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00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page i

THE
POCKET
SPINE
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page ii
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page iii

THE
POCKET
SPINE
Second Edition

Camden Whitaker, MD
Associate Professor, Department of Orthopaedics,
University of Kansas, Wichita;
Orthopaedics and Sports Medicine at Cypress,
Wichita, Kansas

Stephen H. Hochschuler, MD
Chairman and Co-Founder, Texas Back Institute,
Plano, Texas

Quality Medical CRC Press

Publishing, Inc. Taylor & Francis Group

2014
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2014 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20140508

International Standard Book Number-13: 978-1-4822-5401-3 (eBook - PDF)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made
to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any
errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by indi-
vidual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The
information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided
strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, rel-
evant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any
information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urge to consult the
relevant national drug formulary and the drug companies’ printed instructions, and their websites, before administering any of the
drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular
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advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material
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00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page v

Throughout the marathon of my medical training,

there have been few constants.
The one most important and dedicated to me has been my wife,
whose love and understanding have allowed me to complete my training.
To her I owe so much, for which words are inadequate.
Thank you, Heather.
C.W.
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page vi
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page vii

Contributors

Rob D. Dickerman, DO, PhD

Adjunct Professor, University of North Texas Health Science Center,
Fort Worth; Director of Neurosurgery, Texas Health Presbyterian
Hospital Plano; Director of Neurosurgery Spine,
The Medical Center of Plano, Plano, Texas

Stephen H. Hochschuler, MD
Chairman and Co-Founder, Texas Back Institute, Plano, Texas

Eduardo Martinez-del-Campo, MD
Postdoctoral Fellow, Biomechanics of the Spine,
Division of Neurological Surgery, Barrow Neurological Institute,
Phoenix, Arizona

Donna D. Ohnmeiss, DrMed

Texas Back Institute Research Foundation, Plano, Texas

Ralph F. Rashbaum, MD
Co-Founder, Texas Back Institute, Plano, Texas

Hector Soriano-Baron, MD
Postdoctoral Fellow, Biomechanics of the Spine,
Division of Neurological Surgery, Barrow Neurological Institute,
Phoenix, Arizona

vii
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page viii

viii Contributors

Ryan M. Stuckey, MD
Clinical Instructor, Department of Orthopaedics,
University of Kansas, Wichita; Orthopaedics and Sports Medicine
at Cypress, Wichita, Kansas

Nicholas Theodore, MD, FAANS, FACS

Professor of Neurological Surgery; Chief, Spine Section;
Director, Neurotrauma Program, Division of Neurological Surgery,
Barrow Neurological Institute, Phoenix, Arizona

Camden Whitaker, MD
Associate Professor, Department of Orthopaedics,
University of Kansas, Wichita; Orthopaedics and Sports Medicine
at Cypress, Wichita, Kansas
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page ix

Foreword

I wish to congratulate Drs. Whitaker and Hochschuler on this excit-

ing new edition of The Pocket Spine. They have retained the nicely
compact format and have provided generous amounts of information
regarding the presentation, evaluation, and nonoperative and opera-
tive treatment of various common spinal conditions. It is divided into
twelve chapters that can be referenced quickly, with information that
is valuable to trainees as well as young practitioners.
The field of spine medicine has grown tremendously over the last
decade, and sometimes lost in this explosion of new technologies has
been the fact that the majority of conditions that are evaluated and
treated by spine physicians have remained relatively constant. Thus it
is not unusual for trainees in orthopedic surgery and/or neurosurgi-
cal residency and fellowship programs to have difficulty mastering
basic concepts and information while concentrating on higher levels
of sophisticated diagnostic and surgical interventions. This concise
but well-illustrated textbook will provide immediate access to impor-
tant basic and even somewhat advanced concepts for quick and repet-
itive learning. In this respect, this book fills an important need in the
exploding field of spine technologies.
Highlights of the textbook include outstanding classic illustrations,
as well as charts and tables for reference to important data fields. This
is especially evident in the early chapters on medical management and
head and spine trauma. A chapter on the pediatric spine is worth not-
ing for its thorough description of pediatric spinal deformities in an
understandable level.

ix
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page x

x Foreword

Again, I commend Drs. Whitaker and Hochschuler and the col-

leagues who contributed to this new edition on their contribution to
spine literature. It will surely continue to be a standard in the labora-
tory coat pockets of a multitude of medical students, residents, fel-
lows, young practitioners, and other spinal allied health professionals.

Lawrence G. Lenke, MD
Jerome J. Gilden Distinguished Professor and Chief of Spine Service
Washington University School of Medicine
St. Louis, Missouri
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page xi

Preface

It is hard to believe that 8 years have passed since the publication of

the first edition of The Pocket Spine. Throughout my training I found
certain information extremely important, but I often noticed that
studies and information were being misquoted or were difficult to re-
member. I began keeping note cards in my pocket for ready refer-
ence. When those note cards became an unwieldy stack, I began to
think of the value to other residents of turning these notes into a
book. “Quick reference” was the key—and thus The Pocket Spine was
born.
The compilation of this book was influenced by the tremendous
opportunities I had with orthopedic mentors. In medical school my
orthopedic and spine training began with Dr. Marc Asher, with
whom I worked, researched, and published. During my residency and
further training at the University of Kansas, Wichita, I gained a vari-
ety of insights into the art and science of orthopedics by working with
thirty staff orthopedic surgeons. As my focus on orthopedics began to
narrow to spine surgery, so did the focus of The Pocket Spine. During
my fourth year of residency, I spent 6 months at the Shriners Chil-
dren’s Hospital in St. Louis, during which I trained with Drs.
Lawrence Lenke and Keith Bridwell. From this experience I gathered
information on scoliosis. In Plano, Texas, I further refined the book’s
content during my spine fellowship at the Texas Back Institute. Again
with a diverse teaching staff, I benefited from the expertise of eleven
spine surgeons, compiling notes on their techniques and sage advice.

xi
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page xii

xii Preface

Next I spent 6 weeks with Drs. Hillebrand, Albert, and Vacarro and
their fellows, focusing on cervical surgery and spine trauma, guided
by their experience and depth of knowledge.
This book is intended as a quick and convenient reminder of in-
formation for orthopedic residents and fellows, neurosurgical resi-
dents, medical students, family physicians, and emergency room
physicians. This compact manual covers the spectrum of spinal con-
ditions encountered in the clinical setting. The presentation through-
out focuses on clearly delineating the essential points rather than on
lengthy narrative. It is my sincere hope that The Pocket Spine will
prove an invaluable aid to the reader.

Acknowledgment
To all of my mentors I owe great thanks for allowing me into the or-
thopedic field and then training me in the fascinating complexities of
spine surgery. This book is a significant contribution to the spine
community that was initiated through the Texas Back Institute Re-
search Foundation’s Spine Surgery Fellowship program. I would also
like to thank Michelle Berger and the entire Quality Medical Pub-
lishing team for their guidance and skill in bringing this book to pub-
lication.

Camden Whitaker, MD
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page xiii

Contents

1  Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2  Imaging of the Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Donna D. Ohnmeiss, Hector Soriano-Baron, Eduardo Martinez-del-Campo,
Nicholas Theodore, Camden Whitaker

3  Head and Spine Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Camden Whitaker, Rob D. Dickerman, Ryan M. Stuckey

4  Cervical Degenerative Disc Disease . . . . . . . . . . . . . . . . . . . . . . . . . 79

5  Rheumatoid Arthritis of the Cervical Spine . . . . . . . . . . . . . . . . . 101
6  Spinal Deformities in Pediatric, Adolescent,
and Adult Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Camden Whitaker, Ryan M. Stuckey

7  Lumbar Radiculopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

8  Compression Fractures and Osteoporosis . . . . . . . . . . . . . . . . . . . 161
Camden Whitaker, Ryan M. Stuckey

9  Low Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Camden Whitaker, Ryan M. Stuckey

10  Spinal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

xiii
00 Whitaker 2E_FM_r2_cah_i-xvi.qxp:Whitaker 5/7/14 10:03 AM Page xiv

xiv Contents

11  Diagnosis and Treatment of Sacroiliac Joint Pain:

Sacrogenic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Ralph F. Rashbaum

12  Spinal Cord Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Rob D. Dickerman

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 1

1  Medical Management

This chapter outlines some of the preoperative and postoperative

medical management tools for patients undergoing spine surgery.
Because intraoperative management varies depending on the proce-
dure, a lengthy discussion of intraoperative considerations is not
included. However, because of the increased incidence of methicillin-
resistant Staphylococcus aureus (MRSA), the use of vancomycin intraop-
eratively is presented.

PREOPERATIVE MANAGEMENT
 If the hemoglobin level is not 10 g/dl, give 2 units of packed red
blood cells.
 Give antibiotics 30 minutes before incision.
 Patients under 45 years of age do not need a preoperative ECG.

Fluid Maintenance
 Follow for preoperative and postoperative management:

100 ml/kg/hr First 10 kg

50 ml/kg/hr Second 10 kg
25 ml/kg/hr After 20 kg

Treating Fluid Deficits

 Follow for preoperative and postoperative management
 Half in the first 8 hours, then half in the next 16 hours
 10% dehydrated ⫽ 2000 ml loss

Deficit % ⫻ Total weight ⫽ Kilogram deficit

1000 ml ⫽ 1 kg
1
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 2

2 The Pocket Spine

INTRAOPERATIVE MANAGMENT
Using Vancomycin in Cervical, Thoracic, Lumbar, and Pediatric Spinal
Surgery
Surgical site infections are a significant source of morbidity and cost
associated with spine surgery.1 They have been reported to complicate
2% to 13% of spinal fusions.2-5 Risk factors include diabetes, obesity,
tobacco use, previous spinal surgery, long operative time, and high
blood loss.6 Administration of intravenous antibiotics within 60 min-
utes of incision decreases the risk of infection.7 Resistant organisms
such as MRSA are becoming more common and complicate infection
prophylaxis.8 Intraoperative application of powdered vancomycin is
gaining ground in spine surgery.3 The antibiotic doses range from
0.5 to 2.0 g given alone or mixed in cement.2 Yet optimization of the
doses is still in order.4
 Benefits

• Intraoperative local application of vancomycin powder to the

wound edges has been shown to lower the risk of wound infec-
tion after posterior thoracolumbar fusion.9,10
• This technique has a low cost, achieves high local antibiotic con-
centration with MRSA coverage, and leads to minimal systemic
antibiotic absorption.9
• In this retrospective review of 171 patients undergoing poste-
rior cervical fusion, the infection rate fell from 10.9% to 2.5%
(p ⫽ 0.0384) after the introduction of vancomycin powder.11
• No complications related to vancomycin powder use in spinal
surgery have been reported.5,9,12
• Further studies are needed to optimize dosing, assess long-term
safety, and evaluate use in other spinal operations.
 Outcomes

• To date only one study has reported vancomycin concentrations

in drainage fluid after spine surgery: in 2006 Sweet et al5 began
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 3

1  Medical Management 3

to use adjunctive local application of vancomycin in a total dose

of 2 g equally divided between powder form and mixed in with
the bone grafting material in posterior instrumented lumbar and
thoracic spine surgeries. They measured vancomycin concentra-
tions over 3 days after surgery in 178 of 991 patients. The mean
concentrations were 1457, 462, 271, and 128 ␮g/ml on days 0, 1,
2, and 3, respectively. Variability between lowest and highest
concentrations over 3 postoperative days was 8-fold to 23-fold,
yet the lowest observed concentration of 48 ␮g/ml on day 3 was
approximately three times the minimum inhibitory concentra-
tion (MIC) of resistant strains of S. aureus.6 Another reason for
this high variability may be that the concentrations from surgi-
cal drains were not stratified by the type of surgery. Reportedly,
concentrations of vancomycin in 80% of serum samples were be-
low the detection limit of 0.6 ␮g/ml. That is in contrast to the
findings of Desmond et al,7 who reported significant serum van-
comycin levels after topical application of 0.5 g to sternotomy
wounds. Lazar et al8 reported that of 36 patients whose ster-
notomy incision was treated topically with 5 g of powdered van-
comycin, all had measurable concentrations of serum vancomy-
cin on day 6. Oakley et al9 reported that all four of their patients
who underwent cardiopulmonary bypass had peak serum con-
centrations of up to 4.4 ␮g/ml within the first 3 hours and mea-
surable concentrations up to 48 hours after instillation of 1 g of
vancomycin powder.
• On the basis of perioperative surveillance of serum vancomycin
levels and creatinine, Gans12 concluded that the local application
of 500 mg of vancomycin powder for antibiotic prophylaxis
seems to be safe to use in pediatric patients with spinal deform-
ity who have undergone surgery and weigh more than 25 kg, and
that this produces no appreciable systemic affects.
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 4

4 The Pocket Spine

POSTOPERATIVE MANAGEMENT
These measures can be used for different postoperative situations as
they arise or as needed with adult patients; see Table 1-1 (pp. 6 and 7)
for pediatric management.

Hypertension
 Systolic blood pressure ⬎180 and diastolic blood pressure ⬎100
 Nifedipine (Procardia) 10 mg SL q 2 hr prn
 Labetolol 5 to 10 mg IV q hr prn (requires intensive monitoring in
CCU)

SAO2
 Titrate if greater than 90%.

Tachycardia
 Consider pain control.

Wound Care
 Every day or as needed for saturation
 Open/contaminated
• Dalan’s solution: Use at one-quarter strength.
• Apply wet-to-dry dressings once a day.
• If ⬎4 days, reculture the wound.

Diarrhea
 Antibiotics can cause diarrhea.
 Check for Clostridium difficile toxin, white blood cells in feces,
leukocytes.
• If test results are negative, treat with loperamide (Imodium) or
bismuth sulfate.

Dermatitis Secondary to Bed Rest

 Treat with Carrington moisture barrier cream or zinc oxide.
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 5

1  Medical Management 5

Remove Drains
 If drainage is less than 30 ml, remove drain in 24 hours.

Restraints
 Orders must be rewritten every 24 hours.

Temperature
 If the patient’s temperature ⬎101.5° F (38.6° C), follow the Five
Ws of fever management:
• Day 1: Wind (observe for signs of pneumonia, atelectasis)
• Day 2: Water (observe for signs of urinary tract infection)
• Day 3: Wound (observe for signs of wound infection)
• Day 4: Wonder drugs (observe reaction to drugs, especially anes-
thetics)
• Day 5: Walking (walking can help reduce the potential for deep
vein thrombosis and pulmonary embolus)
 Order blood cultures ⫻ 2, 30 minutes apart from separate sites.
 Give acetaminophen (Tylenol) 10 gr q 4 hr prn.
 Have patient use incentive spirometer 10 times/hr.
 Encourage coughing and deep breathing.
 Rule out urinary tract infection.
 Check medications and wounds.

Pain Management
 Pills
• Lortab 5 or 7.5: 1 to 2 tabs PO q 4 hr as needed.
• Oxycodone (Percocet) 1 to 2 tabs PO q 4-6 hr prn.
• Lorcet 10 is the strongest.
• Darvocet N 100 causes less nausea.
• Acetaminophen (Tylenol) 10 gr 1-2 PO q 4 hr prn PO/PR.
 Patient-controlled analgesia (PCA)
• Meperidine hydrochloride (Demerol) 20 to 60 mg IV q hr prn
Table 1-1 Pediatric Management 6

Dosage by
Patient Weight Tylenol With Codeine Lortab Elixir
in Pounds (kg) IV Fluids Motrin Tylenol (120 mg ⴙ 12 mg)/5 ml (7.5 mg ⴙ 500 mg)/15 ml

13 (6) 24 ml/hr 60 mg (3 ml) 90 mg 1.25-2.5 ml q 3-4 hr 0.6 mg (1.8 ml) q 6 hr

18 (8) 32 80 (4 ml) 120 1.5-3.5 ml 1.2 (2.4 ml)
The Pocket Spine

22 (10) 40 D5 1⁄3 NS 100 (5 ml) 150 2-4 ml 1.5 (3 ml)

26 (12) 44 120 (6 ml) 180 2.5-5 ml 1.8 (3.5 ml)
31 (14) 48 140 (7 ml) 210 2.75-6 ml 2.1 (4.2 ml)
35 (16) 52 160 (8 ml) 240 3.25-6.5 ml 2.4 (4.8 ml)
40 (18) 56 180 (9 ml) 270 3.5-7.5 ml 2.7 (5.4 ml)
44 (20) 60 200 (10 ml) 300 4-8 ml 3.0 (6 ml)
55 (25) 65 250 (12.5 ml) 375 5-10 ml 3.75 (7.5 ml)
66 (30) 70 D5 1⁄2 NS 300 (15 ml) 450 6-12 ml 4.5 (9 ml)
77 (35) 75 350 (17.5 ml) 525 7-15 ml 5.25 (10.5 ml)
88 (40) 80 400 (20 ml) 600 8-16 ml 6 (12 ml)
99 (45) 85 450 (22.5 ml) 675 10-20 ml 7.5 (15 ml)
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker

110 (50) 90 500 (25 ml) 750 12.5-25 ml 9 (18 ml)

⬍10 kg: Max dose: Toradol Tylenol Lortab tablets
4 ml/kg/hr 40 mg/kg/day ⬍50 kg: 3 tabs q 3-4 hr 2-5 yr (15-30 kg):
5/5/14

10-20 kg: 20-40 kg: 15 mg IV q 6 hr One tab: 30-50 kg 2.5 tabs q 6 hr

2 ml/kg/hr 200 mg q 6-8 hr ⬎50 kg: Two tabs: ⬎60 kg 5-12 yr (30-50 kg):
⬎20 kg: ⬎40 kg: 30 mg IV q 6 hr 5.0 tabs q 6 hr
1 ml/kg/hr 400 mg q 5-8 hr 0.5 mg/kg q 6 hr ⬎12 yr (⬎50 kg):
1-2 tabs q 5 hr
12:43 PM

NS, Normal saline.

Page 6
Dosage by
Patient Weight Metoclopramide Ondansetron Cefazolin Diazepam
in Pounds (kg) Morphine (Reglan) (Zofran) (Ancef) Clindamycin (Valium)

0.05-0.1 mg/kg 0.1-0.2 mg/kg 50-100 mg/kg/QD 10 mg/kg Spasm/CP 0.04-0.2

IV q 1-2 hr IV/PO q 6-8 hr divided q 8 hr IV q 6 hr mg/kg PO q 4 hr
13 (6) 0.3-0.6 mg 100-200 mg
18 (8) 0.4-0.8 125-250
22 (10) 0.5-1 1-2 mg ⬍20 kg: 2 mg 150-300 100 mg 1-2 mg q 4 hr
26 (12) 0.6-1.2 IV/PO q 8-12 hr 200-400
31 (14) 0.7-1.4 225-450
35 (16) 0.8-1.6 250-500
40 (18) 0.9-1.6 300-600
44 (20) 1-2 mg 2-4 mg 20-40 kg: 4 mg 325-650 200 mg 2-4 mg
55 (25) 1.25-2.5 400-800
66 (30) 1.5-3 3-6 mg 500 mg-1 g 300 mg 3-6 mg
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker

77 (35) 1.75-3.5 500 mg-1 g

88 (40) 2-4 mg 4-8 mg ⬎40 kg: 8 mg 500 mg-1 g 400 mg 4-8 mg
99 (45) 2.25-4.5 500 mg-1 g
1
5/5/14

110 (50) 2.5-5 5-10 mg 500 mg-1 g 500 mg 5-10 mg



Demerol Gentamycin 5 mg/kg Reversal of sedation

1-1.5 mg/kg 2-2.5 mg/kg PO q 6 hr agent: Flumazenil
IV/IM q 3-4 hr IV q 8 hr 10-30 ␮g/kg IV
(200 ␮g max);
12:43 PM

⬎20 kg give 200

mcp
Medical Management

Fentanyl 1-3 ␮g/kg IV q 2-4 hr

Narcan ⬍20 kg: 2 mg IV, ⬎20 kg: 1 mg/kg
Page 7

7
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 8

8 The Pocket Spine

 PCA 60 mg loading dose, 10 mg dose, 10-min intervals, 240

mg q 4 hr lockout
• Morphine 2 to 6 mg IV q hr prn
 PCA 6 mg loading dose, 1 mg dose, 10-min intervals, 24 mg

q 4 hr lockout

Nausea
 Metoclopramide (Reglan) 10 mg IV q 6 hr prn
 Prochlorperazine (Compazine) 25 mg PR q 6 hr as needed
 Phenergan 12.5 to 25 mg IV or IM
 Ondansetron (Zofran) 4 mg IV q 4 hr as needed

Sleeping Aids
 Triazolam (Halcion) 0.125 mg HS prn

Laxatives
 X-prep, 1 can
 Milk of Magnesia 30 ml
 Fleet Phospho-Soda 30 ml in 8 oz of water
 Dulcolax PR

Diuretics
 Foley flush (want 0.5 ml/kg/hr)
 Furosemide (Lasix) 20 to 60 mg IV (check potassium level)
 Bumetanide (Bumex) 2 to 4 mg IV
 Hespan (6% hetasback) 250 ml IV over 2 hr

Insulin Sliding Scale: Finger-Stick Blood Sample

151-180 mg/ml Give 4 U reg SQ ⫻ 1
181-220 mg/ml Give 6 U reg SQ ⫻ 1
221-260 mg/ml Give 8 U reg SQ ⫻ 1
261-300 mg/ml Give 10 U reg SQ ⫻ 1
⬎300 mg/ml Call
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 9

1  Medical Management 9

 Hypoglycemia
• Blood sugar: 40 to 60 mg/ml
 Treat with orange juice.

• Recheck blood sugar if patient becomes symptomatic (shakes)

 Treat with 1⁄2 amp D50.

 Hyperglycemia
• As indicated by insulin AccuCheck ⬎300
• Treat with regular insulin if initial insulin use is:

Minimal 4-6 U
Moderate 10-15 U
Severe 20 U

NG Tube Prophylaxis for Stress Gastritis

 Famotidine (Pepcid) 20 mg IV q 12 hr
 Ranitidine (Zantac) 50 mg IV q 8 hr
 Carafate 1 g PO qid (slurry via NG tube)

Heparin: Anticoagulation
 DVT/PE 80 U/kg bolus, 20 U/kg/hr drip
 Cardiac/other 70 U/kg bolus, 15 U/kg/hr drip
 Adjust for goal aPTT ⬎46 sec for first 16 hr, then 46-70 sec

⬍37 sec Bolus 50 U/kg, ⫹4 U/kg/hr, next PTT 8 hr

37-42 sec Bolus 25 U/kg, ⫹4 U/kg/hr, PTT 8 hr
42-46 sec No bolus, ⫹2 U/kg/hr, PTT at 8 hr
46-70 sec Check next AM
70-80 sec ⫺1 U/kg/hr, PTT at 8 hr
80-115 sec ⫺2 U/kg/hr at 8 hr
⬎115 sec ⫺3 U/kg/hr, PTT at 8 hr; stop infusion in 60 min
⬎150 sec Call physician
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10 The Pocket Spine

Warfarin (Coumadin): Anticoagulation

 Coumadin sliding scale

INR Coumadin (mg)

⬍1.2-1.3 5
1.4-1.5 4
1.6-1.7 3
1.8-1.9 2
2-3 Hold
3.1-4.0 Hold, 2.5 mg vitamin K PO
4.1-5.9 Hold, 5.0 mg vitamin K PO
⬎6.0 Hold, 10 mg vitamin K PO

 Reversing anticoagulation

PT ⬎30 Treat with vitamin K SQ

PT ⬎50 Treat with 2 U FFP

Deep Vein Thrombosis Prophylaxis

Medical comorbidities requiring vigilance in the surveillance for deep
vein thrombosis (DVT) include a history of CHF, MI, CVA, hyper-
coagulable states, tobacco consumption, and obesity.13 The use of
TEDS hose and sequential compression devices is sufficient for DVT
prophylaxis in the surgical management of the spine.13 The potential
complications of epidural hematoma and subsequent neurologic de-
terioration and increased need for postoperative blood transfusion
are used frequently as arguments against chemical DVT prophylaxis
in spine surgery.13
 Plexipulse boots, SCD

 Heparin 5000 U SQ q 12 hr (if elevated, then q 8 hr)

 Enoxaparin sodium (Lovenox) 15 mg bid; if a clot occurs, give

1 mg/kg
 D/C Lovenox if PT ⬎14.0
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 11

1  Medical Management 11

Thromboembolic Prophylaxis for Total Knee Arthroplasty

 Proximal versus distal: Level of trifurcation.
 2% to 3% clot rate status post venogram.
 Postoperative risks return to preoperative risks at 2 weeks.
 Distal clot: 23% rate of propagation to proximal clot.13
 Most clots have occurred by 7 days postoperatively and 80% are
detectable.13
 Immediately after surgery.

STANDARD POSTOPERATIVE ORDERS

The physician’s orders listed in Box 1-1 (pp. 12-14) apply to all pa-
tients.

DISCHARGE SUMMARY
The following points should always be included in discharge sum-
maries.
 Admission and discharge date

 Operations/procedures

 Consultants

 Physical examination

 Laboratory tests and radiographs

 Hospital course

 Condition

 Follow-up: Medication, diet, activity, and follow-up appointment

01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 12

12 The Pocket Spine

Box 1-1 Physician’s Standard Postoperative Orders

Diet
____ NPO
____ NPO/ice chips
____ Regular
____ Clear liquids
____ Advance as tolerated

Laboratory Tests
____ Blood cultures ⫻ 2 for temperature ⬎102° F (38.9° C) or shaking chills

Vital Signs
____ Routine recovery room
____ Every 4 hr ⫻ 24 hr, then every shift
____ Neurologic check q hr ⫻ 8 hr, then every shift (motor, sensory, pulses)
____ Per ICU routine
____ Chest radiograph in recovery room

Activities
____ Bed rest
____ Physical therapy/occupational therapy
____ Ambulation
____ Activities/equipment per protocol
____ Bed positioning
____ Elevate head of bed 30 degrees or to comfort
____ Keep bed flat ⫻ __________ days

Fluids and Medications

____ D5 1⁄2 NS at __________ ml/hr when tolerating fluid PO
____ Decrease to TKO or heparin lock
____ D/C after last dose of IV antibiotics
____ Levofloxacin 500 mg PO q 24 hr (start P IV antibiotics)
____ Cefazolin (Ancef) 1 g IV q 8 hr ⫻ 3 doses
____ Lincocin 600 mg IGM IV q 12 hr ⫻ 3 doses
____ Cephalexin (Keflex) 500 mg PO QID (begin after IV antibiotics are discontinued)
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 13

1  Medical Management 13

Box 1-1 Physician’s Standard Postoperative Orders—cont’d

____ Ciprofloxacin 500 mg PO bid (start after IV antibiotics)

____ Propoxyphene napsylate with acetaminophen (Darvocet N 100) 1-2 PO q 3-4 hr
prn for pain
____ Tramadol hydrochloride (Ultram) 50 mg PO q 4-6 hr prn for pain
____ Ketorolac tromethamine (Toradol) 30 mg IV q 6 hr prn ⫻ 24 hr prn for pain
____ Oxycodone hydrochloride (OxyContin) 20 mg 1-2 tabs q 12 hr prn for pain
____ Acetaminophen and hydrocodone (Vicodin) 1-2 PO q 4-6 hr prn for pain
____ Lortab 7.5 mg 1-2 PO q 4-6 hr prn for pain
____ Hydrocodone (Norco) 10 mg 1-2 PO q 4-6 hr prn for pain
____ Acetaminophen (Tylenol 3) 1-2 PO q 4 hr prn for pain
____ Acetaminophen (Tylenol) 1-2 PO q 3-4 hr PM H/A and mild pain and fever
⬎101° F (38.3° C)
____ Cyclobenzaprine (Flexeril) 5-10 mg 1 PO tid prn for spasms
____ Diazepam (Valium) 10 mg IM or PO tid prn for spasms
____ Ranitidine (Zantac) 150 mg 1 PO bid
____ Ranitidine (Zantac) 50 mg IV q 12 hr; D/C when taking PO meds
____ Dexamethasone (Decadron) 10 mg IV q 8 hr ⫻ 3
____ Morphine PCA
____ 1-2 mg q 8-10 min prn with
____ 2-4 mg bolus 2-4 hr prn
____ 0 mg loading dose
____ 30 mg per 4 hr lockout
____ Metoclopramide (Reglan) 10 mg IV q 6 hr
____ Zolpidem (Ambien) 5 mg PO HS PM; may repeat ⫻ 1
____ Antacid of choice
____ Senokot S 2 tabs PO HS PM for constipation
____ Promethazine (Phenergan) 12.5-25 mg IV q 4-6 hr PM (if not effective within 2 hr,
discontinue)
____ Ondansetron (Zofran) 4 mg IV q 6-8 hr PM (if Phenergan not effective)
____ Diphenhydramine (Benadryl) 25-50 mg PO or IM q 4 hr prn for itching
____ Laxative of choice
____ Preoperative medications per physician
____ Preoperative medications to be resumed are as follows: _______________________
___________________________________________________________________________

Continued
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 14

14 The Pocket Spine

Box 1-1 Physician’s Standard Postoperative Orders—cont’d

Respiratory
____ Encourage coughing and deep breathing q 2 hr while awake
____ Incentive spirometry q l hr while awake
____ Intermittent positive pressure breathing (IPPB) with albuterol (Ventolin) 0.3 ml
NS q 6 hr for __________ days
____ Moist air by face tent with compressed air for __________ days

Orthosis
____ Corset/brace
____ Advantage/thoracolumbosacral orthosis (TLSO) (custom molded)

Genitourinary
____ Foley catheter to gravity drainage
____ Tamsulosin (Flomax) 0.4 mg PO QD until patient voids
____ Urecholine 12.5 mg 1 PO q 6 hr ⫻ 3 doses or until patient voids
____ Straight catheter if patient is unable to void in 6 hr; if unable to void again,
insert Foley and if urine output is 200 ml, leave Foley in

DVT Prophylaxis
____ Bilateral lower extremity compression devices
____ TEDS hose
____ Hot ice machine with setup

Dressings
____ Change the dressing every day starting after POD 2 and prn
____ Keep wound dry; Aquashield for showering
____ Patient may shower with supervision after first dressing change with Aquashield
____ Postoperative dressing pack to room
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 15

1  Medical Management 15

REFERENCES
1. Dakwar E, Vale FL, Uribe JS. Trajectory of the main sensory and motor
branches of the lumbar plexus outside the psoas muscle related to the lateral
retroperitoneal transpsoas approach. J Neurosurg Spine 14:290-295, 2011.
2. Kanj WW, Flynn JM, Spiegel DA, et al. Vancomycin prophylaxis of surgical
site infection in clean orthopedic surgery. Orthopedics 36:138-146, 2013.
3. Vitale MG, Riedel MD, Glotzbecker MP, et al. Building consensus: Devel-
opment of a Best Practice Guideline (BPG) for surgical site infection (SSI)
prevention in high-risk pediatric spine surgery. J Pediatr Orthop 33:471-478,
2013.
4. Chrastil J, Patel AA. Complications associated with posterior and transfo-
raminal lumbar interbody fusion. J Am Acad Orthop Surg 20:283-291, 2012.
5. Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for pro-
phylaxis in instrumented thoracolumbar fusions: Efficacy, drug levels, and pa-
tient outcomes. Spine 36:2084-2088, 2011.
6. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of van-
comycin in adult patients: A consensus review of the American Society of
Health-System Pharmacists, the Infectious Diseases Society of America, and
the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm
66:82-98, 2009.
7. Desmond J, Lovering A, Harle C, et al. Topical vancomycin applied on clo-
sure of the sternotomy wound does not prevent high levels of systemic van-
comycin. Eur J Cardiothorac Surg 23:765-770, 2003.
8. Lazar HL, Barlam T, Cabral H. The effect of topical vancomycin applied to
sternotomy incisions on postoperative serum vancomycin levels. J Card Surg
26:461-465, 2011.
9. Oakley RE, Nimer KA, Bukhari E. Is the use of topical vancomycin to pre-
vent mediastinitis after cardiac surgery justified? J Thorac Cardiovasc Surg
119:190-191, 2000.
10. Kuris E, Moskowitz A. Postoperative drainage and serum vancomycin levels
after topical adjunctive application of vancomycin powder in patient with
posterior instrumented spine surgery (in press).
11. Strom R. Decreased risk of wound infection after posterior cervical fusions
with routine local application of vancomycin powder. Spine 38:991-994,
2013.
12. Gans I. Adjunctive vancomycin powder in pediatric spine surgery is safe.
Spine 38:1703-1707, 2013.
13. Rokito SE, Schwartz MC, Neuwirth MG. Deep vein thrombosis after major
reconstructive spinal surgery. Spine 21:853-858; discussion 859, 1996.
01_Whitaker 2E_r3_cah_001-016.qxp:Whitaker 5/5/14 12:43 PM Page 16
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 17

2  Imaging of the Spine

Donna D. Ohnmeiss, Hector Soriano-Baron, Eduardo Martinez-del-Campo,
Nicholas Theodore, and Camden Whitaker

Imaging is an essential tool in the evaluation of patients with pain or

spinal trauma. A variety of techniques are available; the typical course
is to begin with the least invasive or least expensive diagnostic tools
and progress as necessary to formulate an effective treatment plan.
Although imaging is critical to the care of spine patients, it is imper-
ative to keep this in mind: “Treat the patient, not the x-ray.” The
downside to diagnostic imaging is the fact that not all observed ab-
normalities are related to symptomatology. Any imaging must be in-
terpreted in terms of the patient’s history and the findings on physi-
cal examination to complete the diagnostic picture.

PREOPERATIVE IMAGING
Plain Radiograph
The first line of imaging is plain films. In the cervical and lumbar
spine, anteroposterior (AP) (Fig. 2-1) and lateral flexion-extension
views are the basic views. (See radiograph considerations in Chapter
4 for more information.) A neutral lateral view may be taken as well.
If a pars fracture is suspected, oblique views may be helpful. When
reviewing plain films one should look for the following: fracture, vari-
ations in the appearance of a vertebral body (Fig. 2-2), which may in-
dicate a congenital abnormality, tumor or infection, collapsed disc
space (Fig. 2-3), narrowing of the foramen, spondylolisthesis (Fig.
2-4), pars fracture, shape of the pedicles, and symmetry. The flexion-
extension views may provide information about instability (Fig. 2-5).

17
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 18

18 The Pocket Spine

Fig. 2-1 AP radiograph of the lumbar

spine showing straight alignment and
symmetry.

Fig. 2-2 Lateral view showing

abnormality at the L1 level.

Fig. 2-3 Neutral lateral of the cervical

spine showing narrowing of the C5-6
disc space.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 19

2  Imaging of the Spine 19

Fig. 2-4 A, Flexion and B, extension radiographs of a patient with spondylolisthesis at

L4-5.

Fig. 2-5 A, Flexion and B, extension views are very helpful in identifying abnormal motion,
as seen in the two lowest lumbar levels.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 20

20 The Pocket Spine

In a previously operated spine, one should look for implant-related

problems, such as breakage and/or displacement. In patients with a
previous fusion, the bone graft should be examined for incorporation.
However, unless a blatant nonunion is identified, one should not de-
pend too heavily on plain films for fusion assessment, since it is not
highly reliable.
In patients with spinal deformity such as scoliosis or kyphosis, a
long film should be taken that provides a view from the upper cervi-
cal region to the femoral heads in both the AP and lateral views. In
patients with scoliosis, left- and right-bending films are also impor-
tant to determine the flexibility of the curve.
There is no general consensus in regard to the ideal indications for
obtaining radiographs in patients with back pain. From a clinical
standpoint, fewer films are desirable because of the expense and radi-
ation exposure. However, from a medicolegal standpoint and for fear
of missing the identification of trauma or tumor as soon as possible,
early radiographs may be desirable. The North American Spine
Society (NASS) has published some guidelines for determining
whether obtaining radiographs is appropriate.1 They recommend
that films not be made in patients with an initial episode of back pain
of less than 7 weeks’ duration unless there are other circumstances
related to the pain episode that may be indicative of a serious under-
lying problem. Such symptoms may include pain at night or when ly-
ing down; a motor or sensory deficit that results in bowel or bladder
dysfunction; worsening pain despite adequate treatment; a history
suggestive of possible fracture or trauma; social factors such as the pa-
tient not being able to provide a reliable history; a need for legal eval-
uation; or a need to determine whether it is appropriate for the pa-
tient to engage in certain activities, such as sports. Patients who have
a history of significant spine problems or surgery may require earlier
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2  Imaging of the Spine 21

imaging. The views obtained should include at a minimum an AP and

a lateral view. Lateral flexion and extension films are very helpful in
identifying instability and are often substituted for the neutral lateral
view.

Magnetic Resonance Imaging

For most patients, the second imaging mode to be pursued is MRI
(Figs. 2-6 through 2-8). This is good for assessment of soft tissue, tu-
mors, and infections. The downside of using MRI is that it has been
reported that as many as 76% of subjects without back pain who were
age and occupation matched to a back pain population had abnormal-
ities on their MRIs.2 This reinforces the importance of correlating
images to clinical findings.

Fig. 2-6 A, Lateral and B, axial MRIs show a very large disc herniation at L5-S1.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 22

22 The Pocket Spine

Fig. 2-7 A, Lateral and B, axial views of a large C5-6 disc herniation (same patient as in Fig.
2-3).

Fig. 2-8 MRI of the same patient as in Fig. 2-4. Note the misshapen foramen and abnormal
disc at L4-5 resulting from the patient’s spondylolisthesis.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 23

2  Imaging of the Spine 23

Red Flag: One should be cautious if planning surgery based primarily on MRI
because of the high false-positive rate.

In previously operated patients, a gadolinium-enhanced MRI may

be useful. Images made before and after administration of gadolinium
should be compared to aid in distinguishing scar tissue from recur-
rent disc herniation.
One of the new developments in MRI scanning is upright imaging.
This has the potential advantage of imaging the spine when it is
loaded. It may also provide the opportunity to scan the spine in vari-
ous positions. It has been reported that such loaded dynamic imaging
of the cervical spine provided additional information in the majority
of patients.3 However, for cervical and lumbar standing imaging,
there is a chance of imaging being compromised as a result of artifact
created by patient movement, particularly if the scan requires a rela-
tively long time to image.
NASS’s recommendation for MRI scanning suggests waiting ap-
proximately 7 weeks if the patient has received appropriate care and
his or her symptoms have not improved.4
A recent article found that patients who underwent MRI of the
lumbar spine before the time frame suggested in the guidelines,
which allow early imaging in the presence of red flags, had signifi-
cantly worse outcomes, including extended recovery time and greater
treatment costs of approximately $13,000.5

Red Flag: An MRI may be performed earlier if the patient has signs of an
acute injury, infection, or tumor, or if the patient’s neurologic condition is
progressively worsening.

Under any circumstances, patients must be carefully screened be-

fore the procedure to make certain that the imaging can be per-
formed safely. The screening should focus on any materials that may
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 24

24 The Pocket Spine

be affected or moved by the magnetism required for the scans. It

should also be noted whether the patient is unlikely, because of claus-
trophobia, pain, and so forth, to remain still during the imaging.
A high-intensity zone (HIZ) (Fig. 2-9) is defined as a high-intensi-
ty signal located in the posterior anulus that is dissociated from the
signal from the nucleus and appears brighter than the nucleus.6 It has
been reported that there is a high correlation to HIZ and sympto-
matic disc disruption identified by discography.6,7 However, the sig-
nificance of the HIZ has been questioned in other studies.8-10

Fig. 2-9 An MRI showing disc degeneration at L4-5 and L5-S1

levels, identified by the darkness (caused by dehydration) of
these discs compared with the normal discs at the cephalad
levels. Also note the high-intensity zone (HIZ) at L4-5.

All patients must be carefully screened before an MRI to eliminate

possibly exposing patients with functioning electronic implants, such
as pacemakers or nontitanium metallic implants, shrapnel, or other
metallic fragments, to potentially serious injury from exposure to the
magnetic field required for imaging. In addition, MRI imaging may
be more difficult, if not impossible, in patients with spinal cord and
internal bone stimulators. Patients who are incapable of remaining
still long enough to capture a useful image should not be scanned.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 25

2  Imaging of the Spine 25

Patient movement can significantly compromise the quality of the

images, making them difficult to interpret or leading to misinterpre-
tation.

CT Scans
CT scanning has been somewhat replaced by MRI as an early imag-
ing modality in many patients. However, it remains good for imaging
bony pathology. In cases of trauma, it may provide greater detail of
fracture. It is also useful in the assessment of patients who have un-
dergone fusion to determine if the bone graft has incorporated into a
solid mass or growth into metallic fusion cages (Fig. 2-10). As dis-
cussed in sections below, CT is very helpful following contrast-based
evaluations such as myelography or discography. In the postfusion
patient, CT is the method of choice for evaluating patients for possi-
ble pseudarthrosis.

Fig. 2-10 Axial CT scanning is helpful in the assessment of fusion incorporation, such as in
this patient in whom threaded metallic cages were packed with bone graft.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 26

26 The Pocket Spine

In addition to assessing bony structures, CT scans provide infor-

mation helpful in planning anterior interbody spine surgery, such as
the choice of fusion or total disc replacement. CT also permits visu-
alization of calcification in the large vessels passing anterior to the
lumbar spine (Fig. 2-11).

Fig. 2-11 In addition to the assess-

ment of bony structures, axial CT
views are useful for the assessment
of vascular structures, which may be
helpful in preoperative planning.
In this figure, some calcification of
the vessels is seen anterior to the
spine.

Myelography
Myelography remains the standard for the assessment of problems
such as stenosis. The contrast is very helpful in determining the loca-
tion of the compression of neural tissues. CT scanning after the my-
elogram is useful to further delineate the location of the compression.
Myelography is used for the following situations:
 Unable to obtain an MRI

 MRI is of substandard quality

 Need bony detail

 In older patients with segmental bony stenosis

 Transitional syndrome in patients with old fusion to check for

hardware placement
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 27

2  Imaging of the Spine 27

Discography
Although controversial, discography is a useful procedure when per-
formed and interpreted appropriately. NASS has published a docu-
ment on discography, including indications for the procedure.11
Indications for discography include, but are not limited to, evaluation
of a disc thought to be related to symptoms; assessment of ongoing
pain for which other tests have not identified any correlative abnor-
malities; determination of whether the disc or discs are painful in a
segment where fusion is being considered; assessment of candidates
for minimally invasive disc procedures; and evaluation of previously
operated symptomatic patients to evaluate a disc in a fused segment
that is painful, if there is a painful recurrent disc herniation, or to
evaluate the disc adjacent to a previous surgery. Discography provides
detailed information on the architecture of the disc (see Fig. 2-10).
The critical part of the discogram is the assessment of the patient’s
pain response during the disc injections. This must be interpreted
with respect to the patient’s clinical symptoms. If the test produces
no pain, or pain that is discordant with presenting symptoms, the test
is nondiagnostic, regardless of imaged ruptures.
As with myelography, postinjection CT scanning can provide a
great deal of additional information. The axial CT views made with
contrast medium provide information about the internal architecture
of the disc and the exact location and severity of disc disruption and
degeneration.
One potential complication of discography is discitis. Although the
incidence of complications is low,12 persons performing discography
should be meticulous in technique. Any patient complaining of severe
pain or new onset of pain after the procedure should be carefully eval-
uated for discitis (Fig. 2-12, p. 28).
A review study addressed the accuracy of lumbar discography.13
The authors found evidence-based literature classified as “fair,” sup-
porting that discography performed according to the guidelines of
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28 The Pocket Spine

Fig. 2-12 A, Fluoroscopic view of the discographic injection of contrast into the disc spaces.
The needle is seen in the L4-5 disc. In both the lateral image (A) and the axial CT/disco-
graphic image of L3-4 (B), the disc morphology is normal as the contrast remains in the nu-
cleus as injected. The lateral view shows an abnormal L4-5 disc where the contrast passes
posteriorly from the nucleus (A). The axial CT/discographic image of L4-5 (C) provides further
information on the disc architecture with the contrast identifying right-sided lateral disc
disruption.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 29

2  Imaging of the Spine 29

the International Association for the Study of Pain may be beneficial

in the diagnosis of pain arising from the intervertebral disc.

Bone Scans/SPECT Scans

Bone scans are sometimes used in the evaluation of patients with back
pain. They are typically employed to identify “hot spots” of activity;
that is, areas of high metabolic activity. This test may be useful in
evaluating patients for tumor, infection, or fractures. It has been sug-
gested that single-photon emission computed tomography (SPECT)
may be beneficial in identifying patients with pain arising from the
facet joints. However, the role of SPECT in back pain patients has
not been well defined.

Special Considerations for Imaging in Trauma Patients

Imaging in the early evaluation of trauma patients deserves special
consideration (see Chapter 3 for more information). Incorrect diag-
nosis or missed injuries could have catastrophic consequences for in-
jured patients. It has been noted that the most common reason for
missed spinal injuries is inadequate imaging.14
A patient’s inability or compromised ability to communicate and
cooperate with care providers makes it more difficult to evaluate
symptoms. Patients who are unable to undergo adequate neurologic
evaluation may require more extensive imaging to investigate possi-
ble spinal injuries. General recommendations published in a recent
review were to perform, as a first evaluation, cervical lateral, AP, and
open mouth views (to assess the uppermost cervical vertebrae and the
odontoid).15 The authors stressed the importance of making certain
that the lateral views are true laterals with no rotation, image from
the upper cervical spine to T1 level, and visualization of the spinous
processes. They cited an earlier report that these three views can
identify 99% of injuries.16 Although many other views of the cervical
spine may be made, these should be approached only with specific
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 30

30 The Pocket Spine

considerations—as well as with extreme caution if the additional

views require movement of the acutely injured patient’s spine.
Recommendations for imaging evaluation of the thoracic and lum-
bar spine were to limit this to patients with confirmed cervical injury,
calcaneus fracture caused by a fall, regional tenderness, indications of
high-impact trauma injuries in the trunk or pelvic regions, or neuro-
logic deficits in a distribution suggestive of injury in the thoracic or
lumbar spine.15 Appropriate plain radiographs are AP and lateral
views.
CT scanning can provide excellent delineation of bony injury. In
the case of cervical spine trauma, a recent metaanalysis compared
plain radiographs with CT scans for the evaluation of patients at risk
of cervical injury resulting from blunt trauma.17 The authors suggest-
ed that CT be the initial screening for patients with cervical spine
trauma because of its significantly greater sensitivity compared with
radiographs. However, they noted that in patients presenting with
less risk of significant cervical injury and who can be evaluated well
clinically, initial evaluation with radiographs may be sufficient as a
screening. Brandt et al18 advocated the use of CT as an initial screen-
ing in trauma patients because of its high sensitivity. They suggested
that getting CT scans routinely, rather than plain radiographs, re-
duces the trauma patient’s time in the radiology area, as well as re-
ducing costs and radiation exposure.
MRI has played a lesser role in the early evaluation of trauma pa-
tients. However, it is excellent for evaluating soft tissue injuries and
swelling. When a bony injury cannot be identified that correlates
with symptoms, MRI may be pursued. However, as with any MRI,
patients must be carefully screened for any type of metal implants
that may make scanning dangerous to the patient.

INTRAOPERATIVE IMAGING
Spine surgery is a very demanding surgical discipline, allowing little
room for error while requiring maximum preparation and concentra-
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 31

2  Imaging of the Spine 31

tion. It is crucial to use all resources available to achieve the best re-
sults possible. One of the most powerful tools available in the oper-
ating room is imaging. During the past 25 years, many technologies
have been developed, and as a result, intraoperative imaging has be-
come increasingly important to provide accurate surgical results,
avoid unnecessary dissection, get quicker and more precise trajecto-
ries, and obtain better outcomes.
The exposure of the surgical field allows only two-dimensional
visualization. Therefore it is very important for all surgeons to ac-
quire a deep spatial sense to anticipate in a three-dimensional fashion
the exact final position of inserted implants.19
Plain radiographs are the first line of intraoperative imaging. As
mentioned previously in this chapter, the typical course is to begin
with the simplest and least expensive diagnostic tools and progress to
more complex or more expensive tools as necessary. In the operating
room, wrong-level disc surgery, especially in the thoracic region, is
a potential and unfortunately common occurrence. The use of AP
and lateral view plain radiographs helps the surgeon identify pre-
cisely the level of interest. In contrast, oblique radiographs are diffi-
cult to obtain during surgery and do not add much useful informa-
tion. For spinal screw insertion, the axial plane is the most important
view, but it is not obtainable with conventional radiographs during
surgery.20
Fluoroscopy has been used in spine surgery for many years and
provides real-time feedback. The drawback of fluoroscopy is that it
provides only two-dimensional information in the setting of complex
three-dimensional anatomy. It also delivers high doses of radiation to
the surgeon and patient, which may be especially unnecessary in min-
imally invasive procedures. In some studies, disruption of the pedicle
cortex ranges from 21% to 31% with fluoroscopy and decreases to
5.5% when axial CT images are used for localization.20
Advancements have been made to develop CT scanning and vari-
ous multidimensional fluoroscopy systems for use in the operating
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 32

32 The Pocket Spine

room (Box 2-1). Initially these were most often used for pedicle screw
placement in the thoracic and lumbar spinal regions. Currently their
applications have expanded to include the cervical spine and sacroili-
ac joints. There is enthusiasm about the potential benefit of these im-
aging technologies to provide more accurate device placement, thus
reducing complications such as nerve root injury related to malposi-
tioned spinal implants. The primary disadvantage is the cost of these
technologies. Also, there is a learning curve in their use. More re-
search is needed to help determine for which procedures and in
which patients these systems are cost-effective.

Box 2-1 Intraoperative CT Scan Use

• Maximize screw diameter and length in the thoracic and lumbar spine
• Revision case of the spine
• Extension of cervical fusions to the thoracic spine
• Deformity cases with small pedicles

The Era of Intraoperative Image-Guided Navigation

The need for intraoperative navigation in spine surgery was born out
of the neurosurgical experience with image-guided cranial surgery.
Today image guidance based on frameless stereotactic techniques is
widely used in spine surgery to better define anatomic landmarks, lo-
calize pathologic lesions, assist in creating novel pathways, and facil-
itate precise instrumentation placement.21-23 Spinal navigation pro-
vides the surgeon with additional three-dimensional information,
enhancing the accuracy of surgical procedures. Although computer-
assisted surgery was first introduced in the 1980s for the placement of
needles and probes into the brain, it was first used for spine surgery
in the 1990s.24
The benefits of navigation include increased accuracy, reduced
morbidity, reduced radiation exposure for patients and surgeons, and
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 33

2  Imaging of the Spine 33

improved patient outcomes. Intraoperative navigation is used to pro-

vide real-time feedback on position and instrumentation trajectory
based on a medical image (e.g., MR or CT). This feedback is achieved
by attaching a reference frame to the patient. These frames are usual-
ly attached to the tip of a vertebral spinous process. Optical systems
with infrared lights are the most commonly used.24 The reference
frame position is triangulated between a camera placed at the head or
foot of the operating table and a probe held by the surgeon. The tip of
the probe is displayed on a rendering of an imaging study, which is
shown on a monitor adjacent to the patient.

REQUIREMENTS FOR IMAGE-GUIDED NAVIGATION

Spinal navigation requires preoperative or intraoperative imaging
systems. The available options include preoperative CT images with
or without MR imaging fusion, cone beam CT, intraoperative two-
dimensional fluoroscopy, intraoperative three-dimensional fluo-
roscopy (three-dimensional C-arms rotating around an isocenter),19
and lately intraoperative CT imaging (O-arm, Medtronic Sofamor
Danek, Inc., Memphis, TN; BodyTom, Neurologica Corporation,
Danvers, MA; and Airo Mobile, DePuy Synthes, Raynham, MA). In-
traoperative MR imaging is used in cranial surgery; however, its use
during spine surgery has not been established.25
Digital imaging and communications in medicine (DICOM) image
sets from CT or MR scans that were obtained before or during sur-
gery are transferred to a computer that displays them. Registration
methods that pair imaging with a guidance system have evolved from
paired-point systems to surface-recognition software that can auto-
matically register intraoperative fluoroscopy/CT scanners. However,
the use of fiducials is not practical in the spine.20 After the software
registers the patient, it is extremely important to establish navigation
accuracy (e.g., comparing anatomic landmarks with image data),
which normally ranges from 0.42 to 1.08 mm. Errors ⫾ 1 mm are
generally accepted.24
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 34

34 The Pocket Spine

Red Flag: The use of image guidance requires some planning with respect to
the tracker, camera, and monitor placement.

CLINICAL USE
Navigation significantly improves the accuracy of screw placement in
all spinal locations.26-29

Lumbar Instrumentation
The first successful navigated implantation of pedicle screws was re-
ported in 1995.19,30,31 In 2007 Kosmopoulos and Schizas32 analyzed
37,337 navigated and nonnavigated pedicle screws described in 130
articles, including clinical and cadaveric studies. They found that
placement of nonnavigated pedicle screws had a mean accuracy of
90.3% compared with a mean accuracy of 95.1% for navigated pedi-
cle screws. In 2014 Sembrano et al29 showed a 20% change in sur-
geons’ decisions regarding spine procedures that were influenced by
intraoperative three-dimensional imaging information; these changes
significantly reduced complication rates, optimized surgical results,
and prevented reoperations.

Cervical Instrumentation
The use of cervical navigation, especially at the craniocervical and
cervicothoracic junctions, is quite helpful in spine surgery.19,33-37

Thoracic Instrumentation
The thoracic spine has complex anatomy and small pedicles. Image
guidance can be very helpful in this region.38 Thoracic spine surgery
is associated with a significant risk of injury (major complication rate
of 15% to 30% in herniated-disc surgeries).39-41 Navigation has been
an important factor in improving these complication rates by giving
surgeons real-time feedback during these challenging procedures.
02_Whitaker 2E_r3_cah_017-040.qxp:Whitaker 5/7/14 8:37 AM Page 35

2  Imaging of the Spine 35

In 2007 Rajasekaran et al42 treated 33 patients with thoracic defor-

mities and randomly assigned them into navigated and nonnavigated
screw insertion groups. They found that 23% of the nonnavigated
screws and only 2% of the navigated screws showed pedicle breaches.
Despite the breaches, none of the patients in either group had vascu-
lar or neurologic injuries.

OTHER USES
Other common procedures that benefit from image-guided naviga-
tion are the placement of percutaneous transpedicular screws, trans-
sacral approaches, and screw placement in patients with infection,
trauma, and other spinal deformities.25,43 Image-guided navigation
is not routinely used for anterior approaches and is still under devel-
opment.

Red Flag:
Advantages of navigation
• Reduced morbidity
• Increased implant accuracy
• Reduced exposure of the surgeon and patient to radiation
• Feedback for implant placement in all surgical settings with intraopera-
tive three-dimensional navigation
Disadvantages of navigation
• Repeated verification of landmarks required, with the possibility of losing
accuracy
• Additional time associated with setup
• Longer surgical times during the learning curve

ROBOTIC ASSISTANCE
Although there is limited evidence favoring robot-assisted pedicle
screw placement today,44 this paradigm will most likely be important
in the future of spine surgery.
 Another Random Document on
Scribd Without Any Related Topics
"Let's go in now," suggested the other, after a long silence.
"All right—come on, Major!"
The sun was shining brightly on the water, and the dog barked
joyously as they plunged in. "Keep him here," said Ronald, "I'm
going on out." Robert watched him enviously as he swam north-east
with a long, free stroke, until he was almost out of sight. The dog
was eager to be after him, and, having no collar, was not easily
controlled. When he came back, aglow with life, it seemed to the
other that he had the clean-limbed beauty of a young Greek god.
"You go now," shouted Ronald, "and I'll amuse the pup."
Forsyth swam straight out, with an exultant sense of power in
breasting the waves, and his pulses thrilled with something so vital,
keen, and elemental that it seemed as if he could go on forever.
When he turned back, he saw the gleam of light far to the
northward, where the sun shone on the cross, and thought of
Beatrice, happily, and of the day in the woods. He was well in
toward shore when his muscles suddenly lost their strength—as if he
had forgotten how to swim. He called once, but faintly, then
unutterable darkness surrounded him.
When he came to his senses he was lying on the sand, and Ronald
was rolling him over and over and pounding him vigorously. A whine
sounded indistinct and far, as if it were leagues away, even while the
dog was licking his face.
"My God, man," said the Ensign, with white lips, "I'd almost given
you up!"
The voice beat painfully upon his ears and his senses were confused,
but he tried to sit up. "What was the matter?" he gasped.
"Cramps, I guess—that's the usual thing. We'd better have let Major
drown and gone out together. I had a nice time getting both of you
back to shore."
Ronald continued his violent treatment until the other protested.
"Don't hit me again," he said faintly, "I'm all right!"
"Pile into your clothes, then, or you'll take cold."
He obeyed, but slowly, for he was thoroughly exhausted and
movement was difficult. Ronald was dressed long before he was,
and insisted upon helping him.
"There, now you're fixed," he said, at length; "and if you're good for
it, we'll go back to the bank and sit down a bit. There's no hurry
about going home."
Forsyth was faint when they reached the tall tree they had started
from, and was more than willing to rest. His speech was still thick,
but he stammered his thanks.
"You owe it to Major," explained Ronald, diffidently, "for I never
would have seen you. He started out, all of a sudden, and I went
after him. Of course I wondered what had happened when I didn't
see you, but I thought you were swimming under water. He found
you, though. Good old boy," he added, patting the dog.
"I'm much obliged to both of you," said Robert weakly. "I've been in
the water more or less all my life, and nothing like that ever
happened to me before."
"Hope it won't again—the first time came mighty near being the
last."
Forsyth had more strength than he appeared to have, but the shock
was severe. "There's no hurry," said George, "and we won't go back
till you're ready for a long walk. Say, how did you feel?"
"Why, I don't know exactly. I was all right, and I was thinking what a
glorious swim I was having and how fine the water was, when all at
once I couldn't move, and everything was black. I think I called you,
though."
"Didn't hear you, but I guess the dog did. Queer, isn't it, that it
should come just after we had been talking about death and the
hereafter and so on?"
"Perhaps it was a warning."
"You're superstitious, now," returned Ronald; "but there's no getting
out of it—when we get near the jumping-off place it makes us feel
devilish queer. I was nearly crazy when I got you to shore and found
you were dead—the thing came so quick, why, it was like a stroke of
lightning."
"If that's death, though, it's nothing to be afraid of. Everything was
black and soft, and there was no hurt to it—just a stop."
"Do you know," said the Ensign, "I've never seen very many dead
people, and I've never seen anybody who had been killed in an
accident—suddenly, you know. Those fellows up at Lee's were the
nearest to it, but I didn't see them." His face whitened and his hands
clenched instinctively. "God!" he breathed, between his set teeth, "I
hope I'll be spared a death like that, at the hands of the red devils. I
want to die like a soldier—in battle!"
"Come," said Forsyth, smiling, "we're getting serious—let's go back."
"Do you feel all right?"
"Yes; I'm a little shaky, but I guess I'm good for it. Don't say
anything about it at the Fort, nor anywhere else—the women would
make a great row."
"As you say—it's your business, you know."
In spite of Forsyth's valiant efforts, his progress was slow. "I'm as
weak as a woman," he complained, when he was forced to stop and
rest for the fourth time.
"You'll make it all right," said the other, cheerily; "take your time.
And say, when we get back, come on over to the Fort and get a
good stiff drink of whisky—that will set you on your pegs as quickly
as anything."
When they came to the river Forsyth sat down and waited until
Ronald went down to Mackenzie's, got a pirogue, and came up after
him. "Didn't see anybody," said Ronald, in answer to a question,
"and it's just as well. You're pretty white around the gills yet."
"Steady," he continued, as the boat grazed the shore, "and in ten
minutes you'll be a new man."
Mrs. Franklin and Mrs. Howard were playing battledore on the
parade-ground, while Beatrice and the Lieutenant watched them
from the piazza. Captain Franklin, Mackenzie, and a couple of
Indians were standing in front of the Captain's quarters, and Ronald
yearned to join the group and see what was going on. He gave
Robert his flask, bade him take it slowly, and rushed out.
The Indians were just leaving, and Captain Franklin had started back
to the house, when one of them turned back and said something.
"What did he say?" he asked of Mackenzie.
"Nothing," replied the trader, with the dull colour bronzing his face;
"they ain't our folks, you know."
"I insist upon knowing," said Franklin, peremptorily.
Mackenzie came nearer and lowered his voice to a whisper. "He said
something about the women over there,"—indicating Mrs. Franklin
and Mrs. Howard. "He said 'the white chief's wives are amusing
themselves very much. It will not be long before they are hoeing in
our corn-fields.'"
"Humph!" snorted the Captain.
"Oh!" laughed Ronald, "I must tell 'em!"
"Shut up," said the Captain; "you will do no such thing!"
"All right," returned the younger officer, good humouredly, "they're
not my wives!"
 CHAPTER XIII
GIFTS

"Cousin Rob," said Beatrice, the next morning, "I think you're
dreadfully stupid."
"Why?"
"Because—yesterday, you know."
"You're indefinite."
"Why, when Aunt Eleanor was telling about the quilt that was stolen
—a white quilt, with blue stars—you didn't know where it was."
"Did you?"
"Of course I did—it's in the little house in the woods."
"I wasn't in the house, Bee—you told me about it, but I didn't see
it."
"Well, anyhow, you should have known," she concluded, with truly
feminine inconsistency.
"Perhaps," smiled Robert; "but I'd rather not know, and then there'd
be an excuse for your telling me."
A faint colour came into the girl's cheeks. "I had an awful dream
about you last night," she said, in a low tone; "I dreamed you were
drowned in the lake."
Robert started, but managed to control his voice. "I'm not drowned,"
he answered, with apparent lightness; but he was wondering
whether Ronald had broken his promise. Still, no one had crossed
the river, from either side, since the accident—he was sure of that.
"Be careful, won't you?" Beatrice pleaded earnestly.
"Certainly—but would you care?"
All the rosy tints faded from her face and the mist came into her
eyes. Her "yes" was scarcely audible, but it moved the man
strangely. "I'd do anything to please you, my dear—cousin," he said
tenderly.
"Quarrelling?" asked Mackenzie, from the doorway.
"Not this time," laughed the girl.
"I've got something to tell you, Bee. Black Partridge was here early
this morning, long before you were up, and apologised for running
off with the picture—that is, as nearly as an Indian ever apologises.
From what he said, I infer that he thinks the Great Spirit dwells in
you, but he is willing for you to finish it. The medicine-man of the
tribe told him good would come from it, rather than evil, so he left it
here to be completed."
"All right," she answered; "I'll go to work at it now and try to get it
done before he changes his mind again."
Robert brought the picture and her paints, and they sat down
together on the piazza while she added the finishing touches.
"Couldn't we make a frame for it?" asked Robert.
"What could we make it of?"
"He'd prefer beads, wouldn't he?"
"Yes, I suppose so," she said, with a puzzled little frown; "but I don't
know how to make a bead frame."
"I should think a plain wooden frame might be whittled out, smeared
with pitch or rosin, and the beads stuck on while it was hot."
"You're a genius, Cousin Rob. Get the beads off uncle and make it
while I'm finishing the picture."
Mackenzie willingly placed his stock at their service, and, after taking
careful measurements, Forsyth found a piece of soft pine and made
a narrow, flat frame. Beatrice finished her work in time to help set
the beads in the rosin, and Mackenzie and his wife came out to
admire the result.
The picture was framed to their satisfaction when Black Partridge,
somewhat shamefaced, appeared at the trading station. He took it
with every evidence of delight and made a long speech to
Mackenzie, of which Robert understood only a little.
"What does he say?" asked Beatrice, impatiently.
"He says he is very thankful and very grateful and much pleased,
and that as long as he lives neither of you shall ever want for a
friend. He says while the sun rises and sets and the stars move in
their courses, Black Partridge will be the faithful friend of the
paleface and her lover."
Robert was much embarrassed, but Beatrice only laughed. "Tell him
he is very welcome," she said, "and that when we need a friend we
will not hesitate to call upon Black Partridge."
The speech was duly repeated, with additional assurances which
Mackenzie knew would please the chief, and the visit was ended
with much ceremony.
Ronald was coming across the river, and Beatrice lingered upon the
piazza until he opened the gate, when she gathered up her paints
and went into the house without a word of greeting. There was a
shade of annoyance in the Ensign's salutation, but he made no
allusion to the girl.
"Come on out for a bit," suggested Robert; "I want to talk to you."
They went north along the river bank in silence until they were out
of sight of the house, then Robert turned suddenly and faced him.
"Say," he said, "did you tell any one about my—about yesterday, you
know?"
"No," answered Ronald, meeting his eyes squarely; "why?"
"Oh—nothing. Are you sure you didn't say anything that would lead
any one to suspect?"
"'Nary peep, unless I talked in my sleep. When I found out that
you'd drained my flask of everything but the smell, I went to Doc
after a new supply, and when he asked me what had become of it I
told him you'd taken to drink, but that was all. Now, I'll ask you a
few questions. Why doesn't Miss Manning want me to come over?"
"Why, I don't know," replied Forsyth, wonderingly; "doesn't she?"
"Doesn't look like it," grumbled the other. "Didn't you see her gallop
into the house the minute I opened the gate?"
"I didn't notice."
"You would, if she'd done it to you." Ronald was plainly in a bad
humour. "What's more, if I speak to her, she never answers me
decently. A girl never treated me like that before," he fumed; "just
wait till I get my new uniform!"
"When is it coming?" asked Forsyth, glad of the chance to change
the subject.
"Dunno—the boys are going to start early in the morning, but there's
no telling when they'll get back."
"Are you going?"
"Indeed, and I am not. How can I go when there's no horse for
me?"
"I thought you were going to—to borrow," stammered the other.
"Hardly!" The Ensign stopped and wiped his forehead with his
sleeve. "Suffering Moses!" he said, "wouldn't she be mad!"
"Yes, I think she would, but I don't see why. She lets you lead
Queen, doesn't she?"
"Oh, Lord, yes! I'm allowed to lead the beast twenty times around
the Fort every day for exercise—she said we both needed it, and she
didn't want to ride while it was so hot,—but she particularly
impressed it upon me that under no circumstances was I to mount.
A groom—a stable boy,—that's what she thinks I am! I believe I'll
tell her to lead her own nag!"
"I wouldn't," returned Forsyth.
"Why not?" demanded the other. "What do you know about
women?"
"Not very much," admitted Robert, laughing; "but we're all at sea
there, I fancy."
Gradually Ronald's temper improved, and in a short time he was his
sunny self again. Peace dwelt in the woods along the river, and
where the young officer stretched himself full length under an
overhanging willow, the quiet coolness of the unsunned spaces put
an end, insensibly, to his irritation.
"Say," he said, "did you ever write poetry?"
Forsyth smiled, remembering certain callow attempts in his college
days. "Yes, I called it that."
"Then you're the very man for me," announced George, "for I'm
going to write a poem!"
"What about?"
"Oh—er—anything. Poems don't have to be about anything, do they?
It's to go with a present—a birthday present, you know."
"To a girl?"
Ronald laughed long and loud. "No," he cried; "of course not! It's a
little tribute of affection for the Captain! Lord, but you're green!"
"How can I help you with it if I don't know the circumstances?"
demanded Forsyth. "What is the present?"
"The present isn't much—the poem is the main part of it. It's an
Indian basket that Mrs. B. P. made for me in return for two fists of
beads." Ronald took off his cap, felt around carefully inside of it, and
at length produced a slip of paper, much worn. "I've got some of it,"
he said, "and I thought if I kept it on my head it might stimulate
thought, but it hasn't."
"Let's hear it."
The poet cleared his throat and read proudly:
 "Lovely lady, take this basket;
'Tis your willing slave who asks it."
Robert bit his lips, but managed to turn a serious face toward
Ronald. "Is that all you've got?"
"That's all, so far. I thought myself into a headache about it, but I
couldn't write any more. What shall I put in next?"
"I don't want to seem critical," observed Forsyth; "but you've got a
false rhyme there."
"What's a 'false rhyme'?"
"'Basket' and asks it'—'ask it' would be all right."
"It doesn't fit. We'll leave that just as it is—nobody but you would
notice it, and you're not getting the present."
"What do you want to say next?"
"Well, I don't know, exactly," replied Ronald, confidentially. "Of
course, I want it to be personal in a way, with a delicate reminder of
my affection at the end of it."
"You've got a 'delicate reminder,' as you call it, in the second line."
"Never mind that; go to work."
"Lovely lady, take this basket;
'T is your willing slave who asks it,"
repeated Robert, thoughtfully. "It was made by an Indian maiden—
how would that do?"
"That's all right, only it was a squaw."
"It was made by an Indian squaw, then," continued Robert. "What
rhymes with squaw?"
"Dunno."
"Paw," said Forsyth.
 "It was made by an Indian squaw
With a dark and greasy paw."
"Shut up!" said Ronald. "She'd throw it out of the window if she
thought it wasn't clean. Call her a maiden if you like."
"It was made by an Indian maiden—there isn't any rhyme for
'maiden.'"
"Laden," suggested George, after long and painful thought.
"That's good, if we can work it in."
"It was made by an Indian maiden—
With my love it now goes laden.
"How's that?"
"Fine!" beamed Ronald. "Say, I didn't know you were a poet!"
"Neither did I," replied Forsyth, modestly.
"Lovely lady, take this basket:
'Tis your willing slave who asks it.
It was made by an Indian maiden—
With my love it now goes laden."
"That's simply magnificent!" said Ronald. "We ought to write another
verse, hadn't we?"
"As you say."
"If we can do another one as good as that, it'll be a masterpiece. My
name ought to come in at the end, hadn't it?"
"Nothing rhymes with 'Ronald,' does it?"
"I didn't mean that—I meant my front name."
"Oh," said Forsyth. He was wondering how the girl in Fort Wayne
would like the poem, and longed to ask questions about her, but felt
that it would be improper.
"'Forge' is the only thing I can think of for a rhyme," said the Ensign,
at length; "that wouldn't do, would it?"
"My heart is burning like a forge,
All because I love you—George."
"How's that?"
Ronald's delight knew no bounds. "The very thing!" he shouted.
"Now, all we have to do is to put two lines above it and it will be
done. That's the end of the verse, you know."
"Might put her name in," suggested Robert, not without guile.
Ronald appeared to consider it carefully. "No," he said, "that
wouldn't do. One name is enough to have in it. Something ought to
go in about her looks, don't you think so—eyes, or mouth, or skin?"
"'Skin,'" repeated Robert, laughing; "girls never have 'skin.' They call
it their 'complexion.'"
"Thought you didn't know anything about women," George said,
looking at him narrowly.
"Oh, come now, I can't help knowing that—any fool knows that!"
"Except me," put in the Ensign, pointedly. "However, I'll let the insult
pass for the sake of the poem. Put in something about her mouth,
can't you?"
The vision of Beatrice's scarlet, parted lips, with their dangerous
curves, came before Robert.
"Reddest roses of the South
Are not sweeter than your mouth,"
he suggested.
"Man," said Ronald, soberly, "you're a genius. Write it down quick
before it gets away. Now I'll read the whole thing:
 "Lovely lady, take this basket;
'T is your willing slave who asks it.
It was made by an Indian maiden—
With my love it now goes laden.

"Reddest roses of the South

Are not sweeter than your mouth;
My heart is burning like a forge,
All because I love you—George.
"Sounds like Shakespeare, doesn't it?"
"I wouldn't say that," answered Forsyth, with proper modesty.
"Got any good paper to write it on?"
"Only a little, but you're welcome to it."
"All right, let's go back and get it. Say, do you think she'll be
pleased?"
"She can't help being pleased," Robert assured him.
"I'm ever so much obliged," said Ronald diffidently. "I never could
have done it so well alone."
When they reached Mackenzie's, Beatrice came out on the piazza as
Robert went in after the paper, and she was evidently inclined to
conversation.
"Where have you been?" she asked sweetly.
"Oh, just up-stream a little ways," replied Ronald, carelessly.
"Have you had Queen out this morning?"
"Yes, I rode her half-way to Fort Wayne and back. She got pretty
well used up, but it did her good."
"How dare you!" flamed Beatrice, stamping her foot.
Ronald laughed and leaned easily against the side of the house while
she stormed at him. Even Robert's appearance did not have any
effect upon her wrath.
"Say, Rob," said the Ensign, when she paused to take breath, "your
cousin here doesn't seem to know a joke when she sees it. She
thinks I'd ride that old gun-carriage she keeps in the garrison
stables. Calm her down a bit, will you? Bye-bye!"
The fire died out of the girl's eyes and her lips quivered. Her breast
was heaving, but she kept herself in check till Ronald slammed the
gate, then her shoulders shook with sobs.
"Bee!" cried Robert. "Don't, dear!"
Instinctively he put his arm around her, and she leaned against his
shoulder, sobbing helplessly, her self-control quite gone. Ronald was
untying a pirogue at the landing, when he looked back and saw the
inspiring tableau.
"Good Lord!" he said, under his breath, as Robert, with his arm still
around her, led Beatrice into the house.

Later in the week, as Robert was on his way to breakfast, he met

Maria Indiana in the long, narrow passage back of the living-rooms.
"What have you there, baby?" he asked.
Maria Indiana held out a small Indian basket of wonderful
workmanship, filled with berries, fresh and fragrant, with the dew
still on them. Tucked in at one side was a note, written upon his own
stationery, as he could not help seeing. "It's for Tuzzin Bee!" lisped
the child. "Misser George said nobody mus' see!"
The little feet pattered down the passage, but Robert stood still for a
moment, as if he had turned to stone. Then wild unrest possessed
him and stabs of pain pierced his consciousness. "Fool that I was!"
he said to himself, bitterly; "blind, cursed fool!"
All at once he knew that he loved Beatrice with every fibre of his
being—that she held his heart in the hollow of her hand, to crush or
hurt as she pleased. He was shaken like an aspen in a storm—this,
then, was why her flower-like face had haunted his dreams.
Swiftly upon the knowledge came a great uplifting, such as Love
brings to the man whose life has been clean. It was a proud heart
yielding only to the keeper of its keys—the absolute surrender of a
kingdom to its queen.
Beatrice was late to breakfast, as usual; and Robert, acutely self-
conscious, could not meet her eyes. She brought the basket with her
and offered the berries as her contribution to the morning meal.
Between gasps of laughter she read the poem, thereby causing
mixed emotions in Forsyth. "Did you ever hear anything so
ridiculous?" she asked, wiping the tears of mirth from her eyes.
Robert wished that the giver might see the rare pleasure his gift had
brought to the recipient, but swiftly reproached himself for the
ungenerous thought.
"It was nice of him to remember your birthday, Bee," said Mrs.
Mackenzie, who was always ready to defend Ronald.
"How did he know it was my birthday?" demanded Beatrice.
"I told him," replied Mrs. Mackenzie. "He asked me, long ago, to find
out when it was and to let him know."
"Clever of him," commented Beatrice, somewhat mollified. "Why
didn't you get something for my birthday, Cousin Rob?" she asked,
with a winning smile.
"Perhaps I did," he answered; "the day is still young."
He had already decided what to give her, and knew that his offering
would not suffer by comparison with Ronald's, even though no poem
went with it; but when he went to his room to look in his box for the
moccasins he had bought so long ago, he was astonished to find
that they were gone.
He ransacked the room thoroughly, but without success. He could
not even remember when he had seen them last, though he knew
he had taken them down from the wall of his room and put them
away. Still, he was not greatly concerned, for he was sure that he
could go to the Indian camp and find another pair.
After school he started off on a long, lonely tramp, and returned at
sunset, empty handed and exasperated. Beatrice had on her pink
calico gown, and was sitting demurely upon the piazza—alone. She
seemed like a rose to her lover, and he was about to tell her so, but
she forestalled him.
"Where's my birthday present?" she asked, sweetly; "I've been
looking for it all day!"
Then he told her about the moccasins he had for her, though he
failed to mention the fact that he had bought them for her long
before she came to Fort Dearborn. "When I went after them this
morning," he said, "I discovered that they had been stolen. I've
been out now to see if I couldn't get another pair, but I couldn't
even find a squaw who was willing to make them. You don't know
how sorry I am!"
"Never mind," she said soothingly, "it's no matter. Of course, I'd love
to have the moccasins, but it's the thought, rather than the gift, and
I'd rather know that you found out from Aunt Eleanor when my
birthday was, and tried to give me pleasure, than to have the
pleasure itself."
The colour mounted to Robert's temples, but he could not speak. He
felt that his silence was a lie, and a cowardly one at that, but he was
helpless before the girl's smile.
"What's that?" asked Beatrice, suddenly, pointing across the river.
There was a stir at the Fort. Men ran in and out, evidently under
stress of great excitement, then a tall and stately being, resplendent
in a new uniform, came out and turned a handspring on the
esplanade.
"What's up?" shouted Robert.
Ronald turned another handspring and threw his cap high in the air
before he condescended to answer. "Bully!" he roared; "we're going
to fight! War is declared against England!"
 CHAPTER XIV
HEART'S DESIRE

Those who had complained of Captain Franklin's lax methods were

silent now. The fortifications were strengthened at every possible
point and pickets were stationed in the woods, at points on the lake
shore, along the Fort Wayne trail, and at various places on the
prairie. There was no target practice for fear of a scarcity of
ammunition; but the women were taught to handle the pistols,
muskets, and even the cannon in the blockhouses.
Mackenzie, Forsyth, and Chandonnais divided the night watch at the
trading station. At the first sound of a warning gun, the women and
children were to be taken to the Fort. As before, Beatrice was to go
to Captain Franklin's, Mrs. Mackenzie and the children to Lieutenant
Howard's, and the men to barracks.
"I guess I'll move over anyway," said Beatrice. "I wouldn't care to
make the trip in the night. I'll sleep at the Captain's and eat
wherever I happen to be."
Mrs. Franklin was not told of the plan until Beatrice and Robert
appeared at her door with the enterprising young woman's
possessions, but she made her guest very welcome.
"Why didn't you tell me you were coming?" she asked.
"What would be the use of telling you?" inquired Beatrice. "You'd be
obliged to say you wanted me, so I just came."
The Captain's wife was genuinely glad, for of late she had been very
lonely. Franklin was always more or less absorbed in his own affairs,
and the feeling between Lieutenant Howard and his superior officer
did not tend to promote friendly relations between the women.
There had been no open break, but each felt that there might be
one at any time.
Ronald was in high spirits. Since he had given Beatrice the basket
she had treated him more kindly, and he led Queen twenty times
around the Fort every day for exercise, without a murmur of
complaint. Beatrice stood at the gate and kept count; while, across
the river, Forsyth sat on the piazza and envied the Ensign, even
during his monotonous daily round.
Among the officers at the Fort the declaration of war had not been
altogether unexpected, for vague rumours of England's arrogance
upon the high seas had reached the western limits of civilisation, but
the situation was covered only by general orders from the War
Department.
For once, Lieutenant Howard agreed with the Captain, in that there
seemed to be no great possibility of a British attack. However
valiantly defended, the Fort could not be held long in the face of a
vigorous assault from the enemy, since the fighting force numbered
less than sixty men, but England would have nothing to gain from
that quarter. Other points were far more important than Fort
Dearborn, but the garrison was ready to fight, nevertheless.
Ronald was more sanguine, and lived in hourly hope of hearing the
signal of the enemy's approach. He sharpened the edge of his sword
to the keen thinness of a knife blade, and slept with one hand upon
his pistol. Doctor Norton, too, was making elaborate preparations in
the way of lint and bandages, and Ronald helped him make
stretchers enough to last during a lifetime of war.
But the days passed peacefully, and there were no signs of fighting.
The Indians were particularly lawless, but confined their violence to
their own people, though they had lost, in a great measure, their
wholesome fear of the soldiers at the Fort.
"The devils are insolent because they think there's going to be
trouble, and in the general confusion it will escape notice," remarked
Ronald, as he sat in the shade of Lieutenant Howard's piazza. "I'm in
favour of stringing up a few of 'em by way of example to the rest."
"Yes," replied Howard, twisting his mustache, "and in a few minutes
we'd have the entire Pottawattomie tribe upon us. You don't seem to
understand that they knew war had been declared long before we
did, and that even now, in all probability, they are in league with the
enemy. No people on earth are too low down for England to ally
herself with when she wants territory."
"True," answered Ronald; "but I'm not afraid of England. She's had
one good lesson, and we'll give her another any time she wants it."
"We've got enough on our hands right here," sighed the Lieutenant,
"without any more foreign wars. We've got to have it out with the
Indians yet, and fight our way step by step. The trail of blood began
at Plymouth and will end—God knows where. England is more or
less civilised, but she isn't above setting the Indians upon us to
serve her own ends."
"What are you talking about?" asked Beatrice, coming across from
Captain Franklin's.
"Yes, do tell us," said Katherine, from the doorway.
"Affairs of state," answered the Lieutenant, easily.
"Any British in sight?" inquired Beatrice.
"Not yet," replied Ronald; "but the entire army is likely to drop on us
at any minute."
"What would you do?" she asked curiously.
"Do?" repeated Ronald, striding up and down in front of the house;
"we'd call in the pickets, bar the gates, man the guns, and send the
women and children into the Captain's cellar."
"Could Queen go, too?"
"Can Queen go down a ladder?"
"She never has," answered Beatrice; "but she could if she wanted to
—I'm sure of it."
"If that's the case," said Lieutenant Howard, "we'd better offer her
to the British officers as a trick horse and buy off the attack."
"If they come in the daytime," continued Beatrice, ignoring the
suggestion, "I will go out to meet them all by myself. I'll put on my
pink dress and my best apron, and carry a white flag in one hand
and the United States flag in the other. When the British captain
comes running up to me to see what I want, I'll say: 'Captain, you
are late, and to be late to dinner is a sin. We have been looking for
you for some time, but we will forgive you if you will come now. The
invitation includes the ladies of your party and all the officers.' They
never could shoot after that."
Katherine joined in the laugh that followed, but her heart was
uneasy, none the less. Like Ronald, she was continually expecting an
attack and knew there could be but one result. She believed that the
Indians and the British would make common cause against them,
when the time came to strike.
"I'll tell you what," said Ronald, "some of us ought to go out and
drag in Mad Margaret. If we stood her up on the stockade, there
isn't an Indian in the tribe who would dare to aim an arrow or throw
a tomahawk toward the Fort."
"I've never seen her," said Beatrice, thoughtfully.
"I hope you never will," answered Ronald, quickly. "She's crazy, of
course; but she has an uncanny way about her that a sensitive
person would consider disturbing. She pranced into the Fort on a
Winter afternoon two years ago and prophesied a flood, followed by
a terribly hot Summer, and no crops. When the Spring rains came,
the river spread on all sides, and, sure enough, there were no crops
that year."
"Was it hot, too?"
"Oh, Lord! Was it hot? If hell is any hotter I don't care to go to it."
"You talk as if that was your final destination," observed Katherine.
"That's as it may be," returned the Ensign. "I've often been invited
to go, and several times I've been told that it was a fitting place of
residence for such as I."
"I didn't know about that," said the Lieutenant, thoughtfully,
referring to the fulfilment of the prophecy.
"You weren't here," explained Ronald. "It was before you came—in
1810, I think."
"Cousin Rob told me about her," said Beatrice. "He said she came to
Uncle John's the same day he did, and he's seen her once or twice
since. She always says that she sees much blood, then fire, and
afterward peace."
"Yes," growled the Ensign; "she's for ever harping on blood. She
stuck her claws into me that night, I remember—told me I should
never have my heart's desire."
"What is your heart's desire?" asked Beatrice, lightly.
The Summer faded and another day came back. Once again he sat
before the roaring fire at the trading station, with Forsyth,
Mackenzie, and Chandonnais grouped around him, while phantoms
of snow drifted by and sleet beat against the window panes. Then
the door seemed to open softly and Mad Margaret made her way
into the circle. Chandonnais' wild music sounded again in his ears,
then he felt the thin, claw-like hands upon him and heard the high,
tremulous voice saying, "You shall never have your heart's desire";
and, in answer to his question, "It has not come, but you will know it
soon."
The blood beat in his ears, but he heard Beatrice say, once more,
"What is your heart's desire?"
A flash of inward light revealed it—the girl who stood before him,
with the sunlight on her hair, and her scarlet lips parted; strong and
self-reliant, yet wholly womanly.
Ronald cleared his throat. "You shouldn't ask me such questions," he
said, trying to speak lightly, "when all these people are around."
"We'd better go, Kit," remarked the Lieutenant; "we seem to be in
the way."
"Anything to please," murmured Mrs. Howard, as they went into the
house.
Ronald was looking at Beatrice, with all his soul in his eyes. "I—I
must go," she stammered. "Aunt Eleanor will want me."
"Don't—dear!" The boyishness was all gone, and it was the voice of
a man in pain. The deep crimson flamed into her face and dyed the
whiteness of her neck just below the turn of her cheek. She did not
dare to look at him, but fled ignominiously.
He did not follow her, but she heard him laugh—a hollow, mirthless
laugh, with a catch in it that sounded like a sob. She never knew
how she crossed the river, but she was surprised to find Forsyth
waiting for her. As he helped her out of the pirogue, he said; "I was
just going after you—we feared we had lost you."
"I'm not lost," she said shortly, "and I don't want people running
around after me!"
The shadow that crossed his face haunted her, even while he sat
opposite her at dinner and laughed and joked with her as usual.
When Mrs. Mackenzie took the baby away for his afternoon nap,
with Maria Indiana wailing sleepily at her skirts, Beatrice went to her
own room, fearing to be alone with Robert. She was strangely
restless, and something seemed to hang over her like an indefinite,
threatening fate.
Outside was the drowsy hum of midsummer, where the fairy folk of
the fields rubbed their wings together in the grass and the sun
transformed the river to a sheet of shining silver. Ronald came out,
took the good boat which belonged to the Fort, and pulled down-
stream with long, steady strokes. The river was low, but he passed
the bar with little difficulty and went on out into the lake.
Beatrice heard Robert singing happily to himself, but she could not
stay any longer where she was. She gathered up her sewing and
climbed out of the window, ungracefully but effectively, and went
back to the Fort.
Katherine saw her coming and smiled. That morning, with quick
intuition, she had read the secret in Ronald's heart, and suddenly
knew how much she cared for the boy who teased and tormented,
but never failed her if she needed him. In her own mind, she had
written down Beatrice as an unsparing coquette, and determined to
take up the cudgels in behalf of her victim.
The girl sewed nervously, breaking her thread frequently, but she
kept at it until Katherine said, very gently, "Bee, George cares for
you."
"I know!" snapped Beatrice. Her thread broke again, and her hands
trembled so she could scarcely knot it.
"And Robert, too," said Katherine, presently.
"I know!"
"Well, dear, what are you going to do about it?"
"Cousin Kit," said the girl, angrily, "if you're going to lecture me, I'm
going back home." She folded up her work, but Mrs. Howard put a
restraining hand upon her arm.
"Don't, Bee. You know we talked about my trouble together—why
can't we talk about yours?"
"I haven't any trouble!" Beatrice's face was flushed, but her voice
was softer, and she seemed willing to stay.
"What are you going to do about it?" asked Katherine, once more.
"What can I do about it?" cried Beatrice, in a high key—"why, that's
simple, I'm sure! I can go to Mr. Ronald and say, 'Please, Mr. Ronald,
don't ask me to marry you, because I'm going to marry Cousin Rob.
He doesn't know it yet; in fact, he hasn't even asked me, but I'm
going to do it just the same.' Or, I might go to Cousin Rob and say,
'My dear Mr. Forsyth, I hope you won't ask me to marry you,
because I'm going to marry Mr. Ronald, who hasn't asked me as yet.
In fact," she continued, with her temper rising, "I've about
concluded that I won't marry anybody!"
"Bee, dear, I'm only trying to help you—please don't be cross to me.
Which one do you care for?"
"Neither!" cried Beatrice, in a passion. "I don't care for anybody, and
I'm never going to be married. I'd be happy, wouldn't I? Tied up—
chained like a dog—take what my master gave me—slave—drudge—
bear whatever burden he saw fit to put upon me—eat my heart out
in loneliness—cry all day and all night for my lost freedom. Marry?
Not I!"
"Marriage means all those things, as you say," said Katherine, after a
silence; "but the bitterest part of it is that, when you find your mate,
you have to go. The call is insistent—there is no other way. It means
child-bearing and child loss—it means a thousand kinds of pain that
you never knew before,—loneliness, doubt, sacrifice,
misunderstanding,—and always the fear of change. Before, you think
of it as a permanent bond of happiness; later, you see that it is a
yoke, borne unequally. You marry to keep love, but sometimes that
is the surest way to lose it.
"They say," continued Katherine, with her face white, "that after the
first few years the storm and stress dies out into indifference, and
that happiness and content are again possible. But oh," she
breathed, "those few years! If man and woman must go through the
world together, shoulder to shoulder, meeting the same troubles, the
same difficulties and dangers, why, oh, why, didn't God make us of
the same clay! We are different in a thousand ways; we act in
opposite directions, from differing and incomprehensible motives—
our point of view is instinctively different, and yet we are chained.
Sex against sex it has been since the world began—sex against sex
it shall be to the bitter end!"
"Katherine!" sobbed Beatrice, "I know! That is what I am afraid of!
All the time I keep tight hold of myself to keep from caring, because
I dare not surrender. If I yield, I am lost. If I loved a man, he could
take me between his two hands and crush me—so; I should be so
wholly his!"
"Yes," said the other, bitterly, "and many times he will crush you, just
to see if he can—just to see that he has not lost his command of
you. Power is what he must have—power over your mind and body,
your heart and your soul—for every little unthinking action of yours,
you are held responsible before the bar of his justice. His justice,"
she repeated, scornfully, "when he does not know what the word
means. You have a little corner of his life; you give him all of yours
in return. We are bound like slaves that never can be free—God
made it so—and we obey!"
There was a tense silence, then a step was heard upon the piazza,
and Katherine opened the door to her husband. Beatrice managed to
wipe her wet eyes upon her sewing before he saw that she was
there.
"Well," said the Lieutenant, easily, sinking into a chair, "what have
you girls been doing?"
"Oh, we've just been talking," answered Katherine, diffidently.
"Talking, talking,—always talking," he continued. "What would
women do if they couldn't talk?"
"They'd burst," remarked Beatrice, concisely.
"I guess that's right," laughed the Lieutenant; "but you needn't fear
it will happen to you."
"You're mean to me," said Beatrice, gathering up her work, "so I'm
going home."
"Don't be in a hurry," put in Katherine.
"I haven't been—you don't want me to live here, do you?"
"We should be charmed," replied the Lieutenant, gallantly.
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