Thoracic and Lumbar pedicle screw insertion

Thorasic Spine: As a general rule the starting point for insertion of Pedicle screws is the point " where the superior border of the transverse process converges with the lamina along the lateral border of the articular facet. this point is typically in line with or just medial to the pars.

Lumbar Spine: The starting point is at the junction of the lateral facet and the transverse process (arrow)- taken from Spine Surgery (ed: Benzel; p 1056)
The other way is "Bisection of a vertical line through the facet joints and a horizontal line through the transverse process can also serve as a useful landmark for lumbar pedicle entry site".

Signs and Symptoms of Facet joint syndrome

The signs of Facet joint syndrome are

1. Local paraspinal tenderness;
2. Pain on hyperextension, rotation, and lateral bending;
3. Absence of neurologic deficit;
4. Absence of root tension sign; and hip, buttock, or back pain with straight leg raising .

Symptoms include

1. Hip and buttock pain,
2. Cramping leg pain involving the thigh but not radiating below the knee,
3. Low back stiffness, The back stiffness is typically most marked in the morning and
4. Absence of paresthesias.

Bruns Nystagmus

Bruns nystagmus is an unusual type of bilateral nystagmus most commonly occurring in patients with cerebellopontine angle tumours.
It is caused by the combination of slow, large amplitude nystagmus (gaze paretic nystagmus) when looking towards the side of the lesion, and rapid, small amplitude nystagmus (vestibular nystagmus) when looking away from the side of the lesion.
It occurs in 11% of patients with vestibular schwannoma, and occurs mainly in patients with larger tumours (67% of patients with tumours over 3.5cm diameter).
It may be caused by the compression of both flocculi, the vestibular part of the cerebellum, and improvement in both the nystagmus and balance problems occur commonly after removal of the tumour.
Bruns nystagmus is named for Ludwig Bruns

Stabilization of Dorsal Spine

I had a difficult case to manage independently in the very early post M.Ch period in the recent past.
A case of a 40 year male with a history of fall from a height of 20 feet and having total paraplegia and absent bowel and bladder sensation.
I thought of stabilizing the spine as I can mobilize the patient early and prevent the complications so forth. My experience with with Stabilization of dorsal spine with D2 to D5 screws and rods is very minimal as I had not done a similar case individually earlier.
With good home work I started the case and I could manage to do it reasonably good and safe. I had difficulty in identifying the starting point of the Pedicle screws and the land marks were not clearly visble. But with a little wider exposure I could make out the starting points and rest all went good under fluoro guidence. I had some more difficulty in decompressing the canal when I was trying to remove the anterior compression. But could manage adequate decompression at the end.

Post operatively patient didn't show good improvement and remained Grade 0 all through with no bowel and bladder sensations. POst OP period was uneventful and patient was discharged in a stable state.

Current management of Lumbar stenosis with Low grade Spondylolisthesis

Earlier view regarding the management of spinal canal stenosis with low grade Spondylolisthesis was by doing a laminectomy and wait and watch for the progression of listhesis and intervene accordingly.

But the current ideas regarding this is changing and is presented as a necessity for simultaneous stabilization and laminectomy. "Lumbar spinal fusion plus laminectomy appears to be a better option than laminectomy alone in terms of quality of life for patients with degenerative grade I spondylolisthesis with lumbar spinal stenosis"*.


* Zoher Ghogawala, MD, director of the Wallace Clinical Trials Center at Greenwich Hospital in Greenwich, Connecticut, presented these results from a prospective, 5-center, randomized, controlled trial here at the 80th Annual Scientific Meeting of the American Association of Neurological Surgeons.

Ref:  http://www.medscape.com/viewarticle/762967?src=mpnews&spon=26