Challenging Cases in Spine Surgery
by M. Abdulhak and S. Marzouk
American Journal of Neuroradiology, Books reviews
Eds. New York: Thieme: 2006
Spinal surgery is a "complex" discipline, in which, it might be argued, technology has outstripped clinical wisdom. Perhaps the easiest cases for clinical decision making involve unstable fractures, symptomatic tumors, and infections. Much more difficult are cases of axial spinal pain and those in which a previous surgery has been performed with poor results. Many terms loosely applied in the daily vernacular of spinal surgery such as "micromotion" have never been rigorously defined and yet are used to justify the decision to perform major surgery. There are many causes of the current dilemma in spinal surgery, which might be defined as the rampant application of expensive and invasive technology to poorly understood but widely prevalent problems. Not the least cause is likely to be financial, with spinal instrumentation manufacturers reaping huge profits. Our discipline has a real need for skepticism and standardization, and if we do not take these needs seriously, it is likely that others will do it for us.
Ultimately the average spinal surgeon has only 2 bullets in his or her gun, decompression and fixation leading to fusion. These 2 simple maneuvers are applied to complex problems of pain that are now known to involve molecular and structural changes at multiple levels of the neuraxis, the nerve root, dorsal horn, thalamus, and limbic system, and that are further complicated by pharmacotherapy.
Perhaps one of the worst transgressions of spinal surgeons is the evaluation and reporting of their own results by using nonstandardized terms. In a world filled with placebo and subtle psychological influences, the unblinded self-reporting of the results of elective spinal surgery is not very useful, and when this is published, it only fuels an already troubled, uncritical, and nonsystematic discipline.
Enter Challenging Cases in Spine Surgery, in which a patient with "pain on lumbar flexion," 2 previous surgeries, and a listhesis at L3-4, gets 16 pedicle screws instead of 4. It is well said that "when you have a hammer everything looks like a nail." With respect to its treatment of spinal pain conditions, this book exemplifies what is worst about spinal surgery. This is unfortunate because the presentation of tumors, congential abnormalities, inflammatory conditions, and trauma is generally good. There are several interesting and unusual cases such as angiolipoma, pelvic giant cell tumor, pelvic ganglioneuroma, and spinal teratoma.
This textbook is organized into 6 sections that include 87 case examples that cover the main clinical problems that present to spinal surgeons. The book is easy to read and each case report is brief. This feature, however, is also a weakness because the brevity leads to a very limited analysis of the variability in the presentation of the clinical entities and the multiple variables that go into therapeutic decision making, especially for elective cases. The brief case format of the book may be useful to neurosurgery, orthopedic, or neuroradiology trainees preparing for oral examinations. Unfortunately, the overly brief format greatly detracts from the utility of the book to the serious student of spinal surgery. The text is basically accurate, though the editors at Thieme are to be held culpable for the very poor grammar in this book, exemplified in phrases such as "the redo nature of this case." Multiple ill-defined terms that exist in the vernacular of clinical spinal surgery are used without a glossary. Insofar as the book jacket states "Learn the most advanced techniques for complex spine surgery!" and "seeking.... the underlying principles in the most demanding cases in spine surgery" and the preface states that "the focus is on the thought process and reasoning that accompanies the management of these cases" and "the student looking for more detail," one wonders what havoc the editors may have wrought on a more thorough initial manuscript. The treatment of rheumatoid arthritis is less than 250 words (case 18)!
I had real concerns that the highly aggressive approach to axial spinal pain and revision surgery evidenced in the case series might be seen to reflect the general clinical decision making of spine surgeons, which in my opinion it does not. Cases in point included purported scoliosis (case 51) presented without presurgical films demonstrating the curve, leaving the reader to take at least the radiologic indication for surgery on faith. A nonunion diagnosed at 5 months was revised with anterior lumbar interbody fusion with bone morphogenetic protein (BMP) in a cage. Many surgeons would think it was too early to make the diagnosis of nonunion. In case 47, a 44-year-old obese women who is a heavy smoker presents with low back pain. She is diagnosed with lumbar (anterior column) instability on the basis of "Modic end-plate changes." This patient failed a previous surgery and undergoes L3-S1 instrumented fusion. Her outcome is not described, but the discussion is focused on which criteria are reliable to diagnose successful fusion. Whether Modic type I and II changes reflect spinal instability has not been conclusively proved. It would be important to know how much benefit the patient could obtain from smoking cessation and weight loss before subjecting her to revision surgery.
In case 48, the use of BMP is described in a patient with dynamic film evidence of instability following a pedicle screw fixation. Neither these dynamic views nor postoperative films evidencing successful fusion are provided, and the clinical outcome is not described. Case 14, a young man with L1 and L4 burst fractures, would have been treated nonoperatively in a cast or well-fitted brace by many spine surgeons. The images provided do not show the upper extent of his instrumentation, but it appears to extend from at least T11 to S1. In case 23, a patient with neck pain following a motor vehicle crash is diagnosed with "cervical spondylotic disease" and undergoes a C4 corpectomy. Neck pain can arise from many etiologies, and few surgeons consider it an adequate indication for spinal fusion. Many spine surgeons would have treated cases 28 and 29 with posterior as opposed to anterior surgery. In case 71, a patient who is developing autofusion at T10-11 in the absence of deformity is subjected to a 7-level T6 through T12 pedicle screw fusion for mechanical back pain. Multiple bone biopsies and laboratory data proved the infection was resolved preoperatively. This is perhaps the most questionable of all of the cases presented in the book. The natural history of a segmental osteomyelitis that is proceeding to autofusion is eventual pain resolution. Thoracic pedicle screws are risky to place, and each screw is an independent risk event. The decision making in this case seems quite questionable, and at a minimum, further justification is needed. The outcomes of the procedure are not always stated and range among very vague statements such as "performed with success," "pain free," and "preoperative pain resolved."
The images are generally representative and of adequate quality, but many of the cases lack both presurgical and postsurgical images. In a few examples, there was a lack of coherence between the text, figure legend, and the radiographic image. A case in point is 43, in which the text states that the patient had an acute deficit with a myelographic block but only a minimally compressive lesion is shown on postmyelogram CT. In case 22, it is stated that a patient has cervical spondylosis, "mostly at C3-C4 and C4-C5," but surgery is performed at C3-4 and C5-6. In case 44, a patient has presented with foot-drop, and sagittal T2- and axial T1-weighted images correlate poorly, the former showing no canal stenosis and a minimal spondylolisthesis. In multiple cases, preoperative films are not shown (eg, case 46).
This book compares unfavorably with other texts aimed to educate spinal practitioners, such as 50 Challenging Spinal Pain Syndrome Cases by LGF Giles (Butterworth-Heinemann Medical, 2002), which, though also relatively brief, is better written and more thorough in representing the clinical work-up. The book compares very poorly with the main textbooks in spinal surgery, such as those of Benzel, Menezes and Sonntag, and Herkowitz et al. There is little if any discussion of differential diagnosis in the book. The treatment of traumatic, inflammatory, and neoplastic conditions is reasonable. Only a very limited number of references are provided, though these are generally relevant. The emerging role for stereotaxic radiosurgery in the spine is not described.
I do not recommend this book other than as a set of cases that can be rapidly reviewed in preparation for an oral examination. This book is a real discredit to thinking spine surgeons who want to move elective spinal surgery for axial pain to a more rational and rigorous footing. Furthermore, I think the book provides evidence that it is possible to be too brief and that medical editors should consider the potential ill effects of distilling very complex problems into a few sentences. Because the tools of spine surgery are powerful and invasive, the decision-making process behind their use should be represented in a lucid and balanced manner.
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