Patient presenting with clinically significant cervical spinal cord compression have a variety of surgical strategies that may be appropriate. The common denominator for successful intervention is satisfactory decompression of the neural elements, while avoiding early or late complications. In general, one may think of situations with one or two motion segment involvement versus three or more foci of compression. As most applicable cervical pathology causes anterior cord compression, the logic of direct anterior decompression is very compelling. Thus anterior decompression and fusion procedures have been the mainstay of treatment in many quarters. On the other hand, complications with graft healing or displacement, speech and swallowing disturbance, etc. remain an issue. This is especially true for multi-level disease. Under these circumstances, indirect decompression with posterior surgery plays an important role. Laminoplasty, and to a lesser degree laminectomy and fusion, may prove every bit capable of spinal cord decompression and often with fewer complications. Each case must be evaluated on its own merits and the procedure chosen to optimize the likelihood of success.

Postoperative wound infections are a fact of life for patients and surgeons alike, as well as a major source of morbidity for the unlucky patient and frustration for the surgeon. Though certain risk factors may be clearly appreciated prospectively, it is not often that they can be altered. Local and systemic factors are inescapable realities of some urgent situations, which may create considerable risk for catastrophe, such as obesity, diabetes, malnutrition, immune suppression, radiotherapy, prior surgeries, etc. The risk of wound infection also correlates with the scale of the procedure undertaken. Successful treatment begins with timely recognition of a possible infection. Treatment should be decisive and aggressive, and includes surgical exploration and debridement. Adjunctive measures may include plastic flap closure to provide a sealed environment with healthy vascular tissue. The incremental risk of non-union must also be appreciated, with a low threshold for intervention in the face of failed bone graft healing.

Historically spine surgeons have been powerless to help most patients with painful vertebral insufficiency fractures. Treatment was supportive, hoping that fractures could heal in situ, and accepting the resulting kyphosis and its consequences. Surgery was the court of last resort in instances of disabling neurologic deficits. The very same deficient skeleton that lead to the clinical issue, was simultaneously the principal limiting factor in surgical undertakings. Complications could be common and substantial.

Vertebroplasty was born out necessity in the treatment of ‘inoperable’ vertebral metastases. The technique has become a widely adopted method of managing refractory painful vertebral insufficiency fractures, especially those due to osteoporosis. In skilled hands, vertebroplasty provides a high degree of pain relief and patient satisfaction. The fracture is fixed in situ as the marrow space is embolised with PMMA. Kyphoplasty is a technical evolution that enables active fracture reduction before fixation with PMMA. Much is made about the potential differences between the two treatment methods, but no direct comparative studies are available to allow objective conclusions. In any event, as medical therapies improve the treatment of osteoporosis in general, surgeons now have the opportunity to intervene when painful vertebral fractures are a primary source of functional impairment and life quality.