighted sequences, these the disc space.
same structures will be hyperintense due to edema. Contrast Management of spondylodiscitis begins with guided needle
enhancement and a restricted diffusion pattern can also be used biopsy and antibiotic administration. Conservative treatment
as an indicator of infection. with bracing can be used as first-line therapy with surgical stabi-
Treatment begins with medical therapy. Percutaneous biopsy lization reserved for cases with more severe loss of structural
and blood cultures should be obtained prior to beginning antimi- integrity.
S154 | VOLUME 17 | NUMBER 2 | AUGUST 2019 SUPPLEMENT WWW.CNS.ORG www.operativeneurosurgery-online.com

SPINE

FIGURE 1. MRI of the thoracic spine with and without contrast showing a large dorsal epidural abscess spanning multiple thoracic levels. The
lesion is A, hyperintense on T1 (hypointense signal is typical for epidural abscesses; however, this patient has blood products present in the lesion
causing hyperintensity), B, hyperintense on T2, shows a restricted diffusion pattern on C, ADC, and D, DWI, and E, is contrast enhancing.
On an axial T1-contrast enhanced view at the level of T6, anterior displacement of the thecal sac can be seen. This patient originally presented
with sepsis from an infected hemodialysis catheter. The thoracic epidural abscess was found, and after a failed attempt to drain the abscess using
minimally invasive hemilaminectomies (visible on A, B, E, and F), the patient was transferred to the tertiary care hospital where a T2-T8
laminectomy was performed.
Osteomyelitis if the patient is very unstable and requires posterior supplemen-

Infection of the bony tissue in the spine can also occur and tation for fusion.
usually involves the vertebral bodies and disc spaces where the
infection can spread over multiple levels through the disc space Tuberculosis/Pott’s Disease
(Figure 2). Initial management remains the same as the prior Spinal tuberculosis, also known as Pott’s disease, is a separate
conditions described with biopsy, blood cultures, and empirical entity characterized by substantial bony destruction. Much
antibiotic therapy as initial management. These patients often like pulmonary tuberculosis, risk factors for Pott’s disease
have a significant bony involvement, which may require extensive include living in endemic areas, immune suppression, and HIV
debridement. Instability of the spine can result either from the infection. The mechanism of spread in these cases is most often
disease or from the debridement required to remove infected hematogenous and can come from either an arterial or a venous
tissue. Because of the predilection for the vertebral bodies and spread; however, the valveless venous plexus, also known as
disc spaces, an anterior or lateral approach is preferred to debride Batson’s plexus, which surrounds the spine, may allow for a
and reconstruct the spine column. A posterior approach is seldom spread from level to level. The infection often occurs in the
used unless there is an involvement of the laminae or pedicles or anterior aspect of the body and leads to disc destruction and

AHMAD ET AL
unnecessary as many patients will respond to medical therapy.

However, in cases with severe deformity or a neurological deficit,
debridement and reconstruction may be necessary.
Pearls
√
Injury: this includes blood cultures, biopsy (biopsy may be
√ negative in up to one-third of cases), and empiric antibiotics.
Only start medical therapy once an attempt to identify the
√ causative agent has been made.

Surgical indications include:
r Failure to identify causative organism with minimally
invasive methods
r Neurological compromise
r Spinal instability evidenced by extensive bony destruction
r
VIDEO 1. Case presentation with an associated workup and management √ Unremitting pain
discussion of a patient with a large thoracic epidural abscess. This video Metallic instrumentation is not contraindicated despite the
can be accessed in the HTML version of the article. Please visit www. infective process.
operativeneurosurgery-online.com to view this article in HTML and play the
video.
Case Answers
spinal deformity, which can occur over months to years. Neuro- The patient is suffering from an epidural abscess of unclear
logical compromise is also possible depending on the level of bony origin. Although the patient denies a history of some risk factors
destruction and deformity. (diabetes, HIV, obesity), it is important to check for a history of
Biopsy will show acid-fast bacilli either on tissue culture and IV drug use or to check for other preexisting infections. While
staining, PCR testing, or QuantiFERON gold testing. MRI is obtaining blood cultures, obtaining a biopsy, and starting antibi-
the gold standard for imaging in Pott’s disease. Bony tissue otics may be effective in other cases, this patient is also showing
destruction, paravertebral abscesses, and granulation tissue can be signs of neurological decline. Therefore, a more immediate and
used to identify Pott’s disease, although other bacterial infections aggressive treatment strategy such as surgical decompression is
and metastatic disease can be mimics. indicated to remove the mass effect on the neural elements. Due
Medical therapy should be initiated immediately even if to the lack of bony involvement, it could be presumed that the
the diagnosis is not confirmed. Surgical management is often spine is not unstable, and the patient does not require fusion.
FIGURE 2. MRI of the lumbar spine with and without contrast with osteomyelitis in the L1 and L2 vertebral bodies. Infected
issues are hypointense on T1 A, slightly hyperintense on T2 B, and are contrast enhancing C. This patient was a known IV
drug user with blood cultures positive for Strep pneumoniae. The patient’s chief complaint was focal lumbar pain and on
physical examination showed only focal tenderness over the upper lumbar spine with no neurologic deficits.

SPINE

FIGURE 3. A, T2-weighted midsagittal cervical spine MRI demonstrating a large herniated disc at C3-C4. B, T1 + gadolinium midsagittal cervical spine MRI
demonstrating no abnormal enhancement. C, T2-weighted axial MRI through C3-C4 demonstrating significant cord compression due to a herniated disc.
1. C. Risk factors include IV drug use, diabetes mellitus, clumsiness of his right hand. He also states that he has been
obesity, immunocompromised state, and spinal procedures. having an increasingly unsteady gait, although continues to work
2. B. In patients who have a neurological compromise, surgical full-time as a custodian. His vital signs are unremarkable. His
treatment may become necessary. Laminectomy will allow routine laboratory studies are within normal limits. The MRI scan
for decompression of the neural elements, debridement obtained is shown in Figure 3.
with the removal of infected material, and accurate biopsy.
Depending on the extent of disease, the spine may have 1. What is the most likely pathogenesis?
become unstable and may warrant a fusion procedure, which a. Infection
does not appear to be the case in this patient. b. Degenerative changes
3. C. Instrumentation and fusion are necessary when the spine c. Metastatic disease
becomes potentially unstable due to the bony erosion by d. Demyelinating disease
the infection. This is usually achieved by a combination of 2. What physical exam finding might be present in this patient?
titanium implants and autograft. This is not necessary in a. Positive Hoffman’s sign
this case at this point. b. Diminished upper extremity sensation
c. Spastic gait
SUGGESTED READING d. All of the above
1. Cornett CA, Vincent SA, Crow J, Hewlett A. Bacterial spine infections in 3. Based on the given history, what Nurick grade would be
adults: evaluation and management. J AmAcad Orthop Surg. 2016;24(1):11-18. assigned to his myelopathy?
2. Duarte RM, Vaccaro AR. Spinal infection: state of the art and management
algorithm. Eur Spine J. 2013;22(12):2787-2799.
a. 0
3. Garg RK, Somvanshi DS. Spinal tuberculosis: a review. J Spinal Cord Med. b. 1
2011;34(5):440-454. c. 2
4. Gold M. Magnetic resonance imaging of spinal emergencies. Top Magn Reson d. 3
Imaging. 2015:24(6):325-330.
5. Hazer DB, Ayhan S, Palaoglu S. Neurosurgical approaches to spinal infections. e. 4
Neuroimaging Clin N Am. 2015;25(2):295-308. f. 5
6. Pradilla G, Ardilla GP, Hsu W, Rigamonti D. Epidural abscesses of the CNS. 4. What would be the most definitive treatment option?
Lancet Neurol. 2009;8(3):292-300.
7. Tali ET, Oner AY, Koc AM. Pyogenic spinal infections. Neuroimaging Clin N
a. Trial of nonsteroidal anti-inflammatory drugs
Am. 2015;25(2):193-208. b. Anterior cervical discectomy and fusion
c. Posterior cervical laminectomy and instrumented fusion
d. Posterior cervical laminoplasty
CHAPTER 2: CERVICAL SPONDYLOTIC
MYELOPATHY
Case Presentation and Questions Section Content
A 60-yr-old man presents with complaints of several months Cervical myelopathy is a condition that refers to compression
of progressively worsening neck pain, right arm numbness, and of the cervical spinal cord resulting in a neurological deficit.

AHMAD ET AL
Spondylotic degenerative changes are the most common cause of

cervical myelopathy in patients more than 55 yr of age. TABLE 1. JOA Cervical Myelopathy Grading Scalea
Pathogenesis Motor dysfunction: upper extremities
Spondylosis is a general term referring to the degener- 0 Unable to feed self

ation of the intervertebral discs, vertebral bodies, and/or 1 Unable to handle chopstick
2 Handle chopstick with much difficulty
ligamentous structures. The pathophysiology of cervical spondy-
3 Handle chopstick with slight difficulty
lotic myelopathy (CSM) is likely to be multifactorial, with both Motor dysfunction: lower extremities
dynamic and static forces playing a role. As the spine ages, the 0 Unable to walk

intervertebral disc degenerates, increasing stress on the adjacent 1 Walk with aid
end plates. The increased motion leads to the development of 2 Able to use stairs with support
osteophyte formation, which acts to provide a stabilizing force. 3 Lack of stability and smooth gait
As the osteophyte continues to hypertrophy, it can protrude 4 None
Sensory deficit: upper/lower extremities and trunk
into the spinal canal, causing compression of the cervical spinal 0 Severe sensory loss or pain
cord. Similarly, over time, the ligamentum flavum can stiffen and 1 Mild sensory loss
hypertrophy, also causing stenosis by bulging into the spinal canal. 2 None
Dynamic flexion and extension of the neck further exacerbates Sphincter dysfunction
age-related degenerative changes. In neck flexion, the cervical 0 Unable to void
cord is compressed over the ventral osteophytes; in extension, 1 Marked difficulty in voiding
2 Slight difficulty in voiding
the hypertrophied ligamentum flavum buckles, protrudes into the
3 None
canal, and causes cord compression.
a
Histopathologically, spinal cord injury (SCI) is further Adapted from Baron E, Young W. Cervical spondylotic myelopathy: A brief
review of its pathophysiology, clinical course, and diagnosis. Neurosurgery.
mediated by a variety of ischemic changes. There may be a direct
60(1):S135-41, 2007.
stretching of the spinal arteries over hypertrophied osteophytes,
as well as age-related hypertrophy of the arterial wall, leading to
a decreased blood flow through the vessels supplying the cord. Lhermitte’s sign, in which flexion of the neck causes a shock-like
Similarly, there may also be an impaired venous outflow, leading sensation down the center of the back, may also be present.
to venous congestion. Furthermore, spinal cord compression
is thought to break down the integrity of the blood-spinal Grading
cord barrier, leading to a cascade of inflammatory changes that There are a number of different grading scales assessing the
ultimately cause apoptosis and gliosis within the spinal cord. severity of cervical myelopathy. Perhaps the most widely used
are the Japanese Orthopedic Assessment (JOA) grading scale
Presentation (Table 1) and the Nurick disability scale (Table 2). The JOA
The clinical presentation of patients with CSM is extremely grades dysfunction on the basis of upper and lower extremity
varied, depending on the degree of SCI. Often patients will function, degree of sensation, and bladder function. The JOA
present with neck stiffness, pain, and crepitus with movement. grades the upper extremity function based on the ability to use
They may also complain of an achy pain in the arms, which chopsticks, leading to modified fork-using versions aimed at
may be accompanied by numbness and tingling. As CSM Western countries. The Nurick disability scale grades symptoms
progresses, symptoms become more severe, resulting in weakness based on progressive gait disability. Although all scales can be a
or clumsiness in the upper and lower extremities. Patients may useful metric, they are not without intergrading variability, and
have gait imbalance. Urinary or bowel dysfunction is less common
but can also occur in severe cases.
Physical examination should include detailed motor and TABLE 2. Nurick Cervical Myelopathy Grading Scalea
sensory testing, with a thorough examination for long tract signs.
Patients will often have signs of motor weakness and muscle Grade Signs/symptoms
wasting. Sensation (including light touch, pin-prick, and propri- 0 Root symptoms only, or normal
oception) may be diminished or absent. Hoffman’s maneuver, 1 Signs of cord compression, but normal gait
performed by tapping the fingernail of the ring or middle finger, 2 Gait difficulties, but fully employed
may elicit flexion of the ipsilateral thumb, indicating injury to the 3 Gait difficulties that prevents full time employment, but
cortiospinal pathway. Similarly, performing a Babinski maneuver, walks unassisted
4 Unable to walk without assistance
by stroking the bottom of the lateral aspect of the foot and curving 5 Wheelchair bound
medially, may elicit dorsiflexion of the great toe, also indicating an
a
upper motor lesion. Patients are often hyper-reflexive and demon- Adapted from Nurick S. The pathogenesis of the spinal cord disorder associated with
cervical spondylosis. Brain. 95:87-100, 1972.
strate ankle clonus. Gait testing can reveal a stiff and spastic gait.

SPINE
should be carefully interpreted in the context of each patient’s

history, physical examination, and radiographic studies.
Diagnostic Studies
The initial radiographic screening study in patients with signs
and symptoms of cervical myelopathy is typically MRI. MRI
provides excellent detail and should be reviewed for the degree
of canal stenosis, disc disease, ligamentous hypertrophy, and
intrinsic changes within the spinal cord. The normal anterior–

posterior canal diameter on MRI is between 13 and 15 mm, with a
canal diameter less than 13 mm considered stenotic. An MRI scan
can also help delineate myelopathy caused by pathologies other
than degenerative changes, including spinal cord tumor, demyeli-
nating disease, or infection. A computed tomography (CT) study
and flexion/extension X-rays can be useful for assessing cervical
bony anatomy and alignment, especially if surgical treatment is
being considered.
Treatment Options
Management strategies include nonoperative and operative
treatments. Nonoperative treatments for mild cases of CSM
include medications with nonsteroidal anti-inflammatory drugs
(NSAIDs), opioids, neuroleptic agents, or muscle relaxants.
Other nonoperative treatments include physical therapy, epidural
steroid injections, or traction devices. However, unlike radicu- FIGURE 4. X-ray demonstrating C3-C4 ACDF, in which a graft is placed within
lopathy, there is little evidence to support the efficacy of these the disc space and supported by an anterior plate and screws.
treatments for myelopathy, which tends to progress over time.
Surgical treatment is considered the definitive treatment option,
with the primary intent of halting progression of SCI, and necessitating a faster operation. Many patients who undergo
the secondary intent of regaining neurologic function. Mainstay laminectomy should also undergo concomitant posterior fixation
surgical options include decompression of the cervical cord from to prevent postlaminectomy kyphosis (Video 2). Laminoplasty, in
either an anterior or posterior approach. which the posterior elements are reconstructed to widen the dorsal
Anterior approaches include anterior cervical discectomy arch, is also a good alternative for multilevel decompression while
and fusion (ACDF; Figure 4), with possible corpectomy. The preserving stability and mobility.
advantage of an ACDF is a direct decompression of the
protruding disc or osteophyte. Additional indirect decompression
of the foramina is accomplished via the placement of a graft,
which also restores the focal loss of disc height and lordosis at
that level. However, if the pathology is located dorsal to the
vertebral body (ie, posterior longitudinal ligament hypertrophy),
a more extensive corpectomy would provide a greater exposure
for safe decompression of the spinal canal. The most common
potential complications from an ACDF include dysphagia and
dysphonia. Inadvertent transection of the recurrent laryngeal
nerve can result in vocal cord paralysis. Less common compli-
cations include damage to the vertebral artery during foraminal
decompression, esophageal injury during retraction/placement of
implants, and the feared postoperative hematoma leading to an
airway compromise.
Posterior approaches include laminectomy with or without
fusion, or laminoplasty. Indications for posterior approaches VIDEO 2. Surgical management of central cervical stenosis with a posterior
include hypertrophy of ligamentum flavum or multilevel disco- approach for decompression and lateral mass fixation. This video can
be accessed in the HTML version of the article. Please visit www.
genic disease where an anterior fusion may not be feasible.
operativeneurosurgery-online.com to view this article in HTML and play the
Posterior laminectomy alone is generally performed in patients video.
who have short-segment disease and are medically sick,

AHMAD ET AL
Pearls
√
CHAPTER 3: LUMBAR STENOSIS AND
Degenerative changes in the aging spine are the most NEUROGENIC CLAUDICATION
√ common cause of CSM in adults over 55 yr of age. Case Presentation and Questions
Pathogenesis of CSM is likely multifactorial, with contri-
butions by osteophyte formation, ligamentous hypertrophy, A 73-yr-old male patient presented to the clinic with a chief
√ and ischemic injury. complaint of mild back and leg pain. He reported having a
Clinical presentation of CSM varies, but commonly includes cramping pain down the back of his legs, mostly in his hamstrings,
neck pain, paresthesias, motor weakness, and pathologic which became worse as he walked. During the year prior to
√ reflexes. presentation, he walked shorter and shorter distances because

Conservative therapies like medication, physical therapy, or of this pain. The pain did not stop immediately after cessation
epidural steroid injections are less efficacious for treating of walking, but only after sitting and resting. The leg pain also
√ myelopathy than they are for treating radiculopathy. occurred when he stood for long periods. The mild back pain
Primary aim of surgical treatment is to prevent further SCI. improved with forward bending. The patient also reported that
if he bent forward and supported his weight on an object, such
as a shopping cart, his back pain eased and he could walk for
longer periods. He reported feeling slightly weak while walking,
Case Answers but examination showed 5/5 strength in all muscle groups, intact
sensation, and slightly diminished bilateral reflexes at the knee
1. B. This patient is suffering from CSM from degener-
and ankle. MRI demonstrated moderate lumbar stenosis due to
ative changes (answer B). The MRI demonstrates a large,
ligamentous hypertrophy from L3 to L5 with L3-L4 and L4-L5
rightward-skewed herniated disc at C3-4 causing severe
disc bulges.
stenosis, further exacerbating a congenitally narrow canal
(<13 mm). There are also multiple other levels with 1. What type of pain do patients with neurogenic claudication
smaller bulging discs and ligamentous hypertrophy, causing usually describe?
moderate stenosis. The MRI with gadolinium does not a. Aching pain across the entire lower back
demonstrate evidence of enhancing lesions consistent b. Cramping pain down the back of the legs
with metastatic disease, infection, or demyelinating c. Sharp pain radiating into the groin
disorders. d. Electrical pain radiating into the sides of legs and calves
2. D. The patient is classically presenting with several signs of 2. How can patients with neurogenic claudication relieve their
cervical myelopathy, including motor weakness, numbness, pain?
and spastic gait. Physical examination may also reveal patho- a. By bending forward
logic reflexes, including a positive Hoffman’s sign. b. By bending backward
3. C. Based on his history, he would be considered a Nurick c. By standing
grade 2, in which he has slight difficulty with walking, but d. By ambulating
can continue with full-time employment. 3. What is the best imaging modality to identify lumbar spinal
4. B. Given that he is displaying significant signs of stenosis?
myelopathy, the patient is indicated for surgical treatment a. Radiograph
to prevent further SCI. Conservative measures with medica- b. CT without myelogram
tions do not halt the progression of degenerative changes. c. MRI
The patient’s most significant pathology is a herniated disc d. Positron emission tomography
at C3-4, which would be best suited for ACDF at this 4. What is the most commonly performed surgery to treat
level. lumbar spinal stenosis?
a. Lumbar laminectomy
b. Intraspinous spacer
c. Posterior lumbar interbody fusion
SUGGESTED READING d. Anterior lumbar interbody fusion
1. Tetreault L, Goldstein C, Arnold P, Harrold J, Hilibrand A, Naroui A, Fehling
M. Degenerative cervical myelopathy: a spectrum of related disorders affecting
the aging spine. Neurosurgery. 2015:77(S4): S51-S67. Section Content
2. Baron EM, Young WF. Cervical spondylotic myelopathy: a brief review of its
pathophysiology, clinical course, and diagnosis. Neurosurgery. 2007:60(S1): S35-
Epidemiology
41. Lumbar spinal stenosis with neurogenic claudication is a
3. Karadimas S, Gatzounis G, Fehling MG. Pathobiology of cervical spondylotic common condition in patients in the USA. Acquired stenosis is
myelopathy. Eur Spine J. 2015:24(S2):132-138.
4. Jobe KW (2006). Cervical spine degenerative disease and cervical stenosis. observed in 20% of the US population younger than 40 yr of age,
In Fessler RG, Sekhar L (Eds.), Atlas of Neurosurgical Techniques: Spine and and in up to 47.2% of those older than 60 yr of age. Congenital
Peripheral Nerve (164-68). New York, NY: Thieme. spinal stenosis is observed in 4.7% of the population.

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Etiology the lateral margin of the spinal canal that the nerve root passes
Lumbar spinal stenosis causes the symptoms of neurogenic through to enter the intervertebral foramen.
claudication due to narrowing of the lumbar canal, the lateral Lumbar spinal stenosis with narrowing of the spinal canal and
recesses around the thecal sac, and the lumbosacral nerve roots. lateral recess can occur in the setting of degenerative disease alone,
Pressure on the lumbosacral nerve roots causes ischemia, which or it can be caused by spondylolisthesis, which is the anterior
can worsen during exercise because of increased metabolic translation of one vertebral body onto another. The percentage of
demand. A narrowed lumbar canal can have multiple etiologies the anterior translation of the superior vertebra over the inferior
(Video 3). A congenitally narrow lumbar spinal canal occurs when vertebra is characterized by the Meyerding grade: I: ≤25%, II:
patients have short pedicles from birth. As patients age, they 26% to 50%, III: 51% to 75%, IV: 76% to 100% and V: spondy-

can develop more common degenerative mechanisms of lumbar loptosis (vertebra completely slipped off ).
stenosis, such as degenerative disc disease (DDD), ligamentous Degenerative-related lumbar stenosis and spondylolisthesis
hypertrophy, facet arthropathy or hypertrophy, and spondylolis- causing lumbar stenosis can be either stable or unstable. It
thesis. is evaluated using dynamic radiographic imaging (discussed
DDD is remarkably common in the lumbar spine, and it below). Unstable spondylolisthesis (grade II or higher) is often an
results from long-term biomechanical stress on the intervertebral indication that arthrodesis should be added to a lumbar decom-
disc. Some of the most common imaging signs of DDD include pression surgery.
reactive bony vertebral osteophytes, disc height loss, subchondral
reactive cysts, vertebral body endplate sclerosis, and disc bulging Classic Clinical Presentation
into the spinal canal. Reactive hypertrophy of the bone and The most common presentation of lumbar spinal stenosis
ligaments around the spinal canal may also occur in response is neurogenic claudication, which is characterized by activity-
to the increased biomechanical stress associated with DDD. dependent aching or cramping pain in the hips, calves, thighs, or
The ligamentum flavum, which connects the lamina between buttocks and in unilateral or bilateral lower extremities. Sensory
vertebrae from C2 to the sacrum, may be hypertrophic, or loss also may be present, and this numbness, like the aching pain
overgrown, in DDD, thus causing central spinal canal stenosis. of neurogenic claudication, often occurs in a dermatomal distri-
The facet joint and capsule, comprising the union of the inferior bution. Pain and numbness classically appear with prolonged
articulating process of the superior vertebra and the superior artic- standing or walking. Patients usually have a relief of symptoms
ulating process of the inferior vertebra, may also be hypertrophic, with sitting, squatting, or other maneuvers that involve lumbar
and this overgrowth can result in central canal or neural foraminal flexion, such as biking or leaning over a shopping cart (the so-
stenosis. The facet and synovial capsule can create a synovial called “shopping-cart sign”). Each of these maneuvers tends to
cyst if the facet arthropathy is severe. Superior articular facet increase the diameter of the spinal canal that is being compro-
hypertrophy can cause lateral recess stenosis, which compresses mised by lumbar spinal stenosis. Classically, extension tends to
the exiting nerve root. The lateral recess is the conduit along exacerbate neurogenic claudication pain.
It is critical to clinically distinguish between neurogenic
claudication symptoms and vascular claudication symptoms.
Discomfort from vascular claudication occurs in an entire muscle
group rather than in dermatomes. Furthermore, vascular claudi-
cation pain is consistently exacerbated by a fixed amount of
activity, and it is almost immediately relieved by rest. Symptoms
of vascular claudication coexist with evidence of decreased pulse
intensity and skin perfusion distal to the vascular compromise.
When vascular claudication is a consideration, it is therefore
critical to assess exercise tolerance, ankle-brachial index, and
capillary refill.
Differential Diagnosis
The primary entities in the differential diagnosis of lumbar
spinal stenosis with neurogenic claudication include peripheral
vascular disease (vascular claudication), degenerative hip
disease, and thoracic or lumbar disc herniations. Additional
important entities that may mimic similar symptoms include
VIDEO 3. Imaging case examples for lumbar stenosis with neurogenic claudi-
cation. This video can be accessed in the HTML version of the article. Please
diabetic neuropathy, arachnoiditis, intraspinal tumors, Baastrup
visit www.operativeneurosurgery-online.com to view this article in HTML and syndrome (eg, arthritis and contact of adjacent spinous processes
play the video. in extension), and arthritis of the zygapophyseal (eg, facet) joints
or sacroiliac joints.

AHMAD ET AL
Diagnostics should be considered whenever mobile degenerative spondylolis-

Although plain radiographs are of limited utility in diagnosing thesis, grade II or higher spondylolisthesis, or dynamic instability
lumbar spinal stenosis, dynamic radiography can reveal insta- is observed on radiographs. Fusion can also be considered when
bility, such as when the location of one vertebral body endplate the patient has a recurrence of stenosis at the level of a prior
changes in relation to the opposing vertebral body endplate decompressive operation.
during maximal lumbar flexion compared to lumbar extension.
CT scans of the lumbar spine are useful in revealing bony Surgical Techniques
structure, potential fractures, quality of prospective bone for Laminectomy is the mainstay for surgical decompression
fusion, and bony origins of spinal cord or nerve compression. CT among patients with lumbar spinal stenosis (Video 4). For this

myelography, less commonly used in modern times due to faster procedure, the patient is placed in the prone position, either on
MRI scanning, involves the intrathecal injection of iodinated a Wilson or Jackson frame. Radiolucent Wilson frames place
contrast, which mixes with cerebrospinal fluid and can reveal patients in flexion, which has the benefit of opening the inter-
sites of spinal cord or nerve root compression. CT myelography laminar spaces. In contrast, Jackson frames allow free relaxation
can be used in patients who have implanted devices that are of the thorax and abdomen, which decreases venous pressure,
not MRI compatible. However, MRI is the modality of choice thereby lessening the risk for venous ischemia and reducing intra-
for modern diagnosis of lumbar stenosis. T2-weighted MRIs are operative venous bleeding. Although intraoperative neuromoni-
especially useful in visualizing regions of compression with a loss toring is used at some centers, we have found that for basic lumbar
of cerebrospinal fluid space around the spinal cord and nerve decompression surgeries neuromonitoring is often unhelpful.
roots, nerve root impingement, cystic masses, disc herniation, and Once the patient is placed under general anesthesia and undergoes
ligamentous and facet hypertrophy. endotracheal intubation, fluoroscopy is used to localize the appro-
priate spinal level with an 18-gauge metallic spinal needle.
At the site of the skin incision, lidocaine with epinephrine and
Decision Making bupivacaine are injected both for their anesthetic and hemostatic
First-line management of lumbar spinal stenosis includes properties. A scalpel is used to make a skin incision into the
conservative therapies. Patients are educated to adhere to subcutaneous tissue. Bipolar and monopolar cautery is used
proper bending and lifting techniques and are recommended to sparingly to achieve hemostasis. After the fascia is reached, a self-
undergo physical therapy for strengthening abdominal, leg, and retaining Weitlaner retractor is used to open the subcutaneous
spinal extensor muscles. Nonsteroidal anti-inflammatory drugs, tissues. Dissection of the superficial paraspinal muscles (spinalis,
acetaminophen, muscle relaxants, and opioids can be considered longissimus, and iliocostalis) and deep paraspinal muscles (multi-
for pain relief. Epidural corticosteroid injections, medial-branch fidus, rotatores, and intertransversarii) occurs using a combi-
blocks, and selective nerve-root blocks with long-acting local nation of monopolar cautery and a Cobb elevator. Muscle
anesthetics or corticosteroids along the symptomatic levels of the stripping occurs from superficial to deep; muscles are followed
spine can also provide symptomatic relief. laterally until the medial facet is encountered. After the complete
An understanding of the available surgical options and the stripping of muscles, a full view of the posterior spine should be
indications for each intervention are critical to the successful apparent, including the spinous process, the facet joints, the pars
management of patients with spinal stenosis. Neurogenic claudi-
cation or radiculopathy is the most common indication for
decompression of the lumbar spine when the syndrome is
refractory to conservative management strategies.
Preoperative imaging analysis is critical to determining the site
of neural compression that is potentially amenable to surgical
intervention. The neural structures susceptible to compression
can be simplified by considering an axial plane of the spine
with three regions: central, lateral recess, and contents of the
foramina. After the compressed neural elements are localized,
surgical decompression can be planned that focuses on the
region of compression. Identification of central compression
warrants direct decompression with an open laminectomy or
minimally invasive decompression of stenosis. Patients with
isolated foraminal stenosis may benefit from either procedure.
However, other approaches to consider include indirect methods
VIDEO 4. Open laminectomy for lumbar stenosis (intraoperative case demon-
of decompression, such as interspinous decompressive devices, stration). This video can be accessed in the HTML version of the article. Please
lateral transpsoas interbody fusion, or anterior lumbar interbody visit www.operativeneurosurgery-online.com to view this article in HTML and
fusion. Fusion is indicated when surgical decompression of play the video.
stenosis will sacrifice stabilizing spinal segments. Similarly, fusion

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FIGURE 6. Artist’s illustration demonstrating an axial view of lamina and thecal
sac upon posterior exposure for open laminectomy. Used with permission from the
Barrow Neurological Institute, Phoenix, Arizona.
FIGURE 5. Artist’s illustration demonstrating a posterior view

of open laminectomy exposure. Used with permission from the
Barrow Neurological Institute, Phoenix, Arizona.
interarticularis (the bony ridge between the superior and inferior

articulating process), the lamina, and the transverse processes
(extending laterally from the superior articulating process;
Figures 5 and 6). A large Leksell rongeur is used to grossly FIGURE 7. Artist’s illustration demonstrating an axial view of thecal sac and
remove the spinous processes at the appropriate spinal levels. compressed spinal nerves, with lamina removed and rongeur beginning additional
Before the laminectomy, a sharp curette should be used to free bone removal. Used with permission from the Barrow Neurological Institute,
the ligamentum flavum from the underside of the lamina to allow Phoenix, Arizona.
safe use of a rongeur for the laminectomy. The laminectomy
then proceeds in a medial to lateral direction. The ligamentum
flavum is also often removed during this portion of the surgery; layers: first the paraspinal muscles, then the fascia, subcutaneous
dural tears and cerebrospinal fluid leaks can be prevented by tissue, and skin.
taking care to not dive too deeply with the rongeur (Figure 7). The minimally invasive method for a surgical bilateral decom-
If necessary, additional lateral decompression along the lamina pression involves creating a surgical corridor by dilating through
facilitates a medial facetectomy. For additional lateral decom- muscle with a tubular retractor or minimal-access expandable
pression, a Kerrison punch is often used to perform a partial retractor. A unilateral laminotomy is performed through the
medial facetectomy (Figure 8). Surgical treatment for lateral recess retractor, and the retractor can be directed contralaterally to
stenosis is unique in that a laminectomy with partial facetectomy permit drilling of the underside of the posterior bony margin
is performed to remove the hypertrophied dorsal facet. It is of the spinal canal (spinous process and contralateral lamina).
essential to sacrifice no more than one-third of either facet joint Ligamentum flavum hypertrophy and lateral recess stenosis due
to prevent iatrogenic instability. Once the surgeon has decided to facet hypertrophy can then be removed with a Kerrison bilat-
that decompression is sufficient, the self-retaining retractors are erally to decompress the spinal canal. The neural foramina can be
removed and hemostasis is achieved. The wound is closed in enlarged using a Kerrison as well to decompress the nerve roots.

AHMAD ET AL
Conclusion
Lumbar spinal stenosis is a common disorder in the USA,
for which a systematic approach to management can be applied.
Selection of a patient for surgical management includes consider-
ation of multiple factors, including the degree of canal stenosis,
presence of neuroforaminal stenosis, spinal instability, presence of
scoliotic deformity, and clinical presentation.
Pearls
√

Neurogenic claudication is back and extremity pain that
worsens with activity, is relieved with rest, and is caused
by narrowing of the lumbar canal and the lateral recesses
FIGURE 8. Artist’s illustration demonstrating an axial view of final bone around the thecal sac and by compression of the lumbosacral
removal, with bilateral medial facetectomies and bilateral foraminotomies and
nerve roots. Pressure on the lumbosacral nerve roots causes
resulting nerve decompression. Used with permission from the Barrow Neurological
Institute, Phoenix, Arizona.
ischemia, which can worsen during exercise because of
√ increased metabolic demand.
Pain from neurogenic claudication can be improved in the
back or the legs by leaning forward. Occasionally patients
will describe relief while using a shopping cart, the so-called
Interspinous devices can be used as an indirect decompressive
surgery. Interspinous devices serve as a means to increase the √ “shopping-cart sign”.
MRI is the modality of choice for evaluating the etiology
distance between the superior and inferior vertebral notches,
of neurogenic claudication to identify lumbar stenosis and
thereby indirectly decompressing the intervertebral foramen.
narrowing around the nerve roots and thecal sac. CT can
Interspinous spacers can limit extension mobility at the instru-
be helpful for evaluating bony structure, facet hypertrophy,
mented spinal level and may create a slight kyphosis, altering the
bone quality, and compressive osteophytes. Patients who
normal lumbar lordosis.
cannot undergo an MRI may undergo CT myelograms,
Anterior lumbar interbody fusion and lateral interbody fusion
which can reveal spinal canal stenosis and narrowing around
involve placing an interbody into the disc space to restore
disc height; thus, these methods achieve indirect decompression √ the nerve roots.
Open laminectomy, with a direct decompression of the
of the intervertebral foramen but not as substantial indirect
spinal canal and nerve roots, is the most common surgery
decompression of the spinal canal. Posterior lumbar interbody
performed to treat lumbar stenosis with neurogenic claudi-
fusion and transforaminal interbody fusion also involve placing
cation.
an interbody into the disc space to restore disc height to
achieve indirect decompression of the intervertebral foramen;
however, these techniques are usually accompanied by lumbar
spinal fixation and/or direct decompression with a laminectomy. Case Answers
Fixation traditionally involves pedicle screws and fixation rods This 73-yr-old male patient presented with neurogenic claudi-
placed longitudinally along the spine to facilitate bony fusion cation secondary to ligamentous hypertrophy and L3-L4 and
between adjacent vertebral bodies, thus eliminating excess inter- L4-L5 disc herniation, as sequelae of DDD. Key features of his
vertebral motion. clinical presentation included (1) cramping pain down the legs,
(2) pain relief with rest and worsening with activity, and (3) relief
Complications with flexion. Patients can present with lumbar stenosis pain and
Overall, surgical decompression of the lumbar spine is a well- neurogenic claudication with normal strength, normal reflexes,
tolerated procedure with minimal complications. Risks associated and normal sensation, but they often have some abnormality
with the procedure include durotomy in 5% of primary surgeries on examination, such as diminished reflexes, as was the case for
and 10% of revision surgeries, nerve injury in 5% of cases this patient. In addition to reviewing previously obtained MRIs,
with <1% being permanent, postoperative infection of deep one could consider dynamic radiography to evaluate for mobility
tissue in 6% of cases, and deep venous thrombosis in 3% of in the lumbar vertebrae. Although conservative treatment could
cases. Epidural hematomas are rare in the setting of decompressive be attempted first, this patient would likely ultimately require
procedures, but the placement of a deep drain can serve as a lumbar decompression with a L3-L5 laminectomy.
preventive measure. Risk of nonfusion at an instrumented level,
referred to as pseudarthrosis, increases with multilevel fusions, 1. B. The most common presentation of lumbar spinal
cigarette smoking, and high-dose short-term postoperative use of stenosis is neurogenic claudication, which is characterized
nonsteroidal anti-inflammatory drugs. by activity-dependent aching or cramping pain in the hips,

SPINE

FIGURE 9. A 35-yr-old male presents with severe pain on the right side of the neck. MRI analysis of the cervical spine is
shown for purposes of case demonstration.
calves, thighs, or buttocks and in unilateral or bilateral lower CHAPTER 4: CERVICAL AND LUMBAR
extremities. RADICULOPATHY
2. A. Pain and numbness classically appear with prolonged
standing or walking. Patients usually have a relief of Case Presentation and Questions
symptoms with sitting or squatting or other maneuvers that A 35-yr-old male presents with severe pain on the right side
involve lumbar flexion, such as biking or leaning over a of the neck. He first noticed the pain while lifting 200 pounds
shopping cart (the so-called “shopping-cart sign”). Each of on an incline bench press. The pain on the right side was sharp
these maneuvers tends to increase the diameter of the spinal and soon migrated to the left side of the neck as well. The pain
canal that is being compromised by lumbar spinal stenosis. was temporized with an injection of epidural steroids into the
Classically, extension tends to exacerbate neurogenic claudi- C6-C7 transforaminal space. However, it returned after 2 wk.
cation pain. The pain continued to grow worse and began to radiate down
3. C. MRI is the modality of choice for modern diagnosis into the left upper extremity. The sharp pain was accompanied
of lumbar stenosis. T2-weighted MRIs are especially useful by weakness with an extension at the elbow. MRI analysis of
in visualizing regions of compression with a loss of the cervical spine is shown below. The patient underwent C6-
cerebrospinal fluid space around the spinal cord and nerve C7 anterior cervical discectomy and arthroplasty for his C6-C7
roots, nerve root impingement, cystic masses, disc herni- herniated disc (Figure 9).
ation, and ligamentous and facet hypertrophy.
4. A. Laminectomy is the mainstay for surgical decompression 1. Which cervical nerve root is most commonly compressed in
among patients with lumbar spinal stenosis. disc herniation syndromes?
2. Which lumbar nerve root is most commonly compressed in
disc herniation syndromes?
SUGGESTED READING 3. What is the significance of cauda equina syndrome (CES)
1. Farley CW, Park P, LaMarca F, et al. Stenosis/spondylolisthesis/spondylolysis. in the setting of suspected disc herniation?
In: Harbaugh R, Shaffrey CI, Couldwell WT, et al., eds. Neurosurgery 4. A wrist drop suggests impingement of what nerve root?
Knowledge Update: A Comprehensive Review. 1st ed. New York: Thieme; 2015.
2. Ghogawala Z, Dziura J, Butler WE, et al. Laminectomy plus fusion
versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016;
374(15):1424-1434.
Section Content
3. Greenberg MS. Handbook of Neurosurgery. 8th ed. New York: Thieme; 2016. Epidemiology and Distribution
4. Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence and association
with symptoms: the Framingham Study. Spine J. 2009;9(7):545-550. Radiculopathy is a dysfunction of a nerve root from any of a
5. Riew KD, Lewis S. Decompression for lumbar spinal stenosis. In: De Wald RL, variety of causes but is often due to the compression of a nerve root
Arlet V, Carl AL, et al., eds. Spinal Deformities. New York: Thieme; 2003. as a result of “wear and tear” changes in the spine. This common

AHMAD ET AL
TABLE 3. Cervical and lumbar syndromes categorized by levels of herniation and deficits
Cervical syndromes
Level of herniation C4-C5 C5-C6 C6-C7
Nerve root involved C5 C6 C7
Motor deficit Deltoid Elbow flexion Elbow extension
Sensory deficit Shoulder Thumb/forearm (radial)/upper arm Second/third digit
Lumbar syndromes
C7-T1 L3-L4 L4-L5 L5-S1

T1 L4 L5 S1
Hand intrinsic Quadriceps Tibialis anterior (dorsiflexion) Gastrocnemius (plantarflexion)
Fourth/fifth digit Medial foot Dorsum of foot/large toe Lateral foot
spinal disorder manifests with a myriad of neurological deficits, the intervertebral disc space is in close proximity to the pedicle,
including but not limited to pain in the afflicted dermatome, in contrast to the lumbar region. Cervical nerve roots exit the
sensory abnormality, and functional weakness. Mechanisms of spinal canal above the corresponding vertebra (eg, the C5 root
injury vary as some symptoms may be of insidious onset, while exits above the C5 vertebrae). For the aforementioned reasons, a
others are associated with an acute event/injury. Disc herniation disc herniation syndrome affects the nerve root at the level of the
syndromes are a common occurrence among those who engage in herniation (C5-C6 disc herniation would impact the C6 nerve
excessive movement, such as rotation, lateral bending, flexion, or root).
extension. In the lumbar region, the nerve root exits below the pedicle of
In the USA, cervical radiculopathy affects approximately 85 the corresponding vertebrae. For this reason, in conjunction with
individuals per 100 000. It typically impacts those who perform the greater relative distance of the disc space from the pedicle,
repetitive motions such as athletics, manual labor, excessive most disc herniation syndromes spare the nerve root at the corre-
lifting, and/or activities that result in narrowing of the neural sponding level. They instead impinge the inferior nerve root (L4-
foramen resulting in nerve root injury. The elderly population L5 disc herniation would impact the L5 nerve root).
may develop osteophytes that produce a more chronic onset. Note that although the anatomy is different, the radiculopathy
In contrast, lumbar radiculopathy occurs more frequently, observed in both the cervical and lumbar regions ultimately
affecting 3% to 5% of the population. Lumbar radiculopathy involves the nerve root corresponding to the lower numbered
is most common in women between the age of 50 and 60 and vertebra (Table 3).
men in their 40s. Additional risk factors include those who have
a history of smoking, diabetes, and obesity. Decision Making
The decision to treat radiculopathy with conservative
Natural History management or surgery is dependent upon the severity of
The majority (69%) of cervical disc herniations result in C7 motor and sensory deficits. Conservative management of radicu-
nerve root compression. Compression occurs less frequently at lopathy includes but is not limited to physical therapy, epidural
C6 (19%), C8 (10%), and C5 (2%). The majority of lumbar steroid injections, and symptomatic therapy. Clinicians often
disc herniations result in L5 (45%) or S1 (45%) compression. treat moderate cases with conservative management accom-
L4 (10%) is less commonly impacted. panied by a follow-up visit in 6 wk for reevaluation. In cases with
worsening of symptoms or severe deficits such as loss of function,
Clinical Presentation surgical intervention is reasonable.
The diagnosis of cervical or lumbar radiculopathy is often Most instances of cervical disc herniation resolve without inter-
made with radiographic findings in combination with a thorough vention. Recovery can be palliated with analgesics (NSAIDS) and
neuromuscular exam. MRI in combination with cervical X-rays cervical traction. In contrast, most instances of lumbar disc herni-
often aids with the identification of DDD and understanding the ation resolve with conservative treatment.
overall alignment of the cervical spine.
Surgical Techniques
Anatomy and Distribution ACDF is a common means of surgical management for radicu-
In the cervical region, there are 7 cervical vertebrae and 8 lopathy secondary to cervical disc herniation syndromes. The
cervical nerve roots. Each nerve root exits above the pedicle of the basic goal is to decompress the neural elements, whether for
corresponding vertebrae (opposite in the lumbar region). Inter- central or foraminal stenosis. Generally, the reconstruction of the
vertebral discs separate the adjacent vertebral. These discs are disc space after an anterior approach is achieved with a surgical
formed by the softer nucleus pulposus on the inside and the fusion procedure; however, the advent of motion preservation
tougher annular fibrosis on the outside. In the cervical region, devices such as artificial cervical discs may also be appropriate

SPINE
complexity of the surgery and risk for herniation (Figures 10, 11

Video and Video 5).
Pearls
√
Causes of radiculopathy include all that compromise or
√ compress the nerve root.
C7 and S1 are the most common cervical and lumbar roots
√ involved.
First line of treatment is often nonsurgical, involving the use

√ of NSAIDs, physical therapy, and epidural steroid injections.
Surgery is reserved for severe or progressive cases that do
not respond to conservative treatment or are associated with
neuro-deficits, especially motor.
FIGURE 10. A 43-yr-old male with right-sided S1 radiculopathy, responded to
tubular microdiscectomy.
Case Answers
1. C7. The majority (69%) of cervical disc herniations result
in C7 nerve root compression. Compression occurs less
for certain patient populations. On occasion, if a foraminal disc frequently at C6 (19%), C8 (10%), and C5 (2%).
herniation is noted, a posterior approach, without fusion, may 2. S1. The majority of lumbar disc herniations result in
also be utilized and the patient spared from disruption of the L5 (45%) or S1 (45%) compression. L4 (10%) is less
remaining normal cervical disc. However, the anterior approach commonly impacted.
offers multiple advantages in certain cases, including the removal 3. Urgent surgical intervention. CES is a rare but serious
of osteophytes, immobility/stability (secondary to fusion), and medical condition that requires urgent surgical treatment.
access to centrally herniated discs. Symptoms usually involve acute onset of motor and sensory
In the lumbar spine, posterior approaches are much more loss often with bladder bowel incontinence. This could be
common. Surgical indications include CES and persistent due to a large disc herniation or compression by other lesions
radicular pain for more than 6 wk, weakness, functional such as tumor or trauma. Rapid treatment can reverse some
impairment, or progressive numbness. CES is rare, occurring of these deficits.
in .0004 of patients. As with any disc herniation, patients 4. C6. C5 and C6 contribute to elbow flexion, but C6 is the
who undergo surgery are at risk of reherniation, with rates main root contributing to wrist extension.
between 3% and 19%. Lumbar disc disease may be treated
with either the traditional posterior dorsal approaches or newer
endoscopic/minimally invasive procedures. The primary goal in SUGGESTED READING
most cases is to remove the sequestered or herniated fragment 1. Greenberg M. Handbook of Neurosurgery. 7th ed. Tampa, FL: Thieme; 2010.
2. Hayden Gephart MG. Tarascon Neurosurgery Pocketbook. Burlington, MA: Jones
while leaving the native disc intact. Various types of anatomical and Bartlett; 2014.
factors, including the rupture of the posterior longitudinal 3. Malanga G. Cervical Radiculopathy. Medscape Reference. 2016.
ligament and calcification of the disc, all contribute to the 4. Malanga G. Lumbosacral Radiculopathy. Medscape Reference. 2016.
FIGURE 11. A 41-yr-old female with bilateral L5-S1 radicular symptoms, responded to open laminectomy and discectomy

AHMAD ET AL
a. Mild-moderate back pain

b. Neurological deficits
c. High-grade subluxation
d. Severe deformity
Section Content
Epidemiology
Isthmic spondylolisthesis involves defects in unilateral or

bilateral pars interarticularis and occurs most commonly at the
L5-S1 level (Figure 12). It tends to occur more commonly in
children and adolescents. It has been reported at an incidence
of 5% to 7%. The incidence of spondylolysis and subsequent
spondylolisthesis is higher in persons who subject themselves
VIDEO 5. Cervical and lumbar radiculopathy (case examples). This video
to activities that involve hyperextension and persistent lordosis,
can be accessed in the HTML version of the article. Please visit www. such as gymnastics, weightlifting, diving, football, and volleyball,
operativeneurosurgery-online.com to view this article in HTML and play the which increase shear stresses at the neural arch than in the general
video. population. While likely multifactorial with a possible role of
genetic and developmental factors, Fredrickson and colleagues
evaluated 500 newborns and found no evidence of spondylolysis
or spondylolisthesis, suggesting that the development of a pars
CHAPTER 5: LUMBAR SPONDYLOLISTHESIS defect with subsequent development of spondylolisthesis is likely
AND BACK PAIN an acquired phenomenon.
Anterior subluxation is classified using the Meyerding scale
Case Presentation and Questions (Table 4): grade 1 (<25%), grade 2 (25%-50%), grade 3 (50%-
A 51-yr-old male with no significant past medical history 75%), grade 4 (75%-100%), and grade 5 (>100%). The radio-
presented with gradually worsening lower back pain and tightness logic evaluation of high-grade spondylolisthesis (HGS) is no
of hamstrings over the last several years. Back pain was aggra-
vated by flexion or extension. On examination, a spinous process
step-off was noted in the lumbar spine. Otherwise, he was full
strength in his lower extremities with no long-tract signs, intact
sensation, and normal deep-tendon reflexes. X-ray films demon-
strated spondylolisthesis of L4-L5.
1. The most common locations for degenerative and isthmic

spondylolisthesis, respectively, are
a. L2-L3, L3-L4
b. L4-L5, L5-S1
c. L1-L2, L2-L3
d. None of the above
2. What percentage of subluxation would a patient with grade
III isthmic spondylolisthesis have?
a. <25%
b. 25% to 50%
c. 50% to 75%
d. 75% to 100%
e. >100%
3. What form of imaging can help with determining unstable
spondylolisthesis?
a. MRI
b. CT
c. Dynamic standing X-rays
d. None of the above
FIGURE 12. Isthmic spondylolisthesis demonstrating a pars defect with anterior
4. Which of the following is NOT an absolute indication for subluxation.
surgical intervention?

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TABLE 4. Grading of isthmic spondylolisthesis
Grade Degree of slip
I <25%
II 25% to 50%
III 50% to 75%
Iv 75% to 100%
V >100%

longer limited to the assessment of the degree of translational
slip alone. In fact, recent evidence has demonstrated that it is
the angular kyphotic deformity at the lumbosacral junction that
is more important in determining the risk of slip progression.
A number of newer classification systems have been developed
that incorporate both the translational and angular parameters to
characterize HGS and also provide a basis for surgical treatment
of the same.
As compared to isthmic spondylolisthesis, degenerative
spondylolisthesis is more common in adults and incidence
increases with age. L4-L5 is the most commonly affected level,
and the mechanism generally involves degeneration of the facet FIGURE 13. Degenerative spondylolisthesis demonstrating facet hypertrophy and
joints, causing subluxation of one vertebral body relative to the canal stenosis.
other. The majority of cases with HGS are isthmic in nature
as patients with degenerative spondylolisthesis rarely progress
beyond grade II. In contrast, central canal stenosis may not occur in isthmic
spondylolisthesis as the process involves pars defects. As a result,
Natural History back pain is usually the predominant symptom. In children who
The progression of spondylolisthesis is variable and depends develop spondylolysis (pars defects), symptoms may not present
on several different factors, including age, presence of neuro- until they are older and can sometimes be triggered after sudden
logical symptoms, degree of subluxation, and etiology. Children twisting or lifting motion. Athletes, therefore, can have a higher
tend to have a higher risk of progression than adults. Those risk of developing and exacerbating pars defects.
with neurogenic claudication, radiculopathy, bowel, or bladder
dysfunction are likely to experience clinical deterioration as Diagnosis
opposed to patients with back pain alone. Those with high- Spondylolisthesis is routinely diagnosed with the use of X-rays
grade slips are likely to experience worsening subluxation as (Figure 12) and/or CT. In the isthmic form, these imaging modal-
well. Finally, coexisting conditions, including trauma, arthritis, ities can show the classic “Scottie dog” appearance indicating
scoliosis, or other lumbosacral deformities, may predispose to pars defects. In addition, flexion–extension X-rays can be used to
progression. There is increasing evidence suggesting a role of evaluate for instability. Although the criteria for instability vary
lumbosacral kyphosis in determining the risk of slip progression. across the literature, most authors recommend these dynamic
studies to evaluate for the severity and degree of subluxation.
Clinical Presentation In the presence of neurological deficits, MRI is the imaging
Spondylolisthesis can present in a variety of ways and the modality of choice. MRI can also be helpful in determining
common symptoms and signs can vary by etiology and age. In overall degenerative burden in patients with the degenerative form
patients with degenerative disease, central canal stenosis may of spondylolisthesis. Further imaging studies, including nuclear
occur secondary to subluxation in the lumbar spine, leading to bone scans, can be helpful when evaluating pediatric cases with
neurogenic claudication. Tightening of hamstrings, aggravated isthmic spondylolisthesis as they can help differentiate between
by flexion or extension, can also be an accompanying symptom. chronic and acute pars defects.
Additionally, facet degeneration and hypertrophy (an important
radiographic finding in degenerative spondylolisthesis) can lead Management
to radicular symptoms due to foraminal stenosis (Figure 13). In the absence of neurological symptoms, mild to moderate
Examination may reveal spinous process step-offs on palpation back pain, and presence of comorbid conditions, spondy-
of the spine, hyperlordosis, flexed knee position (due tightening lolisthesis may be managed conservatively. Common measures
of hamstrings), and gait disturbance. include bracing, core strengthening, physical therapy, and anti-

AHMAD ET AL
inflammatory agents. Bracing, in particular, may be useful for deformity. Severe intractable back pain can be also be a
pediatric cases as it restricts flexion–extension motion that can relative indication.
lead to aggravation of symptoms and prevent healing of pars
defects.
Indications for operative management include neurological SUGGESTED READING
deficits, unstable subluxation, progressively worsening slips, or 1. Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The
presence of adjacent lumbosacral deformities. Options include natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am.
1984;66(5):699-707.
decompression, stabilization, and/or fusion. In cases of neuro-
2. Kasliwal MK, Smith JS, Kanter A, et al. Management of high-grade spondy-
logical deficits, decompression is appropriate. In cases of pars lolisthesis. Neurosurg Clin N Am. 2013;24(2):275-291.

defects, stabilization using anterior or posterior fusion is the 3. Resnick DK, Watters WC 3rd, Sharan A, et al. Guidelines for the performance
primary goal (Video 6). of fusion procedures for degenerative disease of the lumbar spine. Part 9: fusion
in patients with stenosis and spondylolisthesis. J Neurosurg Spine. 2005;2(6):679-
685.
Pearls
√ 4. Rosenberg NJ. Degenerative spondylolisthesis. predisposing factors. J Bone Joint
Patients with moderate to mild back pain, absence of neuro- Surg Am. 1975;57(4):467-474.
logical deficit, and coexisting spinal deformity can often be 5. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsur-
gical treatment for lumbar degenerative spondylolisthesis. N Engl J Med.
√ managed conservatively. 2007;356(22):2257-2270.
Patients with severe intractable back pain, neurological
deficit (ie, weakness, radiculopathy, or myelopathy),
coexisting spinal deformity, or who have failed conservative CHAPTER 6: COMMON SPINAL EMERGENCIES
management should be considered for surgical intervention. Case Presentation and Questions
A 25-yr-old man presents with acute worsening of his chronic
Case Answers back pain, with new-onset dysesthesias in his hips and right
1. B. The most common location of degenerative spondylolis- leg, including radicular pain in an L4 distribution worse on
thesis is at L4/L5. Isthmic tends to occur at L5/S1. the right, as well as a lack of bowel movement and incomplete
2. C. The grading scheme for anterior subluxation is as follows: voiding. On examination, he has 4/5 strength in dorsiflexion
grade I: 0% to 25%, grade II: 25% to 50%, grade III: 50% and plantar flexion bilaterally, with altered perineal sensation, but
to 75%, grade IV: 75% to 100%, and grade V: >100%. normal rectal tone. His blood pressure is 121/70, mean arterial
3. C. Flexion/extension X-ray films are studied to determine pressure is 87, heart rate is 64/min, and O2 saturation is 94%
the change in subluxation that can occur with those (Figure 14).
respective movements and can provide a quantitative
measure of instability. 1. CES is associated with all of the following except
4. A. Surgical intervention is generally reserved for neuro- a. Lower extremity weakness
logical deficits, instability, and/or coexisting structural b. Perineal numbness
c. Bladder and/or bowel dysfunction
d. Hyper-reflexive signs (eg, clonus)
e. All of the above
2. What is the next step in management for this patient?
a. Admission to the hospital floor for close observation
b. Early surgical decompression
c. Initiation of phenylephrine and placement of an arterial
line
d. All of the above
e. None of the above
3. What treatment strategies have supporting evidence for use
in CES?
a. Mean arterial blood pressure augmentation for 3 to 7 d
in all cases
b. Corticosteroid treatment of all cases
c. Early surgical decompression
VIDEO 6. Lumbar spondylolisthesis. This video can be accessed in the HTML
version of the article. Please visit www.operativeneurosurgery-online.com to view
d. Intraoperative neuromonitoring in all cases
this article in HTML and play the video. e. Treatment with neuromodulators
f. All of the above

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FIGURE 15. Radiographic assessment of vertebral body anatomy: Assessment of
the anterior marginal line (red), posterior marginal line (blue), spinolaminar line
(green), and interspinous line (orange) can be a rapid method to evaluate spine
malalignment and potential instability.
severity of injury. For individuals with paraplegia, first-year costs

average $519,520 and subsequent yearly costs are approximately
$68,821, whereas those with high tetraplegia have a first-year
cost of $1065,980 on average and subsequent annual costs of
FIGURE 14. Case example of SCI: sagittal midline A and axial B T2 MRIs
of the lumbar spine show an acute L4/5 paracentral disc herniation resulting in
$185,111.
compression of the cauda equina. Postoperative sagittal midline C and axial D Traumatic SCI is most common in males (80%) and non-
T2-weighted MRI of the lumbar spine after resection of the herniated disc shows Hispanic Caucasians (63.5%) and results in a lower than average
an improvement in cauda equina compression. life expectancy in all age groups, which is worse with high grades
of injury. Moreover, life expectancy has not improved since the
1980s, with mortality most commonly resulting from pneumonia
Section Content or septicemia.
The most common spinal emergencies present with partial SCI is identified clinically and radiographically (Figure 15).
or complete injury to the spinal cord or cauda equina (the Treatment of all SCI depends on early recognition, identification
lumbosacral nerve roots distal to the spinal cord). SCIs often result of timing of neurological insult to predict treatment response,
from compression of the spinal cord and/or nerve roots from and decompression with stabilization. SCI classification aids
trauma, infection, vascular anomalies, or neoplasm; however, they in tracking neurological recovery and predicting the outcome.
may also result from an acute degenerative process (eg, a large disc The American Spinal Injury Association (ASIA) International
herniation). Standards for Neurological Classification of Spinal Cord Injury
(ISCNCSCI), commonly referred to as the ASIA grade, is the
Trauma most common classification system. The ASIA grade charac-
Diagnosis/Prognosis. Trauma accounts for the majority of terizes injury based on motor and sensory findings (Figure 16)
spinal emergencies, with most resulting from vehicular trauma via a systematic assessment method of motor strength, sensation,
(38%). Other traumatic causes include falls (30.5%), assault reflexes, and bowel/bladder function (asia-spinalinjury.org/) into
(13.5%), sports-related trauma (9%), and iatrogenic causes (5%). 5 grades, from incomplete injury with return of function to
Traumatic SCI, with an incidence of 17 000 cases annually, results complete injury. SCI results in incomplete tetraplegia in 45%
in a significant morbidity and long-term disability, with direct of cases, incomplete paraplegia in 21.3%, complete paraplegia
and indirect costs of $7 billion in the USA annually. There in 20%, complete tetraplegia in 13.3%, and normal function
is a significant variability in healthcare cost depending on the in 0.4%. A study of 661 patients showed an improvement of

AHMAD ET AL
INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name Date/Time of Exam

CLASSIFICATION OF SPINAL CORD INJURY
Examiner Name Signature
(ISNCSCI)
SENSORY
RIGHT
MOTOR
KEY MUSCLES
Light Touch (LTR) Pin Prick (PPR)
KEY SENSORY POINTS
Light Touch (LTL) Pin Prick (PPL)
MOTOR
KEY MUSCLES LEFT
C2 C2
C2
C3 C3
C4 C2
C4
C3
C5
C3
C5
UER Wrist extensors C6
C4
C6 Wrist extensors UEL

C4
T2
(Upper Extremity Right) Elbow extensors C7 T3 C7 Elbow extensors (Upper Extremity Left)
C8
T4
C8 T5
T1 T6 T1
T2 T7
T2
MOTOR
C8
Comments (Non-key Muscle? Reason for NT? Pain? T8
C6
T3 T3
C7
Non-SCI condition?): T9 (SCORING ON REVERSE SIDE)
T4 Dorsum
T10 T4 0 = Total paralysis
T5 T5
T11 1 = Palpable or visible contraction
T12 2 = Active movement, gravity eliminated
T6 L1 T6 3 = Active movement, against gravity
T7 Palm T7 4 = Active movement, against some resistance
5 = Active movement, against full resistance
T8 S3
T8 NT = Not testable
0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present
T9 L2
Key Sensory
Points
T9
T10 S4-5
T10 SENSORY
(SCORING ON REVERSE SIDE)
T11 L T11 0 = Absent NT = Not testable
2
T12 L L3 T12 1 = Altered 0*, 1*, NT* = Non-SCI
S2 2 = Normal condition present
L1 3
L1
L2 L2
LER L3
Knee extensors L3 Knee extensors LEL
(Lower Extremity Right) L4 L4
L4 (Lower Extremity Left)
Long toe extensors L5 L
4
L5
L5 Long toe extensors
S1 S1 S1
L5
S2 S2
S3 S3
(VAC) Voluntary Anal Contraction (DAP) Deep Anal Pressure
(Yes/No) S4-5 S4-5 (Yes/No)
RIGHT TOTALS LEFT TOTALS
(MAXIMUM) (50) (56) (56) (56) (56) (50) (MAXIMUM)
MOTOR SUBSCORES SENSORY SUBSCORES
UER +UEL = UEMS TOTAL LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL
MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112)
NEUROLOGICAL R L 4. COMPLETE OR INCOMPLETE? (In injuries with absent motor OR sensory function in S4-5 only) R L
3. NEUROLOGICAL
LEVELS 1. SENSORY Incomplete = Any sensory or motor function in S4-5 6. ZONE OF PARTIAL SENSORY
LEVEL OF INJURY
2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION MOTOR
as on reverse Most caudal levels with any innervation
Page 1/2 REV 04/19

This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
FIGURE 16. American Spinal Injury Association (ASIA) grading system: American Spinal Injury Association: International Standards for Neurological Classification
of Spinal Cord Injury, revised 2011; Atlanta, GA, revised 2011, updated 2019.
C 2019 American Spinal Injury Association. Reprinted with permission.
complete injury in 15.5% of ASIA A cases, in 58.8% of ASIA lateral spinothalamic tract resulting in a cape-like distribution
B cases, in 85.8% of ASIA C cases, and in 12.5% of ASIA D of numbness commonly at the level of the shoulder blades with
cases. Even an improvement resulting in a single level of neuro- weakness and/or numbness in the hands (distal > proximal)
logical recovery can be instrumental, such as an improvement and possibly legs (proximal > distal). Brown-Séquard syndrome,
of a C5 to C4 injury allowing powering of a motorized chair from a hemisection of the spinal cord, results in ipsilateral
or improvement of a C6 to C5 injury allowing a patient to paralysis (corticospinal tract), ipsilateral loss of proprioception
feed himself/herself. These results suggest aggressive treatment of and vibration (dorsal columns), and contralateral loss of pain
patients is warranted. and temperature sensation (anterolateral spinothalamic). Anterior
Neurological localization is performed by identifying the level spinal artery injury results in deficits of the ventral horns and
of injury. Tetraplegia involves dysfunction of arms and legs, weakness. Posterior spinal artery injury of the dorsal horns results
whereas paraplegia involves dysfunction of legs only. Other in deficits of proprioception and vibration.
patterns of neurological injury are important in identifying Common imaging modalities used to evaluate SCI include CT
injury types. Central cord syndrome is the consequence of axial and MRI. CT scans now are widely available in hospitals and
loading and is characterized by injury to the traversing antero- are preferred over X-rays for the initial evaluation of traumatic

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TABLE 5. Key studies involving spinal cord injury management
NASCIS I (1985) r Low dose (100-mg bolus + 100 mg/daily) vs high dose (1000-mg bolus + 1000 mg/daily)
r No difference in neurological improvement between groups
r High-dose MPSS was associated with a greater risk of wound infection, sepsis, gastrointestinal hemorrhage,
pulmonary embolism, and death
NASCIS II (1990) r MPSS was compared with the opioid antagonist naloxone or placebo
r No difference in primary outcome was seen, but subgroup analysis showed that patients treated within 8 h of

injury had significantly greater motor recovery
NASCIS III (1997) r MPSS administered within 8 h of injury was compared with an antioxidant, tirilazad mesylate
r Dose of 30-mg/kg bolus + 5.4 mg/kg/hour was used
r No difference in primary outcome was seen, but subgroup analysis showed treatment within 3 to 8 h followed
by a 48-h infusion yielded improved neurological function at 1 yr.
AANS/CNS Guidelines for the r Guidelines discussing prehospital management, medical treatment, and surgical treatment of cervical injury
Management of Acute Cervical
Spine and Spinal Cord Injury (2013)
Patchell et al (2005) r Randomized, controlled trial evaluating 101 patients showed that surgical decompression followed by radiation
was superior to radiation alone in retained ability to walk
STASCIS (2012) r Prospective study of 313 patients given early (<24 h) or late (≥24 h) surgical treatment after SCI. Patients with early
surgery showed a ≥2 grade in ASIA grade compared with late decompression (19.8% vs 8.8%, OR = 2.57)
SCI because of their increased sensitivity and rapid acquisition. of deep vein thrombosis, pulmonary embolism, pneumonia,
A key feature to evaluate on CT is the alignment of the anterior and pressure ulcers. Initially after SCI, a state of spine shock
and posterior marginal lines, spinolaminar line, and interspinous with areflexia/hyporeflexia and autonomic dysfunction exists.
line (Figure 15). Evaluation of all imaging sequences is important This state can progress to neurogenic shock, where discon-
because other markers of significant injury, such as prevertebral nected sympathetic innervation results in a decreased heart rate,
or other tissue swelling, may be identified. MRI can be used for blood pressure, cardiac output, and systemic vascular resistance.
the evaluation of ligamentous injury, herniated discs, epidural Hyporeflexia from SCI can progress to spasticity over hours to
hematoma, and spinal cord T2/STIR signal change, which are days and can require chronic management. A variety of neuro-
important for surgical planning. With the vertebral arteries protective treatments and stem cell therapies have been evaluated
entering together at C6 and ascending through the vertebral for SCI with limited success.
foramen, injury to vessels from fractures can be evaluated rapidly Corticosteroid use for the treatment of SCI has been contro-
and accurately with CT or MR angiography studies. versial. The National Acute Spinal Cord Injury Studies (NASCIS)
were a series of large randomized clinical trials evaluating methyl-
Medical Management. SCI was conceptualized by Allen in 1911 prednisolone sodium succinate (MPSS). Preclinical studies and
as resulting in primary injury, referring to initial traumatic anecdotal evidence initially suggested that corticosteroids might
injury to the spinal cord via shear, laceration, contusion, and reduce oxidative stress, calcium excitotoxicity, and immune-
compression, as well as secondary injury, describing subse- mediated phagocytosis; however, clinical evidence is equivocal
quent neurological injury from a series of complex, interre- (Table 5).
lated molecular processes. As the primary injury is unchangeable,
medical and surgical treatment strategies aim at reducing Surgical Management. In 2013, the American Association of
secondary injury. Neurological Surgeons and Congress of Neurological Surgeons
Medical management strategies include immobilization of published the Guidelines for the Management of Acute Cervical
the level of injury, augmentation of mean arterial blood Spine and Spinal Cord Injury. Discussions of prehospital
pressure (MAP) > 85 mmHg for 3-7 d (with dopamine or management and stabilization, assessment, medical management,
norepinephrine), and initiation of an SCI protocol (eg, bowel and surgical treatment were included. Multiple classification
regimen) to prevent constipation and ileus; lower extremity systems have been devised to identify patients requiring surgical
compression stockings to reduce the risk of deep vein throm- treatment, including the Denis model, the Thoracolumbar Injury
bosis and pulmonary embolism; abdominal binder to improve Classification and Severity scale, the Subaxial Cervical Spine
MAP; cough assistance to reduce risk of pneumonia; nutri- Injury Classification System, and the AOSpine classification
tional support to prevent muscle atrophy and catabolism; peptic (Figure 17).
ulcer prophylaxis; rehabilitation consultation for subsequent care; Surgical management strategies aim at reducing spine insta-
and early mobilization to improve recovery and reduce the risk bility, preventing deformity, and reversing or preventing further

AHMAD ET AL
Cauda Equina Syndrome

Diagnosis/Prognosis. CES deserves a specific mention because
of its potential for significant neurological harm but the possi-
bility of improvement with early recognition and treatment
(Figures 14 and 20). CES results from compression of the
lumbosacral nerve roots below L1, and most often presents
with asymmetric lower extremity weakness, perineal or saddle
numbness (S3-S5 distribution), and bladder/bowel dysfunction,
along with back pain and potential gait dysfunction. Additional

important, but often neglected, features of the neurological
examination that should be evaluated include perineal numbness,
rectal tone, and postvoid residual volumes. Correlation of
symptoms with imaging is important as symptoms can occur
acutely or chronically, and timing is important for surgical
decision-making. CES emergencies occur in patients with acute
or progressing neurological deficits over a 1 to 2 d period of time.
Compression from acute herniated discs, infection, and hemor-
rhage (spontaneous or postoperative) are also possible mecha-
nisms. CES is rare, with a prevalence of 1: 65 000 patients and
occurring in only 1% to 2% of all herniated discs. It should
be distinguished from conus medullaris syndrome, which results
from the compression of the conus (distal tip of the spinal
cord) with bilateral lower extremity weakness, perineal numbness,
and bowel dysfunction. CES can result from fractures, tumors,
infection, or a herniated disc.
Management. Early recognition and surgical decompression

offer the potential for stabilization of deficits or possible reversal.
Symptoms occurring over a 1 to 2 d period respond better to
treatment than cases with >7 d of symptoms. Earlier treatment
has been shown to correlate with improved neurological recovery,
although up to 20% of patients can have continued urological
or sexual dysfunction after treatment. Surgical decompression of
CES from a large acute disc herniation usually involves bilateral
FIGURE 17. AOSpine Injury Classification. AOSpine is a clinical division of laminectomy and discectomy. If there is evidence of instability or
the AO Foundation—an independent medically guided nonprofit organization. if the decompression requires excessive bony removal to facilitate
The AOSpine Knowledge Forums are pathology focused working groups acting safe and adequate decompression, a fusion may also be performed.
on behalf of AOSpine in their domain of scientific expertise. Each forum consists Medical management alone is not supported.
of a steering committee of up to 10 international spine experts who meet on a
regular basis to discuss research, assess the best evidence for current practices, and Malignant Spinal Cord Compression
formulate clinical trials to advance spine care worldwide. Study support is provided
directly through AOSpine’s Research department and AO’s Clinical Investigation Diagnosis/Prognosis. Neoplastic spinal cord compression may
and Documentation unit. C 2018 AOSpine International. CC NC ND 4.0 occur when (1) epidural disease directly results in cord
compression, (2) tumor causes pathological fractures resulting
in a spinal canal compromise, or (3) tumor hemorrhage or
neurological deficit by decompression of the spinal cord and/or vascular insult results in an acute neurological decline causing a
nerve roots (Figure 18). Approaches are broadly categorized into spinal emergency (Figure 21). Tumors can be characterized by
anterior, lateral, posterior, or combined approaches depending on their location, namely, extradural (typically metastatic cancer),
spine level (Figure 19). All spine fusion procedures aim at fixing intradural-extramedullary (meningiomas and schwannomas),
spine levels while allowing bony fusion to complete over a 3 to 6 or intradural-intramedullary (ependymomas and astrocytomas)
mo period of time. Whether the timing of surgical decompression tumors (Figure 21). Additional lesions of the spine include
affects the outcome remains controversial, with evidence from lymphoma, multiple myeloma, chordoma, and a variety of
some large, multicenter randomized clinical trials suggesting that primary bone tumors. Patients with a known history of aggressive
early decompression improves outcome (Table 5). primary cancer are counseled on monitoring for malignant

SPINE

FIGURE 18. Intraoperative views of the spine: A, Posterior cervical midline approach with muscle dissection is shown, with the arrow indicating the base of the occiput.
B, Posterior thoracic midline approach with muscle dissection is shown, demonstrating the interspinous bones and ligaments (arrow). C, Removal of the spinous process
and lamina to decompress the spinal cord (arrow) is shown.
spinal cord compression by evaluating changes in neurological sensation preserved; C: incomplete, strength preserved ≤3
symptoms. Importantly, a patient with known cancer and new- strength; D: incomplete, strength >3; and E: incomplete,
onset back pain should have MRI evaluation to rule out metastatic √ normal function.
spine disease. Most cases of SCI are incomplete tetraplegia, where early,
aggressive management of SCI can improve recovery more
Management. A landmark study by Patchell et al showed that commonly than in complete injury.
√
the treatment of malignant spinal cord compression with surgical Central cord syndrome (central spine injury) produces a
decompression followed by radiation has been shown to be better cape-like distribution of numbness around the shoulder
than radiation alone for preservation of neurological function. blades with weakness and/or numbness in the hands
Surgery for SCI due to neoplasm follows the same general and possibly legs. Brown-Séquard syndrome (hemisection)
principles as for traumatic SCI, including rapid decompression results in ipsilateral paralysis, ipsilateral loss of proprio-
of the spinal cord and nerves roots followed by stabilization ception and vibration, and contralateral loss of pain and
if necessary. Surgical approaches to the cervical, thoracic, and temperature sensation. Anterior spinal artery injury impairs
lumbar spine vary based on tumor location, tumor type, and the ventral horns and motor strength, whereas posterior
response to prior treatment (including radiation). For patients spinal artery impairs the dorsal horns, proprioception, and
with back pain without neurologic symptoms, bracing, radiation, vibration.
√
or kyphoplasty are potential treatment strategies. Conus medullaris and CES (compression) result in a
loss of perineal sensation, lower extremity weakness, and
Conclusion bladder/bowel dysfunction.
√
Cases of compromise of the spinal cord, conus medullaris, or Compression of neurological structures or pathological
cauda equina can be recognized by obtaining a proper history and fractures due to neoplastic disease can result in a rapid
complete physical examination along with radiographic infor- decline. Early decompression followed by radiation therapy
mation. Various mechanisms for SCI include trauma, infection, has been shown to improve neurological outcomes.
tumors, and postoperative injury. Early recognition of acute
SCI, CES, and neoplastic disease is critical to improving patient
outcome by initiating medical management strategies as well as Case Answers
surgical decompression if warranted. 1. E. CES is commonly associated with acute-onset back
pain and lower extremity weakness, perineal numbness, and
Pearls dysfunction of bowel (eg, incontinence) and bladder (eg,
√
The ASIA grading system is a rapid method to assess the retention). A full neurological examination should be under-
level and severity of SCI into A: complete; B: incomplete, taken, including timing of symptoms, motor strength, rectal

AHMAD ET AL
SUGGESTED READING
1. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression
for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute
Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):e32037.
2. Hadley MN, Walters BC. Introduction to the Guidelines for the Management
of Acute Cervical Spine and Spinal Cord Injuries. Neurosurgery. 2013;72(Suppl
2):5-16.
3. Karsy M, Hawryluk G. Pharmacologic management of acute spinal cord injury.
Neurosurg Clin N Am. 2017;28(1):49-62.
4. National Spinal Cord Injury Statistical Center. Facts and Figures at a Glance.
National Spinal Cord Injury Statistical Center, https://www.nscisc.uab.edu/.

Accessed December 17, 2016.
5. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical
resection in the treatment of spinal cord compression caused by metastatic
cancer: a randomised trial. Lancet. 2005;366(9486):643-648.
CHAPTER 7: SPINAL TUMORS—PRIMARY AND

METASTATIC
Case Presentation and Questions
A 68-yr-old male with a past medical history of prostate cancer
presents with sudden onset of lower back pain. The patient was
getting down off a ladder 5 h prior when he experienced sudden
back pain with left leg radiculopathy. Neurological examination
showed 3/5 strength and decreased sensation of the left lower
extremity. MRI with contrast revealed an L4 enhancing lesion and
burst fracture with compression of the thecal sac and nerve roots.
1. What is the most common primary tumor to metastasize to

FIGURE 19. Examples of posterior cervical and lumbar fusion. A, Anteroposterior
the spine?
and B, lateral views of the cervical spine showing decompression and instrumented
fusion from C3-C6 using lateral mass screws and connecting rods. C, Anteropos-
a. Breast
terior and D, lateral view of the lumbar spine showing decompression, postero- b. Prostate
lateral fusion at L3-L5, and interbody devices at L3/L4 and L4/L5. c. Lung
d. Melanoma
2. What is the most common intradural intramedullary spinal
tone, and postvoid residuals in addition to the evaluation of tumor?
imaging studies. a. Ependymoma
2. B. After initial stabilization, early decompression of the b. Glioblastoma
cauda equina will give the patient the best chance of c. Metastasis
recovery. The patient should be admitted to a critical d. Hemangioblastoma
care unit, not the hospital floor, to ensure his blood 3. In a patient with a metal implant, which is the best imaging
pressure remains stable in the immediate postoperative modality to diagnose an intradural extramedullary spinal
period. Although the placement of an arterial line may be tumor?
warranted, currently the patient is maintaining adequate a. MRI without contrast
MAPs. Dopamine or norepinephrine should be used instead b. CT myelogram
of phenylephrine (B) for MAP augmentation since phenyle- c. Plain X-rays
phrine can cause reflex bradycardia in the setting of neuro- d. PET CT
genic shock. 4. Which is the most common region for spinal metastases to
3. E. Augmentation of MAP, initiation of an SCI protocol, present?
and early decompression to reduce secondary injury have a. Lumbar
the best evidence supporting improvement of neurological b. Thoracic
function. Use of corticosteroids remains controversial and c. Cervical
may be beneficial in cases of early use after injury but d. Sacral
certainly not in all patients (B). While acute SCI and CES 5. In which compartment do spinal tumors most commonly
are distinct pathologies, many of the treatment strategies can present?
be similar, such as initiation of an SCI protocol. a. Extradural

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FIGURE 20. Herniated lumber disc causing CES. A, A diagram of the cauda equina is shown with termination of the spinal cord around L1. A herniated lumber
disc at B, L4/5 or C, L5/S1 causing cauda equina compression and neurological symptoms is shown. Reproduced from Cauda equina syndrome, Lavy et al, BMJ 338,
b936, Copyright 2009, with permission from BMJ Publishing Group Ltd.
b. Intradural extramedullary Aside from MRI and CT, several other studies may be indicated
c. Intradural intramedullary for the diagnosis of spinal tumors. In certain types of suspected
extradural spinal lesions, a CT-guided biopsy may be helpful in
confirming diagnosis, thereby facilitating appropriate treatment
Section Content planning. Plain radiographs have a low sensitivity but may
Epidemiology be beneficial in examining vertebral body integrity and may
Tumors of the spine and spinal cord are much rarer than be helpful in diagnosing some primary bone tumors such as
intracranial tumors. They make up 15% of CNS tumors. The Ewing sarcoma (mottled, moth-eaten appearance). Angiography
most common tumor of the spine is a metastasis, which is mostly is sometimes useful for determining the vascularity of the tumor
seen in patients with a known history of malignancy. Unlike preoperatively. It can be coupled with preoperative embolization
intracranial tumors, most primary tumors of the spinal cord are for highly vascular lesions like hemangioblastomas and renal
benign. We classify spinal tumors based on the compartment in metastasis in order to minimize intraoperative blood loss. Lumbar
which they present: extradural (55%), intradural extramedullary puncture for CSF cytology can help diagnose metastatic disease
(40%), and intradural intramedullary (5%) (Figure 22 and Video of the meninges.
7). Certain tumors have a predilection for certain compart-
ments. The acuity of symptoms, histopathology, compartment, Extradural Spinal Tumors
and location determine the management and surgical approaches Background. Extradural tumors arise outside of the thecal sac
for each tumor. in either the vertebral body or the epidural space and are the
most common spinal tumor. By far the most common extradural
Diagnosis spinal tumor is a metastasis. They make up approximately 90%
Pure clinical diagnosis of spinal tumors is usually difficult. of extradural tumors with primary tumors of the spine only repre-
When conducting a history, inquire about a history of malignancy senting 10%. These tumors damage the spinal cord through
(metastasis), von Hippel–Lindau disease (hemangioblastomas), direct compression or by occluding venous outflow leading to
and neurofibromatosis type 2 (schwannomas). The gold standard venous congestion and possible infarction. The effects of acute
for diagnosing pathology of the spinal cord is MRI. MRI with and compression can be reversible, but chronic compression of neural
without gadolinium contrast is useful for delineating malignant elements will lead to irreversible deficits.
lesions of the spine. T2-weighted images demonstrate edema and
identify cystic components of tumors. Enhancement patterns on Clinical Presentation. Clinical presentation of extradural spinal
T1-weighted images with contrast help with diagnosis and deter- tumors is dependent on tumor growth rate, bony destruction,
mining the extent of tumor involvement. In patients where MRI and extent of neural compression. Pain is the most common
is contraindicated, CT myelography is an acceptable alternative. presenting symptom and can be classified as local, referred, or

AHMAD ET AL

FIGURE 21. Neoplastic diseases of the spine. A, A diagram of pathology types and specific locations of the spine is shown.
B, Lateral and C, axial views of a case of pathological fracture are shown. A 63-yr-old man presented with progressive lower
extremity weakness and back pain after L2 fracture from a renal cell carcinoma. D, Lateral and E, axial views are shown
after posterior spinal fusion T12 to L4 with corpectomy at L2.
radicular. Motor, autonomic, and sensory dysfunction can also and prostate, respectively. Metastasis can cause compression
occur. Acute onset of severe back pain, profound weakness, saddle or burst fractures of the vertebral bodies, which may result
anesthesia, and bladder or bowel incontinence may suggest CES in a sudden onset of symptoms.
due to pathological bony destruction or epidural extension of r Chordomas: Arise from remnants of the embryonic
tumor. Acute-onset epidural spinal cord compression should be notochord. They most commonly arise in the clivus or the
treated within 24 to 48 h of symptom onset, or the potential for sacrum. These tumors are slow growing, hyperintense on
neurologic recovery will be minimal. T2-weighted imaging, occur in the midline, and may present
with a cranial nerve deficit if arising from the clivus.
r Chondrosarcomas: Arise from cartilage and are malignant
Differential Diagnosis tumors. These tumors are hyperintense on T2-weighted
r Metastasis: Most common extradural spinal tumor. More
imaging, may have calcifications, and may present with pain
common in men than women. Mostly spread to vertebral that worsens at night.
bodies but can present in the epidural space as well. The r Bone tumors: Arise directly from the vertebrae and
spinal column is the third most common place for metastases include osteosarcoma, Ewing’s sarcoma, osteoid osteoma,
to arise. The thoracic spine is the most common location. osteoblastoma, aneurysmal bone cyst, giant cell tumor,
The most common metastatic spinal lesions are lung, breast, osteochondroma, and vertebral hemangioma.

SPINE

FIGURE 22. Spinal tumor compartments. A, Extradural tumor, B, intradural extramedullary tumor, and C, intradural
intramedullary tumor.
r Other: Other extradural tumors include plasmacytoma,

multiple myeloma, eosinophilic granuloma, chloroma, and
angiolipoma.
Treatment
r Metastatic extradural tumors: The treatment of metastatic
extradural tumors focuses on preserving neurological
function and maintaining or restoring spinal stability. Roy
Patchell’s landmark prospective study helped elucidate some
criteria that can be used to identify patients who are surgical
candidates. These include tissue-proven cancer, spinal cord
displacement on imaging, at least one neurological sign,
symptom, or pain, a single area (one level or multiple
VIDEO 7. Spinal tumors: case presentations. This video can be accessed in
contiguous spinal levels), and a life expectancy of at least 3 the HTML version of the article. Please visit www.operativeneurosurgery-
mo. The Patchell exclusion criteria are radiosensitive tumor, online.com to view this article in HTML and play the video.
paraplegic for greater than 48 h, isolated root compression,
and prior radiation therapy to that area. Although these
criteria provide a framework for analyzing potential surgical
patients, each patient must be considered individually prior Intradural Extramedullary Spinal Tumors
to recommending treatment. Adjuvant therapy includes Background. Intradural extramedullary tumors arise in the
corticosteroids, chemotherapy, and radiation therapy. subdural space between the dura and pia mater and are the second
r Primary extradural tumors: Histopathology, spread, and most common spinal tumors. Most tumors that arise in this area
size of the tumor play an important role in deter- are benign and include meningiomas, schwannomas, neurofi-
mining the correct therapeutic management. En bloc bromas, hemangioblastomas, and paragangliomas. Schwannomas
resection with wide margins is ideal for tumors that are and hemangioblastomas are associated with neurofibromatosis
amendable to surgery. Chemotherapy and radiation may and von Hippel–Lindau, respectively. These tumors are slow
help prevent recurrence. Osteosarcomas and chondrosar- growing. Metastases rarely arise in this compartment.
comas are radioresistant. Ewing sarcoma and plasmacy-
tomas can be managed with chemotherapy and radiation Clinical Presentation. Intradural extramedullary tumors are
alone. typically slow growing; therefore, the onset of symptoms is usually

AHMAD ET AL
insidious. The most common symptom is localized or radicular

pain, but impaired gait, weakness, paresthesia, impotence, and
autonomic dysfunction may also be present. Upper motor neuron
symptoms are common on physical examination.
Differential Diagnosis
r Schwannomas: Nerve sheath tumor that arises from
Schwann cells. Typically, slow growing. Often dumbbell
shaped as they extend through neural foramina. Hyper-

intense on T2-weighted images and may have a cystic
component. Typically, involve only one fascicle of a nerve
root.
r Meningiomas: Arise from arachnoid cap cells most
commonly of the thoracic spine. More common in women
and typically present in patients older than 50 yr. Hyper- VIDEO 8. Intramedullary spinal tumor resection. This video can be accessed
intense on T2-weighted imaging and do not have a cystic in the HTML version of the article. Please visit www.operativeneurosurgery-
component. Enhance homogeneously with gadolinium. online.com to view this article in HTML and play the video.
May be completely extradural or mixed intra/extradural.
r Neurofibromas: Nerve sheath tumors. Associated with
neurofibromatosis type 1. Hyperintense on T2-weighted
imaging. May grow from the central root as an enlargement
of the nerve itself. of these tumors. Symptoms include local or radicular pain,
r Paragangliomas: Rare neuroendocrine tumor arising from weakness, parasthesias, spasticity, and autonomic dysfunction.
paraganglia in chromaffin-negative glomus cells. Hyperin-
tense on T2-weighted imaging and brightly enhance with Differential Diagnosis
gadolinium contrast. r Ependymomas: Arise from the ependymal cells of the central
r Metastases: More commonly extradural but do present canal of the spinal cord. They are more prevalent in adults.
intradurally. They are generally well-circumscribed lesions that enhance
with gadolinium contrast. Hemorrhage and cystic degen-
eration may be present. Syringomyelia is frequently an
Treatment. Observation is generally recommended for
associated finding on diagnostic imaging.
intradural, extramedullary tumors in asymptomatic patients. r Astrocytomas: Arise from astrocytes and can range from
With the progression of neurologic symptoms, surgery is the
low-grade to glioblastomas. May have syrinx formation
treatment of choice. Intraoperative monitoring is recommended
and perilesional cysts. Predominately in the cervical spine.
to assess motor and sensory function during tumor resection.
Heterogeneously enhance with gadolinium.
When complete resection is not possible due to a lack of a clear r Hemangioblastoma: Composed of endothelial cells,
plane between tumor and neural tissue, debulking is recom-
pericytes, and stromal cells of the CNS. Associated with
mended. Some tumors require internal debulking to decrease
von Hippel–Lindau syndrome. Brightly enhance with
manipulation of the spinal cord and nerve roots before dissecting
gadolinium. Often associated with a large syrinx.
the tumor–neural interface. r Other: Dermoid tumors, epidermoid tumors, cavernous
Intradural Intramedullary Spinal Tumors malformations, lipomas, lymphoma, and intramedullary
metastasis.
Background. Intramedullary tumors arise inside the spinal cord
and are the third most common spinal tumors. The most
common intramedullary tumors are ependymomas and astro-
cytomas but also include hemangioblastomas and lipomas. Treatment. Tumor histology and neurological examination on
Cavernous malformations are non-neoplastic vascular malforma- presentation are the most important prognostic factors for
tions that may also present as an intramedullary mass lesion. Most intramedullary tumors. There are no standard chemotherapies
of these tumors are slow growing and typically present in the for any intradural tumors. Maximal, safe surgical resection is the
cervical and upper thoracic regions. There is an 80% mortality goal of therapy for these tumors (Video 8). Astrocytomas rarely
rate for high-grade astrocytomas, whereas ependymomas and have distinct planes and should be internally debulked. Because
hemangioblastomas can be cured with complete resection. ependymomas and hemangioblastomas tend to have clear planes,
complete resection is the goal. Somatosensory-evoked potentials
Clinical Presentation. Clinical course is typically insidious and and motor-evoked potentials are recommended for neurological
spinal cord function may be maintained due to the slow growth monitoring during the resection.

SPINE
Pearls in the posterior fossa and are usually slow-growing benign

√ tumors.
The most common tumor compartment is extradural and
the most common location is in the thoracic spine. The most 3. B. Some patients with certain metallic implants are unable
to get an MRI scan, and in these patients the best imaging
√ common spinal tumor is a metastasis. modality is a CT myelogram. These include patients with
Acute-onset extradural spinal cord compression associated
with profound weakness requires immediate decompression deep brain stimulation implants and pacemakers. With this
within 24 to 48 h to prevent long-term neurological in mind, it is important to investigate with the radiologist
and device manufacturer, as nothing can substitute the soft-
√ dysfunction. tissue resolution obtained with MR imaging.
MRI is the gold-standard imaging modality when

diagnosing spinal tumors. 4. B. The thoracic spine is the most common site for
spinal metastases. The cervical spine is the least commonly
involved, only in about 10% of cases. This can be
explained by preferential venous drainage—discussed in
Case Answers question 1.
Here we have a man with a known history of a malignancy 5. A. Metastatic spinal tumors reach the spinal column, most
with a predilection for metastasizing to the spine. The patient often, by hematogenous spread; thus, they cannot breach
presents with sudden onset of local and radicular pain after the blood–brain barrier. Metastases are the most common
minimal trauma. This is indicative of a pathological fracture. The extradural spinal tumor.
acute onset of pain and decreased sensation and a single lesion
on MRI make this patient a candidate for urgent decompression
SUGGESTED READING
and resection of his extradural metastatic lesion. Operating
1. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical
on these patients within 24 to 48 h of symptom onset is crucial resection in the treatment of spinal cord compression caused by metastatic
in preventing long-term neurological dysfunction. cancer: a randomised trial. Lancet. 2005;366(9486): 643-648.
2. Laufer I, Rubin DG, Lis E, et al. The NOMS framework: approach to the
1. C. Thoracic and lumbar spine are the most common sites for treatment of spinal metastatic tumors. Oncologist. 2013;18(6):744-751.
spinal metastases in general. Breast and lung cancer prefer- 3. Hirano K, Imagama S, Sato K, et al. Primary spinal cord tumors: review
of 678 surgically treated patients in Japan. A multicenter study. Eur Spine J
entially metastasize to the thoracic spine because of local
2012;21(10):2019-2026.
venous drainage through the pulmonary veins in the case 4. Engelhard HH, Villano JL, Porter KR, et al. Clinical presentation, histology,
of lung cancer and the azygous vein in the case of breast and treatment in 430 patients with primary tumors of the spinal cord, spinal
cancer. Similarly, prostate metastases tend to involve the meninges, or cauda equina. J Neurosurg Spine. 2010;13(1):67-77.
lumbosacral spine.
2. A. Ependymomas are the most common intramedullary Disclosure
tumor in adults, while astrocytomas are the most common The authors have no personal, financial, or institutional interest in any of the
in children. These tumors are similar to ependymomas seen drugs, materials, or devices described in this article.

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ESSENTIAL NEUROSURGERY FOR MEDICAL STUDENTS

Faiz U. Ahmad, MD∗

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Osteomyelitis if the patient is very unstable and requires posterior supplemen-

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unnecessary as many patients will respond to medical therapy.

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Spondylotic degenerative changes are the most common cause of

Pathogenesis Motor dysfunction: upper extremities

Spondylosis is a general term referring to the degener- 0 Unable to feed self

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should be carefully interpreted in the context of each patient’s

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Diagnostics should be considered whenever mobile degenerative spondylolis-

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FIGURE 5. Artist’s illustration demonstrating a posterior view

interarticularis (the bony ridge between the superior and inferior

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complexity of the surgery and risk for herniation (Figures 10, 11

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a. Mild-moderate back pain

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1. The most common locations for degenerative and isthmic

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TABLE 4. Grading of isthmic spondylolisthesis

Grade Degree of slip

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severity of injury. For individuals with paraplegia, first-year costs

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INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name Date/Time of Exam

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Page 1/2 REV 04/19

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