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Chapter 17 - Spine oral core topics
- from Section 4 - The adult elective orthopaedics oral
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- By Alex Barker, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, UK, Niall Craig, Aberdeen Royal Infirmary, Aberdeen, UK
- Edited by Paul A. Banaszkiewicz, Deiary F. Kader
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- Book:
- Postgraduate Orthopaedics
- Published online:
- 05 February 2012
- Print publication:
- 19 January 2012, pp 263-280
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- Chapter
- Export citation
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Summary
Introduction
Spine surgery is a diverse and rapidly evolving area of orthopaedics. As a career choice this makes it interesting and rewarding, but for the exam the breadth and depth of knowledge required make it a challenging area to review. There is now a requirement on examiners for the FRCS (Tr & Orth) to ask questions on spine topics, and it is unlikely that a candidate will be successful without a solid core knowledge in this area. However, the candidate has an advantage; most examiners are not full-time spine surgeons. Also, examiners are aware that most candidates are not going to become full-time spine surgeons either. Questions tend to be of one of two types. Either they are sufficiently ‘core’ that any consultant orthopaedic surgeon should know about the condition and be able to manage or refer the condition appropriately, or they are general orthopaedic questions that are being applied to the spine. In response to this increased emphasis on spine topics in the exam there are now several pre-exam spine courses being advertised (Spineclass, RCS Eng. and Cardiff). In order to cover the breadth of material required, this chapter will aim to be succinct, cover core topics in sufficient depth to ensure a pass and provide the candidate with a framework with which to tackle spine questions. Areas that will be covered include:
General knowledge
Degenerative conditions
Spinal trauma
Tumours affecting the spine
Infection and inflammation
The paediatric spine
Surgical approaches
Other miscellaneous conditions
Current areas of debate.
Structure of the intervertebral disc
There are two main components making up the intervertebral disc: the annulus fibrosus and nucleus pulposus (Figure 17.1). The annulus fibrosus is made up of concentric rings of type I collagen. Sequential layers of oblique fibres resist hoop stresses and prevent excessive movement. The nucleus pulposus forms the gelatinous core, which allows elastic deformation. Type II collagen predominates in the nucleus pulposus. In adults nutrition is via diffusion through the vertebral end-plate. In children vessels cross the end plate to the disc.
19 - Spine oral core topics
- from Section 4 - Adult elective orthopaedics oral
-
- By Niall Craig
- Edited by Paul A. Banaszkiewicz
- Edited in association with Deiary F. Kader, Nicola Maffulli, Keele University
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- Book:
- Postgraduate Orthopaedics
- Published online:
- 22 August 2009
- Print publication:
- 18 December 2008, pp 237-270
-
- Chapter
- Export citation
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Summary
Surgical approaches
Cervical spine: anterolateral approach (Smith–Robinson)
Background information
One of the most common approaches to the neck
Extensile – allows access to all levels
Uses – anterior discectomy and fusion, anterior corpectomy and fusion or cage insertion for burst fracture, tumour or infection, kyphosis correction and vertebral artery exposure
Technique
Patient placed in supine position with their head slightly extended and fixed, i.e. in Mayfield clamp
Skin incision is made along the transverse skin crease or longitudinally
Risk of recurrent laryngeal palsy is lower with approaches from left
Platysma incised in line of incision
Fascia incised anterior to sternocleidomastoid
Blunt dissection between omohyoid/sternothyroid and midline structures
Dissect between carotid sheath (laterally) and thyroid (medially) to expose deep fascia
Can ligate thyroid artery for access
The prevertebral plane is behind the fascia deep to the posterior pharynx
Anterior longitudinal ligament divided in midline, retracted laterally with periosteum ±longus colli to improve exposure
Complications
Injury to recurrent laryngeal nerve, hypoglossal nerve, vascular or visceral injury
Neck swelling with airway compromise requiring urgent decompression; early dysphagia due to swelling
Cervical spine: posterior approach
Background information
Access to occiput and posterior elements of cervical spine
Can access the lateral masses
Carried out for posterior cervical fusion, decompression of the canal, reduction and fixation for trauma and removal of lateral discs by foraminotomy
Technique
Skull traction recommended
Patient prone, head supported (no pressure on eyes)
The shoulders are taped down, tilt head up
Midline skin incision at occipitocervical junction; incision from below occipital protuberance to C3
Fascia divided – access occiput and spinous process of C2
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