Topics

Endoscopic Spine Surgery (ESS)

Thoracic Spine Fractures

Cervical Facet Dislocations

Adult Pyogenic Vertebral Osteomyelitis

Neuromuscular Scoliosis

Spinal deformity occurring in patients with underlying neuromuscular disorders Characterised by: Progressive coronal curvature Associated pelvic obliquity Results from muscle imbalance, weakness, or paralysis

Pediatric Spondylolysis and Spondylolisthesis

Spondylolysis: Defect or stress fracture of the pars interarticularis Spondylolisthesis: Forward translation of a vertebra due to bilateral pars defect Most commonly occurs at L5–S1

Adult Isthmic Spondylolisthesis

Timing of Surgery

Pediatric Spine Trauma

Vertebral Compression Fractures (VCFs)

Lumbar Spine Fractures

Occipitocervical Injuries

Chance Fractures (Flexion-Distraction Injuries)

Lumbar Spinal Stenosis

Spinal Cord Monitoring

Spinal cord monitoring is an essential intraoperative tool used to prevent neurological injury during spinal surgery. The main modalities include somatosensory evoked potentials (SEP) for dorsal column function, motor evoked potentials (MEP) for corticospinal tracts, and electromyography (EMG) for nerve root integrity. SEPs are reliable and anesthetic-resistant but limited to sensory pathways, while MEPs are highly sensitive to anterior spinal ischemia yet affected by anesthesia. EMG, both spontaneous and triggered, helps identify nerve irritation or pedicle screw breaches in real time. A >50% reduction in signal amplitude or latency prolongation indicates potential cord compromise requiring immediate correction. Combined multimodal monitoring significantly improves intraoperative safety and postoperative neurological outcomes.

Spinal Cord Injury Management

Acute spinal cord injury (SCI) is a devastating condition resulting in high morbidity and long-term disability. Management focuses on rapid diagnosis, spinal immobilization, airway protection, and maintenance of perfusion with a target mean arterial pressure of ≥85–90 mmHg. The pathophysiology involves a primary mechanical insult followed by secondary injury cascades—ischemia, inflammation, and apoptosis—which are key therapeutic targets. High-dose steroids are no longer routinely recommended due to limited benefit and adverse effects. Early surgical decompression, ideally within 24 hours, has been shown to improve neurological outcomes in selected patients (STASCIS trial). Emerging therapies such as neuroprotective agents, stem cell transplantation, and neuroprosthetic technologies are under investigation. A structured multidisciplinary approach combining early stabilization, evidence-based acute care, and long-term rehabilitation remains the cornerstone of SCI management.

Degenerative Spondylolisthesis

Degenerative spondylolisthesis is the forward or backward slip of one vertebra over another due to facet and disc degeneration, most commonly affecting the L4–L5 level in elderly women. It presents with mechanical back pain, neurogenic claudication, or radiculopathy secondary to spinal stenosis. Standing lateral radiographs confirm diagnosis and grading, while MRI assesses canal and neural compression. Conservative treatment—including physiotherapy, anti-inflammatories, and injections—is first-line for low-grade, stable cases. Surgical decompression with or without fusion is reserved for patients with persistent pain, neurological deficits, or instability, providing superior outcomes compared with nonoperative care.

Burst Fractures

A spinal burst fracture involves disruption of both the anterior and middle columns of the vertebral body under axial-compression load. Retropulsion of posterior wall fragments into the spinal canal is typical and may cause neurological injury through direct compression or secondary deformity. The thoracolumbar junction (T11–L2) is most often affected because it transitions from rigid thoracic to mobile lumbar segments. Common mechanisms include falls from height and motor-vehicle accidents.

Subaxial Cervical Spine Fractures

Subaxial cervical spine injuries (C3–C7) are common consequences of high- to moderate-energy trauma, though even low-energy mechanisms can cause significant damage in elderly or ankylosed spines. They result from flexion, extension, compression, or burst mechanisms, most frequently between C5 and C7. Diagnosis begins with ATLS evaluation and cervical immobilization, followed by neurologic assessment and imaging. Standard radiographs (AP, lateral, odontoid) are complemented by CT for fracture detail and MRI for disco-ligamentous complex (DLC) and cord evaluation. Classification systems such as AOSpine, SLIC, and Allen–Ferguson guide management. Stable compression fractures without posterior ligamentous involvement may be managed conservatively using a rigid orthosis, whereas unstable or displaced injuries—especially burst and flexion teardrop fractures—require surgical decompression and fixation. Prognosis depends on the initial neurological deficit, fragment displacement, and timing of surgery; patients with ankylosing spondylitis are at higher risk of neurological deterioration and often need long-segment stabilization.

Spine Trauma Classifications

Early systems such as Denis’ three-column model and Allen–Ferguson’s mechanism-based classification emphasized anatomical and mechanical concepts of instability. Over time, modern systems evolved to integrate neurological evaluation and clinical relevance, resulting in improved surgical decision-making. For cervical injuries, multiple region-specific classifications exist — including Anderson–Montesano for occipital condyle fractures, Traynelis for occipito–atlantal dislocation, Fielding–Hawkins for atlantoaxial rotatory fixation, and Anderson–D’Alonzo for odontoid fractures. In the thoracolumbar region, progression from Holdsworth’s two-column theory to Denis’ three-column model, followed by Magerl’s AO classification, established the foundation for contemporary systems. The Thoracolumbar Injury Classification and Severity Score (TLICS) and its evolution — the AO Spine Thoracolumbar Classification (AO TLS) — combine morphology, neurological status, and modifiers, guiding evidence-based operative versus nonoperative management.

Neurologic Assessment

Concise clinical guide covering motor, sensory, and reflex examination of spinal segments, with key diagnostic patterns, special tests, and upper vs. lower motor neuron distinctions.

Spinal Stability Principles

Anatomy & Biomechanics

The human spine is a complex, segmented column providing both mobility and stability for the body. It consists of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 fused coccygeal segments. These vertebrae are interconnected through discs, ligaments, and muscles, forming a biomechanically dynamic structure that supports axial load, enables movement, and protects the spinal cord. Each vertebra comprises a vertebral body and a posterior arch. The body, primarily cancellous bone, functions as the main weight-bearing element. The posterior arch, composed mainly of cortical bone, includes pedicles, laminae, and spinous and transverse processes, which provide attachment points for ligaments and muscles. Between adjacent vertebral bodies lie the intervertebral discs, acting as flexible cushions that absorb compressive forces while allowing controlled motion.