A Plea for Language Accuracy in Spinal Treatment

Language accuracy is fundamental to communication in all phases of life, and medicine is one of the areas in which precise accuracy is essential. Spinal surgeons have developed over many years a language of the profession. However, there remain areas of inadequacy and imperfection that need to be solved. This article is an attempt to identify and clarify some of these areas. REVIEW OF THE LITERATURE The efforts of various societies, especially the Scoliosis Research Society and the North American Spine Society, through their terminology committees, have greatly improved the confusion that once existed. A good example is the definition of spinal curvature types by the position of the apex of the curve. Another good example was the universal adoption of the Lippman–Cobb method of measurement of curves on a plain x-ray film. MATERIAL AND METHODS The authors, frequent attendees at many spinal conferences in North America as well as worldwide, have developed a list of commonly misused terms. As this list grew and as we continued to hear these misused terms, we decided to go to the dictionary and the already-existing terminologies of various societies to determine what was correct and what was not. The following terms are those we thought the most glaring and most in the need of proper definition. RESULTS ”Thoracic” Versus “Dorsal” Those vertebrae occurring in the chest or thoracic area, defined as those to which ribs are customarily attached, are thoracic vertebrae. The word “dorsal” is the opposite of the word “ventral.” A dorsal spondylodesis (arthrodesis) refers to a posterior fusion operation on the spine and can occur anywhere from the occiput to the sacrum. A thoracic spondylodesis (arthrodesis) refers to a fusion operation involving the thoracic vertebrae, whether done anteriorly (ventrally) or posteriorly (dorsally). TLSO Brace ”TLSO” stands for thoraco-lumbar-sacral orthosis. The word “orthosis” is a synonym for “brace.” It is therefore redundant (and incorrect) to use the phrase “TLSO brace.” Scoliosis Curve As the word “scoliosis” means a lateral curvature of the spine, the phrase “scoliosis curve” is redundant (and incorrect). In Situ For reasons that are difficult to understand, the word “in situ” has frequently been used as synonymous with “noninstrumented.” According to Webster’s New Universal Unabridged Dictionary (2nd ed., Simon and Schuster, New York, 1979), the word “in situ” means “in its original place.” If we are dealing with a spondylolisthesis problem in an adolescent and choose to do a noninstrumented arthrodesis, but we achieve a partial reduction of the deformity by casting, this cannot be called an “in situ” fusion. It is a reduction and fusion without instrumentation. Anterior Release Another phrase that has incorrectly crept into our vocabulary is “anterior release,” when what we really mean is “anterior discectomy and fusion.” This is especially wrong as most of the time we approach the scoliosis from its convexity, removing the convex annulus and the disc contents, but not the concave annulus. The additional correction achieved is due to convex shortening, not concave release of tight structures. When dealing with a structural Scheuermann kyphosis, the phrase “anterior release” is more appropriate because we do release tight anterior ligament tissues. However, it is still not accurate as a discectomy and anterior fusion are also done. Can anterior release be done without anterior discectomy and fusion? Yes, of course. The authors had the occasion in 1995 to do a pure anterior release (without either discectomy or fusion) in a 5-year-old boy with a very stiff 100° kyphosis. We wanted to release the very tight anterior longitudinal ligament and anterior annuli without doing anything that would halt or impair anterior growth. He was then slowly stretched with halo traction and held with a halo cast. We suggested that the phrase “anterior discectomy and fusion” be used for our usual anterior operation for scoliosis and “anterior release and fusion” for our usual operation for hyperkyphosis. (The authors thank Dr. David Bradford for bringing to view this particular phraseology problem at the GICD meeting in Ottawa, Canada, in September 1996.) Hardware ”Hardware” refers to those things that one obtains from a hardware store, such as a hammer, saw, screwdriver, chisel, screw, nail, etc., as well as computer hardware. What we place in our patient is a spinal implant. Those tools that we use to insert the implants are called “instruments.” We do not do an operation to “remove the hardware”; we perform an “implant removal.” Epophysiodesis ”Epophysiodesis” refers to the ablation or removal of an epiphyseal plate or, more correctly, a physeal plate. As our profession advances, it may become possible to operate on a young growing child with a worrisome lateral curvature by an endoscopic laser obliteration of the convex one-half of the physeal plates in the curvature area. This could be done without disc removal, attempted arthrodesis, or implants crossing the disc space. The obvious advantage would be to obliterate pathologic convex growth while preserving concave growth and mobility. Therefore, the term “epiphysiodesis” should be reserved for pure physeal plate obliteration. The operation we do now, removal of one-half of the disc and growth plate anteriorly plus convex hemiarthrodesis both anteriorly and posteriorly, should be properly called “anterior and posterior convex hemiepiphysiodesis” (hemiarthrodesis). ”Vertebrectomy” Versus “Corpectomy” The word “vertebrectomy” means removal of the vertebra. This is an operation we do for some tumors and some severe curvatures. Removal of a vertebral body, for example, for decompression of a burst fracture, should be called a “corpectomy” as only the vertebral body is removed, not the other elements of the vertebra. ”Conservative” Treatment Versus “Nonoperative” Treatment Surgical treatment of certain problems is the conservative approach, that is, in a small child with congenital kyphosis, a growing adolescent with a dystrophic neurofibromatosis kyphoscoliosis, or an adolescent idiopathic patient with lordoscoliosis and reduced pulmonary function. SUMMARY AND CONCLUSIONS Several words and phrases have been identified that are commonly, but improperly, used. It is hoped that by bringing these terms to the attention of the spinal “community,” a greater precision of language and therefore greater accuracy of communication can occur in our profession.

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