The changing role for neurosurgeons and the treatment of spinal deformity

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✓ Spinal deformity has classically and historically been studied by those in the discipline of orthopedic surgery. This may be attributable to the orthopedic interventionalists' experience with osseous fixation for long-bone and other skeletal fractures. Neurosurgeons have maintained a long-standing interest in complex cervical spinal disorders, and their interest in the larger field of complex spinal deformity has been expanding.

An understanding of spinal deformity disorders, biomechanics, bone biology, and metallurgy is necessary before clinical, teaching, and research activities can be undertaken within neurosurgery.

The authors describe basic and advanced concepts of spinal deformity management with cases to illustrate teaching points.

Article Information

Address reprint requests to: J. Patrick Johnson, M.D., Institute for Spinal Disorders, 444 South San Vicente Boulevard, Suite 800, Los Angeles, California 90048. email: johnsonjp@cshs.org.

© AANS, except where prohibited by US copyright law.

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Figures

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    Magnetic resonance image obtained in a 22-year-old patient presenting with progressive spastic quadriparesis due to severe basilar invagination and a large syrinx. He underwent a transoral approach to decompress the severe deformity and then occipito-cervical fusion for stabilization.

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    Long-cassette 36 × 14—in AP (left) and lateral (right) radiographs obtained to evaluate spinal curvature and sagittal balance.

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    Adult patient with degenerative lumbar scoliosis (left panels) who underwent a multilevel anterior lumbar interbody fusion and posterior instrumentation-assisted fusion (right panels).

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    Sagittal MR image revealing Scheuermann kyphosis with classic multilevel degenerative discs, multiple endplate irregularities, and wedging of multiple vertebral bodies (arrows).

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    Postoperative images of posterior lumbar L2—S1 spinal fusion (left) and a T11–12 fusion (right) causing severe flat-back syndrome with a typically stooped position. The patient was treated with an L-3 posterior PSO to correct the deformity.

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    Photograph of a patient with asymmetrical elevation of the chest wall (that is, rib hump) due to scoliosis causing spine rotation in rib-cage elevation.

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    Diagrams showing the use of a goniometer (left) for measurement of Cobb angles from the vertebral endplates at the distal ends of the curve and measured to determine the maximum curve angle, measurement of the sagittal-plane angle (center), and measurement of the coronal-plane angle (right).

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    Method for establishing a sagittal plumb line (from center of the C7—T1 disc and the anterior S-2 border; left) and coronal plumb line (C1—sacrum; right) along the long axis of the spinal column.

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    Idiopathic scoliosis evaluated on AP lateral radiographs with the patient bending to the left (left) and right (right), demonstrating a structural curve (short arrow) to distinguish it from flexible, nonstructural curves (long arrows).

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    Illustrations from the time of Hippocrates. The attempt to correct spinal deformity is depicted.

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    Preoperative (left) and postoperative (right) radiographs obtained in a 14-year-old patient with severe idiopathic scoliosis who underwent anterior release and posterior multisegmental screw fixation.

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    Anteroposterior (left) and lateral (right) radiographs demonstrating pelvic fixation utilized in a long-segment correction of posttraumatic kyphosis in a patient treated with L-4 PSO.

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    Preoperative (left) and postoperative (right) radiographs acquired in a 15-year-old patient with thoracolumbar scoliosis who underwent short-segment anterior segmental deformity correction.

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    Illustrations of three-point bending techniques used for correction of spinal curvatures.

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    Illustrations of cantilever techniques to achieve correction of kyphotic deformities.

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    Illustrations of the PSO procedure in which osseous resection of the facets and pedicles allows restoration of lordosis at a single vertebral level.

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