Surgical Anatomy & Techniques to the Spine

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Surgical Anatomy and Techniques to the Spine
Copyright page
Associate Editors
Dedications
Acknowledgments
Preface
Contributors
Instructions for online access
Table of Contents
A Craniovertebral Junction and Upper Cervical Spine
	1 Surgical Anatomy and Biomechanics of the Craniovertebral Junction
		Overview
		Embryology of the Craniovertebral Junction
			Normal Developmental Embryology of the Craniovertebral Junction
			Developmental Anomalies of the Craniovertebral Junction
		Surgical Anatomy of the Craniovertebral Junction
			Bony Structures of the  Craniovertebral Junction
				Foramen Magnum and Occipital Condyle
					Occipital Condyle.
				The Atlas (C1)
				Axis (C2)
			Ligamentous and Membranous Structures of the Craniovertebral Junction
			Neuroradiology of the  Craniovertebral Junction
				Skull Base and Atlantoaxial Morphometry
					Indices for Skull Base and Craniocervical Junction on a Lateral (Sagittal) View (Table 1-1).
					Indices for Skull Base and Craniocervical Junction on an Anteroposterior (Coronal) View (Table 1-2).
					Indices for Atlantoaxial Instability (Table 1-3).
		Biomechanics of the Craniovertebral Junction
			Occ–C1 Complex
			Atlantoaxial Complex
		Conclusions
		Acknowlegment
		References
	2 Transoral Approach to the Craniocervical Junction and Upper Cervical Spine
		Overview
		Anatomy
		Ventral Pathology of the Craniocervical Junction
		Indications
		Relative Contraindications
		Surgical Technique
			Preparation and Positioning
			Surgical Procedure
		Conclusion
		References
	3 Transmaxillary and Transmandibular  Approaches to the Clivus  and Upper Cervical Spine
		Overview
		Anatomy Review
			Bony and Ligamentous Anatomy
			Muscular Anatomy
			Relevant Neurovascular Anatomy
		Indications and Contraindications
		Operative Technique
			Unilateral Le Fort I Osteotomy with Palatal Split
			Bilateral Le Fort I Osteotomies with Downfracture of the Maxilla
			Bilateral Le Fort I Osteotomies  with Palatal Split
			Mandibulotomy
			Mandibulotomy with Midline Glossotomy
			Mandibular Swing-Transcervical
		Complications
		References
	4 High Cervical Retropharyngeal Approach to the Craniocervical Junction
		Overview
		Medial Retropharyngeal Approach (Anterior Retropharyngeal Approach)
		Lateral Retropharyngeal Approach
		Summary
	5 Approaches to the Craniocervical Junction:
		Overview
		Posterior Approaches
			Anatomy
			Positioning
			Surgical Technique
		Lateral Approaches
			Indications
			Positioning
			Surgical Technique
		Lateral Retropharyngeal Approach
			Indications
			Positioning
			Surgical Technique
		Far-Lateral Approach
			Indications
			Positioning
			Surgical Technique
		Conclusions
	6 Posterior and Far-Lateral Approaches to the Craniovertebral Junction:
		Overview
		Anatomy Review
			Muscle Layers
			Bony Anatomy
			Vertebral Artery
			Cranial Nerves
		Indications
			Intramedullary
			Extramedullary, Intradural
			Extradural
		Relative Contraindications
		Preoperative Imaging
			Magnetic Resonance Imaging
			Computed Tomography
			Vertebral Angiogram
		Operative Technique
			Equipment
			Patient Positioning
			Incision
			Muscle
			Bone Exposure
			Intradural Exposure
			Closure
		Postoperative Care
		Complications
			Neurologic
			Vascular
			Closure and Leaks
		References
	7 Endoscopic Approaches to the Craniovertebral Junction
		Overview
		Surgical Anatomy
			Endoscopic Endonasal Approach
			Endoscopic Transoral Approach
			Endoscopic Transcervical Approach
		Operative Techniques
			Endoscopic Endonasal Approach
				Rationale
				Preparation and Positioning
				Surgical Procedure
			Endoscopic Transoral  Robotic Surgery
				Rationale
				Preparation and Positioning
				Surgical Procedure
			Transcervical Endoscopic Approach
				Rationale
				Preparation and Positioning
				Surgical Procedure
		Complications
		Discussion
		References
	8 Surgical Approaches to Craniovertebral Junction Congenital Malformations, Chiari Malformations, and Cranial Settling (Invagination)
		Surgical Anatomy of the Craniocervical Junction
		Basilar Invagination
			Indications for Surgical Treatment
			Anterior Surgical Approaches
				Transoral-Transpalatopharyngeal Approach
				Advantages and Disadvantages of the  Anterior Approaches
			Posterior Approaches
				Occipital Screw Technique
				C1 Lateral Mass Screw Technique
				C1–C2 Transarticular Screw Technique
				C2 Pars/Pedicle Screw Technique
				Translaminar Screw Technique
				C3–C7 Lateral Mass Screw Technique
				Advantages and Disadvantages of the  Posterior Approaches
			Endoscopic Approaches
				Endoscopic Endonasal Approach
				Advantages and Disadvantages of  Endoscopic Approaches
		References
	9 Surgical Approaches to the Craniovertebral Junction in Rheumatoid Arthritis
		Overview
		Diagnosis and Evaluation
			Atlantoaxial Subluxation
			Atlantoaxial Rotatory Subluxation
		Indications and Relative Contraindications
		Surgical Approach
			Transoral Approach
				Preoperative Preparation
				Anesthesia and Equipment
					Equipment
				Patient Positioning
				Surgical Technique
			Extended Transoral Procedures
				Open-Door Maxillotomy
				Median Mandibulotomy and Glossotomy
				Endoscopic-Assisted Anterior Approach
				Posterior-Only Approach
				Combined Anterior and Posterior Approach
		Postoperative Care
		Complications
		Summary
		References
	10 Craniovertebral Junction Instabilities and Surgical Fixation Techniques
		Overview
		Anatomy Review
		Indications
		Operative Technique
			Equipment
			Positioning
			Approach
			Arthrodesis
				Occipital Plating
				Occipital Bolt or “Inside-Out” Technique
				Occipital Condyle Screw
				Occipitocervical Wiring: Historic Technique Useful in Some Circumstances
		Postoperative Care
		Complications
			Vascular Complications
			Neurologic Complications
			Biomechanical Complications
		References
	11 Odontoid Fractures  and Screw Fixation
		Overview
		Indications
		Contraindications
		Operative Technique
			Equipment
			Patient Positioning
			Incision and Soft Tissue Dissection
			Placement of K-Wire and Drill Guide System
			Screw Placement
		Postoperative Care
		Technical Variations
		Complications
		References
	12 C1–C2 Trauma Injuries and Stabilization Techniques
		Overview
		General Operative Techniques for Posterior Atlantoaxial Fixation
		C1–C2 Lateral Mass–Pars Interarticularis Screw Fixation
		C1–C2 Lateral Mass–Pedicle Screw Fixation
		Atlantoaxial  Transarticular Fixation
		Atlantoaxial  Translaminar Fixation
		Halifax Clamp Fixation
		Atlantoaxial Wiring Techniques
			Interspinous Fusion
			Gallie Fusion
			Brooks Fusion
		Indications for Posterior  Fixation and Fusion of the  Upper Cervical Spine
		Anterior Approaches for  Upper Cervical Spine Instability After Trauma
			Indications and Techniques
			Anterior Atlantoaxial Facet Screw Fixation
		Conclusion
		References
B Mid and Lower Cervical Spine
	13 Surgical Anatomy and Biomechanics in the Mid  and Lower Cervical Spine
		Overview
		Surface Anatomy
		Vertebral Column
			Vertebral Body
				End Plates
				Uncal Process
				Transverse Process
				Neural Foramen
				Anterior and Posterior Tubercles
				Pedicles
				Spinal Canal
				Lateral Mass
				Facet Joint
				Lamina and Spinous Processes
			Intervertebral Disk Space
				Disk Space
				Intervertebral Disk
				Annulus Fibrosus
				Nucleus Pulposus
			Spinal Cord
				Spinal Cord and Nerve Roots
				Spinal Cord Blood Supply
		Neurovascular Structures
			Carotid Sheath
				Superior Laryngeal Nerve
				Inferior (Recurrent) Laryngeal Nerve
				Hypoglossal Nerve
				Sympathetic Chain
				Vertebral Artery
		Viscera
		Ligaments
			Anterior Longitudinal Ligament
			Posterior Longitudinal Ligament
			Ligamenta Flava
			Capsular Ligaments
			Ligamentum Nuchae
			Intertransverse Ligaments
		Fascia and Musculature
			Fascia
				Investing Layer
				Pretracheal (Visceral) Layer
				Prevertebral Layer
			Ventral Musculature
				Superficial Layer
					Platysma.
					Sternocleidomastoid.
				Deep Layer
					Scalenus Group.
					Longus Group.
					Infrahyoid Group.
			Dorsal Musculature
				Superficial Layer
				Intermediate Layer
				Deep Layer
			Cervical Triangles
				Ventral Triangle
				Dorsal Triangle
	14 Anterior Cervical Diskectomy and Fusion
		Overview
		Indications
		Contraindications
		Operative Technique
			Equipment
			Patient Positioning
			Marking the Incision
			Preparation and Draping
			Incision and Soft Tissue Dissection
			Exposure of the Vertebra
			Diskectomy and Foramenotomy
			Intervertebral Graft
			Cervical Plating
			Autograft Harvesting
			Closure
		Postoperative Care
		Complications
		References
	15 Endoscopic Anterior Cervical Foraminotomy (Jho Procedure)
		Overview
		Surgical Indications for  Anterior Cervical Foraminotomy (Jho Procedure)
		Surgical Tools and Techniques
			Surgical Instruments
				Endoscopes
				Endoscope Lens Cleanser
				Endoscope Holder
				Endoscopic Surgical Instruments
		Surgical Technique
			Positioning
			Surgical Exposure of the Uncovertebral Juncture
			Original Description of Microsurgical Anterior Cervical Foraminotomy
			Evolution of Anterior Cervical Foraminotomy (Jho Procedure)
				Type 1: Transuncal Approach
				Type 2: Upper Vertebral Transcorporeal Approach
				Type 3: Lower Vertebral Transcorporeal Approach
				Type 4: Anterior Cervical Foraminoplasty
			Spinal Cord Decompression via Anterior Cervical Foraminotomy
		Postoperative Management
		Surgical Results
		Discussion
		Acknowledgment
		References
	16 Anterior and Posterior Endoscopic Approaches to the Cervical Spine
		Overview
		Anatomic Considerations
		Surgical Indications and  Relative Contraindications
		Instruments and Equipment
			Instruments for the Anterior Approach
			Instruments for Posterior Approach
		Surgical Preparations and Techniques
			Anterior Approaching Technique
			Posterior Approach
			Surgical Tips
		Controversies
		Summary
		References
	17 Cervical Corpectomy, Fusion, and Vertebral Restoration Techniques
		Overview
		Anatomy Review
			Muscles
			Vascular Anatomy
			Visceral Structures
			Nervous System Structures
		Indications and Contraindications
			Indications
			Contraindications (Relative)
		Operative Technique
			Equipment
			Vertebral Body Restoration Technologies
				Bone Grafts: Autograft and Allograft
				Polymethylmethacrylate Reconstruction
				Titanium Mesh Cages/Harms Cage
				Modular Cages
				Expandable Cages
			Preoperative Considerations
				Patient Positioning
			Approach (Figs. 17-16 and 17-17)
			Diskectomy (Fig. 17-18)
			Corpectomy
			End Plate Preparation
			Removal of Posterior  Longitudinal Ligament
			Veterbral Replacement Preparation
				Bone Graft (Fig. 17-20)
				Polymethylmethacrylate (see Fig. 17-10)
				Titanium Nonexpandable Cages (see Fig. 17-11)
				Modular Cages (see Fig. 17-12)
				Expandable Cages (see Fig. 17-13)
			Supplemental Instrumentation
				Anterior Plating (Figs. 17-21 and 17-22)
				Adjunct Posterior Instrumentation
			Closure
		Postoperative Care
		Complications
			Soft Tissue
			Vascular
			Neurologic
			Otolaryngologic
			Graft Complications (Fig. 17-23)
		References
	18 Anterior Cervical Instrumentation Techniques
		Overview
		Anatomy Review
		Indications
		Relative Contraindications
		Equipment
		Operative Technique
			Positioning
			Incision
			Technique for Approaching the  Cervical Spine
			Technique for Approaching the Upper Cervical Spine
			Diskectomy
			Cage Placement and Instrumentation
			Closure
		Complications
		References
	19 Cervical Disk Arthroplasty Techniques
		Overview
		Indications and Contraindications
		Potential Disadvantages of Cervical Artificial Disk Replacement
		Preoperative Radiologic Evaluation
		Equipment
		Operating Room Setup
		Patient Positioning
		Operative Technique
			Incision Location
			Incision, Soft Tissue Dissection, and Exposure  of the Vertebra
			Sequential Identification and Dissection of Important Anatomic Structures
			Exposure of the Vertebra
			Retractor Placement
			Anterior Cervical Diskectomy
			Artificial Disk Replacement
			Closure
		Postoperative Care
			Postoperative Radiologic Assessment
		Complications and Adverse Outcomes of Cervical Artificial Disk Replacement
			General Complications
			Adjacent-Segment Disease after Cervical Artificial Disk Replacement
		References
	20 Cervical Microforaminotomy and Decompressive Laminectomy
		Overview
		Diagnosis
		Indications and Contraindications
			Posterior Cervical Microforaminotomy
				Indication
				Relative Contraindications
			Laminectomy
				Indications
				Contraindications
		Operative Technique
			Equipment
			Patient Positioning
			Minimally Invasive Approach
			Cervical Microforaminotomy
			Diskectomy
			Osteophytectomy
			Decompressive Laminectomy
		Postoperative Care
		Complications
		Conclusions
		References
	21 Cervical Laminoplasty
		Overview
		Types of Laminoplasty
		Anatomy Review
		Indications and Contraindications
			Indications
			Contraindications
		Advantages and Disadvantages
			Advantages
			Disadvantages
		Operative Technique
			Equipment
			Positioning
			Prepping and Draping
			Incision and Exposure
			Trough Preparation
			Opening the Laminoplasty
			Posterior Arch Reconstruction using  Graft or Plating
			Foraminotomy Technique
			Arthrodesis Technique
			French Door Laminoplasty
			Wound Closure
		Postoperative Care
		Complications
			Illustrative Case
		References
	22 Posterior Cervical Stabilization Techniques:
		Overview
		Cervical Pedicle Screw Fixation
			Indications
			Contraindications
			Operative Technique
				Patient Positioning and Incision
				Subaxial Pedicle Screw Insertion
				Fusion
				Wound Closure
			Postoperative Management
			Complications
		Lateral Mass Screw Fixation
			Indications
			Contraindications
			Operative Technique
				Surgical Approach
				Insertion Point and Trajectory
				Drilling and Screw Placement
				Vertebral Artery
				Wound Closure
			Complications
		Posterior Wiring of the  Subaxial Spine
			Indications
			Contraindications
			Operative Technique
				Positioning and Incision
				Procedures and Wiring Techniques
					Interspinous Wiring (Bohlman’s Triple-Wire Technique).
					Facet Wiring Technique (Fig. 22-9).
				Wound Closure
			Postoperative Care
			Complications
		References
	23 Facet Dislocation Injuries and Surgical Management
		Overview
		Clinical Presentation
		Radiographic Evaluation
		Initial Management
		Surgical Management
		Surgical Technique
			Anterior Approach
			Posterior Technique
		Postoperative Management
		References
	24 Ossification of the Posterior Longitudinal Ligament
		Overview
		Epidemiology
		Pathophysiology
		Clinical Presentation and  Natural Course
		Diagnostics and  Radiographic Findings
		Surgical Options and Outcomes
			Laminectomy
			Laminectomy Plus Fusion
			Anterior Approaches
			Combined Anterior and Posterior Approaches
			Laminoplasty
				Laminoplasty Techniques
				Indications and Contraindications for Laminoplasty
					Indications
					Relative Contraindications
				Operative Technique: Open-Door Laminoplasty
					Equipment
					Patient Positioning and Intubation
					Location of Incision
					Preparation and Draping
					Incision and Soft Tissue Dissection
					Laminoplasty
					Bone Graft and Instrumentation
					Closure
		Postoperative Care
		Complications
		Conclusions
		References
C Cervicothoracic Junction and Thoracic Spine
	25 Surgical Anatomy and Biomechanics in the Cervicothoracic Junction and Thoracic Spine
		Overview
		Surgical Anatomy
			Anterior Approaches
		Anterolateral Transthoracic Approaches
		Posterolateral Approaches
		Biomechanics
			Anatomic Considerations
			Instrumentation
		References
	26 Anterior Approaches to the Cervicothoracic Junction
		Overview
		Anatomy
			Thoracic Inlet
			Vascular and Visceral Compartments  of the Superior Mediastinum
				Fascial Layers
				Venous Structures
				Arterial Structures
			Retropharyngeal and  Retromediastinal Spaces
		Operative Techniques
			Low-Cervical Approach
			Supraclavicular Approach
			Transmanubrial-Transclavicular Approach
			Transsternal-Transthoracic Approach
	27 Posterolateral Approaches to the Cervicothoracic Junction:
		Overview
		Anatomy
			Muscles of the Scapular and  Parascapular Region
				Superficial Muscle Group (Fig. 27-1)
					Trapezius
					Rhomboid Major
					Rhomboid Minor
					Levator Scapulae
				Intermediate Muscle Group
					Serratus Posterior
					Splenius Capitis
					Spenius Cervicis
				Deep Muscle Group
					Erector Spinae
					Iliocostalis
					Longissimus
					Spinalis
					Transversospinalis
					Semispinalis
					Multifidus
					Rotares
			Posterior Thoracic Cage (Fig. 27-3)
				Vertebral Body and Rib Articulation
				Ligaments of Rib Articulation
				Rib Interconnection
					Retromediastinal Space
					Neural structures (Fig. 27-7):
		Surgical Approaches
			Laminectomy
				Indications and Advantages
				Contraindications and Disadvantages
				Patient Positioning and Preparation (Fig. 27-9)
				Operation
				Closure
			Posterolateral Approaches
				Transpedicular Approach
					Indications and Advantages.
					Contraindications and Disadvantages.
					Patient Positioning and Preparation.
					Operation
					Closure.
				Costotransversectomy
					Indications and Advantages.
					Contraindications and Disadvantages.
					Patient Positioning and Preparation.
					Operation
					Closure
				Lateral Extracavitary Parascapular  Extrapleural Approach
					Indications and Advantages.
					Contraindication and Disadvantages.
					Patient Positioning and Preparation.
					Operation
					Closure
		Summary
		References
	28 Anterolateral Transthoracic Approaches to the  Thoracic Spine
		Overview
		Anatomic Considerations
			Superficial (Extrapleural)
			Deep (Intrapleural)
		Indications
		Contraindications
		Operative Technique
			Disk Lesions
			Foraminal Decompression
			Corpectomy
		Postoperative Care
		Considerations Specific  to the Proximal Thoracic  Spine Approach
		Considerations Specific  to the Thoracolumbar  Junction Approach
		Complications
			Decreased Pulmonary Function
			Infection
			Chyle Leak
			Dural Tear/Cerebrospinal Fluid Leak
		Conclusion
		References
	29 Anterior and Posterior Cervicothoracic Junction Stabilization Techniques
		Overview
		Operative Anatomy
		Surgical Approaches
			Anterior Surgical Approaches to the Cervicothoracic Junction
		Positioning
		Technique
			Low Cervical Approach
			Transsternal-Transmanubrial Approach
			Thoracotomy
			Posterior Approach
		Posterior Surgical Approaches to the Cervicothoracic Junction
			Lateral Mass Screws
				Positioning
				Technique
			Pedicle Screws
				Technique
			Translaminar Screw
		Anterior-Posterior Approach
		Posterior-Anterior- Posterior Approach
		Conclusion
		References
	30 Thoracic Microdiskectomy:
		Overview
		Prevelance and Presentation
		Anatomic Considerations
		Imaging
		Surgical Indications
		Anterolateral Approaches
			Transthoracic Approach
		Lateral Approaches
			Retropleural Approach
				Indications and History
				Positioning
				Incision, Dissection, and Diskectomy
				Minimally Invasive Considerations
				Advantages
				Disadvantages
			Costotransversectomy
				Indications and History
				Positioning
				Incision, Dissection, and Diskectomy
				Advantages
				Disadvantages
			Lateral Extracavitary Approach
				Indication and History
				Positioning
				Incision, Dissection, and Diskectomy
				Advantages
				Disadvantages
				Minimally Invasive Considerations
		Posterolateral Approaches
			Transpedicular Approach
				Indication
				Positioning
				Incision, Dissection, and Diskectomy
				Minimally Invasive Considerations
				Advantages
				Disadvantages
			Transfacet Approach
				Indication and History
				Positioning
				Incision, Dissection, and Diskectomy
				Minimally Invasive Considerations
				Advantages
				Disadvantages
		Postoperative Course
		Complications
		Conclusion
		References
	31 Thoracoscopic and Posterior Endoscopic Approaches to the Thoracic Spine
		Thoracoscopic Approach
			Overview
			Indications
			Contraindications
			Surgical Technique
				Instruments
				Anesthesia
				Positioning
				Localization
				Placement of Portals
				Prevertebral Dissection and Diaphragm Detachment
				Screw Insertion
				Diskectomy
				Corpectomy
				Plate or Rod Placement
				Final Fixation
				Closure
			Postoperative Care
			Complications
			Case Illustration
		Posterior Endoscopic Approach
			Introduction
			Indications
			Contraindications
			Surgical Technique
				Preoperative Preparation
				Instruments
				Procedures of C-Arm–Guided PETD using Rigid Working-Channel Scope
				Procedures of Real-Time CT-Guided PETA Using LASE
			Case Illustration
		References
	32 Surgical Decompression and Stabilization Techniques in Thoracic Trauma
		Overview
		Anatomy Review
		Indications and Contraindications
			Indications
			Contraindications
		Operative Technique
			Posterior
			Anterolateral
			Reconstruction
		Complications
		References
	33 Surgical Approaches to Thoracic Primary and Secondary Tumors
		Overview
		Incidence of Primary and Secondary Tumors of the Thoracic Spine
		Clinical Presentation  and Evaluation
		Radiographic Studies and Preoperative Diagnosis
		Surgical Decision Making and Patient Expectations
			Patients with Primary Osseous Lesions
			Patients with Metastatic Disease
		Preoperative Embolization
		Approaches to the Thoracic  Spine (Fig. 33-1)
			Thoracic Laminectomy
				Advantages
				Disadvantages
			Transpedicular Approach and Costotransversectomy
				Advantages
				Disadvantages
				Transpedicular Approach
				Costotransversectomy
			Lateral Extracavitary (Parascapular) Approach
				Advantages
				Disadvantages
			Thoracotomy (Transthoracic Approach)
				Advantages
				Disadvantages
			Suprasternal Approach
				Advantages
				Disadvantages
		Conclusion
		References
D Thoracolumbar and Lumbar Spines
	34 Surgical Anatomy and Posterior Approach to the Thoracic and Thoracolumbar Spine
		Overview
		Muscular Anatomy
		Posterior Thoracic Cage
		Posterior Mediastinal Space and Neurovascular Structure
		Lateral Extracavitary Approach
			Positioning and Incision
			Muscle Dissection
			Rib Resection
			Identification of the Neural Foramen
			Corpectomy or Disketomy
			Vertebral Body Reconstruction
			Wound Closure
		Transcostovertebral Approach
		Costotransversectomy
			Positioning and Incision
			Muscle Dissection
			Rib Resection
			Exposure of Vertebral Bodies  and Spinal Cord
			Wound Closure
		Total En Bloc Spondylectomy: Thoracic Spine
			Indications
			Surgical Technique
				Step 1. En Bloc Resection of the Posterior Element of the Vertebra by Posterior Approach
					Exposure.
					Introduction of the T-Saw Guide.
					Cutting the Pedicles and Resection of the Posterior Element.
				Step 2. En Bloc Corpectomy by Posterior Approach
					Posterior Ligamentous Release of the Vertebral Body.
					Dissection of the Spinal Cord and Removal of the Vertebra.
			Corpectomy with Anterior Approach
			Anterior Reconstruction and Posterior Instrumentation
			Postoperative Management
		Staged Operation of Thoracic Spine Tumors with Involvement of the Ribs
			Indications
			Incision and Positioning
		Single-Stage Posterolateral Transpedicular Approach for Spondylectomy and Epidural Decompression
		References
	35 Thoracoabdominal Approach to the Thoracolumbar Junction
		Overview
		Transthoracic Approach to the Midthoracic Level
			Positioning and Incision
			Muscle Dissection
			Rib Removal
			Exposure of Vertebral Body (Transpleural)
			Vertebral Body Resection
			Exposure of the Vertebral Body (Extrapleural)
			Bilateral Segmental Vessel Ligation
		Anterior Approach to Thoracolumbar Junction (Transpleural-Transdiaphragmatic Approach with Tenth Rib Resection)
			Positioning and Incision
			Soft Tissue Dissection
			Rib Removal
			Diaphragm Incision
			Exposure of Each Vertebral Body
			Closure
		Transpleural-Retroperitoneal Approach (Diaphragm Detach) to the Thoracolumbar Junction
			Identification of the Insertion Point  of the Crus
			Incision of the Diaphragm Insertion
			Psoas Muscle Dissection
		Extrapleural-Retroperitoneal Approach to Thoracolumbar Junction with Eleventh Rib Resection
			Positioning and Incision
			Muscle Incision and Rib Removal
			Retroperitoneal Space Dissection
			Costal Cartilage Splitting
			Extrapleural Space Dissection
			Diaphragm Release from the Insertion to the Twelfth Rib
			Vertebral Body Exposure
			Widening of Vertebral Body Exposure
			Wound Closure
		Minithoracotomy-Transdiaphragmatic  Approach (Mini-TTA)
			Diaphragmatic and Relevant Anatomy
			Anesthesia
			Positioning
			Technique
			Prevertebral Dissection and  Diaphragm Detachment
			Corpectomy and Decompression  of the Spinal Canal
			Bone Grafting, Cage Placement, and Instrumentation
			Closure
			Postoperative Care
			Complication Rates
			Advantages of Mini-TTA versus Traditional Thoracoabdominal Approach
			Advantages of Mini-TTA versus Thoracoscopic Surgery
				Familiar Three-Dimensional View
			Whole-Lung Ventilation
			Simplicity in Equipment and Assistance
			Low Rate of Surgery-Induced Rib Intercostal Neuralgia
		References
	36 Surgical Stabilization Techniques for Thoracolumbar Fractures
		Classifications of Spinal Fractures
			Historical Review
			The Iowa Classification System  and Algorithm
		Stabilization Techniques
			Anterolateral Approach to the Thoracolumbar Spine (T11–L4)
			Posterolateral Transpedicular Approach with Vertebral Body Reconstruction
			Posterior Minimally Invasive Techniques
				Screw Placement
				Rod Insertion
		References
	37 Anterior Retroperitoneal Approach to the Lumbar Spine
		Overview
		Anatomy Review
		General Indications
			Anterior Approach
			Thoracoabdominal/Flank Approach
			Direct Lateral (Minimally Invasive) Approach
		Contraindications
			Anterior Approach
			Thoracoabdominal/Flank Approach
			Direct Lateral (Minimally Invasive) Approach
		Operative Technique
			Equipment/Assistance
				Anterior Approach
				Thoracoabdominal/Flank Approach
				Direct Lateral (Minimally Invasive) Approach
		Patient Positioning
			Anterior Approach (Fig. 37-5)
			Thoracoabdominal/Flank and Direct Lateral Approaches (Fig. 37-6)
		Dissection
			Anterior Approach
			Thoracoabdominal/Flank Approach
			Direct Lateral (Minimally Invasive) Approach
		Postoperative Care
		Potential Complications
		References
	38 Posterior and Posterolateral Approaches to the  Lumbar Spine
		Overview
		Anatomy
		Indications/Contraindications
			Indications
			Contraindications
		Patient Positioning
		Operative Technique
			Wiltse’s Approach
			Anterior Column Surgery
			Special Considerations at L5–S1
		Closure
		Complications
		Conclusion
		References
	39 Surgical Approaches to  Lumbar Fractures
		Overview
		Classification of Lumbar Fractures
		Types of Fractures
		Radiographic Evaluation  of Fractures
		Indications for Surgery
			Neurologic Injury
			Radiographic Analysis
		Evaluation for Surgical Approach
			Approach Surgeon
		Adjuncts to Surgical Intervention
			Fluoroscopy and Spinal Navigation
			Neuromonitoring
		Surgical Approaches for  Location of Injury
			Upper Lumbar Fractures: L1, L2, and L3
				Posterior Approach
				Posterior Approach with Anterior  Column Stabilization
				Lateral Retroperitoneal Approach
			Lower Lumbar Fractures: L4 and L5
				Posterior
		Procedure
		Intraoperative Complications
		Recovery and Rehabilitation
		Summary
		References
	40 Surgical Decompression  and Stabilization for  Lumbar Lesions:
		Overview
		Preoperative Preparation
		Posterior Approaches
			Laminectomy
			Lateral Transpedicular-Extracavitary Approach
		Anterior Approaches
			Lateral Retroperitoneal Approach
			Anterior Retroperitoneal Approach
		En Bloc Spondylectomy
		Reconstruction
		Complications
		Postoperative Care
		References
	41 Lumbar Microdiskectomy:
		Overview
			History
			Prospective Studies
		Indications
		Anatomy
			Lumbar Spine
			Spinal Canal
			Posterior Elements
			Nerve Roots
		Equipment
		Positioning/Preparation
		Midline Open Lateral Diskectomy
			Bony Decompression
			Disk Removal
			Closure
		Transmuscular Far-Lateral Diskectomy
			Localization
			Exposure
			Disk Resection
			Closure
		Minimally Invasive Tubular Microdiskectomy
			Localization
			Exposure
			Complications
			Postoperative Care
		Acknowledgment
		References
	42 Percutaneous and  Endoscopic Diskectomy
		Overview
		Surgical Anatomy
			Transforaminal Approach
				Triangular Safe Zone
				Endoscopic Anatomy
			Interlaminar Approach
		Indications and Contraindications
			Indications
				Soft Lumbar Disk Herniation
			Relative Contraindications
		Operative Technique
			Equipment (Fig. 42-8)
				Spinal Endoscope
				Instruments for Access
				Mechanical Instruments
				Electrosurgical Instruments
			Patient Positioning and Operating  Room Setup
			Anesthesia
			Surgical Technique
				Transforaminal Endoscopy
					PELD for Nonmigrated Herniations
						step 1. needle insertion.
						step 2. chromodiskography.
						step 3. instrument placement.
						step 4. fragmentectomy.
					PELD for Migrated Herniations.
				Technique of Interlaminar PELD
					Step 1. Chromodiskography.
					Step 2. Needle Insertion.
						axillary herniation.
						shoulder herniation.
					Step 3. Instrument Placement.
					Step 4. Fragmentectomy.
				Techniques to Increase Access for Herniations
					Extraforaminal Disk Herniation.
					Highly Downmigrated Herniations.
		Complications
		Conclusion
		References
	43 Surgical Anatomy and Operative Techniques of Lumbar Stenosis
		General Considerations
		Symptoms
		Surgical Approach/Operative Techniques
			Subtotal/Total Laminectomy
			Unilateral Hemilaminotomy/Hemilaminectomy
			Tubular Hemilaminotomy
		Wound Closure
		Postoperative Regimen
		Avoiding Complications
	44 Transpedicular Screw  Fixation:
		Overview
		Pedicle Anatomy
		Techniques of Transpedicular Screw Insertion
			FreeHand Technique
			Fluoroscopically Assisted Screw Placement
			Image-Guided Navigation-Assisted  Screw Placement
			Electromyelographic Monitoring
		Conclusion
		References
	45 Posterior and Transforaminal Lumbar Interbody Fusion
		Overview
		Indications and Contraindications
			Indications
			Contraindications
		Operative Technique
			Equipment
			Posterior Lumbar Interbody  Fusion Procedure
				Laminectomy
				Traditional Diskectomy
				End Plate Preparation
				Bone Graft Preparation
				Bone Graft Placement
				Closure and Postoperative Care
			Transforaminal Lumbar Interbody  Fusion Procedure
				Patient Positioning and Pedicle Screw Placement
				Unilateral Facetectomy and Contralateral Distraction
				Total Diskectomy through a Unilateral Approach
				End Plate Preparation
				Cancellous Bone and Strut Bone or Cage Graft
				Final Assembly of a Rod-and-Screw System  and Closure
		Postoperative Care
		Complications
		References
	46 Anterior Lumbar Interbody Fusion
		Overview
		Advantages of an Anterior Approach
		Patient Selection
		Indications and Contraindications
			Indications
			Relative Contraindications
		Operative Technique  (Mini-Open Approach)
			Equipment
			Patient Positioning
			Exposure
			Vascular Dissection
			Diskectomy
			Interbody Implants
			Plating (Optional)
			Biologics (Optional)
			Closure
		Postoperative Care
		Complications
		Conclusion
	47 Lateral Lumbar  Interbody Fusion
		Overview
		Indications
		Contraindications
		Preoperative Planning
		Operative Technique
		Postoperative Care
		Complications and  Bailout Strategies
		Conclusion
		References
	48 Spondylolisthesis Reduction
		Overview
		Classification
		Evidence-based Decision Making
		Treatment Options
			Low- and High-Grade Slip Treated  with Fusion
			Formal Reduction Maneuver
			High-Grade Slip Treated with Anterior and Posterior Techniques
				Anterior Surgical Technique
				Posterior Surgical Technique
			Spondyloptosis
		Conclusion
		References
	49 Lumbar Facet Screw Fixation Techniques
		Overview
		Anatomy Review
		Indications
		Contraindications
			Relative Contraindications
		Operative Technique
			Equipment
			Patient Positioning
			Approach
			Technique
				Open Technique Direct Facet Screw Placement
				Open Translaminar Technique
				Percutaneous Translaminar Facet Fixation
			Pearls
			Closure
		Postoperative Regimen and Care
		Complications
		Conclusions
		References
E Lumbar Sacral Pelvic Junction
	50 Surgical Anatomy, Approaches, and Biomechanics in the Lumbosacral Pelvic Junction
		Overview
		Anatomy
			Surface Anatomy
			Bony Antatomy of the  Lumbosacral Junction
			Biomechanics of Lumbosacral Junction
			Vascular Anatomy
			Neural Anatomy
		Approaches to the  Lumbosacral Junction
			Anterior Versus Posterior Pathology-Guided Approach
			Anterior Approach to the  Lumbosacral Junction
				Midline Transperitoneal Approach
					Positioning.
					Incision and Soft Tissue Dissection.
					Intraperitoneal Dissection.
					Retroperitoneal Dissection.
					Diskectomy/Osteophytectomy.
					Closure.
					Complications.
				Retroperitoneal Approach
					Anterior Retroperitoneal Midline Approach
						positioning.
						incision.
						soft tissue dissection.
						retroperitoneal dissection.
						diskectomy/osteophytectomy.
						closure.
						complications.
					Anterior Retroperitoneal Flank Approach
						lateral decubitus positioning.
						lateral decubitus incision.
						soft tissue dissection.
						retroperitoneal dissection.
						closure.
						complications.
			Posterior Approaches to the  Lumbosacral Junction
				Posterior Positioning
				Posterior Incision: Midline, T-Shaped, Paramedian,  or Transverse (Fig. 50-17)
				Posterior Midline Approach
				Posterior Paramedian Approach
				Posterior Transverse Approach
				Bony Work and Tumor Resection
				Closure
				Complications
		References
	51 Surgical Management  of Sacral Fractures
		Overview
		Anatomy
		Diagnosis
		Classification: Sacral Fractures
			Denis Classification
			Roy-Camille Subclassification and Strange-Vognsen and Lebech Modification
			Isler Classification of  Lumbosacral Injuries
		Surgical Management
			Surgical Timing
			Approach to Surgical Stabilization
			Posterior Stabilization Techniques
				Lumbopelvic Stabilization
					Indications
					Operative Setup and Equipment
					Surgical Technique: Open Lumbopelvic Stabilization
					Minimally Invasive Approaches.
				Open Reduction Internal Fixation
					Indications
				Percutaneous Sacroiliac Fixation
					Indications
					Relative Contraindications
					Complications
		Surgical Outcomes
		Complications
		Conclusions
		References
	52 Axial Lumbar Interbody Fusion
		Overview
		Anatomy Review
		Indications and Contraindications
		Operative Technique
			Equipment
			Patient Preparation and Positioning
			Approach
			Technique of Diskectomy
			Screw Placement
			Two-Level Technique
			Closure
		Postoperative Care
		Complications
		Pearls and Pitfalls
		References
	53 Sacral Screw Fixation and Plating Techniques
		Overview
		Historical Background
		Sacral Anatomy
		Sacral Biomechanics
		S1 Pedicle Screws
			Indications for S1 Pedicle Screws
			Relative Contraindications for S1  Pedicle Screws
			Operative Equipment
			Preoperative Planning
			Patient Positioning
			Surgical Approach
			Surgical Technique
		Jackson Intrasacral  Rod Technique
			Indications for Jackson Intrasacral Rod
			Relative Contraindications for S1  Pedicle Screws
			Operative Equipment
			Preoperative Planning
			Patient Positioning
			Surgical Approach
			Surgical Technique
		S2 Alar Screws
			Indications for S2 Alar Screws
			Relative Contraindications for S1  Pedicle Screws
			Operative Equipment
			Preoperative Planning
			Patient Positioning
			Surgical Technique
		Chopin Plate/Colorado II  Sacral Plate
			Indications for Chopin Plate/ Colorado II Sacral Plate
			Relative Contraindications for S1  Pedicle Screws
			Operative Equipment
			Preoperative Planning
			Patient Positioning
			Surgical Approach
			Surgical Technique
		References
	54 Iliac Fixation
		Overview
		Indications
		Surgical Techniques
			Equipment
			Patient Positioning and Incision
			Screw Insertion
			Fusion Site Preparation
			Connection to the Construct
			Closure
			Alternative Technique
		Postoperative Care
		Complications
			Intraoperative Complications
			Postoperative Complications
		References
	55 Surgical Resection of Sacral Tumors/Sacrectomy and Lumbopelvic Reconstruction
		Overview
		Tumors Involving S3 and Below
		Tumors Involving Proximal Sacrum (Combined Anterior  and Posterior Approach)
			Ventral Sacrectomy
			Posterior Sacrectomy
		Sacral Reconstruction
			Modified Galveston Technique
				Rod Contouring
			Double Iliac Screw Fixation with  Lumbar Segmental Fixation
			Triangular Frame Reconstruction
			Transiliac Rod Placement
			Posterior Iliosacral Plating
		References
F Spinal Deformity
	56 Surgical Approaches to Cervical Kyphosis and Deformity
		Overview
		Etiology
		Clinical Presentation
		Clinical Evaluation
		Surgical Indications
		Surgical Approach: Anterior, Posterior, or Combined?
		Surgical Techniques
			Anterior Approach
				Anterior Surgical Technique
				Results
				Complications
				Current Practice
			Combined Anterior-Posterior Approach
				Anterior-Posterior Surgical Technique
				Results
				Complications
			Posterior Approach
				Posterior Surgical Technique
				Results
				Complications
		Conclusion
		References
	57 Surgical Management of Scheuermann Kyphosis
		Overview
		Indications and Contraindications
			Indications
			Contraindications
		Operative Technique
			Equipment
			Patient Positioning
			Location of Incision
			Incision and Soft Tissue Dissection
			Exposure of the Vertebrae
			Retractor Placement
			Instrumentation
			Correction
			Bone Graft
			Closure
		Postoperative Care
		Complications
		References
	58 Surgical Approach to Posttraumatic Thoracic Kyphosis
		Background
		Normal Sagittal Balance
		Impact of Spinal Column Trauma on Alignment
		Presenting Symptoms  of Thoracic Kyphosis
		Correction of Thoracic Kyphosis
		Complications Associated  with Osteotomies
		Summary
	59 Anterior Release and Fusion Techniques for Scoliosis
		Overview
		Indications
		Relative Indications
		Endoscopic Contraindications
		Relative Contraindications
		Selection of Level of Fusion
		Equipment
			Open
			Additional Endoscopic Equipment
		Preoperative and  Perioperative Considerations
		Positioning
			Lateral Decubitus (Endoscopic or Open)
			Prone (Anterior Release Only)
		Operative Technique
			Incision/Exposure
				Upper Thoracic Access (T1–T4)
				Single and Double Thoracotomy: Convex
				Endoscopic Access
				Thoracolumbar (T10–L4) Access
			Dissection of Pleura
			Remove Disk/Vertebrae
			Rib Head Removal
			Graft Placement
			Internal Thoracoplasty
			Segmental Vessels
			Screw Placement and Staples
			Rod Reduction/Cantilever
			Rod Derotation
			Direct Vertebral Body Derotation
			Compression
			In Situ Bending
			Closure
		Outcomes
		Conclusion
		References
	60 Anterior and Posterior Treatment for Thoracolumbar and Lumbar Scoliosis
		Overview
		Anterior Approaches
			Thoracic Curves
			Thoracolumbar Spine
			Lumbar Spine
		Posterior Approach
			Lumbar Decompression
			Posterior Release
			Posterior Instrumentation
			Posterior-Only Approach
		Adolescent Idiopathic Scoliosis
		Neuromuscular Scoliosis
		Adult Spinal Deformity
		Degenerative Scoliosis
		References
	61 Surgical Treatment of Adolescent Idiopathic Scoliosis:
		Overview
			Classification
			Type I
			Type 2
			Type 3
			Type 4
			Type 5
			Type 6
		Indications/Contraindications
		Operative Technique
			Equipment
			Positioning
			Approach
			Osteotomies
			Freehand Pedicle Screw Placement
			Reduction Techniques
			Derotation Maneuver
			Decortication/Grafting
			Closure
		Postoperative Care
	62 Surgical Treatment of Flat Back Deformity
		Overview
		Etiology
		Clinical Presentation
		Radiographic Workup  and Evaluation
		Conservative Management
		Operative Management
			Smith-Peterson Osteotomy
				Surgical Technique
			Pedicle Subtraction Osteotomy
				Surgical Technique
			Anterior Surgery
		Patient Outcomes
		Summary
		References
	63 Surgical Management of Degenerative Lumbar Scoliosis
		Overview
		Natural History
		History and Physical Examination
		Radiologic Evaluation
		Nonoperative Management
		Operative Care
			Risks
			Preoperative Planning
			Sagittal Alignment
			Staging
			Our Preferences
		References
G Spinal Tumors and Vascular Lesions
	64 Primary Malignant and Benign Tumors of the Spine
		Overview
		Presentation
		Evaluation
		Management
		Malignant Tumors
			Multiple Myeloma and Plasmacytoma
			Ewing Sarcoma
			Chondrosarcoma
			Osteosarcoma
			Chordoma
		Benign Tumors
			Hemangioma
			Osteoid Osteoma and Osteoblastoma
			Giant Cell Tumors
			Chondroma, Enchondroma, and Osteochondroma
			Aneurysmal Bone Cyst
		Conclusion
		References
	65 Secondary Metastatic Tumors of the Spine
		Overview
		Clinical Presentation
		Evaluation
		Management
		Surgical Management “Pearls”
		Conclusion
		References
	66 Surgical Technique for Resection of Intradural Tumors
		Overview
		Indications and Contraindications
			Indications
			Relative Contraindications
		Surgical Technique
			Equipment
			Patient Positioning
			Exposure
			Dural Opening
			Approach to Intradural- Extramedullary Tumor
			Approach to Intramedullary Tumor
			Hemostasis
			Closure
		Postoperative Care
		Complications
		Conclusion
		References
	67 Vascular Lesions of the  Spinal Cord
		Overview
		Normal Vascular Anatomy of the Spinal Cord
			Anterior Spinal Artery
			Posterior Spinal Artery
			Pial Arterial Plexus
			Radicular Arteries
			Central Arteries
			Veins of the Spinal Cord
			Capillaries of the Spinal Cord
		Hemangioblastoma
			Genetics
			Epidemiology
			Pathology
			Imaging
			Surgical Considerations
			Surgical Technique
			Outcomes
		Spinal Cord Cavernous Malformations
			Genetics
			Epidemiology
			Clinical Presentation and Natural History
			Pathology
			Imaging
			Surgical Considerations
			Surgical Technique
				Dorsally Located Lesions (Fig. 67-5)
				Ventrally Located Lesions
			Outcomes
		Spinal Cord Arteriovenous Malformations
			Genetics
			Classification
			Epidemiology and Natural History
				Extradural Arteriovenous Fistulas
				Intradural Dorsal Arteriovenous Fistulas
				Intradural Ventral Arteriovenous Fistulas
				Extradural-Intradural Arteriovenous Malformations
				Intramedullary Arteriovenous Malformations
				Conus Arteriovenous Malformations
			Pathophysiology
			Imaging
			Surgical Considerations
			Surgical Technique
				Extradural Arteriovenous Fistulas
				Intradural Dorsal Arteriovenous Fistulas
				Intradural Ventral Arteriovenous Fistulas
				Extradural-Intradural Arteriovenous Malformations
				Intramedullary Arteriovenous Malformations
				Conus Arteriovenous Malformations
				Spinal Cord Aneurysms
		References
H Inflammatory Disease
	68 Ankylosing Spondylitis:
		Overview
		Osteotomy for Correction  of Kyphotic Deformity of Ankylosing Spondylitis
			Indications
			Contraindications
			Posterior Cervical Osteotomy for Correction of Kyphotic Deformity of Ankylosing Spondylitis
				Advantages
				Disadvantages
				Preoperative Evaluation
				Intraoperative Technique
				Postoperative Management
				Complications
			Pedicle Subtraction Osteotomy  for Kyphotic Deformity of the Thoracolumbar Spine
				Advantages
				Disadvantages
				Preoperative Evaluation
				Location of Osteotomy
				Operative Technique
					Equipment
					Patient Positioning.
					Location of Incision.
					Intraoperative Technique.
				Postoperative Care
				Complications
		Conclusion
I Spinal Infection
	69 Bacterial, Fungal, and Tuberculosis Diskitis and Osteomyelitis of the Cervical, Thoracic, and Lumbar Spine
		Overview
		Indications and Contraindications for Surgical Management of Spinal Infection
			Indications
			Contraindications
		Operative Technique
			General Considerations
			Cervical Diskitis and Osteomyelitis
				Positioning
				Approach
				Débridement and Decompression
				Reconstruction
					Strut Graft Without Anterior Instrumentation
					Strut Graft with Anterior Instrumentation.
					Posterior Instrumentation
			Thoracic Diskitis and Osteomyelitis
				Anesthesia
				Patient Positioning
				Localization
				Surgical Approach
				Decompression and Reconstruction
					Supine Position
					Lateral Decubitus
					Anterior Instrumentation
					Posterior Instrumentation
			Lumbar Diskitis and Osteomyelitis
				Positioning and Anesthesia
				Exposure
				Débridement and Decompression
				Anterior Reconstruction
				Posterior Stabilization
			Tuberculosis and Fungal Infections  of the Spine
			Epidural Abscess
		Postoperative Care
		Complications
		References
J Miscellaneous
	70 Surgical Management of Gunshot Wounds to the Spine
		Overview
		Epidemiology
		Mechanisms of Injury
		Prehospital and Emergency  Room Management
		Neurologic Evaluation
		Radiologic Evaluation
		Indications for Surgical Intervention
			Cerebrospinal Fluid Fistula
			Spinal Instability
			Neurologic Deficit
			Special Indications
				Disk Herniation
				Lead Toxicity
				Bullet Migration
		Late Complications
		Louisiana State University–New Orleans Experience
		Summary
		References
	71 Vertebroplasty and Kyphoplasty
		Overview
		Treatment Objectives
		Indications
		Contraindications
		Complications
		Preoperative Preparation
		Radiologic Anatomy for Kyphoplasty and Vertebroplasty
		Equipment for Vertebroplasty and Kyphoplasty
		Procedure
			Inserting Tools into the Fractured Vertebral Body
				Unipedicular Posterolateral Approach
				Transpedicular Approach
				Extrapedicular Approach
			Placing and Inflating the Bone Tamp (Balloon Kyphoplasty)
			Mixing the Cement and Filling the Void
		Postoperative Management
		Potential Adverse Results
		References
	72 Bone Graft Harvesting Techniques
		Overview
		Selecting a Bone Graft
		Techniques of Bone Graft Harvest
			Anterior Iliac Crest Grafts
			Posterior Iliac Grafts
			Alternative Autologous Sites
			Allograft and Fusion Supplements
		Conclusion
		References
	73 Dural Tears
		Overview
		Anatomy Review
		Clinical Diagnosis
		Conservative and Nonsurgical Treatment of Dural Tears
		Intraoperative Surgical Repair
			Surgical Methods and Materials
				Suture
				Dural Substitutes
					Allografts.
					Autogenous Dural Substitutes.
					Synthetic or Chemically Modified Materials.
				Dural Sealants
				Other Dural Tear Surgical Solutions
			Postoperative Surgical Repair
		Summary
		References
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
	Z
Clinical Key ad