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Synopsis of Spine Surgery

Third Edition

How ard S. An , MD
Th e Mor ton In tern at ion al Professor
Director, Division of Spin e Su rger y an d Sp in e Fellow sh ip Program
Dep ar t m en t of Or th opaedic Su rger y
Rush Un iversit y Medical Cen ter
Ch icago, Illinois
Ker n Sin gh , MD
Associate Professor
Co-Director, Min im ally Invasive Sp in e In st it u te
Dep ar t m en t of Or th opaedic Su rger y
Rush Un iversit y Medical Cen ter
Ch icago, Illinois

266 illust rat ion s

Th iem e
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Lib rar y of Con gress Cat alogin g-in -Pu blicat ion Dat a
Nam es: An , How ard S., auth or. | Singh , Kern , au th or.
Title: Synopsis of spine surgery / Howard S. An, Kern Singh.
Descr ipt ion : Third edit ion . | New York : Th iem e, [2016] |
In clu des bibliograph ical referen ces an d in dex.
Id en t ifiers: LCCN 2015036666 | ISBN 9781626230309
Su bject s: | MESH: Spinal Diseasessurger yOutlin es. |
Sp in al Diseasesdiagn osisOutlin es. | Spin e
p hysiologyOutlin es. | Spinesurger yOu tlin es.
Classificat ion : LCC RD768 | NLM W E 18.2 |
DDC 617.5/6059dc23
LC record available at h t t p://lccn .loc.gov/2015036666

Im p or t an t n ote: Medicin e is an ever-ch anging scien ce


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Th is book, in clu ding all par t s th ereof, is legally protected


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I w ould like to dedicate th is book to m y m oth er, fath er, m y w ife, an d m y ch ildren , w h o
h ave given m e u n con dit ion al love an d su pp ort th rough ou t m y life.
How ard S. An
I dedicate th is book to m y m oth er an d fath er. Th an k you both for alw ays forcing m e to
be th e best I cou ld be. With out you r love, p at ien ce, an d dedicat ion , I w ou ld n ot be th e
physician , fath er, or son I am today.
Kern Singh

Contents
Preface ..................................................................................................................................... ix
1 An atom y an d Su r gical Ap p roach es ................................................................................... 1
2 Histor y an d Ph ysical Exam in at ion ..................................................................................47
3 Rad iograp h ic An atom y.......................................................................................................57
4 Sp in al Im agin g an d Diagn ost ic Test s ..............................................................................67
5 In t raop erat ive Neu rom on itor in g ....................................................................................80
6 Biom ech an ics of t h e Sp in e an d Sp in al In st r u m en t at ion ..........................................83
7 Ph ysiology of Bon e Healin g an d Fu sion ..................................................................... 104
8 Bon e Graft s, Su bst it u tes, an d Biologics ...................................................................... 111
9 Evalu at ion an d Man agem en t of Sp in al Cord In ju r y ................................................ 116
10 Cer vical Sp in e Trau m a..................................................................................................... 122
11 Th oracolu m bar Sp in e Fract u res ................................................................................... 134
12 Sp in al Reh ab ilit at ion an d Disab ilit y Evalu at ion ...................................................... 142
13 Bioch em ical Asp ect s of In ter ver teb ral Disk Degen erat ion ................................... 148
14 Degen erat ive Cer vical Sp in e Disord er s ....................................................................... 154
15 Degen erat ive Th oracic Sp in e Con d it ion s ................................................................... 167
16 Lu m b ar Disk Disease: Pat h ogen esis an d Treat m en t Op t ion s ............................... 171
17 Su r gical Man agem en t of Lu m b ar Degen erat ive Disk Disease .............................. 183
18 Lu m b ar Sp in al Sten osis ................................................................................................... 197
19 Lu m b ar Sp on d ylolist h esis .............................................................................................. 210
20 Ad u lt Sp in al Defor m it y ................................................................................................... 221
21 Ped iat r ic Sp in al Defor m it y ............................................................................................. 227
22 Ped iat r ic Cer vical Sp in e Disord er s ............................................................................... 252
23 Sp in al Tu m or s .................................................................................................................... 264
24 Sp in al In fect ion s ............................................................................................................... 280
25 Rh eu m atoid Ar t h r it is ...................................................................................................... 295
26 Seron egat ive Sp on d yloar t h rop at h ies .......................................................................... 307
In d ex .................................................................................................................................... 317

vii

Preface
The th ird edit ion of the Synopsis of Spine
Surgery reflects the rapid advances in the
field since the first edit ionadvances that
h ave ch anged ou r approach to patient care,
part icularly involving m inim ally invasive
surger y. In addit ion , sign ifican t advan ces
h ave been m ade in bon e physiology and
biologics. The third edit ion succin ctly
sum m arizes th ese advan ces w ith th e
reader being able to quickly reference
these new spine surgical developm ents.
Th e prem ise beh in d th is book is to
con cisely sum m arize in form at ion in
an ou tlin e form at . Th e reader is able to
p eru se broad topics in an expedit iou s
m an n er, w h ile being directed to key

referen ces th at m ay provide greater


det ail on topics of part icular in terest . Th is
book is w rit ten prim arily for orth opedic
su rgeon s an d n eu rosu rgeon s-in -t rain ing.
Th e easy-to-read form at also m akes th is
an excellen t resou rce for p ract icing spin e
su rgeon s as w ell as n on op erat ive sp in e
physician s.
We h ope th at th is book w ill provide our
readers w ith a th orough un derstan ding
of th e m odern field of spin e surger y in
th e m ost efficacious m an n er possible,
in creasing th e qualit y of care given to
spin e pat ien t s.
How ard S. An, MD
Kern Singh, MD

ix

1 Anatomy and Surgical Approaches

1.1 Basic Anatomy of the Spine


I. Vertebral colu m n .
A. Th e spin al colum n h as speci cally adapted an atom ical feat ures to m ain tain
st abilit y, protect n eu ral elem en t s, an d allow range of m ot ion .
B. St abilit y is augm en ted by th e in ter vertebral disks, ligam en ts, an d m u scles.
C. Th ere are 33 vertebrae in th e sp in al colu m n (7 cer vical, 12 th oracic, 5 lu m bar,
5 sacral, an d 4 coccygeal).
D. Th ere are fou r sagit tal cu r ves in th e vertebral colu m n .
1. Cer vical lordosis (2040).
2. Th oracic kyph osis (2050).
3. Lu m bar lordosis (3179).
4. Sacral kyph osis.
E. Th e kyph ot ic cur ves are called prim ar y becau se th ey form during th e fet al
p eriod.
1. Caused by th e w edge-sh aped n at ure of ver tebrae.
F. Th e lordot ic cu r ves are called secon dar y becau se th ey begin to form du ring
th e late fetal period an d con t in ue to form after birth . Head an d body w eigh t
con t ributes to th eir form at ion .
1. Caused by di eren ces in th e an teroposterior dim en sion s of th e
in ter vertebral disks.
G. Each ver tebra con sists of a posterior bony arch an d an an terior body, both of
w h ich surroun d th e ver tebral can al.
1. Posterior bony arch es bet w een t w o adjacen t ver tebrae form a foram en for
th e spin al n er ve root s.
2. An terior bodies of th e lum bar spin e su ppor t 80% of th e axial load on th e
spin al colu m n .
H. Posterior bony arch com p on en t s (Table 1.1).
II. In ter vertebral disks (Table 1.2).
A. Th ere are 23 in ter vertebral disks in th e spin al colu m n (6 cer vical, 12 th oracic,
5 lum bar).
B. Each disk is located bet w een adjacen t ver tebral en d plates, w h ich are covered
by hyalin e an d brocar t ilage an d supported by subch on dral bon e.
C. Vertebral disks m ake u p on e qu arter of th e sp in al colu m n h eigh t . Th e disks
exp an d w h en th e colu m n is h orizon tal becau se w ater an d n u t rien t s en ter th e
disk, but th ey collapse u n der th e st ress of prolonged stan ding or sit t ing.
D. Th e disk is a relat ively avascu lar st ru ct u re w ith th e ou ter layers receiving
n u t rien t s from th e en d ar terioles an d th e cen t ral p ort ion s receiving n u t rien ts
by di usion from th e ver tebral en d plates.
E. Each disk con sist s of an outer ann u lus brosus, w h ich surroun ds a cent ral
n u cleu s pu lposu s (Fig. 1.1).
1

2 1 Anatom y and Surgical Approaches

Table 1.1

Posterior bony arch components

Components

Function

Pedicles and lam inae

Form the borders of the vertebral canal with the posterior


border of the vertebral body

Spinous and
transverse processes

At tachment sites for supporting ligam ents and m uscles

Articular processes

The superior articular process of the caudal vertebrae form s a


facet joint with the inferior articular process of the cephalad
vertebrae bilaterally.
The articular facet joints support 20% of the axial load on the
spinal colum n.
The pars interarticularis is the bony region bet ween the
superior and inferior articular processes of an individual
vertebra.

Table 1.2

Histological characteristics of the intervertebral disk

Intervertebral
disk component

Characteristics

Annulus brosus

1020 layers of concentric lam ellae of brocartilage


Type I collagen
Lat tice m ade of sheets running in opposite directions that give
the disk greater rotational strength
Thickest portion is anterior. Thinnest portion is posterolateral.
Outer portions of the annulus are continuous with the anterior
and posterior longitudinal ligam ents.

Nucleus pulposus

Mucoid t ype II collagen and water-im bibing proteoglycans


(e.g., aggrecan)
Cushions axial load
Cannot be compressed under pressure due to it s uid nature,
but rather will deform in all directions

1 Anatom y and Surgical Approaches 3

Fig. 1.1

The nerve structures of the lum bar plexus.

4 1 Anatom y and Surgical Approaches

1.2 Neuroanatomy
I. Spin al cord.
A. Gross st ruct ure.
1. Th e spin al cord t ypically en ds at L1L2 (con us m edullaris).
a. It m ay be as h igh as T12 or as low as L2L3.
b. In n ew born in fan ts, th e cord en ds at L2L3.
2. Length : 45 cm cord an d 25 cm lum term in ale (10% in crease in length w ith
exion , m ostly at C1, T1, an d L1, least at C6 an d T6).
3. Mean diam eter (10 m m , t ran sverse diam eter greater th an sagit t al diam eter).
4. Relat ion sh ip bet w een cord an d ver tebral segm en t s (Fig. 1.2) (Table 1.3).

Fig. 1.2 The spinal cord and nerve


roots. The spinal cord em erges from
the foram en m agnum as a continuation of the m edulla oblongata and
ends in a cone-shaped structure
known as the conus m edullaris. The
location of the conus m edullaris is
usually the L1L2 intervertebral disk
in adults. The cervical cord enlarges
m axim ally at the C6 vertebra to provide C3T2 innervation to the upper
lim bs, and the lumbosacral enlargem ent is present at T11L1 vertebral
segm ents to provide L1S3 cord segm ents to the lower extremities.

1 Anatom y and Surgical Approaches 5

Table 1.3 Relationship bet ween cord and


vertebral segm ents
Cord segment

Vertebral segment

C1

C1

C8

C7

T6

T5

T12

T8

L2

T10

L5

T11

S3

T12

B. In tern al st ru ct u res (Fig. 1.3) (Table 1.4).


1. Th e periph eral w h ite m at ter an d cen t ral gray m at ter.
a. Gray m at ter: cell bodies of e eren t n eu ron s.
(1) Posterior h orn s: som atosen sor y.
(2) An terior h orn s: som atom otor.
(3) In term ediolateral h orn s: visceral.
(4) Re ex som at ic cen ters.
b. W h ite m at ter: n er ve bers an d glia.
(1) Posterior fu n iculus: posterior colum n s (fasciculus cun eat us laterally
an d gracilis m edially).
(2) Lateral fun iculus: lateral cor t icospin al an d lateral spin oth alam ic
fascicu lu s.
(3) An terior fun icu lus: an terior spin oth alam ic t ract .
2. Cen t ral epen dym al can al: passage of cerebrospin al uid.
3. Spin al cord syn drom es (Table 1.5).
C. Vascu larit y of th e spin al cord.
1. Cer vical spin e.
a. Th e an terior sp in al arter y: th e m ajor vessel for an terior an d cen t ral
asp ects of th e cord:
(1) Tw o m edullar y feeders at th e brain stem by th e vertebral arteries.
(2) Oth er m edullar y feeders from th e ver tebral ar teries an d ascen ding
cer vical ar teries, par t icularly C2 an d C6 from th e left an d C2, C5, C6
from th e righ t .
b. Tw o posterior spin al ar teries from th e posterior in ferior cerebellar
arteries h ave m in im al con t ribu t ion to th e cen t ral gray m at ter.
2. Th oracolum bar spin e.
a. Th e an terior sp in al arter y, t w o p osterior spin al ar teries.

6 1 Anatom y and Surgical Approaches

b
Fig. 1.3 (a,b) Cross section of the spinal cord with the outer white m at ter and the inner gray m at ter.
The white m at ter of the spinal cord contains nerve bers and glia and is divided into three columns:
posterior, lateral, and anterior. The posterior column includes the fasciculus cuneatus laterally and the
fasciculus gracilis m edially. The lateral colum n contains the descending m otor lateral corticospinal
and lateral spinothalam ic fasciculi, and the anterior funiculus contains the ascending anterior spinothalam ic tract and other descending tract s. The lateral spinothalam ic tracts cross through the ventral com missure to the contralateral side of the cord. The gray m at ter of the spinal cord contains cell
bodies of e erent and internuncial neurons.

1 Anatom y and Surgical Approaches 7

Table 1.4

Spinal cord function

Motor function

Components

Notes

Cerebral cortex

Lateral corticospinal fasciculus:


tracts for the upper extrem ities
are m edial to the lower
extrem ities

Internal capsule
Corticospinal tract
Pyramidal tract (90%
decussate at the m edulla
to the contralateral lateral
corticospinal fasciculus)
Anterior horn cells
Sensory function

Fasciculus gracilis: lower limbs


and below m idthorax
Fasciculus cuneatus: upper
lim bs and above m idthorax

Sensory tracts cross to the


opposite side in the m edulla
oblongata and to the sensory
cortex
Tactile discrimination,
proprioception, and vibration sense

Lateral spinothalam ic
fasciculus: pain, temperature,
and light touch

Most bers cross through the


ventral commissure to the
opposite side and ascend through
the lateral spinothalamic tract

Anterior spinothalam ic
fasciculus: crude touch

Posterior cord syndrom e: only


crude touch is spared

b. Feeders.
(1) Superior in tercost al ar ter y: bran ch of deep cer vical ar ter y, w h ich is a
bran ch of th e righ t subclavian ar ter y, feeds th e cord at th e cer vical
th oracic ju n ct ion .
(2) On e to ve segm en t al vessels: ten uou s blood su pply for th e upper
th oracic cord (w atersh ed crit ical zon e from T4 to T10).
(3) Th e ar ter y of Adam kiew icz (80% from T10 from th e left , but origin
m ay var y from T5 to L5) su p p lies th e th oracic cord .
(4) An astom ot ic loop of th e con us m edullaris from aort ic segm en t al an d
lateral sacral ar teries.
3. Ven ou s drain age (azygos an d h em iazygos vein s).
a. Vein s of th e sp in al cord an teriorly an d p osteriorly.
b. Bat sons plexus: from basioccipu t to th e coccyx.
c. Clin ical sign i can ce: m et ast at ic dissem in at ion an d in fect ion s
II. Sp in al m en inges (Fig. 1.4).
A. Dura m ater: outer covering of th e spin al cord.
B. Leptom en in x: pia m ater (ou ter lin ing of th e cord) an d arach n oid m em bran e
(t ran sparen t sh eet con t ain ing th e cerebrospin al uid).

8 1 Anatom y and Surgical Approaches

Table 1.5

Spinal cord syndrom es (incomplete cord injury)

Syndrome

Characteristics

Common causes

Recovery

Central
cord
syndrome
(m ost
com m on)

Greater m otor de cit


in upper extrem ities
(m edial tracts of the
lateral corticospinal
fasciculus) compared
with the lower
extrem ities (lateral
tracts).

Extension injury
m echanism in
patients with
spondylosis
due to anterior
osteophytes and
posterior infolded
ligam entum avum
(pincer e ect)

Good prognosis (full


functional recovery
is rare)

Anterior
cord
syndrome

Motor function and


sensation to light
touch are impaired.
The posterior colum n
functions (pressure and
proprioception) are
spared.

Direct compression
of anterior spinal
cord or anterior
spinal artery injury
from bony spicules

Worst prognosis
1020% m otor
recovery

Brown
Squard
syndrome

Pain and temperature loss


are contralateral and one
or two levels below the
injury, whereas motor and
proprioception loss are
ipsilateral and at the level
of the injury. The motor
paralysis is accid at the
level of the injury (lower
motor injury). Below the
level of injury, the motor
paralysis is spastic (upper
motor injury).

Penetrating traum a
(stab wound to the
back)

Excellent prognosis
99% recovery of
am bulatory function

Posterior
cord
syndrome
(very rare)

Loss of proprioception
and vibration sense only
(posterior spinal cord).

Injury to the
posterior spinal
artery

Rare and not well


characterized

Lower extrem it y and


bladder function
recover before
upper extrem ities

1 Anatom y and Surgical Approaches 9

b
Fig. 1.4 (a,b) Cross section of the spinal cord and m eninges. The spinal cord is covered by the pia
m ater, which is the outer lining of the cord, and the transparent arachnoid mater, which contains the
cerebrospinal uid. The dura m ater is the outer covering of the spinal cord. The spinal cord is anchored
to the dura by the dentate ligam ent s that project laterally from the lateral side of the cord to the
arachnoid and dura m idway bet ween the exiting spinal nerves.

10 1 Anatom y and Surgical Approaches

C. Den t ate ligam en t: bet w een th e dorsal an d ven t ral n er ve root s, st abilizes th e
sp in al cord w ith in th e du ra.
D. Sept u m p ost icu m bet w een th e p ia an d arach n oid on th e d orsal aspect from
low er cer vical to con u s region s.
E. Epidural space: space bet w een th e bon e an d dura.
1. Space: 2 m m at L3L4, 4 m m at L4L5, 6 m m at L5S1.
2. Plica m ediana dorsalis durae m atris: a m edian fold at the lum bosacral region.
F. Term in at ion of th e du ra/arach n oid envelope varies from S1S2 to S2S3, an d
th e dura invest s th e lum term in ale an d at tach es to th e coccyx.
III. Sp in al n er ves.
A. Th irt y-on e pairs of spin al n er ves: 8 cer vical, 12 th oracic, 5 lum bar, 5 sacral,
1 coccygeal.
B. Th e sp in al root n er ve con sist s of m otor an d sen sor y rootlet s, th e dorsal root
ganglion , an d th e sp in al n er ve.
1. Sym path et ic con n ect ion s by preganglion ic (w h ite) ram i an d un m yelin ated
p ostganglion ic (gray) ram i.
2. Bran ch es: sin uvertebral n er ve to th e an n ulus of th e disk, an d dorsal ram us
for facets an d p osterior m u scles.
a. Th e sin uvertebral n er ve reen ters th e spin al can al th rough th e foram en
to lie an terior to th e n er ve root an d cran ial to th e disk. Th e sin uver tebral
n er ves in n er vate th e p osterior longit u din al ligam en t , th e posterior p ar t
of th e an n ulus, an d th e ven t ral par t of th e dura. Th e sin uver tebral n er ves
t yp ically ascen d to in n er vate th e su p erior disk as w ell.
b. Th e dorsal prim ar y ram i gives m edial (in n er vates facet join t s above an d
below, segm en tal m u scles, an d in terspin ous ligam en t), lateral (in n er vates
iliocostalis m u scle), an d occasion ally in term ediate (in n er vates
longissim u s m u scle) bran ch es.
C. Th e C1 n er ve em erges above th e C1 vertebra, an d th e C8 em erges above th e T1
ver tebra. In th e th oracic an d lu m bar region s, th e sp in al n er ves em erge ben eath
th e pedicles bearing th e sam e n um ber.
D. Sp in al n er ves in th e in ter ver tebral foram in a:
1. Cer vical spin e: n o in ter vertebral foram en for C1 an d C2, but C3C8 escape
th rough correspon ding foram in a occupying ~ 75% of space.
2. Th oracic spin e: th oracic spin al n er ves are sm all an d occu py 20% of th e
foram en an d exit below th e p edicle.
3. Lum bar spin e: large lum bar n er ves occu py 33% of th e foram en an d exit
obliqu ely below th e pedicle.
4. Sacrum : an terior ram i em erge th rough th e an terior sacral foram in a, an d
p osterior ram i th rough th e p osterior sacral foram in a.
E. Derm atom es an d m yotom es (Fig. 1.5) (Table 1.6).
F. Dyn am ics:
1. L5 or S1 n er ve roots m ay glide u p to 1 cm du ring exion exten sion .
2. Th e spin al cord an d n er ve root s gen erally st retch in exion an d relax in
exten sion , bu t th e spin al can al an d foram en en large in exion an d n arrow in
exten sion .
G. Cau da equ in a:
1. Lum bar an d sacral roots are organ ized in a speci c pat tern .
2. Fift y percen t com pression of th e th ecal sac leads to dysfun ct ion .

1 Anatom y and Surgical Approaches 11

a
Fig. 1.5

(ac) Anterior and posterior derm atom es.

H. Ner ve root an om alies (Kadish an d Sim m on s) (Fig. 1.6):


1. Type I: in t radu ral an astom osis.
2. Type II: an om alous origin of n er ve root s.
3. Type III: ext radural an astom osis.
4. Type IV: ext radural division .
I. Vascu lat u re of th e n er ve root:
1. Proxim al an d dist al radicu lar arteries an astom ose in th e proxim al th ird of
th e root in th e foram en , w h ich m ay be a vascular-de cien t area.
2. In t rin sic vasculat ure: in terfascicular an d in t rafascicular vessels w ith
com pen sat ing coils an d arterioven ous an astom osis allow con siderable
in terfascicu lar m ot ion an d st retch of th e root .
3. A th in pia m ater allow s exch ange of m et abolites w ith cerebrospin al uid.
4. Mech an ical com pression causes vascular com pression , w h ich m an ifest s in
n eu roisch em ic clau dicat ion clin ically.
J. Plexu s:
1. Cer vical an d brach ial plexus.
a. Th e an terior ram i of C1C4 form th e cer vical p lexu s.

12 1 Anatom y and Surgical Approaches

Table 1.6

Myotom e and derm atom e distribution

Nerve
root

Motor

Sensory

Re ex

C4

Diaphragm and trapezius

Base of neck

None

C5

Deltoid and biceps

Upper outer arm

Biceps brachii

C6

Wrist extensors

Thumb

Brachioradialis

C7

Triceps and wrist exors

Long nger

Triceps brachii

C8

Finger exors

Lit tle nger

None

T1

Intrinsic m uscles of the hand

Medial forearm

None

L1

Transversus abdom inis

Inguinal region

None

L2

Iliopsoas

Upper thigh

None

L3

Quadriceps

Anterior and m edial


thigh

None

L4

Tibialis anterior

Anterior knee, m edial


leg, ankle, and foot

Patellar tendon

L5

Extensor hallucis longus

First web space

Hamstring

S1

Gastrocnem ius

Posterior thigh,
sm all toe

Achilles tendon

S2

Bladder sphincter

Posterior thigh and


leg

Bulbocavernosus
(S2S3)

S3S5

Anal sphincter (S3)

Perineum , anus

Anal tone (cauda


equina syndrom e)

Fig. 1.6

The four t ypes of nerve root anom alies.

1 Anatom y and Surgical Approaches 13

b. Th e an terior ram i of C5T1 form th e brach ial plexus.


(1) Branches: suprascapular (C5C6), subscapular (C5C6), subclavius
(C5C6), long thoracic (C5C7), m usculocutaneous (C5C6), m edian
(C5T1), axillary (C5C6), radial (C5T1), m edial cutaneous nerve of arm
and forearm (C8T1), m edial cutaneous (C8T1), ulnar (C8T1).
2. Lu m bosacral an d coccygeal plexus.
a. Lu m bosacral t ru n k (L4, L5) an d S1, S2, S3, an d S4 an terior ram i.
b. Sciat ic (L4S3) an d pu den dal (S2S4) n er ves.
c. Bran ch es: su perior gluteal (L4S1), in ferior gluteal (L5S2), n er ve to
th e obt urator in tern us, n er ve to th e quadrat us fem oris (L5S2), an d th e
p osterior cut an eous n er ve of th e th igh (S1S3).
d. An terior coccygeal plexus: S5 an d coccygeal an terior ram i to becom e
an terior cau dal n er ve.
IV. Au ton om ic system s (sym path et ic an d p arasym p ath et ic system s).
A. Sym path et ic cen ters.
1. C8 to L4 spin al cord.
2. Sym path et ic t run k an d ganglion s: cer vical to sacral.
3. Cardioaccelerator cen ter, sw eat glan ds, vasom otor, bron ch opulm on ar y,
abd om in al splan ch n ic, an orectal/bladder con t in en ce, an d ejacu lat ion cen ter.
4. Loss of sym path et ic system .
a. Perip h eral vasod ilat ion (hyp oten sion ), bradycardia, in abilit y to p erspire,
an d hyp oth erm ia du e to sp in al cord inju r y (inju r y of th e p reganglion ic
ber an d in term ediolateral cell colu m n ).
b. Horn ers syn drom e: drooping of upper eyelid (ptosis), en oph th alm os,
con t ract ion of th e pupil (m iosis), absen ce of sw eat ing (an h idrosis) (injur y
to cer vical or rst th oracic sym path et ic ch ain ).
c. Urogen it al problem s: ret rograde ejaculat ion due to im proper closing of
th e bladder n eck (injur y to th e hypogast ric plexus).
d . Au ton om ic dysre exia.
(1) Spinal cord injur y above sym path etic splanchnic visceral out ow (T6).
(2) Hyperten sion , sw eat ing, h eadach e, u sh ing (ret urn of re ex).
B. Parasym path et ic system s: brain stem an d sacral spin al cord (visceral an d p en ile
erect ion fu n ct ion s).

1.3 Surgical Anatomy


I. Cer vical spin e (Fig. 1.7).
A. Bony an atom y (Fig. 1.8).
1. Atlas: n o vertebral body, an terior t ubercle (longus colli at t ach m en t),
p osterior t ubercle (rect u s m in or an d suboccip ital m em bran e at t ach m en t),
an d large t ran sverse processes w ith t ran sverse foram en (su p erior an d
in ferior obliqu e m u scle at tach m en t).
a. Th e p osterior n eu ral arch fu ses at 3 years, an d an terior n eu ral arch (t w o
sites) fu ses at 7 years.
b. Th e atlas h as large t ran sverse processes, w h ere th e superior an d in ferior
oblique m uscles at t ach. Th e t ran sverse foram en is located w ith in th e
t ran sverse process, th rough w h ich th e ver tebral ar ter y passes.

14 1 Anatom y and Surgical Approaches

a
Fig. 1.7

The hum an spine. (a) Posterior musculature of the spine.

1 Anatom y and Surgical Approaches 15

b
Fig. 1.7 (Continued) The hum an spine. (b) Posterior m usculature of the spine and its innervation.

16 1 Anatom y and Surgical Approaches

Fig. 1.8

(ad) Morphology of the C4 and C7 vertebrae from superior and lateral views.

c. The posterior arch h as a groove along its superior border for the vertebral
arter y, w h ich run s along it on its w ay to th e foram en m agn um of th e sku ll.
d. Superior art icular facet s form th e atlan to-occipital art iculat ion w ith th e
occipit al con dyles. Th is join t accoun t s for th e m ajorit y of exion an d
exten sion of th e h ead.
e. Th e in ferior art icu lar facet con t ribu tes to th e atlan toa xial join t .
f. Th e p on t icu lu s p ost icu s (arcu ate foram en ) is a m alform ed bony bridge
bet w een th e posterior su perior art icular process an d th e superior m argin
of th e posterior arch of th e atlas.
(1) Th e arcu ate foram en con t ain s th e vertebral ar ter y an d th e
su boccip it al n er ve.
(2) It can be m istaken for a posterior arch .
(3) Lateral m ass screw placem en t th rough th e arcuate foram en can cause
vertebral ar ter y inju r y.
2. Axis: odon toid process w ith oval art icular facet an teriorly, m aking a syn ovial
join t w ith th e an terior arch facet an d large bi d sp in ou s process (rect u s
m ajor an d in ferior obliqu e m u scle at t ach m en t).
a. Th e syn ch on drosis bet w een th e den s an d arch an d th e n eu rocen t ral cleft
bet w een th e body an d arch fuse at 3 to 6 years.
b. Th e pedicle of th e axis is large an d p rojects m edially at 30 an d su periorly
at 20.

1 Anatom y and Surgical Approaches 17

c. Th e t ran sverse ligam en t secures th e den s to th e an terior arch of th e atlas.


Exten sion of th is ligam en t su periorly an d in feriorly creates th e cruciform
ligam en t .
d. Respon sible for th e m ajorit y of cer vical rotat ion aroun d th e a xis.
e. Th e alar ligam en t s con n ect th e odon toid to th e occip it al con dyles, fu rth er
st abilizing th e join t .
f. Th e t ran sverse p rocesses also con t ain th e t ran sverse foram en w ith th e
vertebral ar ter y.
3. C3C6 ver tebrae: bi d spin ous processes, pedicle, lam in ae, art icu lar
p rocesses, lateral m ass (bet w een th e art icu lar processes), t ran sverse
p rocesses w ith an terior an d posterior t u bercles an d t ran sverse foram en
(carot id t ubercle for C6 an terior t ubercle an d vertebral ar ter y in th e
foram en ), u n cin ate p rocesses (join t s of Lu sch ka), an d t riangu lar vertebral
foram en .
a. Th e su p erior su rfaces of th e cer vical ver tebrae are con cave, an d th e
in ferior surfaces are convex.
b. Th e cer vical ver tebrae h ave sm all bodies com pared w ith th e vertebral
can al.
c. Th e facet s gradually becom e steeper an d orien ted m ore sagit tally as on e
p rogresses dow n th e cer vical spin e.
(1) Th e lateral m asses are bony region s bet w een th e cer vical facet s ju st
lateral to th e lam in ae.
d. Th e vertebral arter y t ravels w ith in th e t ran sverse foram in a, dividing it
in to p osterior an d an terior t u bercles, bet w een w h ich passes th e exit ing
n er ve root .
4. C7 ver tebra: large, th ick spin ou s process an d n ot bi d.
a. Tran sit ion al vertebra w ith u n iqu e ch aracterist ics.
b. In ferior surface larger th an superior surface.
c. Taller an d sh allow er lateral m asses.
d . Th e p edicles en large st art ing w ith C7 an d going dow n th e spin e.
e. Th e sp in ou s p rocess is th e site of at t ach m en t of th e ligam en t u m n u ch ae.
f. It h as t ran sverse foram in a bu t th e ver tebral arter y p asses th rough th em
in on ly 5% of pat ien t s.
B. Ligam en tou s an atom y an d art icu lat ion .
1. Atlan to-occipit al ar t iculat ion : art iculat ion bet w een th e con dyles of th e
occipit al bon e superior facets of th e atlas, supported by an terior an d
p osterior occipit al m em bran es (con t in u at ion of th e an terior longit udin al
m em bran es an d ligam en t u m avu m , resp ect ively), an d capsu le ( exion ,
exten sion , an d lateral m ot ion ).
2. Atlan toaxial art icu lat ion (Fig. 1.9).
a. Rot at ion al m ovem en t bet w een th e odon toid process an d an terior arch of
th e atlas (respon sible for 50% of cer vical rot at ion ).
b. Ligam en t s.
(1) An terior an d posterior atlan toaxial ligam en t s.
(2) Tran sverse ligam en t: across th e arch of atlas to h old th e den s again st
th e an terior arch of th e atlas (cruciform ligam en t of th e atlas:
t ran sverse ligam en t plus superior an d in ferior exten sion ).

18 1 Anatom y and Surgical Approaches

Fig. 1.9

Ligam entous anatomy of the upper cervical spine.

(3) Alar ligam en t (sides of den s to con dyles of occipit al bon e) an d apical
ligam en t (from th e apex of th e d en s to th e foram en m agn u m as a
rem n an t of th e n otoch ord in th is area).
(4) Tectoral m em bran e: con t in uat ion of th e posterior longit udin al
m em bran e.
3. C2C7 art iculat ion .
a. Flexion an d exten sion m ot ion .
b. Facet join t an d capsule: h orizon tal p lan e (45 obliqu e) of th e join t an d
w eak cap su le allow m ore m obilit y th an lu m bar an d th oracic vertebrae.
c. Ligam en ts.
(1) An terior an d posterior longit udin al ligam en t s.
(2) Ligam en t um avum : from th e posterior aspect of th e lam in a below
to th e an terior aspect of th e lam in a above w ith de cien cy in th e
m id lin e.
(3) In terspin ous ligam en t: oblique orien t at ion from th e posterior
su perior asp ect to th e an terior in ferior asp ect .
(4) Supraspin ous ligam en t .
(5) Ligam en t um n uch ae: broelast ic sept um from th e occiput to C7.
d. In ter vertebral disks: an n ulus brosus an d n ucleus pu lposus.
C. Mu scles.
1. Posterior m u scles.
a. Su p er cial: t rap eziu s (from th e extern al occip it al prot u beran ce an d C7 to
th e T12 spin ous processes to in ser t at th e lateral clavicle, acrom ion , an d
sp in e of th e scapu la).
b. In term ediate: splen ius capit is an d cer vicis.
c. Deep: sem ispin alis capit is, sem ispin alis cer vicis, an d m ult i dus w ith
rotators.

1 Anatom y and Surgical Approaches 19

2. Suboccipital m uscles.
a. Rect u s cap it is posterior m ajor: C2 sp in ou s process to in ferior n u ch al lin e.
b. Rectus capitis posterior m inor: C1 posterior tubercle to inferior nuchal line.
c. Obliqu us capit is in ferior: C2 spin ous process to t ran sverse process of C1.
d. Obliqu us capit us superior: C1 t ran sverse process to occipital bon e
bet w een su perior an d in ferior n u ch al lin es.
3. An terior m uscles.
a. Plat ysm a: from deltoid an d pectoral fascia to m an dible an d skin ,
in n er vated by facial (VII) n er ve.
b. Stern ocleidom astoid: from stern u m an d clavicle to m astoid process.
c. St rap m uscles of lar yn x: stern ohyoid an d stern othyroid m u scles.
d. Om ohyoid: superior an d in ferior bellies to depress th e hyoid bon e.
e. Longu s colli: an terior asp ect of th e vertebral bodies.
II. Th oracolu m bar spin e, sacru m , an d coccyx.
A. Bony an d ligam en tous an atom y (Fig. 1.9).
1. Th oracic vertebrae (Fig. 1.10).
a. Mech an ically st i er an d less m obile becau se of rib at t ach m en t .
b. Physiological kyph osis (prim ar y cur ve).
c. Th e upper an d m iddle th oracic vertebrae h ave st abilit y again st
an teroposterior t ran slat ion , an d th e low er th oracic ver tebrae h ave
stabilit y again st rotat ion du e to facet join t orien t at ion .
d . Th e t ran sverse processes decrease from T1 to T10.
e. Th e spin al can al is circu lar an d h as less free space for th e spin al cord th an
th e cer vical an d lum bar region .
f. Ar t icu lar facet s for ribs: body an d t ran sverse p rocess an d ligam en t s
(radiate an d costovertebral ligam en t s bet w een th e body an d rib, an d
costot ran sverse an d in tert ran sverse ligam en ts bet w een th e t ran sverse
p rocess an d rib).
g. Con n ected to th e ribs at th e ju n ct ion bet w een th e body an d th e p edicle
an d also at th e t ran sverse costal facet of th e t ran sverse process. Th e
t ran sverse processes are posteriorly angulated to leave room for th e ribs.
h . A h ear t-sh aped body w ith a p ossible dep ression du e to th e descen ding
aort a on th e left sid e. Th e spin ou s p rocesses are long, slen der, an d
d ow nw ard-poin t ing so th at th ey overlap th e ver tebral arch es of th e
in ferior vertebra.
2. Lum bar vertebrae (Fig. 1.11).
a. St rong facet join t an d capsu le for rot at ion al stabilit y an d su p erior
ar t icu lar p rocesses (m am m illar y p rocess) are lateral an d an terior to th e
in ferior ar t icu lar process below.
b. Pedicles: st rong an d directed posteriorly 1 m m in ferior to th e t ip of th e
in ferior ar t icu lar process in th e m iddle of th e t ran sverse processes. Th ey
arise from th e u p per p ar t of th e vertebral body.
c. Triangu lar spin al can al.
d. Ligam en t s:
(1) Su praspin ous ligam en t: en ds aroun d L3.
(2) In terspin ous ligam en t: orien ted obliquely from ceph alad to caudad
from posterior to an terior.

20 1 Anatom y and Surgical Approaches

Fig. 1.10 (ac) Bony anatomy of


the thoracic spine.

e.
f.

g.
h.

(3) Posterior longit u din al ligam en t .


(4) An terior longit udin al ligam en t .
(5) Ligam en t u m avum : from th e posterior aspect of th e lam in a below
to th e an terior aspect of th e lam in a above.
Kidn ey-sh aped ver tebral bodies th at are w idest t ran sversely.
Th e facet s are in a sagit t al orien t at ion , lim it ing th e axial rot at ion .
Th e except ion is th e L5S1 facet because it is m ore coron al to resist
an terop osterior t ran slat ion .
More prom in en t p ars in terar t icu laris.
Broad an d t all sp in ou s p rocess.

1 Anatom y and Surgical Approaches 21

Fig. 1.11

Bony anatomy of the lumbar spine.

i. Sm aller t ran sverse process:


(1) Th e L5 t ran sverse process at tach es to th e iliolum bar ligam en t .
(2) Th e accessor y process is on th e m edial aspect of th e t ran sverse
p rocess w h ere it join s th e posterior bony arch .
3. Sacrum an d coccyx (Fig. 1.12).
a. Bony st ru ct u res of th e sacru m : ala, prom on tor y, m edian sacral crest ,
sacral foram in a, ar t icu lar su rface (Fig. 1.13).
b. Coccyx: th ree or four elem en t s an d th e last t w o to th ree segm en t s are
fu sed.
(1) At tach m en t site for th e m uscles of th e pelvic oor.
c. Sacroiliac join t .
(1) Art icular process: sacral hyalin e car t ilage an d iliac brocart ilage.
(2) Ligam en ts: in terosseous sacroiliac ligam en t , posterior sacroiliac
ligam en t , an d an terior sacroiliac ligam en t .
d. Con n ect ing ligam en t s.
(1) Sacrot uberous ligam en t: sacrum to isch ial t uberosit y.
(2) Sacrospin ous ligam en t: divides pelvis in to greater an d lesser sciat ic
n otch es.
(3) Iliolum bar ligam en t s: L5 t ran sverse processes to ala of sacru m .

22 1 Anatom y and Surgical Approaches

b
Fig. 1.12

(a) Anterior and (b) posterior anatomy of the sacrum .

1 Anatom y and Surgical Approaches 23

Fig. 1.13

(ad) Bony anatomy of the sacrum .

B. Soft t issu e st ru ct u res.


1. Muscles.
a. Su p er cial.
(1) Lat issim us dorsi: origin from T6 to T12, lum bar spin e, sacrum , an d
p osterior iliac crest an d low er fou r ribs to in sert at th e bot tom of th e
in tert u bercular groove of th e h um eru s.
(2) Levator scapulae: origin from C1 to C4 t ran sverse processes to in sert
at th e m ed ial border of th e scapu la above th e spin e.
(3) Rh om boid m in or: origin from C7 to T1 to in ser t at m edial border of
th e scapula at th e root of th e spin e.
(4) Rh om boid m ajor: origin from T2 to T5 an d in sert ion at th e m edial
border of th e scapula below th e spin e.

24 1 Anatom y and Surgical Approaches

b. Deep m uscles of th e back.


(1) Super cial layer (t ran sversocost al group or erector spin ae):
iliocost alis, longissim us, an d spin alis.
(2) Deeper layer (t ran sversospin al group): sem ispin alis, m ult i du s, an d
rot ators.
(3) Deepest layer: in terspin ales an d in tert ran sverse m u scles.

1.4 Surgical Approaches


I. Cer vical spin e.
A. Posterior approach es: reverse Tren delen burg posit ion an d May eld tongs h elp
to secure th e head an d m in im ize ven ous bleeding in th e surgical eld.
1. Posterior approach to occiput to C1C2 (Fig. 1.14):
a. Midlin e in cision from th e extern al occipital p rot u beran ce to C2 sp in ou s
p rocess (68 cm ).

Fig. 1.14
m idline.

The course of the vertebral artery and the greater occipital nerve in relation to the posterior

1 Anatom y and Surgical Approaches 25

b. Ligam en t u m n uch ae an d paravertebral m uscle dissect ion to th e posterior


elem en ts of C1 an d C2.
c. Lateral exposure sh ould not go beyon d 1.5 cm on th e C1 ring (cer vical
ganglion an d vertebral ar ter y), w ith care n ot to fract u re th e C1 ring.
(1) Aberran t an atom y sh ould be iden t i ed (pon t iculus post icus).
d. Separate occipitoatlan tal an d atlan toaxial m em bran es from th e bon e an d
w iring.
e. Occip u t: m ake d rill h oles above th e foram en m agn u m an d rem ove bon e
distally for decom pression . Extern al occipit al prot uberan ce can be used
for w iring for fu sion .
f. Neu rovascu lar st ru ct u res:
(1) Suboccipital n er ve (C1): w ith in th e suboccipital t riangle (m otor).
(2) Greater occipit al n er ve (C2): ben eath an d over th e in ferior oblique
m u scle (sen sor y).
(3) Th ird occipital n er ve (lateral to th e su boccipit al t riangle [sen sor y]).
(4) Vertebral ar ter y: from C6 t ran sverse foram en to atlas t ran sverse
foram en an d p ierces th e lateral angle of th e p osterior atlan tooccipit al m em bran e.
2. Posterior approach to th e low er cer vical spin e:
a. Midlin e in cision dow n to th e sp in ou s p rocesses an d lam in a (in terlam in ar
sp ace is w ide, an d cau t ion sh ou ld be t aken to avoid p en et rat ion to th e
dura).
b. Lateral exposure to th e t ran sverse processes, exposing th e facet s an d
lateral m asses.
c. Lam in ectom y, foram in otom y (resect ion of th e m edial aspect of superior
an d in ferior facet s), or excision of disk or osteophytes of th e join t s of
Lu sch ka to decom p ress th e n er ve root s.
(1) Th e C5 n er ve root form s ~ 45 w ith th e spin al cord; th is angle
in creases as on e descen ds an d is ~ 90 at th e C8 level.
(2) Ner ve root s (foram en borders): disks an d join ts of Lusch ka an teriorly,
zygapophyseal join t s posteriorly, pedicles su periorly an d in feriorly.
Also, th e ver tebral arter y is an terior to th e root s.
B. An terior app roach es: Gard n erWells tongs are u sed for t ract ion an d to keep th e
n eck sligh tly exten d ed (Fig. 1.15).
1. An terior m edial approach to th e m idcer vical spin e (Sm ith Robin son ).
a. Lan dm arks:
(1) Hard palate: arch of th e atlas.
(2) Low er border of m an dible: C2C3.
(3) Hyoid bon e: C3.
(4) Thyroid car t ilage: C4C5.
(5) Cricoid cart ilage: C6.
(6) Carot id t u bercle: C6.
b. Use a t ran sverse in cision from th e m idlin e to th e an terior border of th e
stern ocleidom astoid .
c. Split th e plat ysm a longit udin ally or t ran sversely.

26 1 Anatom y and Surgical Approaches


Fig. 1.15 The infrahyoid and sternocleidom astoid m uscles.

d. Incise the pretracheal fascia im m ediately anterior to the


sternocleidom astoid, followed by blunt nger dissection to the
vertebral bodies, retracting the carotid sheath (carotid artery, internal
jugular vein, and vagus nerve) laterally, and retract the strap m uscles,
trachea, and esophagus m edially (Fig. 1.16).
e. Th e su perior thyroid arteries m ay lim it dissect ion above C3C4 an d th e
in ferior thyroid arter y below C6 (m ay ligate an d divide).
f. Divide th e prevertebral fascia an d an terior longit u din al ligam en t in th e
m id lin e, ret ract ing th e longu s colli laterally.
g. Neu rovascu lar an d vit al st ru ct u res (Fig. 1.17):
(1) Recurren t lar yngeal n er ve: ascen ds in th e n eck bet w een th e t rach ea
an d esoph agu s from th e arch of th e aort a on th e left side an d ru n s
along th e t rach ea after h ooking arou n d th e su bclavian ar ter y on th e
righ t side. It crosses from lateral to m edial to th e m idlin e t rach ea in
th e low er par t of th e n eck, m aking th e righ t-sided approach sligh tly
m ore vu ln erable. Protect it by p lacing th e ret ractor below longu s colli
m u scles.
(2) Sym path et ic n er ves an d stellate ganglion : avoid dissect ion out on to
th e t ran sverse processes an d keep dissect ion subperiosteal.
(3) Carot id sh eath con ten t s: from th e m edial to lateral carot id
ar ter y, in tern al jugu lar vein , an d vagu s n er ve an terior to th e
stern ocleidom astoid m u scle.
(4) Esoph agus: t ake precaut ion on deep m edial ret ract ion .

1 Anatom y and Surgical Approaches 27

Fig. 1.16 Blunt nger dissection is done through the Sm ithRobinson interval toward the anterior
cervical spine.

Fig. 1.17

The neural and vascular structures of the neck.

28 1 Anatom y and Surgical Approaches

C. Oth er an terior ap p roach es to th e cer vical sp in e:


1. Tran soral approach to C1C2 (Fig. 1.18):

b
Fig. 1.18 (a,b) The transoral approach, which allows exposure of the m idline bet ween the arch of
the atlas and C2. The exposure may be extended cephalad by dividing the soft and hard palate to allow
access to the foram en m agnum and lower half of the clivus.

1 Anatom y and Surgical Approaches 29

a. Fiberopt ic n asot rach eal in t u bat ion an d n asogast ric t u be are u sed .
b. Th e pat ien t is placed in th e supin e posit ion w ith th e h ead h eld in sligh t
exten sion u sing th e May eld fram e.
c. Th e oral cavit y is clean sed w ith ch lorh exidin e, an d perioperat ive
an t ibiot ics w ith an in t raven ou s cep h alosp orin an d m et ron idazole are
in st it u ted for 72 h ours as prophylaxis again st w oun d in fect ion .
d. Th e key surgical lan dm ark is th e an terior t ubercle on th e atlas to w h ich
th e an terior longit u din al ligam en t an d longus colli m uscles are at tach ed.
e. Th e t ran soral ret ractors are in serted, exposing th e posterior oroph ar yn x.
Th e area of th e in cision is in lt rated w ith 1:200,000 epin eph rin e.
f. A m idlin e 3 cm ver t ical in cision cen tered on th e an terior t u bercle is
m ad e th rough th e p h ar yngeal m u cosa an d m u scle.
g. Th e t u bercle of th e atlas an d an terior longit u din al ligam en t are exposed
su periosteally, an d th e longu s colli m u scles are m obilized laterally.
h . A h igh -speed bu r m ay be u sed to rem ove th e an terior arch of th e atlas to
exp ose th e odon toid p rocess.
2. An an terom edial approach to th e u pper cer vical spin e by de An drade an d
Macn ab:
a. Th e n eck is hyp erexten d ed , an d th e ch in is t u rn ed to th e opp osite side.
b. A skin incision is m ade along the anterior aspect of the sternocleidom astoid
m uscle and curved toward the m astoid process.
c. Th e plat ysm a an d th e super cial layer of th e deep cer vical fascia are
divided in th e lin e of th e in cision to expose th e an terior border of th e
stern ocleidom astoid .
d. Th e stern ocleidom astoid m uscle is ret racted an teriorly an d th e carot id
arter y laterally.
e. Th e su p erior thyroid arter y an d lingu al vessels are ligated. Th e facial
arter y is iden t i ed at th e u p per p or t ion of th e in cision , w h ich h elp s to
n d th e hyp oglossal n er ve adjacen t to th e digast ric m u scle.
f. Th e su p erior lar yngeal n er ve is in close p roxim it y to th e su perior thyroid
arter y, an d excessive ret ract ion of th is n er ve sh ou ld be avoided .
g. St rip p ing of th e longu s colli m u scle exp oses th e an terior asp ect of th e
u pp er cer vical spin e an d basioccipu t .
3. An terior ret roph ar yngeal exposure of th e upper cer vical by McAfee:
a. A right-sided subm andibular transverse incision and division of the platysm a
leads to the sternocleidom astoid m uscle and its deep cervical fascia.
b. Th e m an dibular bran ch of th e facial n er ve sh ould be iden t i ed w ith th e
aid of a n er ve st im u lator, an d th e ret rom an dibu lar vein is ligated d u ring
th e in it ial st age of dissect ion .
c. Th e an terior border of th e stern ocleidom astoid m uscle is m obilized. Th e
su bm an dibu lar salivar y glan d an d th e jugu lar digast ric lym p h n odes are
resected.
d . Care sh ould be taken to su t ure th e duct in th e salivar y glan d to preven t a
salivar y st u la.
e. Th e digast ric ten don is d ivided an d tagged for later repair.
f. Th e hyp oglossal n er ve is n ext iden t i ed an d m obilized . Th e carot id
sh eath is open ed, an d ar terial an d ven ou s bran ch es are ligated, in clu ding
th e su perior thyroid arter y an d vein , lingual ar ter y an d vein , ascen ding

30 1 Anatom y and Surgical Approaches

p h ar yngeal arter y an d vein , an d facial arter y an d vein , begin n ing


in feriorly, progressing su periorly.
g. Th e su perior lar yngeal n er ve is also iden t i ed an d m obilized .
h . Th e p rever tebral fasciae are t ran sected longit u din ally to exp ose an d
dissect th e longus colli m uscles.
4. Th e an terolateral ret roph ar yngeal approach by W h itesides an d Kelley:
a. Th e skin in cision is m ade from th e m astoid along th e an terior asp ect of
th e stern ocleidom astoid.
b. Th e extern al jugu lar vein is ligated, an d th e greater auricular n er ve is
sp ared if p ossible.
c. Th e stern ocleidom astoid an d splen ius capit u s m u scles are det ach ed from
th e m astoid, leaving a fascial edge for later repair. Th e spin al accessor y
n er ve sh ou ld be iden t i ed an d protected .
d. Ret ract th e carot id con ten t s along w ith th e hypoglossal n er ve an teriorly,
w h ile ret ract ing th e sternocleidom astoid posteriorly. Blun t dissect ion
leads to th e t ran sverse p rocesses an d an terior aspect of C1C3.
5. Lateral approach to th e cer vical spin e by Verbiest:
a. Th e exposu re is ach ieved by dissect ing an terior to th e carot id sh eath an d
exposing th e ver tebral ar ter y an d n er ve root s p osterior to th e t ran sverse
p rocesses.
b. Th is lateral approach m ay be used for lesion s th at are localized laterally
or if th e vertebral ar ter y m u st be exposed.
6. Cer vicoth oracic jun ct ion : an terior exposure of th e upper thoracic vertebrae
m ay be accom plish ed th rough th e low cer vical, su p raclavicu lar ap p roach ,
stern u m -sp lit t ing app roach , or t ran sth oracic ap proach (Fig. 1.19, Fig. 1.20,
Fig. 1.21, Fig. 1.22, an d Fig. 1.23).
a. Low cer vical ap proach to C6T2: an exten sion of th e an terom edial
app roach to th e low er cer vical sp in e.
b. Th e supraclavicular approach to C6T2.
(1) A t ran sverse in cision above th e clavicle an d a dissect ion posterior to
th e carot id sh eath .
(2) After in cision of th e plat ysm a m uscle, th e clavicu lar h ead of th e
stern ocleid om astoid is divided. Th e fascia ben eath is divided to
release th e om ohyoid from its pu lley.
(3) Th e subclavian arter y an d it s bran ch es, w h ich in clude th e
thyrocer vical t run k, suprascapular ar ter y, an d t ran scer vical arter y,
m u st be id en t i ed. Th e dom e of th e lu ng an d th e p h ren ic n er ve are in
close proxim it y to th e scalen u s an terior m uscle.
(4) Division of th e scalen u s an terior m uscle exposes th e Sibsons fascia in
th e oor of th e w oun d, w h ich covers th e dom e of th e lung.
(5) Sibsons fascia is divided t ran sversely using scissors, an d th e visceral
p leura an d lung sh ou ld be ret racted in feriorly.
(6) Th e t rach ea, th e esophagus, an d th e recu rren t lar yngeal n er ve m ust
be protected during m edial ret ract ion . Th e posterior th orax, stellate
ganglion , an d u p per th oracic vertebral bodies are n ow visible looking
from above dow nw ard th rough th e th oracic in let . Th e recu rren t
lar yngeal n er ve sh ould be iden t i ed an d protected. Likew ise, th e
in ferior thyroid ar ter y an d vertebral arter y sh ould be iden t i ed. Th e
th oracic duct sh ould be iden t i ed if approach ed from th e left .

1 Anatom y and Surgical Approaches 31

b
Fig. 1.19 (a) The sternal-split ting approach. (b) After division of the plat ysma, the deep cervical
fascia is divided sharply.

32 1 Anatom y and Surgical Approaches

Fig. 1.20 To complete the exposure, the esophagus, trachea, and brachiocephalic trunk are gently
retracted to the right, and the thoracic duct is retracted to the left.

1 Anatom y and Surgical Approaches 33

Fig. 1.21 (a) A T-shaped incision is perform ed during the sternal split ting approach. (b) Deeper
exposure reveals the sternocleidom astoid and pectoralis m ajor muscles.

34 1 Anatom y and Surgical Approaches

Fig. 1.22 The sternal and clavicular heads of the sternocleidom astoid are detached at the level of
the manubrium.

1 Anatom y and Surgical Approaches 35

Fig. 1.23 (a) The m edial third of the clavicle and a rectangular piece of the m anubrium are rem oved.
(b) Retraction of the vessels and trachea exposes the cervicothoracic junction.

36 1 Anatom y and Surgical Approaches

c. Th oracotom y to T1T4 (Fig. 1.24, Fig. 1.25, Fig. 1.26, Fig. 1.27, Fig. 1.28,
an d Fig. 1.29).
(1) Th e righ t-sided approach is preferred to avoid th e left su bclavian
ar ter y, w h ich is m ore cu r ved th an th e righ t brach iocep h alic arter y.
(2) Th e in cision is m edial an d in ferior to th e scapula. Th e scapula
is ret racted laterally by dividing th e t rap ezius, lat issim us dorsi,
rh om boids, an d levator scapu lae m uscles.
(3) Th e ch est is en tered th rough th e th ird rib.
(4) Th e posterior 7 to 10 cm of each of th e secon d, th ird, fou rth , an d fth
ribs m ay be rem oved.
(5) Exposu re of th e vertebrae is m ade w ith an L-sh aped in cision in th e
p leura.

b
Fig. 1.24 (a) High transthoracic approach to the upper cervicothoracic spine. (b) The trapezius m uscle is divided close to the spinous processes and parallel to the skin.

1 Anatom y and Surgical Approaches 37

b
Fig. 1.25 (a) The rhom boid m ajor is divided near it s insertion, and the serratus anterior m uscle is
divided as caudally as possible. (b) The scapula can then be retracted superolaterally, and the periosteum can be incised.

d. Th e stern um -split t ing approach to C4T4.


(1) Th e skin in cision is m ade an terior to th e left stern ocleidom astoid
m u scle an d exten ds along th e m idstern al area d ow n to th e xip h oid
p rocess.
(2) After division of th e plat ysm a m uscle an d su per cial cer vical fascia,
blun t dissect ion is don e bet w een th e laterally sit u ated n eurovascular
bun dle an d m edial visceral st ruct u res.
(3) Th e ret rostern al adipose an d thym us t issues are ret racted from th e
m an u briu m .

38 1 Anatom y and Surgical Approaches

Fig. 1.26

Retractors are positioned and the upper thoracic spine is exposed.

(4) A m edian stern otom y sh ould be perform ed carefully to preven t


injur y to th e pleura. Th e stern ohyoid, stern othyroid, an d om ohyoid
m u scles are iden t i ed an d t ran sected as n ecessar y.
(5) Th e in ferior thyroid arter y is ligated an d t ran sected.
(6) Blun t dissect ion is perform ed from th e cran ial tow ard th e caudal
por t ion un t il th e left brach ioceph alic vein is exposed.
(7) Ret ract ion of th e carot id arter y laterally, brach ioceph alic vein
in feriorly, an d t rach ea m edially exposes th e vertebrae.
II. Th oracolum bar sp in e.
A. Posterior approach es: th e pat ien t is usually posit ion ed on th e four-poster or
Relton -Hall fram e (Surgm ed, Dor val, Quebec, Can ada) for th e th oracolum bar
sp in e an d kn eeling posit ion for th e lu m bar spin e.
1. Th oracic spin e.
a. Posterior: m idlin e exp osu re of th e posterior elem en t s (sp in ou s p rocess,
lam in a, facets, pedicle, an d t ran sverse p rocesses).
(1) Tran spedicular approach : th e th oracic pedicle is located by crossing
a h orizon t al lin e at th e m idport ion of th e t ran sverse p rocess an d
a vert ical lin e at th e ju n ct ion bet w een th e lam in a an d t ran sverse
p rocess.
(2) Posterolateral: costot ran sversectom y approach :
(a) A C-sh aped cur ved in cision is m ade along th e paraspin ous
m u scles, sp an n ing abou t fou r to ve ribs.

1 Anatom y and Surgical Approaches 39

Fig. 1.27

The incision employed for a transthoracic approach to the spine.

(b) Th e m iddle part of th e in cision sh ou ld be ~ 2.5 in from th e


m idlin e.
(c) By un derm in ing th e skin an d subcu tan eous t issue, exposure of
th e paraspin ous m uscles an d posterior elem en t s of th e spin e is
com pleted.
(d) Th e t rapezius an d lat issim us dorsi m uscles are divided eith er
longit u din ally or t ran sversely.
(e) Th e rib an d t ran sverse process are resected at on e to four
levels, depen ding on th e exten t of th e lesion . Th e rib is exposed
su bp eriosteally an d excised ~ 3.5 in ch es lateral to th e vertebra an d
disart iculated at th e costover tebral jun ct ion .
(f) Carefu l ret ract ion of th e pleu ra w ill lead to th e vertebrae.
2. Lum bar spin e.
a. Lam in ectom y or lam in otom y:
(1) Expose th e spin ou s process, lam in a, an d ligam en t um avum .
(2) Excise th e ligam en t um avum to en ter th e epidu ral space.
(3) Rem ove part of th e superior facet to decom press th e lateral recess.
(4) Ret ract the n er ve root m edially to rem ove th e o en ding disk
m aterial.
b. Transpedicular approach (Fig. 1.26): th e p edicle is located by crossing
a h orizon tal lin e at th e m idp ort ion of th e t ran sverse p rocesses an d a
vert ical lin e at th e lateral edge of th e su p erior facet .
B. An terior ap p roach es:
1. Th oracic spin e:
a. Transthoracic approach by rem oving a rib and dividing the pleura (Fig. 1.27).
(1) Th e skin in cision is m ade along th e rib in ten ded for rem oval from
th e an terior m argin of th e lat issim us m uscle an teriorly to th e
costoch on dral jun ct ion .

40 1 Anatom y and Surgical Approaches

Fig. 1.28 (a) The anterior aspect of the latissim us is divided, exposing the underlying rib. (b) The
underlying rib is dissected free of the periosteum .

Fig. 1.29 The overlying rib is resected near its articulation with the costovertebral junction. The parietal pleura is incised, and the overlying prevertebral fascia is identi ed. Shown are the ligated segm ental vessels overlying the thoracic vertebrae.

1 Anatom y and Surgical Approaches 41

(2) Th e an terior aspect of th e lat issim us m uscle can be u n derm in ed or


m in im ally in cised, an d th e posterior border of th e serrat u s an terior
m u scle is m obilized or t ran sected .
(3) Th e lateral m argin of th e t rapezius m uscle is m obilized an d
t ran sected if n ecessar y.
(4) Rib resect ion is th en perform ed by rst in cising th e overlying
periosteum in th e m idpor t ion of th e rib using elect rocauter y. A rib
st rip per is th en u sed to dissect o th e in tercostal m u scu lat u re.
(5) Th e rib is divided at th e costoch on dral jun ct ion an teriorly, elevated
an d resected as far p osteriorly as th e exp osu re w ill allow.
(6) Th e ch est is th en sh arply en tered in th e cen ter of th e rib bed, an d th e
lu ng ret racted an teriorly an d in feriorly.
(7) Th e pleura overlying th e vertebral bodies is th en in cised an d th e
segm en t al vessels ligated as n eeded in th e m idd le of th e vertebral
bodies.
b. Th oracoabdom in al approach by rem oving th e ten th rib an d dividing th e
diaph ragm an d en tering th rough th e ret roperiton eal space.
(1) A skin in cision is m ade over th e ten th rib from th e lateral border of
th e paraspin ou s m u sculat u re to th e cost al car t ilage. Th e in cision is
cu r ved an teriorly to th e edge of th e rect us sh eath .
(2) Th e dissect ion is exten ded dow n to th e m uscle layers to rem ove th e
10th rib.
(3) Th e cost al car t ilage is split after rem oval of th e 10th rib. Th e pleura
is in cised an d th e lung is ret racted, an d th e ret rop eriton eal sp ace is
iden t i ed by th e ligh t areolar t issue.
(4) Blun t dissect ion is perform ed to m obilize th e periton eum from th e
u n dersu rface of th e diap h ragm an d abdom in al w all.
(5) After th e periton eum is ret racted, th e extern al oblique, in tern al
oblique, an d t ran sverse abdom in is m u scles of th e abdom en are
divided on e layer at a t im e.
(6) Th e diaph ragm is in cised circum feren t ially 1 in from its periph eral
at tach m en t to th e ch est w all. Marker st itch es or clips are placed for
resu t uring th e diaph ragm later.
(7) For th e exposure of th e T12L1 region , th e crus of th e diaph ragm is
cu t an d m obilized.
(8) Th e segm en t al vessels are t ied an d ligated as n ecessar y to m obilize
th e aor t a.
2. Lum bar spin e.
a. An terolateral ret rop eriton eal app roach : lateral d ecu bit u s p osit ion .
(1) Dissect ion is th rough th e extern al oblique, in tern al oblique, an d
t ran sverse abdom in is m uscles (skin in cision depen ds on th e level of
exp osu re).
(2) Th e ret roperiton eal space is en tered laterally by iden t ifying
th e ret roperiton eal fat , t aking care to avoid pen et rat ion of th e
p eriton eu m ju st lateral to th e rect u s sh eath .
(3) Blun t dissect ion an terior to th e psoas m u scle sh ould lead to th e
sp in e.

42 1 Anatom y and Surgical Approaches

(4) On e sh ould iden t ify th e gen itofem oral n er ve on th e an terior surface


of th e psoas m uscle an d th e sym path et ic ch ain s m edial to the m u scle
(Fig. 1.30):
(a) Th e L4L5 level is at m ost risk for n eural an d vascular inju r y.
(b) Preven t ion : direct visu alizat ion w h ile dissect ing th e p soas m u scle
w ith con curren t n eurom on itoring.
(5) Th e ureter is u n der th e periton eu m an teriorly.
(6) Vessels (aort a or ven a cava) are m obilized, an d segm en t al vessels are
iden t i ed in th e m iddle port ion of th e vertebral bodies an d ligated as
n ecessar y.
(7) Dissect ion of th e psoas m uscle sh ould be accom pan ied w ith t riggered
elect rom yography.
b. An terior m uscle-split t ing approach .
(1) A vert ical param edian in cision is m ade from th e um bilicu s to th e
pubis at th e edge of th e rect us.
(2) Th e fascia of th e rect us abdom in is is divided, an d th e m uscle is
ret racted m edially.
(3) Th e posterior rect us sh eath is carefully divided along th e periton eal
at t ach m en t .
(4) Blun t nger dissect ion of th e periton eum leads to the low er lum bar
spin e (L3S1).

Fig. 1.30 The anterolateral peritoneal approach dem onstrating the genitofem oral nerve on the anterior surface of the psoas m uscle and the sympathetic chains.

1 Anatom y and Surgical Approaches 43

c. Tran speriton eal approach to lum bosacral jun ct ion .


(1) A vert ical or t ran sverse in cision is m ade above to th e pubis (Fig. 1.31
an d Fig. 1.32).
(2) Th e periton eu m is en tered, an d th e bow el st ruct u res are ret racted
(Fig. 1.33a).
(3) Th e posterior periton eum is lifted an d divided.
(4) Th e iliac vessels are m obilized to expose L4S1 (Fig. 1.33b).
Fig. 1.31 (a) The transperitoneal
approach to the lumbar spine.
(b) The vertical incision splits the
rectus abdominis in the midline
linea alba.

44 1 Anatom y and Surgical Approaches


Fig. 1.32 (a) The overlying peritoneum is incised,
with care to avoid dam aging the underlying peritoneum . (b) The abdominal viscera are retracted,
and the underlying vertebral bodies are exposed.

1 Anatom y and Surgical Approaches 45

b
Fig. 1.33 (a) The omentum and peritoneal contents are re ected, exposing the bifurcation of
the aorta. (b) Retractors are placed along the com m on iliac arteries bilaterally, exposing the L5S1
interspace.

46 1 Anatom y and Surgical Approaches

Suggested Reading
An HS. An atom y. In : An HS, Sim pson JM, eds. Su rger y of th e Cer vical Spin e. Lon don , UK:
Mart in Dun it z an d William s an d Wilkin s; 1994
An HS. Su rgical ap proach es. In : An HS, Sim p son JM, eds. Su rger y of th e Cer vical Spin e.
Lon don , UK: Mart in Dun it z an d William s an d Wilkin s; 1994
An HS. Su rgical exposu re an d fu sion tech n iqu es of th e sp in e. In : An HS, Cotler JM, eds.
Spin al In st rum en tat ion . Balt im ore, MD: William s an d Wilkin s; 1992
An HS, Gord in R, Ren n er K. An atom ic con siderat ion s for p late-screw
cal spin e. Sp ine 1991;16(10, Su ppl):S548S551

xat ion of th e cer vi-

Blan d JH, Boush ey DR. An atom y an d physiology of th e cer vical sp in e. Sem in Ar th rit is
Rh eum 1990;20(1):120
Fang HSY, Ong GB. Direct an terior approach to th e up p er cer vical spin e. J Bon e Join t Su rg
Am 1962;44:15881593
Lubelski D, Abdullah KG, Stein m et z MP, et al. Lateral ext racavitar y, costot ran sversectom y,
an d t ransth oracic th oracotom y approach es to th e th oracic spin e: review of tech n iques
an d com plicat ion s. J Spin al Disord Tech 2013;26(4):222232
Ph illip s JH, Kling TF Jr, Coh en MD. Th e radiograph ic an atom y of th e th oracic pedicle. Spin e
1994;19(4):446449
Watkin s RG. Su rgical App roach es to th e Spin e. New York, NY: Springer-Verlag; 1983

2 History and Physical Examination

2.1 History
I. Degen erat ive disorders of th e spin e.
A. Histor y is th e m ost im por tan t com pon en t of th e pat ien t evaluat ion .
1. Est ablish es th e in it ial di eren t ial diagn oses.
2. Guides physical exam in at ion an d select ive diagn ost ic test s.
B. Sp in al p ain can be described as m ech an ical versu s n on m ech an ical, or axial
versu s rad icu lar.
1. Mech an ical versus n on m ech an ical.
a. Mech an ical pain ten ds to be associated w ith act ivit y.
(1) Relieved by rest .
(2) Progressively w orse over th e course of th e day.
b. Non m ech an ical pain is t ypically due to t um ors or in fect ion s.
(1) In depen den t of act ivit y.
(2) Worse at n igh t .
(3) Not relieved by rest or im m obilizat ion .
2. Axial versus radicular.
a. Axial p ain is u su ally di u se.
(1) Referred pain to th e scapula or sh oulder in cer vical spin e disorders.
(2) Referred pain to the buttock or posterior thigh in lum bar spine disorders.
b. Radicular pain is t ypically associated w ith paresth esia, n um bn ess, or
w eakn ess in a derm atom al dist ribu t ion (Fig. 2.1).
(1) Associated w ith ten sion sign s (Table 2.1).
C. Myelop athy (Fig. 2.2):
1. Presen ts w ith poorly ch aracterized pain .
a. Vagu e sen sor y an d m otor sym ptom s over a long p eriod of t im e are also
com m on .
2. Associated w ith n eck, arm , or leg pain in a n on derm atom al pat tern or w ith
pain in a cer vical derm atom e.
3. Ch aracterized by a slow an d broad-based gait .
4. Problem s w ith upper-ext rem it y n e m otor fun ct ion s.
a. Di cu lt y w ith fasten ing bu t ton s is n oted early.
b. Low er-ext rem it y dysfu n ct ion an d spast icit y.
c. Bow el an d bladder dysfun ct ion are n oted later.
5. Associated w ith path ological long t ract sign s (Table 2.2).
II. Trau m at ic d isorders.
A. Th e air w ay, breath ing, an d circulat ion (ABC) sh ould be ch ecked rst in any
t raum a pat ien t .
B. Th e m ech an ism of inju r y sh ou ld be sough t .
C. Pain an d n eu rological sym ptom s sh ou ld be docu m en ted.
47

48 2 History and Physical Exam ination

b
Fig. 2.1

(a,b) Motor exam ination for cervical and lum bar nerve roots.

III. Spin al deform it y.


A. Deform it y an d pain are th e t w o m ost com m on presen t ing com plain ts.
1. Pain is a m ore om in ou s sign in the ch ild.
a. Th ere are several p ossible et iologies:
(1) Spin al cord or bony t um or.
(2) Sch euerm an ns disease.
(3) Spon dylolisth esis.

2 History and Physical Exam ination 49

Table 2.1

Nerve tension signs

Cervical tension signs

Findings

Spurlings

Neck extension and rotation toward the painful side


causes radicular lim b pain.

Compression

Axial loading on the head reproduces pain.

Distraction test

Skull traction relieves pain.

Shoulder abduction

Elevation of painful lim b relieves pain.

Lumbar tension signs

Findings

Lasegues (straight leg


raise [SLR])

Elevation of painful lim b causes radicular lim b pain,


not back pain. Pain should be reproduced with
< 60 of hip exion.

Bowstring

After reproducing the patients pain and obtaining


a positive Lasegues sign, the knee is exed. This is
positive if the patients pain resolves with exion of
the knee.

Fajersztajns (contralateral SLR)

Elevation of the nonpainful lim b causes back and


lim b pain on the opposite side (usually m eans
sequestered or large extruded herniated disk).

Femoral stretch (reverse SLR)

Hip extension in either the lateral decubitus or


prone position stretches the fem oral nerve and
reproduces pain in the L3 or L4 distribution.

2. In adults, pain associated w ith deform ities tends to be present at the convexit y.
a. Du e to m u scle fat igu e early.
b. Localizes to the concavit y w hen degenerat ive ch anges have occurred later.
B. Medical h istor y, fam ily h istor y, on set of m en arch e, t im e of cu r ve detect ion , an d
p rogression sh ou ld be obt ain ed in th e adolescent scoliot ic pat ien t .

2.2 Physical Examination


I. In sp ect ion .
A. Look for obvious deform it ies in both th e coron al an d th e sagit t al plan e.
1. Coron al plan e (Fig. 2.3).
a. Scoliosis evalu ated by a plu m b lin e d rop p ed from th e seven th cer vical
vertebra.
b. Pelvic obliquit y.
c. Sh oulder im balan ce.
d. Scapular prot uberan ce.
e. Rib p rom in en ce.

50 2 History and Physical Exam ination


b

d
Fig. 2.2 Myelopathic m otor exam ination ndings. (a) Finger escape sign. (b) Jaw-jerk re ex. Myelopathic motor examination ndings. (c) Ho mans sign. (d) Babinskis sign.

2. Sagit t al balan ce an d region al deform it ies.


a. Norm al cer vical lordosis: 20 to 40.
b. Norm al th oracic kyph osis: 20 to 45.
c. Norm al lu m bar lordosis: 40 to 60.
B. Look for skin or su bcu t an eou s lesion s.
1. Caf au lait spot s in n euro brom atosis pat ien ts.
2. Midlin e t uft s of h air, dim ples, or rosy spot s m ay in dicate occult spin al
dysraph ism .
C. Mu scle at rop hy sh ou ld be obser ved in n eu rologically im p aired p at ien ts.
II. Palpat ion .
A. Bony palpat ion .
1. Spin ous processes.
2. Posterior su perior iliac spin es: dim ples.
3. Scapula an d ribs.
4. Iliac crests.
5. Sacrum an d coccyx.
6. Troch an ter an d ischial t uberosit y.
B. Soft t issu e p alpat ion for sp asm or t rigger p oin t ten dern ess.
1. Trapezius m uscle.
2. Rh om boid/levator m uscles.

2 History and Physical Exam ination 51

Table 2.2

Myelopathic signs

Long tract sign/re ex

Findings/provocative maneuver

Lhermit tes grip release

Neck exion causes electric shock sensation or paresthesias


radiating into the upper and lower extremities. Patient
has trouble making a st and fully extending ngers
repeatedlynormal 20 times in 10 seconds.

Finger escape

Ask the patient to keep the ngers in full extension and


the ulnar digits tend to gradually ex and abduct.

Jaw jerk

Hyperre exia on tapping the jaw suggests an upper motor


neuron lesion at the level of the brain stem; involves the
masseter and temporalis muscles and the fth cranial nerve.

Shim izu
(scapulohumeral)

Tapping the tip of the spine of the scapula and the


acrom ion elicits elevation of the hum erus. Re ex suggests
spinal cord compression at the upper cervical region.

Inverted radial

Tapping of the brachioradialis tendon causes spastic nger


exor contraction instead of norm al extension of the wrist.
Positive re ex suggests spinal cord compression at the C6
region.

Ho mans

Holding the m iddle nger extended and suddenly


extending the distal interphalangeal joint (DIP) will
produce nger and thum b exion.

Babinskis

Gentle stim ulus applied to the lateral aspect of the sole


of the foot starting over the heel extending toward the
fth digit. A positive Babinskis sign refers to the initial
dorsi exion of the great toe upward and the spreading of
the other toes.

Clonus

Rhythm ic, nonvoluntary movem ents of the m uscle with


rm passive continuous stretch

3. Paravertebral m uscles.
4. Glu teus m uscles.
5. Piriform is m uscle.
6. Sciat ic n er ve.
III. Range of m ot ion .
A. Cer vical spin e.
1. Flexion : 45 (th e ch in tou ch es th e ch est).
2. Exten sion : 75.
3. Lateral ben d ing: 40.
4. Rotat ion : 75.

52 2 History and Physical Exam ination

Fig. 2.3 Pelvic obliquit y, shoulder im balance, scapular protuberance, and rib prom inence in the coronal plane in a scoliosis patient.

B. Th oracolu m bar sp in e.
1. Flexion : 80 (m easure th e dist an ce from th e t ip of h an ds to th e oor).
2. Exten sion : 40.
3. Lateral ben ding: 40.
4. Rotat ion : 45.
IV. Neu rological exam in at ion of in dividu al root s.
A. Sen sor y test s.
1. Four distinct sen sat ions w ith de ned anatom ical pathw ays in the spinal cord:
a. Pain p ercept ion m ay be tested w ith de n ed an atom ical path w ays of th e
sp in al cord.

2 History and Physical Exam ination 53

b. Ligh t touch m ay be tested w ith a cot ton sw ab.


c. Tem perat ure m ay be tested w ith t w o test t ubes con tain ing eith er a h ot or
a cold solu t ion .
d. Propriocept ion begin s dist ally at th e dist al ph alan x or great toe an d
p roceeds proxim ally to each larger join t .
2. Th e aim of sen sor y test ing is to iden t ify w h eth er th ere is a derm atom al
p at tern of sen sor y dysfu n ct ion , w h ich w ould suggest spin al root path ology,
or a possible glove/stocking dist ribu t ion th at w ould suggest a n europathy
(Table 2.3) (Fig. 2.4).
B. Motor test s.
1. Muscle ton eresist an ce to passive range of m ot ion .
a. Hyp erton ia m ay in d icate an u p p er m otor n er ve lesion .
b. Hypoton ia m ay in dicate a low er m otor n er ve lesion .
2. Mu scle st rength .
a. Grade 5: n orm al.
b. Grade 4: w eak again st resistan ce.
c. Grade 3: m ot ion again st gravit y.
d . Grade 2: m ot ion w ith gravit y elim in ated.

Table 2.3

Anatomy of derm atom al distribution

Nerve root

Dermatomal distribution

C5

Upper outer arm

C6

Thum b

C7

Long nger

C8

Lit tle nger

T1

Medial forearm

T4

Nipple

T10

Um bilicus

L1

Groin

L2

Anterior thigh

L3

Knee

L4

Medial m alleolus

L5

Great toe

S1

Sm all toe

S2

Posterior thigh

S3S5

Anal

54 2 History and Physical Exam ination

b
Fig. 2.4

(a,b) Norm al distribution of dermatom al levels.

e. Grade 1: eviden ce of con t ract ilit y.


f. Grade 0: n o eviden ce of con t ract ilit y.
3. Motor root test ing/re exes (Table 2.4).
V. Special provocat ive test s (Fig. 2.5).
A. Adsons test .
1. Test to evaluate th oracic outlet syn drom e.
2. Abduct , exten d, an d extern ally rotate th e arm w h ile feeling th e radial pulse.
Also rot ate th e h ead tow ard th e test ing arm .
a. If the pulse disappears w ith reproduction of sym ptom s, the test is positive.
B. Sacroiliac test s.
1. Pat ricks test: exion , abduct ion , an d extern al rot at ion of th e h ip cause pain
referred from th e sacroiliac join t .
2. Gaen slens test: dropping th e leg on th e t able (exten sion of th e h ip) causes
p ain in th e ipsilateral sacroiliac join t .

2 History and Physical Exam ination 55

Table 2.4

Motor strength testing

Root

Muscles

Re ex

C5

Deltoid, biceps

Biceps

C6

Biceps, wrist extensors

Brachioradialis

C7

Triceps, wrist exion

Triceps

C8

Finger exors

T1, T2

Hand intrinsics

T2T12

Intercostals,
rectus abdominis

L1L3

Iliopsoas

L4

Tibialis anterior

Patellar tendon

L5

Extensor hallucis longus

Posterior tibial tendon

S1

Peronealis, gastrocnem ius

Achilles

Beevors sign (abdom inal)asym m etric


contraction of the um bilicus with
stim ulation of the abdom en

C. Bu lbocavern ou s re ex (Fig. 2.4):


1. Mon itoring th e an al sph in cter con t ract ion in respon se to squeezing th e glan s
p en is or clitoris or pu lling an in dw elling Foley cath eter.
D. Sch obers test .
1. Norm al lum bar excursion is usually > 5 cm . Mark 10 cm from th e posterior
su p erior iliac sp in e level w h en th e p at ien t is stan ding erect , an d m easu re
th e dist an ce on for w ard exion . If it becom es < 15 cm , on e sh ould suspect
an kylosing sp on dylit is.
E. Waddells sign s.
1. Non organ ic physical exam n dings.
2. If th ree or m ore sign s are foun d, it is suggest ive th at th e pat ien ts pain
com plain t s m ay n ot be an atom ical.
a. Non an atom ical or su p er cial ten d ern ess th at is n ot prop or t ion al to exam
n d ings.
b. Sim ulated rot at ion or com pression test s:
(1) In st ruct th e pat ien t to stan d w ith th e feet togeth er an d rot ate th e
p at ien ts pelvis or press on th e top of th e h ead. Th ese m an euvers
sh ou ld n ot cau se pain .
c. Exten ding the leg in th e sit t ing posit ion is n egat ive but st raigh t leg
raising in th e su p in e p osit ion is m arkedly p osit ive.
d . Weakn ess an d sen sor y n dings th at do n ot correspon d to accepted
d erm atom al dist ribut ion .
e. Verbal or p hysical overreact ion to a part icu lar m an euver.

56 2 History and Physical Exam ination

b
Fig. 2.5

(a) Adsons and the (b) m odi ed Adsons test to evaluate for thoracic outlet syndrom e.

Suggested Reading
Al Nezari NH, Sch n eiders AG, Hen drick PA. Neu rological exam in at ion of th e p erip h eral
n er vou s system to diagn ose lu m bar spin al disc h ern iat ion w ith su spected radicu lopathy: a system at ic review an d m eta-an alysis. Sp in e J 2013;13(6):657674
Clark CR. Cer vical sp on dylot ic m yelop athy: h istor y an d p hysical n d ings. Spin e 1988;13
(7):847849
Iversen T, Solberg TK, Rom n er B, et al. Accu racy of physical exam in at ion for ch ron ic lu m bar radiculopathy. BMC Muscu loskelet Disord 2013;14:206
Stan ley Hoppenfeld S. Physical exam in at ion of th e cer vical sp in e an d tem porom an dibu lar
join t . In : Physical Exam in at ion of th e Spin e an d Ext rem it ies. Nor w alk, CT: App leton
Cen t ur yCrofts; 1976:105132

3 Radiographic Anatomy

3.1 General Considerations


I. Th e abilit y to prop erly diagn ose an d t reat spin al path ology requ ires a th orough
u n derst an ding of th e n orm al sp in al an atom y.
II. Pat ien t sym ptom s m u st correlate w ith p osit ive im aging n dings to su rgically
ad dress th e speci c p ath ology.
III. On ce a diagn osis is con rm ed , th e su rgeon m u st plan th e best su rgical t reat m en t
opt ion based on each pat ien ts in dividual an atom y.
IV. Plain lm rad iograp h s are often th e rst im aging st u dy obtain ed for m ost sp in erelated com plain ts.
A. Lateral view s are useful to assess spinal align m en t an d in stabilit y.
1. Cer vical spin e (Fig. 3.1).
2. Lu m bar spin e (Fig. 3.2).
B. Op en -m ou th view : to assess th e den s an d atlan toaxial join t (Fig. 3.3).

Fig. 3.1 Lateral plain lm radiograph of (A) the


anterior border of the vertebral bodies, (B) the posterior border of the vertebral bodies, and (C) the
junction of the laminae and spinous processes.

57

58 3 Radiographic Anatom y
Fig. 3.2 Lumbar spine (lateral plain
lm radiograph in extension). 1, superior
articular process (SAP); 2, inferior articular process (IAP); 3, spinous process; 4,
intervertebral disk space (no evidence of
anterior slip).

Fig. 3.3 Radiograph, open-m outh


view. 1, dens; 2, atlantoaxial joint.

V. Magn et ic reson an ce im aging (MRI) is part icularly useful to an alyze region al


an atom y an d assess th e safet y an d feasibilit y of su rger y.
A. Cer vical spin e (Fig. 3.4).
B. Lu m bar sp in e (Fig. 3.5).
VI. Com puted tom ography (CT) can also be u sed for preoperat ive plan n ing (Fig. 3.6).

3 Radiographic Anatom y 59
Fig. 3.4 Magnetic resonance
imaging axial cut at C4 demonstrating normal anatomy. 1, trachea; 2,
esophagus; 3, transverse process
(foramina transversaria); 4, spinal
cord (note the high-intensit y signal
surrounding the spinal cord (cerebrospinal uid); 5, external carotid
artery; 6, internal carotid artery; 7,
internal jugular vein; 8, facet joint
complex; dot ted line, surgical plane
for ACDF.

Fig. 3.5 Lumbar spine (magnetic


resonance imaging, T2axial cut
L4L5 disk). 1, left common iliac
artery (immediately after bifurcation of the abdominal aorta; 2,
inferior vena cava (prior to bifurcation of the left and right common
iliac veins; 3, left psoas muscle;
4, spinal canal (cauda equina); 5,
facet joint; MF, multi dus muscle;
LS, longissimus muscle; arrow,
intermuscular Wiltse plane (used
in minimally invasive approaches
and pedicle screw placement).

Fig. 3.6 Lumbar spine (axial computed tomography at L3). P, pedicle; SP, spinous process; TP,
transverse process; dot ted lines, trajectory for
spinal access needles and pedicle screws.

60 3 Radiographic Anatom y

3.2 Common Spinal Pathologies


I. Spon dylosis: degen erat ive spin al disease.
A. Frequen t radiograph ic n dings.
1. Loss of cer vical lordosis.
2. Disk space n arrow ing (Fig. 3.7).
3. Osteophyte form at ion s (Fig. 3.8).
a. Osteop hytes can be obser ved in p lain lm radiograph s, bu t CT bet ter
delin eates th e size and exten t of osteophyt ic form at ion (im port an t for
su rgical p lan n ing).
Fig. 3.7 Lateral plain lm radiograph. 1,
normal disk height; 2, decreased disk height;
solid line, loss of cervical lordosis; dotted
line, normal cervical lordosis.

Fig. 3.8 Lumbar spine (sagit tal computed


tomography). Notice osteophyte formation
anteriorly. L1, pedicle; L3, inferior articular
process (IAP); L4, superior articular process
(SAP); L5S1, spondylosis.

3 Radiographic Anatom y 61

B. MRI ch anges.
1. Reduced disk sign al on T2.
a. T2 is th e preferred m odalit y to ch aracterize disk p ath ology. A n orm al disk
w ill dem on st rate a h igh -in ten sit y n ucleus surroun ded by a low -in ten sit y
an n u lu s.
(1) Loss of disk h eigh t an d darken ing of th e in ter vertebral disk are
com m on MRI n dings in degen erat ive disk path ology (Fig. 3.9 an d
Fig. 3.10).
Fig. 3.9 Sagit tal m agnetic resonance im aging cut of cervical
spine. 1, posterior arch of C1
(atlas); 2, spinal cord; 3, C5C6
disk degeneration with posterior disk protrusion; C7, spinous
process.

Fig. 3.10 Magnetic resonance


imaging, axial cut at C5C6.
1, plat ysma m uscle; 2, thyroid
gland; 3, comm on carotid artery;
4, internal jugular vein; 5, normal
exiting nerve root; 6, facet joint;
7, longus colli muscle; 8, deep
cervical m uscles; 9, trapezius; 10,
left herniated nucleus pulposus
(HNP) causing foraminal stenosis.

62 3 Radiographic Anatom y

2. Facet join t hyper t rophy.


3. In ter vertebral disk bulge or prot rusion (h ern iated n ucleus pulposus).
a. Cen t ral.
b. Paracen t ral.
c. Far lateral (Fig. 3.11 an d Fig. 3.12).
Fig. 3.11 Magnetic resonance
imaging axial cut at L5S1. 1,
left common iliac vein; 2, left
paracentral herniated nucleus
pulposus; 3, left L5 lamina; 4,
ilium.

Fig. 3.12 Magnetic resonance


imaging sagit tal cut through the
spinous process. 1, end of spinal
cord (conus medullaris); 2, normal L3L4 intervertebral disk
intensit y; 3, L5S1 disk degeneration with posterior herniation.

3 Radiographic Anatom y 63

II. Vertebral body collap se.


A. Com pression fract u res in osteoporot ic pat ien t s.
B. Path ological fract u res from t u m ors (m ore often m etastat ic).
C. Ch aracterized by loss of vertebral body h eigh t w ith or w ith ou t segm en t al
kyph osis in lateral plain lm radiograph s (Fig. 3.13 an d Fig. 3.14).
D. CT is th e best im aging st u dy for assessing bony an atom y.

Fig. 3.13 Lateral plain lm radiograph. L1 body


dem onstrates decreased body height with local
kyphotic deformit y.

Fig. 3.14 Magnetic resonance


imaging axial cut at the L1 body.
1, bony defect consistent with
compression fracture.

64 3 Radiographic Anatom y

III. Spin al sten osis.


A. Narrow ing of th e spin al can al or n euroforam en can cause n eurological
sym ptom s (Fig. 3.15, Fig. 3.16, an d Fig. 3.17).
B. Narrow ing of th e sp in al can al m ore often occu rs in elderly pat ien t s (> 60 years)
due to degen erat ive ch anges (Fig. 3.18):
1. Disk prolapse.
2. Hypert roph ic facet join t s or ligam en t um avum .
3. Degen erat ive spon dylolisth esis.
C. MRI is th e m odalit y of ch oice for assessing size an d sh ap e of th e sp in al can al.

Fig. 3.15 Magnetic resonance


imaging axial cut at C5C6 disk
space: severe spinal stenosis.
1, central spinal stenosis (note
the absence of high-signal cerebrospinal uid surrounding the
spinal cord).

Fig. 3.16 Magnetic resonance imaging axial cut at


L4L5 disk space. 1, severe
lumbar spinal stenosis; 2,
facet joint hypertrophy.

3 Radiographic Anatom y 65
Fig. 3.17 Magnetic resonance
imaging (MRI) sagittal cut through
the spinous process. 1, end of spinal
cord (conus medullaris); 2, L3L4 disk
prolapse; 3, L4L5 disk prolapse. MRI
sagittal cut through right pedicles. 4,
L1 pedicle; 5, normal L2 exiting nerve
root; 6, stenosed L4 nerve root.

Fig. 3.18 Magnetic resonance


imaging sagit tal cut through
the left-side pedicles. 1, normal
nerve root (high-intensit y fat
surrounding low-intensit y nerve
root); 2, L3 pedicle; 3, L4 spinous
process; 4, L5 foraminal stenosis.

IV. Spon dylolisth esis.


A. Refers to th e for w ard slip of a vertebral body on th e on e below (Fig. 3.19).
B. More often occu rs as a resu lt of a defect in th e p ars in terar t icu laris bu t can also
occur as a resu lt of degen erat ive disk disease.
C. Plain lm radiographs are used to determ ine the degree of the listhesis (Fig. 3.20).
D. MRI allow s visu alizat ion of n eu ral st ru ct u res.
1. Spin al cord.
2. Spin al n er ve root s.
a. Foram in al sten osis.
E. CT im aging is th e m ost sen sit ive for detect ing a pars defect .
1. It can also be used for preoperat ive plan n ing.

66 3 Radiographic Anatom y
Fig. 3.19 Magnetic resonance
imaging axial cut L5S1 disk. 1, left
foraminal stenosis; 2, facet joint
arthropathy; SP, spinous process.

Fig. 3.20 Lateral plain lm radiograph ( exion). 1, L2 spinous process;


2, L2 inferior articular process; 3, L3
superior articular process; 4, L4L5 slip
(anterolisthesis); arrow, pars defect.

Suggested Reading
Bogduk N. Clin ical An atom y of th e Lum bar Spin e an d Sacrum . Ph iladelp h ia, PA: Elsevier;
2005
Del Gran de F, Mau s TP, Carrin o JA. Im aging th e in ter vertebral disk: age-related ch anges,
h ern iat ion s, an d radicu lar p ain . Radiol Clin North Am 2012;50(4):629649
Karan tan as AH. W h ats n ew in th e use of MRI in th e or th opaedic t raum a pat ien t? Injur y
2014;45(6):923933
Vaccaro AR, Rizzolo SJ, Balderston RA, et al. Placem en t of p edicle screw s in th e th oracic spin e. Par t II: An an atom ical an d radiograph ic assessm en t . J Bon e Join t Su rg Am
1995;77(8):12001206

4 Spinal Imaging and Diagnostic Tests

4.1 Imaging Modalities


I. Gen eral con siderat ion s.
A. Spin al im aging m odalit ies (Table 4.1):
1. Plain radiograph s.
2. Com puted tom ography.
3. Magn et ic reson an ce im aging (MRI).
4. Bon e scin t igraphy.
5. Myelography.
6. Angiography.
7. Diskography.
B. A th orough h istor y an d p hysical exam in at ion sh ou ld lead to a p relim in ar y
clin ical diagn osis th at sh ould predicate both th e select ion an d th e t im ing of
im aging test s.
1. Diagn ost ic test s sh ould be used to con rm in form at ion ascer tain ed during
th e h istor y an d physical exam in at ion .
C. Select ion of im aging test s sh ou ld be based on th e app reciat ion of th e sen sit ivit y,
sp eci cit y, an d accu racy of variou s im aging m odalit ies in conju n ct ion w ith
d i eren t disease processes.
1. Acute n eck or back pain an d radiculopathy:
a. Th e n at u ral h istor y is th at of im provem en t w ith con ser vat ive t reat m en t .
b. Diagn ost ic im aging sh ould be delayed un t il 4 to 6 w eeks after th e on set of
sym ptom s.
(1) Th ere are except ion s to an earlier im aging evalu at ion :
(a) Traum a.
(b) Progressive n eurological de cit .
(c) Suspected n eoplasm or in fect ion .
2. Im aging evaluat ion alon e w ith out clin ical correlat ion is associated w ith an
ext rem ely h igh false-p osit ive rate.
a. Plain radiograph s sh ow aging an d degen erat ive p rocesses in vir t u ally all
in dividu als after th e age of 40 years (Fig. 4.1).
b. MRI n dings of th e cer vical spin e dem on st rate th e follow ing:
(1) Four teen percen t of asym ptom at ic in dividu als < 40 years old an d 28%
> 40 years old h ad eviden ce of a h ern iated d isk.
(2) Degen erat ive disk disease is m ore com m on in asym ptom at ic
in dividuals, w ith an in ciden ce of 25% for < 40 years old an d 56% for
> 40 years old.
c. MRI n dings of th e lum bar spin e dem on st rate th e follow ing:
(1) In asym ptom at ic in dividuals, a h ern iated disk w as n oted in 21% of
pat ien t s bet w een 20 an d 39 years of age an d 36% of in dividuals > 60
years of age.
67

>

68 4 Spinal Im aging and Diagnostic Test s

4 Spinal Im aging and Diagnostic Test s 69

70 4 Spinal Im aging and Diagnostic Test s


a

Fig. 4.1 (a) Lateral radiograph of the lumbar


spine dem onstrating a vacuum disk sign at L4
L5. This is suggestive of disk space collapse and
disk degeneration. (b) Lateral radiograph of
the cervical spine dem onstrating disk degeneration. (Reproduced from Bohndorf K, Im hof
H, Pope TH Jr. Musculoskeletal Imaging: A Concise Multim odalit y Approach. Stut tgart, Germ any: Georg Thiem e Verlag; 2001: Figs. 9.61
and 9.62, with perm ission.)

(2) Spin al sten osis is foun d in 21% of th ose > 60 years of age, an d bulging
disks are foun d in > 50% of pat ien t s in all age groups.
II. MRI (Fig. 4.2).
A. Con t rain dicat ion s:
1. Ferrous m et al im plan t s in th e brain .
2. Metal debris in th e eye.
3. In ner ear im plan t s.
4. Pacem akers.

4 Spinal Im aging and Diagnostic Test s 71


Fig. 4.2 Magnetic resonance im aging (T2 sagit tal im age) of the lum bar
spine with decreased signal intensit y
at the L4L5 and L5S1 interspace
with minim al loss of disk height.

B. Im aging arou n d m et al im p lan t s is p oor u n less special tech n iqu es are u sed an d if
th e m etal is t it an ium in stead of st ain less steel.
C. T1- versu s T2-w eigh ted im ages t ake advan t age of in t rin sic t issu e p rop ert ies
(Fig. 4.3) (Table 4.2).
1. Repet it ion t im e (TR): t im e bet w een radiofrequ en cy (RF) pulses.
2. Ech o t im e (TE): t im e bet w een RF an d recording.
3. T1-w eigh ted im age: sh ort TR (400600 m s), sh ort TE (530 m s).
4. T2-w eigh ted im age: long TR (1,5003,000 m s), long TE (50120 m s).
D. Sp ecial in dicat ion s:
1. Postoperat ive scar versus recurren t disk h ern iat ion .
a. Use of gadolin iu m con t rast .
b. Th e scar is vascular an d en h an ces w ith gadolin ium . Th e disk does n ot
en h an ce w ith con t rast agen t s. Th is is obser ved on T1-w eigh ted sequ en ce.
2. In fect ion versus t um or.
a. In sp in al osteom yelit is, th ere is abn orm al t issu e w ith decreased sign al
in ten sit y on T1-w eigh ted im ages an d in creased sign al in ten sit y on T2w eigh ted im ages at th e disk m argin .
b. In t um ors, th e in ter vertebral disk is spared, an d sim ilar ch anges are n oted
involving th e en t ire vertebral body.
3. Com pression fract ures versus path ological fract ures.
a. More d i cu lt to di eren t iate.
b. In path ological fract u res.
(1) En t ire ver tebral body involvem en t .
(2) Frequen t involvem en t of th e pedicle.
(3) Presen ce of soft t issue m asses.
(4) Can al com prom ise.

72 4 Spinal Im aging and Diagnostic Test s


a

Fig. 4.3 (a,b) T1-weighted m agnetic resonance im aging (axial and sagit tal) of the lum bar spine.
(c,d) T2-weighted MRI im aging (axial and sagit tal) of the lumbar spine.

Table 4.2

Magnetic resonance im aging ndings of human tissue

Tissue type

T1 signal

T2 signal

Cortical bone

Low

Low

Tendon/ligament

Low

Low

Hyaline cartilage

Intermediate

Interm ediate

Free water

Low

High

Adipose

High

Low

Abscess

Interm ediate

High

c. In osteoporot ic com pression fract ures.


(1) No involvem en t of th e pedicle.
(2) Par t ial involvem en t of th e ver tebral body.
4. Spin al cord inju r y.
a. Dist ingu ish es sp in al cord edem a versu s h em orrh age.
(1) Edem a is bright on T2- and decreased on T1-weighted im ages (Fig. 4.4).

4 Spinal Im aging and Diagnostic Test s 73


Fig. 4.4 T2-weighted magnetic resonance imaging demonstrating increased signal intensit y suggestive of spinal cord
edema. (Reproduced from Uhlenbrock D. MR Imaging of the
Spine and Spinal Cord. Stuttgart, Germany: Georg Thieme
Verlag; 2004: Fig. 7.6, with permission.)

(2) Hem orrh age is brigh t on T1- an d decreased on T2-w eigh ted im ages
(Fig. 4.5).
E. Disk degen erat ion (Fig. 4.6 an d Fig. 4.7):
1. A radial tear of th e an n ulus brosu s is outlin ed as a ssure exten ding from
th e n ucleus to th e periph er y.
a. A h igh -in ten sit y zon e in th e p osterior an n u lu s suggest s a radial tear th at
m ay be clin ically sign i can t .
2. Modic en d plate ch anges:
a. Typ e 1 (Fig. 4.8).
(1) Low intensit y on T1-weighted im age and high intensit y on T2-weighted
im age.
(2) Associated w ith segm en tal spin e in st abilit y an d pain .
b. Type 2 (Fig. 4.9).
(1) High intensit y on T1-weighted im age and norm al on T2-weighted im age
(2) Fat t y m arrow ch anges aroun d th e en d plates.
(3) Less likely to be sym ptom at ic.
c. Type 3 (Fig. 4.10).
(1) Hypoin ten se on T1- an d T2-w eigh ted im ages.
(2) Sclerot ic advan ced degen erat ive ch anges w ith less segm en t al m ot ion .

74 4 Spinal Im aging and Diagnostic Test s

Fig. 4.5 (a,b) T1-weighted m agnetic resonance im aging demonstrating increased signal intensit y
suggestive of hem orrhage. (Reproduced from Uhlenbrock D. MR Im aging of the Spine and Spinal Cord.
Stut tgart, Germ any: Georg Thiem e Verlag; 2004: Fig. 8.2a,b, with perm ission.)

4 Spinal Im aging and Diagnostic Test s 75

Fig. 4.6 Axial cut (computed tom ographic scan) at L4 that dem onstrates the pedicles and bony anatomy. Note: the thecal sac can be visualized as well.

Fig. 4.7 (a) Lateral diskogram dem onstrating extravasation of dye at the L5S1 level suggestive of
an annular tear. (b) Computed tomography postdiskography (sagit tal) dem onstrating extravasation of
dye posteriorly at L4L5.

76 4 Spinal Im aging and Diagnostic Test s

Fig. 4.8 (ac) Sagit tal m agnetic resonance imaging demonstrating t ype 1 Modic changes. (Reproduced from Im hof H, et al. Spinal Im aging. Direct Diagnosis in Radiology Series. Stut tgart, Germany:
Georg Thieme Verlag; 2008: Figs. 3.4 and 3.5, with perm ission.)

Fig. 4.9 Sagit tal magnetic resonance imaging demonstrating t ype 2 Modic changes. (Reproduced from
Uhlenbrock D. MR Imaging of the Spine and Spinal
Cord. Stut tgart, Germany: Georg Thieme Verlag; 2004:
Fig. 4.31, with permission.)

4 Spinal Im aging and Diagnostic Test s 77

Fig. 4.10 (a,b) Sagit tal m agnetic resonance imaging demonstrating t ype 3 Modic changes. (Reproduced from Uhlenbrock D. MR Im aging of the Spine and Spinal Cord. Stut tgart, Germ any: Georg
Thiem e Verlag; 2004: Fig. 4.33, with perm ission.)

4.2 Electrodiagnostic Tests


I. Elect rom yography (EMG) an d n er ve con du ct ion st u dies (NCSs).
A. EMG/NCS on ly evaluates th e m otor t ract s of th e n er ve root .
1. Radiculopathy m ay also involve m otor, sen sor y, an d auton om ic bers of th e
n er ve root .
B. Com p ou n d m u scle act ion p oten t ial in p erip h eral n er ves w ill sh ow red u ced
am p lit u de in prop or t ion to th e am ou n t of axon al degen erat ion th at occu rs after
a com pressive n er ve root lesion .
C. Com p ou n d m u scle act ion p oten t ial in p erip h eral n er ves is m ore m arked w h en
m u lt ip le root s are involved, as in lu m bar sp in al sten osis.
D. Ner ve con du ct ion velocit y or laten cy sh ou ld not be a ected by a focal p roxim al
lesion , such as in radicu lopathy.
E. Th e gold st an dard for elect rodiagn osis of radiculopathy is n eedle EMG.
1. Th e earliest EMG n ding in acute radiculopathy is a decrease in th e n um ber
of m otor un it poten t ials seen on recruit m en t .
2. An in crease in th e n um ber of polyph asic m otor un it poten t ials m ay be seen
early.
3. Prolonged H re ex laten cy for C7 or S1 root s an d reduced n u m ber of F w aves
in w eak m uscles m ay be obser ved after several days of radicu lopathy.
4. Spon t an eous m otor act ivit y, brillat ion s, an d posit ive F w aves are th e
h allm arks of acu te radicu lopathy.
5. Large, long-durat ion , polyph asic poten t ials in dicate rein n er vat ion .
6. As th e radiculopathy resolves, polyph asic poten t ials ten d to reduce in th e
n u m ber of p h ases, bu t th e m otor u n it p oten t ials m ay rem ain larger an d
be of longer durat ion th an th e n orm al m otor un it poten t ials of un involved
m u scles.

78 4 Spinal Im aging and Diagnostic Test s

F. In dicat ion s for EMG/NCS:


1. Clin ical n dings suggest oth er n eurological disorders, su ch as an terior h orn
cell disease, n er ve en t rapm en t syn drom e, cer vical sten osis, am ong oth ers.
2. Im aging st u dies an d clin ical n dings do n ot correlate w ell in pat ien t s w ith
su spected radicu lopathy.
3. In cases w h ere n eurological progression or deteriorat ion m ust be
docu m en ted.
II. Som atosen sor y evoked p oten t ials (SSEPs) an d m otor evoked poten t ials.
A. Assess sen sor y t racts from a periph eral n er ve to th e posterior colum n of th e
sp in al cord (Fig. 4.11).
B. Most com m on ly u sed as an in t raop erat ive m on itoring tech n iqu e to protect th e
sp in al cord du ring su rger y.
C. Derm atom al SSEPs can be u sed to m on itor n er ve root fu n ct ion du ring su rger y.
D. Motor evoked p oten t ials assess th e m otor p ath w ay in th e sp in al cord,
p ar t icu larly during an terior procedu res of th e spin e th at m ay jeopardize th e
an terior part of th e spin al cord.

Fig. 4.11 Cortical som atosensory-evoked potential from the posterior columns. (Reproduced from
Devlin VJ, Schwart z DM. Intraoperative neurophysiologic m onitory during spinal surgery. J Am Acad
Orthop Surg 2007;15(9):549560, with perm ission.)

4 Spinal Im aging and Diagnostic Test s 79

Suggested Reading
Berquist TH. Im aging of th e postop erat ive sp ine. Radiol Clin North Am 2006;44(3):
407418
de Graaf I, Prak A, Bierm a-Zein st ra S, Th om as S, Peul W, Koes B. Diagn osis of lum bar
spin al sten osis: a system at ic review of th e accu racy of diagn ost ic test s. Spin e 2006;
31(10):11681176
Haugh ton V. Im aging in ter vertebral disc d egen erat ion . J Bon e Join t Su rg Am 2006;
88(Su ppl 2):1520
Jayaku m ar P, Nn ad i C, Saifu d din A, Macsw een ey E, Casey A. Dyn am ic degen erat ive lu m bar sp on dylolisth esis: diagn osis w ith axial loaded m agn et ic reson an ce im aging. Sp in e
2006;31(10):E298E301

5 Intraoperative Neuromonitoring

5.1 General Considerations


I. In t rodu ct ion .
A. Con tem porar y in t raoperat ive n eu rophysiological m on itoring (IONM) of th e
sp in al t ract s stem s from advan cem en t s m ade in th e 1970s.
B. Prior to m odern m odalit ies, th e Stagn ara w ake-u p test w as th e gold st an dard
for th e assessm en t of global m otor fu n ct ion .
1. Ch aracterized by aw aken ing th e pat ien t to assess m otor fun ct ion .
2. Pat ien t w as aw aken ed after crit ical poin t s during th e procedure (e.g.,
im p lan t p lacem en t , cur ve reduct ion ).
a. Lim ited app licat ion s ou t side of scoliosis correct ion .
3. Sign i can t lim it at ion s of th e w ake-u p test .
a. Poor pat ien t coop erat ion .
b. Lack of real-t im e m on itoring.
c. False-n egat ives.
d . Ven ou s air em bolism .
e. In abilit y to detect delayed n eu rological in su lt s.
f. In abilit y to t ake expedit iou s correct ive m easu res.
C. Som atosen sor y evoked p oten t ial (SSEP) m on itoring w as th e rst advan cem en t
in IONM.
1. Sen sor y dorsal colum n m edial lem n iscus path w ay.
D. Recen t advan ces in clu de th e assessm en t of t ran scran ial m otor evoked poten t ials
(tcMEPs) an d elect rom yography (EMG).
1. En able real-t im e m on itoring of th e m otor t racts an d n er ve root s an d lim it
sign al in terferen ce from an esth esia.
E. Num erou s variables con foun d IONM.
1. An esth esia (m ost com m on ).
2. Body tem perat ure.
3. Degree of n eural developm en t (age, n eurom uscu lar com orbidit ies, delayed
developm en t).
4. Mean ar terial pressures.
5. Medicat ion s.
6. Length of procedure.
7. Person n el expert ise.
II. Som atosen sor y evoked p oten t ials (SSEPs):
A. Elicited by th e st im u lat ion of a periph eral ner ve, t ypically eith er th e posterior
t ibial, peron eal, u ln ar, or m edian n er ves.
B. Th e sign al t raverses th e dorsal colum n m edial lem n iscus path w ay in th e spin al
cord to th e brain .
C. Th e ascen ding sign al is capt u red by an am pli er placed on th e h ead, w h ich th en
records cor t ical SSEPs.
80

5 Intraoperative Neurom onitoring 81

1. Subcort ical respon ses can also be t racked by placing th e am pli er elect rodes
on th e an terior or posterior n eck.
2. Subcort ical SSEPs are th ough t to be less in h ibited by th e e ect s of an esth esia
an d th e d egree of n eu ral develop m en t .
D. Am p lit u de redu ct ion of > 50% or laten cy of m ore th an 10% of baselin e is cau se
for con cern .
E. Sign i can t lim itat ion s of SSEPs:
1. Not t rue real-t im e m on itoring, because th e poten t ials m u st sum m ate w h en
th ey are recorded.
2. Lack of m otor t rack m on itoring.
3. Sign i can tly a ected by n euroan esth esia.
III. Tran scran ial m otor evoked p oten t ials:
A. Record th e descen ding m otor cort icospin al t ract s.
B. Ch aracterized by t ran scran ial st im u lat ion .
C. A record ing elect rod e is p laced in th e su bdu ral sp ace of th e spin e, or a
su bd erm al elect rode can be u sed to record th e p erip h eral m u scu lat u re.
1. Descen ding st im ulat ion can sum m ate tem porally or spat ially to t rigger
skeletal m u scle act ion , th ereby p rod u cing com p ou n d m u scle act ion
p oten t ials (CMAPs).
2. Epidural m on itoring is ch aracterized by m on itoring th e D-w ave, w h ich
rep resen t s d irect st im u lat ion of th e cort icospin al n euron s.
D. Myogen ic MEPs (m MEPs):
1. Assess th e n er ve roots an d periph eral n er ves.
E. A loss of MEPs or a sudden decrease in 75% of am plit u de is ch aracterist ic of
n eu ral in su lt .
IV. Elect rom yograp hy:
A. Placem en t of con cen t ric n eedle elect rodes in to th e ext rem it y m usculat ure
to record am plit ude, frequ en cy, durat ion , an d sh ape of th e m otor u n it act ion
poten t ial.
1. Assesses spin al n er ve root in sult s due to st retch or direct inju r y.
2. Records ch anges in th e pat tern of m otor un it act ion poten t ials as a result of
n er ve root inju r y/irritat ion .
3. Provides real-t im e in form at ion to th e surgeon to reverse any n oxiou s st im uli
to th e n er ve roots.
a. False n egat ives are often en cou n tered if n er ve root inju r y resu lt s from
vascu lar inju r y or p rolonged st retch inju r y, w h ich m ay h ave a delayed
presen tat ion .
B. Triggered EMG (tEMG).
1. Used during im plan t placem en t w ith t ran spedicular screw xat ion .
2. A curren t is applied to th e pedicle screw h ead after placem en t , an d th e
CMAPs of th e correspon ding n er ve root m uscu lat ure are recorded.
3. Assess th e sign al in ten sit y requ ired to depolarize th e m usculat ure:
a. With pedicle w all breach , th e st im u lu s m agn it u de is sign i can tly low er
th an con t rol valu es, because th ere is less im pedan ce of curren t ow to
th e n eu ral elem en ts.
b. Less th an 10 m illiam ps m ay be in dicat ive of a m edial w all breach .
4. Con t in u ous EMG is used w h ile th e surgeon is t raversing th e psoas m u scle in
an e ort to p reven t lu m bosacral p lexu s inju r y.

82 5 Intraoperative Neurom onitoring

V. An esth et ic e ect s:
A. Need to st rike a balan ce to provide adequate an esthesia w h ile en su ring reliable
an d m ean ingfu l IONM.
B. In h alat ion al agen t s, in clu ding sevo u ran e, iso u ran e, an d des u ran e, are often
im p licated for produ cing laten cy in SSEPs.
C. Total in t raven ou s an esth esia (TIVA) is often u sed in conju n ct ion w ith IONM to
p reven t su p pression of cort ical respon ses.
D. Neu rom u scu lar blocking agen t s in terfere w ith th e acqu isit ion an d reliabilit y of
MEPs an d EMG recordings.
1. Th ere is considerable con t roversy regarding th e use of par t ial
n eu rom u scu lar blocking agen t s in conju n ct ion w ith IONM.
VI. Mult im odal m on itoring w ith SSEPs an d MEPs is t ypically u sed at m ost centers to
accou n t for lim it at ion s of each m odalit y.
VII. Correct ive m easures:
A. If an in t raoperat ive n eu rom on itoring aler t arises, th e rst steps involve
h em odyn am ic st abilizat ion .
1. Main t ain MAPs at least aroun d 60 m m Hg an d tem porarily raise pressures as
an in it ial step .
2. Ch eck th e pat ien ts body tem perat ure.
3. Ch eck for tech n ical issues.
a. Pat ien t p osit ion ing.
b. Mon itoring equipm en t m alfun ct ion .
c. Drug in fusion dosing.
d . Lin es.
B. Reverse previou s su rgical m an euver (im p lan t placem en t , cu r ve correct ion , rod
p lacem en t , d ist ract ion ).
C. If n on e of th e correct ive m easu res resolves th e issu e, an in t raop erat ive w ake-u p
test sh ou ld be con sidered.
D. Th ere is con siderable con t roversy regarding w h eth er th e case sh ou ld be
d iscon t in u ed if n europoten t ials can n ot be restored.

Suggested Reading
Clark AJ, Ziew acz JE, Safaee M, et al. In t raoperat ive n eu rom on itoring w ith MEPs an d predict ion of postoperat ive n eurological de cit s in pat ien t s un dergoing surger y for cervical an d cer vicoth oracic m yelop athy. Neu rosurg Focu s 2013;35(1):E7
Fehlings MG, Brodke DS, Nor vell DC, Det tori JR. Th e eviden ce for in t raoperat ive n europhysiological m on itoring in sp in e surger y: does it m ake a di eren ce? Sp in e 2010;
35(9, Suppl):S37S46
Mich ael KW, Boden SD. In t raoperat ive neurom on itoring in spin e su rger y. Con tem p Spin e
Surg 2012:13
Ziew acz JE, Ber ven SH, Mu m m an en i VP, et al. Th e design , developm en t , an d im plem en t at ion of a ch ecklist for in t raoperat ive n eu rom on itoring ch anges. Neu rosu rg Focu s
2012;33(5):E11

6 Biomechanics of the Spine and


Spinal Instrumentation
6.1 General Considerations
I. In t rodu ct ion .
A. Fun ct ion al spin al un it .
1. In ter ver tebral disk.
2. Adjacen t vertebral bodies.
3. Facet join t com plex.
B. Sp in al st abilit y.
1. Un der physiological loading, th ere is n eith er abn orm al st rain n or excessive
m ot ion in th e fu n ct ion al sp in al u n it .
2. Th is stabilit y is m ain tain ed by th e bony an d ligam en tous com pon en t s of th e
fu n ct ion al sp in al u n it , m u scu lar ten sion , abdom in al an d th oracic pressu res,
an d rib cage su pp ort .
C. Sagit tal balan ce.
1. De n ed an d m ain t ain ed by th e cer vical lordosis, th oracic kyph osis, lum bar
lordosis, an d p elvic t ilt .
2. On a stan ding lateral plain lm radiograph , th e w eigh t-bearing axis or
p lu m b lin e sh ou ld cross C1, C7, T10, an d S2.
3. Modulat ion of back exten sion by th e paraspin al m uscles can h elp cen ter th e
w eigh t-bearing axis over th e p elvis an d feet .
4. Addit ion al m ain ten an ce of th e sagit t al balan ce is ach ieved by ret roversion of
th e pelvis (pelvic t ilt).
II. Kin em at ics.
A. Cer vical spin e.
1. Occipitoatlan t al join t (occiputC1).
a. Th ir teen degrees exion /exten sion .
(1) Head n od.
b. Eigh t degrees lateral ben ding.
c. Four degrees axial rotat ion .
d. Coupled m ot ion .
(1) Occipitoatlan t al extension w ith ch in -out m an euver.
2. Atlan toaxial join t (C1C2) (Fig. 6.1).
a. App roxim ately 45 of axial rot at ion .
b. Ten degrees exion /exten sion .
c. No lateral exion .
3. Suba xial cer vical spin e.
a. Flexion /exten sion .
(1) Greater m obilit y in th e sagit t al plan e due to th e orien t at ion of th e
facet join t s (45 h orizon t al p lan e).
(a) C2C3 (8).
83

84 6 Biom echanics of the Spine and Spinal Instrum ent ation

Fig. 6.1 Powers ratio (BC/DA) > 1 signi es anterior occipitoatlantal instabilit y. The distance bet ween
the basion and the spinolaminar line of C1 is divided by the distance bet ween the posterior margin of
the foramen m agnum (opisthion) and the posterior m argin of the anterior arch of C1.

(b) C3C4 (13).


(c) C4C5 (12).
(d) C5C6 (17).
(e) C6C7 (16).
(f) C7T1 (9).
b. Lateral ben ding.
(1) Sixt y degrees coupled w ith rot at ion .
(a) Th e spin ous processes rot ate tow ard th e convexit y.
c. Axial rot at ion .
(1) Fift y percen t of cer vical rot at ion takes place in th e subaxial cer vical
sp in e.
B. Th oracic spin e.
1. Th e ribs an d steep orien t at ion of th e facets lim it range of m ot ion (ROM).
a. Flexion /exten sion .
(1) Seven t y- ve degrees com bin ed sagit t al m ot ion .
(2) Flexion is greater th an exten sion .
(3) Flexion in creases caudally.
b. Axial rot at ion .
(1) Seven t y degrees axial rot at ion .
(2) Rotat ion decreases caudally.
c. Lateral ben ding.
(1) Seven t y degrees lateral ben ding.
2. More exion /exten sion an d lateral ben ding m ot ion is presen t in th e low er
vertebral segm en t s, bu t th ere is less rot at ion .

6 Biom echanics of the Spine and Spinal Instrum ent ation 85

3. Som e degree of rotat ion accom pan ies lateral ben ding.
a. Spin ou s processes rotate tow ard th e convexit y in th e u pp er th oracic
region .
b. In th e m iddle to low er th oracic region , th e direct ion of coupling is n ot
con sisten t .
C. Lu m bar sp in e.
1. Flexion /exten sion .
a. Eigh t y ve d egrees com bin ed exion /exten sion ROM.
b. Flexion is greater th an exten sion .
c. Mot ion is greater caudally.
2. Lateral ben ding.
a. Th irt y degrees ROM.
3. Axial rot at ion .
a. Sagit tal orien tat ion of th e facet s lim it s rot at ion .
b. Rot at ion is least at L5S1.
III. Biom ech an ics of sp in al in st abilit y, orth osis, an d in st ru m en t at ion .
A. Occiputcer vical spin e (Table 6.1).
1. C2 fract ures.
a. Odon toid fract u res p rodu ce C1C2 in st abilit y.
b. C2 pedicle or th e h angm ans fract ure (t raum at ic spon dylolisth esis of C2)
(Fig. 6.2):
(1) Un st able in exion .
B. Fixat ion of th e u pper cer vical sp in e.
1. Posterior m eth ods.
a. C1 lateral m ass screw /C2 p edicle screw (Fig. 6.3 an d Fig. 6.4).
(1) St rongest biom ech an ical xat ion .
2. An terior odon toid screw s (Fig. 6.5).
a. Biom ech an ically st ronger w ith t w o screw s.
(1) On e screw m ay be adequate clin ically.
3. C2 t ran slam in ar screw.
a. Used if th e p osterior elem en ts are in t act .
C. Biom ech an ics of th e low er cer vical sp in e.
1. W h ite an d Panjabi ch ecklist for clin ical in stabilit y (Table 6.2).
a. An atom ical com p on en t s.
(1) An terior stabilit y.
(a) An n ulus brosus.
(b) An terior longit udin al ligam en t .
(c) Ver tebral body.
(2) Posterior st abilit y.
(a) Posterior longit udin al ligam en t .
(b) Facet join t an d capsules.
(c) Lam in a an d in terspin ous ligam en t s.
2. Ligam en tous disrupt ion of > 3.5 m m or 11 in dicates in st abilit y (Fig. 6.6).
3. Bony disrupt ion :
a. Ver t ical com pression an d com p ressive exion inju ries.
(1) Th e stat us of th e posterior colum n in uen ces th e overall st abilit y.

86 6 Biom echanics of the Spine and Spinal Instrum ent ation

Table 6.1

Biom echanical m easurem ents

Pathology

Measurement

Abnormal

OcciputC1
instabilit y

Distance from the tip


of the dens to basion
of the occiput

Greater than 1 mm
translation on exion
extension is abnormal

Powers ratio used to


determ ine anterior
atlanto-occipital
dislocation

A ratio > 1 signi es


anterior atlantooccipital instabilit y

McGregors line

Greater than 4.5 m m


odontoid projection
above the foram en
m agnum

Ranawats C1C2
index

Less than 13 m m is
abnorm al

RedlundJohnell O
C2 index

Less than 34 m m
(m en)

Basilar
invagination

Notes

Distance bet ween the


basion (midpoint of
the anterior margin
of the foramen
magnum) and the
spinolaminar line of
C1 divided by the
distance between the
posterior margin of
the foramen magnum
(opisthion) and the
posterior margin of
the anterior arch of C1

Less than 29 m m
(wom en)
Atlantoaxial
(C1C2)
instabilit y

Atlantodens interval
(ADI)

ADI > 3 m m indicates


rupture of the
transverse ligam ent
Greater than 5 m m of
ADI indicates rupture
of the transverse and
alar ligam ent
Greater than 4.5 mm
is abnormal in children

Space available for


the cord (SAC)
Atlas fracture with
> 6.9 mm lateral
displacement indicates
rupture of the
transverse ligament

SAC < 14 m m
impinges on the
spinal cord

Transverse ligam ent


is essential for
stabilit y

6 Biom echanics of the Spine and Spinal Instrum ent ation 87


Fig. 6.2

Illustration of type II hangmans fracture.

c
Fig. 6.3 (ac) Starting points and trajectory for a C1 lateral mass screw (Harm s technique) and a C2
pedicle screw.

88 6 Biom echanics of the Spine and Spinal Instrum ent ation

Fig. 6.4 (a) Anteroposterior and (b) lateral radiographs dem onstrating a C1C2 posterior cervical
fusion accomplished via a C1 lateral mass screw and C2 pedicle screw.

Fig. 6.5 (a) Open mouth and (b) lateral radiographs dem onstrating anterior odontoid screw xation
for a C2 dens fracture.

Table 6.2

White and Panjabi checklist for clinical instabilit y

1. A total of 5 point s or m ore is considered unstable.


a. Disruption of anterior elem ents: 2
b. Disruption of posterior elem ents: 2
c. Relative sagit tal plane translation > 3.5 m m : 2
d. Relative sagit tal plane rotation > 11: 2
e. Positive stretch test: 2
f. Cord dam age: 2
g. Root dam age: 1
h. Abnorm al disk narrowing: 1
I. Dangerous loading anticipated: 1

6 Biom echanics of the Spine and Spinal Instrum ent ation 89

Fig. 6.6

(a,b) Ligamentous disruption of > 3.5 m m or 11 indicative of instabilit y.

(a) Lam in ectom y or facetectom y.


i. Lam in ectom y.
Eigh teen p ercen t loss of st abilit y.
Lam in ectom y at C2 or C7 cau ses greater in stabilit y.
ii. Lam in ectom y plu s facetectom y.
Sixt y percen t loss of st abilit y.
Part ial bilateral facetectom y (> 50%) cau ses in st abilit y.
D. Cer vical fusion .
1. An terior cer vical fusion .
a. Disru pt ion of all an terior ligam en ts redu ces st rength by 52%.
(1) An terior in terbody fusion restores st abilit y to 100% of n orm al in
exion .
(2) Fift y- ve percent restoration in extension (Sm ithRobinsont ype graft).
(3) Bon e m in eral den sit y a ects th e com pressive st rength of th e graft .
(4) An terior in terbody fusion plus plat ing adds st rength in exten sion .
2. Posterior cer vical in st rum en tat ion .
a. In tersp in ou s w iring.
(1) Thirt y-th ree percen t of n orm al st abilit y in exion .
(a) St rength varies w ith di eren t tech n iques.
b. Posterior lateral m ass screw rod (Fig. 6.7 an d Fig. 6.8).
(1) St rongest in both exion (92%) an d exten sion (60%).
c. Pedicle screw.
(1) Greatest level of rigidit y in all plan es of m ot ion .
(2) High in ciden ce of m edial w all violat ion .
(3) Done w ith either uoroscopic im aging or lam inoforam inotom ies or both.
E. Cer vical orth osis (Table 6.3) (Fig. 6.9).

90 6 Biom echanics of the Spine and Spinal Instrum ent ation

Fig. 6.7 Comparison schem atic of (a) Magerl, (b) Anderson, and (c) An m ethods of lateral m ass
screw orientation.

Fig. 6.8 Close-up diagram of the


An technique of lateral m ass screw
placement.

6 Biom echanics of the Spine and Spinal Instrum ent ation 91

Table 6.3

Cervical orthosis

Type

Notes

Soft collar

Used only for com fort


Does not m aintain stabilit y

Philadelphia (Miam i J) collars


(Fig. 6.9)

Thirt y percent of norm al exion/extension


allowed
Ine ective in controlling rotation and lateral
bending

Four-poster-t ype orthosis

Good for controlling exion/extension at the


m idcervical level (20% of norm al m otion is
allowed)

Cervicothoracic-st yle orthosis


Sterno-occipital-m andibular
im m obilized (SOMI) brace
Rigid cervicothoracic braces
(Yale t ype)

Good for controlling upper cervical spine exion


(C2C5)
Does not restrict extension e ectively
Good for controlling exion/extension
Controls rotation slightly
Controls bending by only 50%

Halo devices

Best for restriction of all planes of m otion,


particularly for the upper cervical spine
Cannot m aintain distractive force (Fig. 6.10)

Fig. 6.9

Imm obilization of the cervical spine.

92 6 Biom echanics of the Spine and Spinal Instrum ent ation

Fig. 6.10 (ad) Halo application. The safe zone is shown for anterior halo pin placem ent. Anterior
pins should be placed below the equator of the skull, lateral to the supraorbital nerve. The patients
eyes should be closed during halo placement to allow the patient to blink norm ally once the halo is
placed.

F. Th oracic an d th oracolu m bar spin e in st ru m en tat ion .


1. Suppor t ing st ruct u res:
a. An terior.
(1) An terior an d posterior longit u din al ligam en t s.
(2) In ter ver tebral disk.
(3) Ver tebral body.
b. Posterior.
(1) Ligam en t um avum .
(2) Facet join ts.
(3) Pedicle.
(4) Costover tebralt ran sverse com plex.

6 Biom echanics of the Spine and Spinal Instrum ent ation 93

2. Th e th oracic spin e is m ech an ically st i er an d less m obile th an th e lum bar


sp in e.
a. St ress con cen t rat ion du e to ch ange in st i n ess at th e th oracolu m bar
ju n ct ion .
3. Th oracic or th oracolum bar t rau m a:
a. Th oracolu m bar inju r y classi cat ion an d severit y (TLICS) score (Table 6.4).
(1) Classi cat ion system based on injur y m orph ology, in tegrit y of th e
diskoligam entous com plex, an d n eu rological stat u s.
(2) Operat ive m an agem en t is w arran ted if th e TLICS score is 5.
(a) A score of 4 can be m an aged w ith n on operat ive or operat ive
m an agem en t (dealers ch oice).
(b) A score < 4 sh ou ld be t reated n on operat ively.
b. Spin e st abilit y.
(1) Th ree-colum n classi cat ion of Den is (Fig. 6.11) (Table 6.5).
(a) If t w o or m ore colu m n s are disrupted, th e spin e is con sidered to
be un st able.
(b) If th e m id dle colu m n is disru pted, th e spin e is regarded as
u n st able.
i. Middle-colu m n disrupt ion is less im por tan t above T8 because
of th e st abilit y provided by th e rib cage.
c. Com pression fract ures.
(1) An terior colum n failure.

Table 6.4 Thoracolum bar injury classi cation and


severit y (TLICS) classi cation
Score
Morphology
Compression fracture
Burst fracture
Translational/rotational fracture
Distraction

1
2
3
4

Neurological involvement
Intact

Nerve root involvement


Cord, conus m edullaris comprom ise
Incomplete
Complete
Cauda equina

2
3
2
4

Posterior ligamentous complex


Intact
Suspected injury
Injured

0
2
3

94 6 Biom echanics of the Spine and Spinal Instrum ent ation


Fig. 6.11 Three-column classi cation of Denis.

Table 6.5

Denis classi cation

Anterior colum n

Anterior longitudinal ligament


Anterior annulus brosis
Anterior half of the vertebral body

Middle column

Posterior longitudinal ligam ent


Posterior annulus brosis
Posterior half of the vertebral body

Posterior colum n

Pedicle
Facet joints
Lam ina
Spinous processes
Interspinous and supraspinous ligam ents

(2) En d plates are w eaker th an th e in ter ver tebral disks.


(a) Displacem en t of th e n ucleus pulposus in to th e vertebral body
m ay occu r.
(3) Bony fract ures are m ore com m on in older osteoporot ic pat ien ts.
d. Burst fract ures.
(1) An terior an d m iddle colum n failure.
(2) Neurological injuries are com m on secon dar y to ret ropulsion of th e
m idd le colu m n .

6 Biom echanics of the Spine and Spinal Instrum ent ation 95

e. Fract u re/dislocat ion .


(1) Th ree-colum n failure.
(2) Sh ear/t ran slat ion al, exion /dist ract ion , or exion -rot at ion injuries.
(3) Posterior st abilizat ion is required.
4. In st ru m en t at ion for th oracolum bar fract u res:
a. Pu rpose:
(1) Early m obilizat ion .
(2) Preven t late deform it y an d pain .
(3) In direct decom pression by dist ract ion an d exten sion in t raum at ic
inju ries.
(4) Tem porar y st abilizat ion un t il fusion m at ures in creases h ealing rates.
b. Tran spedicular inst rum en tat ion (Fig. 6.12):
(1) Provides th e st i est con st ru ct w ith th e sh or test segm en t fusion .
(2) Th e gold stan dard for th oracolum bar fract ure m an agem en t .
c. An terior fusion :
(1) Prim ar y t reat m en t in fract ures w ith n eurological de cit .
(2) Adjun ct t reat m en t after posterior in st rum en t at ion .
(3) An terior plate con st ru ct is equal to a con st ruct w ith an an terior st rut
graft plu s posterior t ran sp edicu lar in st ru m en t at ion .
d. Percut an eous fract ure xat ion :
(1) Uses m in im ally invasive tech n iques in an e or t to lessen
in t raoperat ive blood loss, operat ive t im e, postop erat ive pain , an d
risk of in fect ion , an d to lessen th e e ect s on p osterior p araspin al
m u scu lat u re an d st abilit y
(2) Th ese ben e t s are param oun t for polyt raum a pat ien t s, w h o carr y th e
greatest risk for com plicat ion s.
(3) On e screw m ay be adequate clin ically.

Fig. 6.12

(a,b) Thoracic pedicle screw starting points.

96 6 Biom echanics of the Spine and Spinal Instrum ent ation

e. Som e eviden ce suggests th at th oracolu m bar bu rst fract u res m ay n ot


requ ire fu sion .
(1) Surgical m an agem en t of th oracolum bar fract ures involves th e
restorat ion of ver tebral h eigh t an d avoidan ce of kyph osis.
(2) Often su pplem en ted w ith t ran spedicular screw xat ion for rigid
st abilizat ion .
(3) In addit ion , fusion en ables early reh abilitat ion an d am bulat ion .
(4) Recen t , albeit w eak, eviden ce suggest s th at posterior in st rum en t at ion
alon e p rovides com parable ou tcom es to in st ru m en tat ion an d fu sion
for th oracolu m bar fract u res.
5. Spin al deform it ies in th e th oracolum bar spin e:
a. Scoliosis.
(1) Lateral exion w ith rotat ion of th e spin ous process tow ard th e
con cavit y of th e spin e.
(2) Hypokyph osis an d posterior w edging of th e ver tebral body are
frequ en tly seen (Fig. 6.13).
(3) Correct ion .
(a) Th oracic cur ve: dist ract ion on th e con cave side correct s coron al
align m en t an d p rodu ces th oracic kyph osis, w h ich is gen erally
desired.
(b) Lu m bar cu r ve: com p ression on th e convex side corrects coron al
align m en t an d restores lu m bar lord osis.

Fig. 6.13

Hypokyphosis and posterior wedging of the vertebral body.

6 Biom echanics of the Spine and Spinal Instrum ent ation 97

(c) Ben ding an d t ran slat ion :


i. Can t ilever ben ding an d segm en t al xat ion correct th e
deform it y in th e coron al an d sagit t al plan e.
ii. Rot at ion derotat ion also correct s th e deform it y in coron al
an d sagit tal p lan es by sh ift ing th e region s of th e sp in e en bloc.
b. Kyphosis.
(1) Th e anterior colu m n fails w ith com pression .
(2) Th e posterior colum n fails w ith ten sion .
(3) Deform it y in creases th e m om ent arm , furth er in creasing deform it y.
(4) Eccen t ric loading a ect s car t ilagin ous grow th .
(a) Com pression decreases grow th an teriorly.
(b) Ten sion in creases grow th posteriorly.
(5) Various in st rum en t at ion s are used to correct kyph ot ic deform it ies.
(a) Posterior com pression rods can correct m ild an d exible cur ves
(Fig. 6.14).
(b) Greater cu r ves sh ou ld be ap proach ed by com bin ed an terior an d
p osterior fu sion an d in st rum en t at ion .
i. Posterior in st rum en t at ion is applied w ith can t ilever ben ding
an d com p ression forces.

Fig. 6.14

Posterior rod instrumentation.

98 6 Biom echanics of the Spine and Spinal Instrum ent ation

G. Lu m bar an d lu m bosacral spin e.


1. St abilit y (Fig. 6.15):
a. An terior st abilit y:
(1) An terior longit u din al ligam en t .
(2) Vertebral body.
(3) An n ulu s brosus.
b. Posterior stabilit y:
(1) Facet join t .
c. Th e role of th e m u scles, in cluding th e erector spin ae, abdom in al m u scles,
an d p soas, is im port an t in overall st abilit y.

c
Fig. 6.15

(ad) White and Panjabis criteria for lum bar segm ental instabilit y.

6 Biom echanics of the Spine and Spinal Instrum ent ation 99

2. Low er lum bar an d lu m bosacral spin e.


a. Degen erat ive d isk an d facet diseases.
(1) In ter vertebral disk.
(a) An n ulus brosus.
i. Collagen bers arranged in an obliqu e direct ion .
ii. Provides axial loading st abilit y an d 40 to 50% torsion al
st abilit y.
(b) Nu cleu s pu lp osu s.
i. Th e gel-like core act s as a ball bearing, ch anging th e cen ter of
rot at ion .
(2) In t radiskal pressure.
(a) Th e load on th e disk is about t w ice th e body w eigh t w h en sit t ing.
(b) Th ir t y percen t low er disk p ressu re w h en stan ding.
(c) Fift y percen t low er disk pressu re w h en lying on th e side.
(d) Eigh t y to 90% low er disk pressure w h en lying supin e com pared
w ith sit t ing.
(3) Disk degen erat ion .
(a) Sh ift s th e in st an t cen ter of rotat ion posteriorly.
(b) In creases st ress to th e facet join t .
(c) Disk degen erat ion a ect s th e m ot ion of th e fun ct ion al spin al
u n it .
i. Early disk degen erat ion w ith radial tears of th e an n u lus
brosu s decreases st i n ess in exion , lateral ben ding, an d
rot at ion .
ii. Advan ced disk d egen erat ion w ith loss of disk h eigh t an d
osteophytes in creases th e st i n ess.
(d) P rrm an n classi cat ion of disk degen erat ion (Fig. 6.16):
i. Based on T2-w eigh ted MRI n dings.
ii. Provides a stan dard n om en clat ure to classify disk
degen erat ion .
(4) Facet join t s.
(a) Provide torsion al st abilit y.
(b) Su p port < 20% of load w ith w eigh t bearing.
b. Spon dylolisth esis.
(1) Abru pt ch ange in st i n ess across th e lum bosacral jun ct ion .
(2) Th e pars in terar t icularis is st rong but suscept ible to fat igue fract u res,
especially w ith exten sion inju ries.
(3) Sh ear st ress at th e pars in terar t icularis:
(a) Physiological exion con t ract ure of th e h ip an d secon dar y
hyperlordosis create a pin cerlike e ect from th e su perior
ar t icu lar p rocess of S1 an d th e in ferior ar t icu lar p rocess of L4.

100 6 Biom echanics of the Spine and Spinal Instrum ent ation

Fig. 6.16 Algorithm for a grading system and assessm ent of lum bar disk degeneration. (P rrmann
CWA, Met zdorf A, Zanet ti M, et al. Magnetic resonance classi cation of lumbar intervertebral disc
degeneration. Spine 2001;26(17):1873. Lippincot t William s & William s, Inc. Used with perm ission.)

H. Biom ech an ics of t ran sp ed icu lar in st ru m en t at ion .


1. An atom y.
a. Th e p ed icle is a cylin der of cort ical bon e.
(1) Th e h orizon t al diam eter from T9 to L5 in creases from 7 m m to 1.5 cm
(Fig. 6.17).
(a) Th e vert ical diam eter is ~ 1.5 cm .
(b) Th e in n er diam eter is < 80% of th e ou ter diam eter.
(c) Th e pedicle screw diam eter sh ould be sm aller th an th e in n er
diam eter.
(2) Th e pedicle depth is ~ 45 to 50 m m from th e en t ran ce poin t to th e
an terior ver tebral m argin .
b. En t ran ce poin t s an d direct ion s (Fig. 6.12):

6 Biom echanics of the Spine and Spinal Instrum ent ation 101

Fig. 6.17

Pedicle diam eter (mm ) as a function of spinal level. (Courtesy of Orthobullets.)

2. Pedicle screw design an d biom ech an ics.


a. St ru ct u ral ch aracterist ics.
(1) Th e m ost sign i can t factor for pullout st rength is th e outer (m ajor)
diam eter.
(2) Deeper th reads in crease th e pullout st rength .
(a) Ben ding st rength dim in ish es due to a sm aller m in or diam eter
(Fig. 6.18).
(b) Pu llou t st rength is also in creased by th e depth of pen et rat ion .
(c) Not sign i can tly a ected by th e sh ape of th read.
3. Tran sverse con n ectors.
a. Im p or tan t for less rigid system s.
b. Im por tan t if t riangulat ion tech n iqu e is to be used.
c. Im por tan t in th e osteoporot ic spin e.
d. Im proves torsion al stabilit y of the con st ruct .

102 6 Biom echanics of the Spine and Spinal Instrum ent ation
Fig. 6.18 Lateral radiograph of the lum bar
spine. Note that the sacral screw has broken
because fusion has not occurred. Pedicle
screws will eventually fail with cyclical loading if a solid arthrodesis is not obtained.

I. Sacral/pelvic xat ion .


1. Types:
a. Galveston tech n iqu e.
b. Iliosacral screw.
c. Sacral screw s.
d. Sacral alar screw s.
e. Iliac screw s (iliac bolt s).
f. Tran siliac bar.
g. S2 alar iliac screw (S2AI).
h . In t rasacral rods (Jackson ).
i. Du n n McCarthy rods (th rough S1 foram en ).
2. Screw s are gen erally bet ter th an h ooks in th e sacrum .
a. Sacral xat ion w ith a single sacral screw h as a h igh failu re rate (pu llou t).
b. S1 screw :
(1) An terom edial direct ion tow ard th e sacral prom on tor y below th e
su p erior sacral en d p late.
(a) Safest an d biom ech an ically accept able.
c. S2 screw :
(1) Weak bu t m ay en h an ce overall stabilit y.
(2) Th e screw is directed 30 to 40 laterally.
(a) Avoid pen et ran ce of th e an terior cortex if th e screw is directed
laterally to avoid inju ries to th e iliac vein , lum bosacral t ru n k, an d
sigm oid colon .

6 Biom echanics of the Spine and Spinal Instrum ent ation 103

J. In st ru m en t at ion rigidit y an d st i n ess.


1. A rigid im plan t con st ruct in creases fusion m ass.
2. May also cau se device-related osteoporosis (st ress sh ielding):
a. St ress sh ielding by rigid in st ru m en t at ion is ~ 15%.
b. Th e ben e t of rigid in st rum en tat ion out w eigh s th e st ress-sh ielding
p h en om en on .

Suggested Reading
Izzo R, Guarn ieri G, Guglielm i G, Muto M. Biom ech an ics of th e sp in e. Part I: sp in al stabilit y.
Eur J Radiol 2013;82(1):118126
Izzo R, Gu arn ieri G, Guglielm i G, Mu to M. Biom ech an ics of th e sp in e. Par t II: sp in al in stabilit y. Eu r J Radiol 2013;82(1):127138
Perez-Orribo L, Kalb S, Reyes PM, Ch ang SW, Craw ford NR. Biom ech an ics of lu m bar cor t ical screw -rod xat ion versu s p edicle screw -rod xat ion w ith an d w ith ou t in terbody
su pport . Sp in e 2013;38(8):635641
Surat w ala SJ, Pin to MR, Gilbert TJ, W in ter RB, Wroblew ski JM. Fun ct ion al an d rad iological
outcom es of 360 degrees fu sion of th ree or m ore m ot ion levels in th e lum bar spin e for
degen erat ive disc disease. Spin e 2009;34(10):E351E358

7 Physiology of Bone Healing and Fusion

7.1 General Considerations


I. Bon e cells an d ext racellu lar m at rix.
A. Cells (Fig. 7.1).
1. Osteoblast s.
a. Resp on sible for form ing th e st ru ct u ral bon e m at rix an d regu lat ing
osteoclast act ivit y.
b. Derived from the bon e m arrow st rom al cells an d periosteal m em bran e
cells.
c. Secrete t ype I collagen .
d. Express parathyroid h orm on e receptors an d alkalin e ph osph at ase.
(1) Crit ical for regulat ing bon e product ion .
2. Osteocytes.
a. Act ive osteoblast s em bedd ed w ith in th e m in eralized m at rix.
b. Do n ot express alkalin e ph osph at ase.
c. Com m un icate via can aliculi an d regulate bon e h om eost asis.

Fig. 7.1

104

Bone resorption and bone form ation and associated factors.

7 Physiology of Bone Healing and Fusion 105

3. Osteoclast s.
a. Mu lt in u cleated bon e resorbing cells.
b. Hem atopoiet ic cells th at derive from th e m on ocyte/m acroph age fam ily.
c. Th ese cells h ave a ru ed border th at secretes proteases an d ion s, w h ich
h elp dissolve th e bony m at rix (How sh ip s lacu n ae) (Fig. 7.2).
d. Tigh tly regulated by th e receptor act ivator of n uclear factor kB ligan d
(RANKL).
B. Ext racellu lar m at rix (ECM).
1. Th e ECM con sist s of 60 to 70% m in eral m at rix an d 20 to 25% organ ic m at rix.
a. Min eral m at rix.
(1) Provides th e com pressive st rength of bon e.
(2) Calcium (hydroxyapat ite) an d ph osph ate (t ricalciu m ph osph ate)
m ake u p th e m ajorit y of th e m in eral m at rix.
b. Organ ic m at rix.
(1) Com posed prim arily of t ype I collagen (90%).
(a) It s t riple h elical con form at ion con t ributes ten sile st rength to the
ECM.
II. Bon e form at ion .
A. Ossi cat ion (Fig. 7.3).
1. In t ram em bran ous (e.g., pelvic bon es): form at ion of bon e directly from
m esen chym al t issu e.
2. En doch on dral (e.g., vertebrae): m esen chym al t issue is rst replaced by a
cart ilage m odel, w h ich th en u n dergoes ossi cat ion .
B. Key grow th factors an d cytokin es.
1. Bon e m orph ogen et ic protein s (BMPs).
2. Tran sform ing grow th factor-b (TGF-b).
3. Basic broblast grow th factor (bFGF).
4. In sulin grow th factor (IGF).
5. In terleukin s (ILs).

Fig. 7.2 Microscopic hematoxylin-eosin image of osteoclasts and Howships lacunae.

106 7 Physiology of Bone Healing and Fusion

Fig. 7.3 Mesenchym al stem cell di erentiation into endochondral versus intram em branous bone
form ation.

III. Bon e rep air an d rem odeling (Fig. 7.4).


A. Hem atom a an d in am m ator y respon se.
1. Predom in an t cell t ypes.
a. Macrop h ages.
b. Platelet s.
2. Cytokin es.
a. IL-1, IL-6.
b. TGF-b.
c. Prost aglan din E2.
B. Early st age.
1. Predom in an t cell t ypes.
a. Mesen chym al cells.
b. Fibroblasts.
2. Protein expression .
a. BMP.
b. TGF-b.
C. Hem atom a m at u rat ion .
1. New collagen ous m at rix is produced an d slow ly replaced by cart ilage
form at ion (en doch on dral ossi cat ion ).
2. Collagen t ypes I an d II are predom in an t .
D. Conversion of car t ilage to bon e.
1. Th e form ed hyper t roph ic cart ilage is slow ly replaced by bon e.

7 Physiology of Bone Healing and Fusion 107

Fig. 7.4

Process of bone repair and rem odeling.

2. Protein expression :
a. BMP.
b. TGF-b.
c. IGFs.
d. Collagen t ypes I an d V.
e. Osteocalcin .
E. Bon e rem odeling.
1. New ly form ed bon e (w oven bon e) is th en rem odeled th rough t igh t
regu lat ion bet w een osteoblast s an d osteoclast s.

7.2 Physiology of Bone Grafts


I. Types of graft s.
A. Autograft .
1. Iliac crest bon e graft (ICBG) is th e gold stan dard.
B. Allograft s.
1. Fresh , frozen .
2. Freeze dried.
3. Cort ical can cellous ch ips.
4. Dem in eralized bon e m at rix (DBM).
II. Bon e graft u se in spin e su rger y (Fig. 7.5).
A. In duces fusion bet w een vertebral segm en t s.
B. Replaces bon e defect s secon dar y to t rau m a, t u m or, or in fect ion s.
III. Bon e graft in corp orat ion .
A. Un di eren t iated progen itor cells are recruited from th e h ost bed an d th e
im plan ted au tograft .
1. Osteogen ic cells from th e au tograft h elp to form th e in it ial bon e m at rix
(osteogen esis).

108 7 Physiology of Bone Healing and Fusion


Fig. 7.5

Use of bone graft.

B. Ch em ot axis of th ese p rogen itor cells is in du ced by th e release of in t racellu lar


cytokin es an d protein expression as a resu lt of th e follow ing:
1. Cell death .
2. Surgical t raum a.
3. Decort icat ion .
4. Low oxygen ten sion an d low pH.
C. Un d i eren t iated progen itor cells becom e ch on droblast s an d osteoblasts
m ediated by grow th factors an d cytokin es (en doch on dral ossi cat ion ).
D. Th e grafts protein m at rix act s as a sca old for bony ingrow th .
IV. Gen eral categories of bon e graft s.
A. Subst it utes: gen eral term s for m aterials or com posite graft s to be in ten ded to
replace au tograft s (e.g., allograft , DBM, BMP).
B. Exten ders: u sed in com bin at ion w ith au tograft to in crease th e am ou n t of
osteocon duct ive an d osteoin duct ive factors for fusion (e.g., calcium ph osph ate
ceram ics, allograft , DBM).
C. En h an cers: m aterials u sed in conju n ct ion w ith au tograft to in crease th e rate of
fu sion ; sh ou ld n ot be u sed alon e (e.g., DBM, BMP, stem cells).
V. Factors a ect ing spin al fusion .
A. Pat ien t factors.
1. Age.

7 Physiology of Bone Healing and Fusion 109

B.

C.

D.
E.

F.
G.
H.
I.

2. Sm oking (n icot in e con sum pt ion ).


3. Diabetes m ellit us.
4. Met abolic bon e disease.
5. Vit am in D de cien cy.
An atom ical region s.
1. Spin e segm en t .
a. Cer vical spin e.
(1) Less body m ass to support .
(2) Min im al in ter ver tebral displacem en t an d m icrom ot ion due to larger
con t act area bet w een adjacen t vertebral bodies.
(3) Low st rain environ m en t opt im izes bon e form at ion .
(4) Fusion rates are 82 to 100%.
b. Th oracic spin e.
(1) Rib at t ach m en t s provide addit ion al stabilit y an d m in im ize exion ,
ben ding, an d rot at ion of ver tebral segm en ts.
(a) Associated w ith h igh fusion rates.
(2) Th e th oracolum bar t ran sit ion (T12L1), h ow ever, is h igh ly m obile.
(a) Suscept ible to m icrom ot ion , h ardw are failu re, an d fusion failure
(p seu dar th rosis).
c. Lum bar spin e.
(1) High join t react ion forces.
(2) Th e prim ar y m ot ion is exion an d exten sion , w ith m in im al lateral
exion an d rot at ion .
(3) Posterior elem en t s dem on st rate greater excursion th an th e an terior
colum n .
(4) In st rum en tat ion th at coun teract s th e large forces of th e lum bar spin e
is crit ical to prom ote spin al fu sion .
(5) Fusion rates range from 70 to 100%.
Su rgical procedu res.
1. Prim ar y or revision surger y.
2. Levels of fusion .
3. In st rum en tat ion .
4. Surgical tech n iques.
a. Met icu lou s decor t icat ion .
b. Graft preparat ion .
Typ es an d qu an t it y of bon e graft .
Medicat ion s.
1. Non steroidal an t i-in am m ator y drugs.
2. Ch em oth erapy.
3. Cort icosteroid exposure.
Radiat ion .
Elect rical st im u lat ion .
Ult rason ography.
Sp in al align m en t .

110 7 Physiology of Bone Healing and Fusion

Suggested Reading
Ch en Y, Guo Q, Pan X, Qin L, Zh an P. Sm oking an d im p aired bon e h ealing: w ill act ivat ion of ch olin ergic an t i-in am m ator y path w ay be th e bridge. In t Orth op 2011;35(9):
12671270
Coh en MM Jr. Th e n ew bon e biology: path ologic, m olecular, an d clin ical correlates. Am J
Med Gen et A 2006;140(23):26462706
Dodw ell ER, Latorre JG, Parisin i E, et al. NSAID exp osu re an d risk of n on u n ion : a m et aan alysis of case-con t rol an d coh ort st u dies. Calcif Tissu e In t 2010;87(3):193202
Knigh t MN, Han ken son KD. Mesen chym al stem cells in bon e regen erat ion . Adv Wou n d
Care (New Roch elle) 2013;2(6):306316
Olabisi R. Cell-based th erapies for sp in al fusion . Adv Exp Med Biol 2012;760:148173
Reid JJ, Joh n son JS, Wang JC. Ch allenges to bon e form at ion in spin al fusion . J Biom ech
2011;44(2):213220

8 Bone Grafts, Substitutes, and Biologics

8.1 General Considerations


I. Types of bon e grafts an d biologics.
A. Autograft .
1. Iliac crest bon e graft (gold st an dard).
2. Local bon e graft .
B. Allograft s.
1. Fresh , frozen , or freeze dried.
2. Cort ical can cellous bon e ch ips.
3. Dem in eralized bon e m at rix (DBM).
C. Ceram ics.
D. Bon e m orp h ogen et ic p rotein s (BMP-2, BMP-7).
E. Bon e m arrow aspirate an d stem cells.
II. Prop ert ies of bon e graft s.
A. Osteogen ic: directly provide cells th at go on to produce bon e.
1. Exam ples in clude bon e m arrow aspirate an d autologous bon e graft s.
B. Osteoinductive: contain factors that induce progenitor cells into bone-form ing cells.
1. Exam ples in clu de BMPs (BMP-2 an d BMP-7).
C. Osteocon du ct ive: p rovide a sca old for n ew bon e form at ion .
1. Exam ples in clude DBMs.
III. Au tograft versu s allograft (Table 8.1).

8.2 Allografts
I. DBM.
A. Proper t ies.
1. Allograft bone that is treated w ith acid extraction to isolate grow th factors and
structural proteins (collagen). The resulting bone m atrix contains < 8%calcium .
a. DBM d oes n ot con t ain osteop rogen itor cells.
b. Good osteocon du ct ive proper t ies.
2. Biologic e ect s var y w idely am ong com m ercially available DBMs.
a. Prep arat ion .
(1) Dem in eralizat ion .
(2) Sterilizat ion .
(3) Carrier.
(a) Glycerol.
(b) Calcium hyaluronate.
(c) Cellulose.
(4) Am oun t an d rat ios of BMPs.
111

112 8 Bone Graft s, Substitutes, and Biologics

Table 8.1

Autograft versus allograft

Type of graft

Autograft

Allograft

Osteogenic

Osteoinductive

Osteoconductive

Donor site m orbidit y

Im m une reaction

Disease transm ission

Types

Limitations

Lim ited supply


Large defects (tum or,
infection)

Cortical
Corticocancellous
Cancellous
Vascularized
Bone m arrow aspirate

Fresh
Frozen
Freeze dried
Cortical cancellous chips
Demineralized bone matrix

Slow incorporation
High incidence
of resorption in
posterolateral fusions

b. Don or ch aracterist ics.


(1) Pat ien t age an d gen der.
(2) Bisph osph on ate ut ilizat ion .
B. Urist reported on DBM-in du ced bon e form at ion in 1965.

8.3 Synthetic Substitutes


I. Ceram ics.
A. Proper t ies.
1. Com bin at ion of m et allic an d n on m et allic in organ ic elem en ts h eld togeth er
by ion ic or covalen t bon ds.
2. Do n ot provide osteogen ic or osteoin duct ive proper t ies.
3. Provide im m ediate st ruct ural su ppor t an d are osteocon duct ive.
B. Biom ech an ical st rength .
1. Low fract u re resist an ce an d ten sile st rength .
2. Quest ion able in dicat ion for an terior graft ing w ith out supplem en tal xat ion .
C. Bon ding an d release of BMPs.
D. Calciu m based ceram ics.
1. Hydroxyapat ite, t ricalcium ph osph ate.
2. Calcium sulfate.

8 Bone Graft s, Substitutes, and Biologics 113

3. Calcium ph osph ate cem en ts.


4. Calcium ph osph ate ceram ics.
E. Clin ical use of ceram ics.
1. An terior spin al applicat ion .
a. Com bin at ion w ith cages or p lates.
2. Filling bony defects (ver tebroplast y/kyph oplast y).
3. Graft exten ders.

8.4 Grow th Factors (Biologics)


I. Bon e m orp h ogen et ic protein s (BMP-2 an d BMP-7) (Fig. 8.1).
A. Proper t ies.
1. Mem bers of th e t ran sform ing grow th factor-b su perfam ily.
2. Poten t osteoin duct ive proper t ies.
3. Associated w ith in creased fusion rates com pared w ith allograft .
4. BMPs are soluble, locally act ing, an d n at urally occurring sign aling protein s.
a. In du ce m esen chym al cells to di eren t iate in to cart ilage an d bon eform ing cells:
(1) Have th e abilit y to in du ce bon e form at ion in both soft t issue (m uscle,
ten don s) an d bon e.
b. Tigh tly con t rolled regu lator y m ech an ism s cause bon e in duct ion on ly at
th e site of BMP an d on ly w h ile BMP is presen t .
c. Th e biologic e ect of com m ercially available recom bin an t h um an BMPs
w ill depen d on th e dose an d m eth od of deliver y.
B. Food an d Drug Adm in ist rat ion ap proved BMPs.
1. In fu se (BMP-2; Medt ron ic).
a. Ap p roved for a single-level an terior lu m bar in terbody fu sion (ALIF) from
L4S1 to t reat degen erat ive d isk disease.
(1) To be used w ith a t apered in terbody fusion device.
b. Approved for acute, open t ibial sh aft fract ures after in it ial in t ram edullar y
n ail xat ion .

Fig. 8.1

Regulatory mechanism s in the action of bone m orphogenetic proteins.

114 8 Bone Graft s, Substitutes, and Biologics

2. OP-1 (BMP-7; Olym pus).


a. Ap proved for th e rep air of sym ptom at ic, p osterolateral (in ter t ran sverse)
lu m bar spin e pseu darth rosis in p at ien ts for w h om au tologous bon e an d/
or bon e m arrow h ar vest are n ot feasible.
b. Pat ien t s m ust h ave at least on e of th e follow ing com orbidit ies:
osteoporosis, diabetes, or n icot in e use.
c. Approved for recalcit ran t long bon e n on un ion s w h ere th e use of
au tograft is u n feasible an d altern at ive t reat m en t s h ave failed .
d. Available as sterile dr y pow der an d put t y.
C. Con t roversies w ith BMPs.
1. Majorit y of BMP use is o -label.
2. Reported adverse e ect s.
a. Neu roforam in al bon e grow th .
b. Osteolysis.
c. Ret rograde ejaculat ion .
d. Dysph agia.
e. Air w ay com p rom ise.
f. Can cer.
3. Biased an d con icted report s in th e literat ure.
a. Yale Open Dat a Access (YODA) project .
(1) Quest ion able un derreport ing of com plicat ion s.
(2) Lim ited ran dom ized, con t rolled prospect ive st udies.
(3) Lack of con sisten t repor t ing an d un derpow ered an alyses.
II. Bon e m arrow asp irate an d stem cells (Fig. 8.2).
A. Most com m on sources.
1. Iliac crest an d ver tebral body.
2. Th e n u m ber of stem cells in th e bon e m arrow.
a. On e in 50,000 in you ng in dividu als.
b. On e in 2,000,000 in th e elderly.
c. Poten cy of m arrow aspirate m ay be in creased via cen t rifugat ion or clon al
exp an sion .
3. Com m ercially available stem cellderived bon e graft subst it ute.
a. Provides a sca old for bony ingrow th .
b. Con t ain s adu lt m esen chym al cells an d osteoprogen itor cells to prom ote
bon e form at ion .
c. Screen ed cellular allograft th at u n der w en t select ive rem oval of
im m u n ogen ic elem en t s (blood cells, w h ite blood cells, osteoclast s).
d. Un dergoes an t im icrobial an d an t ifungal t reat m en t .
e. Th e processed t issu e h as a 5-year sh elf life, becau se it is cr yop reser ved .
B. Poten t ial ben e t s of m esen chym al stem cells (MSCs).
1. Oxidat ive st ress m odulat ion .
2. Au togen ous bon e con t ain s osteoblast ic cells.
a. Spin al fu sion is largely m ediated by th ese cells.
b. In pat ien ts w ith redu ced cellular stores (ch ron ic illn ess, elderly,
osteoporosis), MSC m ay aid in obt ain ing a solid fusion .

8 Bone Graft s, Substitutes, and Biologics 115

Fig. 8.2

(a,b) Bone m arrow aspiration.

3. Secret ion of cytokin es an d grow th factors:


a. Im m u n om odu lat ion .
b. An t i-in am m ator y e ects.
c. Angiogen esis.
d. An t iapoptot ic e ect s.
e. Osteogen ic p rop ert ies.
4. Self-ren ew ing.

Suggested Reading
Cran dall DG, Revella J, Pat terson J, Hu ish E, Ch ang M, McLem ore R. Tran sforam in al lum bar
in terbody fusion w ith rh BMP-2 in spin al deform it y, sp on dylolisth esis, an d degen erat ive d iseasep art 1: Large series diagn osis related ou tcom es an d com p licat ion s w ith
2- to 9-year follow -up . Sp in e 2013;38(13):11281136
Fu R, Selph S, McDon agh M, et al. E ect iven ess an d h arm s of recom bin an t h u m an bon e
m orp h ogenet ic protein -2 in spin e fu sion : a system at ic review an d m et a-an alysis. An n
In tern Med 2013;158(12):890902
Hsu W K, Nickoli MS, Wang JC, et al. Im proving the clin ical eviden ce of bon e graft subst it ute tech n ology in lu m bar sp in e su rger y. Global Sp in e J 2012;2(4):239248
Sim m on ds MCBJ, Brow n JV, Heirs MK, et al. Safet y and e ect iven ess of recom bin an t h um an bon e m orph ogen et ic p rotein -2 for spin al fu sion : a m et a-an alysis of in d ividu alpar t icipan t dat a. An n In tern Med 2013;158(12):877889
Yam ada T, Yosh ii T, Sotom e S, et al. Hybrid graft ing using bon e m arrow aspirate com bin ed w ith p orou s b -t ricalcium ph osp h ate an d t rep hin e bon e for lu m bar posterolateral spin al fusion : a prosp ect ive, com parat ive st u dy versu s local bon e graft ing. Sp in e
2012;37(3):E174E179

9 Evaluation and Management of


Spinal Cord Injury
9.1 General Considerations
I. In t rodu ct ion .
A. Approxim ately 12,000 to 14,000 spin al cord injuries (SCIs) occur in North
Am erica per year.
1. Th ey m ost com m on ly occur in adolescen t m ales.
2. Most are related to m otor veh icle collision s.
II. Preh ospital evalu at ion p eriod .
A. Care of any t raum a pat ien t begin s w ith im m obilizat ion of th e spin e at th e scen e
of injur y.
B. Am erican College of Su rgeon s m n em on ic for in - eld m an agem en t of a t rau m a
p at ien t:
1. Aair w ay.
2. Bbreath ing.
3. Ccircu lat ion .
4. Ddisabilit y.
5. Eexposure an d environ m en t .
C. All t rau m a p at ien t s sh ou ld be im m obilized w ith a rigid cer vical orth osis an d
t ran sferred using lateral bolsters.
1. The patient should be placed on a long backboard secured w ith tapes or straps.
2. Helm eted ath letes:
a. Helm et an d sh ou lder p ads sh ou ld not be rem oved.
III. Em ergen cy room m an agem en t .
A. Polyt raum a pat ien t s m ay h ave an altered level of con sciousn ess an d are
vu ln erable to fu rth er w orsen ing of th eir n eu rological inju ries.
B. On ce th e ABCs h ave been est ablish ed, a th orough but focused physical
exam in at ion sh ou ld assess th e p at ien ts n eu rological fu n ct ion .
1. Th e en t ire spin al colum n sh ould be palpated for step -o or m isalign m en t
of th e spin ous processes.
C. Head t rau m a:
1. Glasgow Com a Scale.
a. Total score can range from 15 (n orm al respon ses to st im u li) to 3 (n o
respon se or com atose) (Table 9.1).
D. Evalu at ion of air w ay an d breath ing:
1. Elect ive in t ubat ion sh ould be perform ed in pat ien t s w ith severe h ead
injuries or w h o are un able to protect th e air w ay becau se of a depressed level
of con sciousn ess (Glasgow Com a Scale score < 8).
2. Pat ien t s w ith SCIs (part icularly above C5) h aving di cult y w ith respirat ion
sh ou ld be con sidered for elect ive in t u bat ion .
3. Man ual in -lin e stabilizat ion of th e cer vical spin e during orot rach eal
in t u bat ion m in im izes m ot ion of th e u n stable cer vical spin e.
116

9 Evaluation and Managem ent of Spinal Cord Injury 117

Table 9.1

Glasgow Com a Scale

Eye opening

Verbal response

Motor response

Spontaneous

Voice

Pain

None

Oriented

Confused

Inappropriate

Incomprehensible

None

Obeys com m ands

Localized pain

Withdraws

Decorticate

Decerebrate

None

E. Neurological exam in at ion (Fig. 9.1):


1. Th e Am erican Spin al Injur y Associat ion (ASIA) st an dard of n eu rological
test ing provides a con cise an d detailed m eth od of evaluat ing spin al cord an d
periph eral n er ve root fu n ct ion .
a. Sen sat ion is d eterm in ed in all 28 derm atom es bilaterally by th e p at ien ts
abilit y to detect th e sh arp en d of a pin (Fig. 9.2).
b. Motor fu n ct ion is docum en ted an d graded 1 to 5 based on resist an ce to
physical m an ipulat ion or gravit y (Table 9.1).
c. Based on both th e m otor an d th e sen sor y exam in at ion , th e pat ien t is
fu rth er classi ed or grad ed u sing th e ASIA m odi cat ion of th e Fran kel
n eu rological classi cat ion system (Table 9.2).
F. SCIs:
1. Com plete injur y.
a. No fu n ct ion al m otor (less th an grad e III m otor st rength ) or sen sor y
act ivit y below th e zon e of inju r y.
2. In com plete injur y.
a. Part ial p reser vat ion of m otor or sen sor y fu n ct ion below th e zon e of
inju r y.
G. Im aging evalu at ion :
1. In it ial radiograph s.
a. St an dard an terop osterior/lateral view s of th e cer vical, th oracic, an d
lum bosacral sp in e.
(1) Ten to 15% of pat ien ts h ave n on con t iguou s spin al colum n fract ures.

118 9 Evaluation and Managem ent of Spinal Cord Injury

Fig. 9.1

Clinical manifestations of spinal cord injury according to level of injury.

9 Evaluation and Managem ent of Spinal Cord Injury 119

Fig. 9.2 Am erican Spinal Injury Association spinal cord injury assessment form . (From the American
Spinal Injury Association. International Standards for Neurological Classi cation of Spinal Cord Injury.
Revised 2002. Chicago, IL: American Spinal Injury Association; 2006. Reproduced with permission.)

b. Alw ays visualize th e align m en t of th e cer vicoth oracic ju n ct ion .


c. Com puted tom ography (CT):
(1) Used to furth er delin eate bony an atom y.
(2) Helpful in visualizing th e cer vicoth oracic (C7T1) jun ct ion .
(3) A CT scan m ust be obt ain ed if C7T1 is not visible on lateral
radiograp h s.
(a) Most t raum a cen ters h ave n ow begun rout in ely obtain ing CT
scan s of th e cer vical sp in e as th e gold stan dard for cer vical sp in e
clearan ce, obviat ing th e n eed for plain radiograph s.
d. Magn et ic reson an ce im aging:
(1) Used in all cases of n eurological com prom ise.
(2) Useful for visualizing soft t issu e an atom y an d disrupt ion .
H. Treat m en t:
1. Th e severit y of th e in it ial im pact on th e spin al cord is t ypically re ected by
th e pat ien ts in it ial n eurological presen tat ion .
2. Th e exten t of th e pat ien ts n eu rological recover y is n ot solely depen den t on
th e prim ar y injur y.
a. Secon dar y inju r y to th e sp in al cord resu lt s from a p hysiological cascade.
(1) In it ial h em orrh age follow ed by in am m at ion , m em bran e hydrolysis,
isch em ia, calciu m in u x, an d cellular ap optosis.

120 9 Evaluation and Managem ent of Spinal Cord Injury

Table 9.2

Am erican Spinal Injury Association (ASIA) Classi cation Scale

1. Determ ine if patient is in spinal shock.


Check bulbocavernosus re ex.
2. Determ ine neurologic level of injury.
Lowest segm ent with intact sensation and antigravit y (3 or m ore) m uscle function
strength.
In regions where there is no myotom e to test, the motor level is presum ed to be
the sam e as the sensory level.
3. Determ ine whether the injury is COMPLETE or INCOMPLETE.
COMPLETE de ne as ASIA A
no voluntary anal contraction (sacral sparing) AND
0/5 distal m otor AND
0/2 distal sensory scores (no perianal sensation) AND
bulbocavernous re ex present (patient not in spinal shock)
INCOMPLETE de ned as
voluntary anal contraction (sacral sparing)
sacral sparing critical to determ ine complete vs. incomplete
OR palpable or visible muscle contraction below injury level OR
perianal sensation present
4. Determ ine ASIA Impairm ent Scale (AIS) Grade:
ASIA Impairm ent Scale
A

Complete

No motor or sensory function is present in the sacral segments S4S5.

Incomplete

Sensory function preserved but no m otor function is preserved


below the neurological level and includes segm ents S4S5.

Incomplete

Motor function is preserved below the neurological level, and


m ore than half of key m uscles below the neurological level have a
m uscle grade less than 3.

Incomplete

Motor function is preserved below the neurological level, and


at least half of key m uscles below the neurological level have a
m uscle grade of 3 or m ore.

Incomplete

Motor and sensory function are norm al.

Source: Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards for
neurological classi cation of spinal cord injury (Revised 2011). J Spinal Cord Med
2011;34(6):535546. Used with permission.

3. Ph arm acological in ter ven t ion :


a. Th e m ost com m on ly u sed agen t is m ethylpredn isolon e. How ever, th e
exten t of recover y in term s of im p roved fu n ct ion al abilit y an d th e risk to
th e pat ien t h ave been exten sively debated.
(1) Nat ion al Acute Spin al Cord Injur y St udy (NASCIS) guidelin es are m ost
com m on ly used.
(2) Methylpredn isolon e: bolus dose of 30 m g/kg of body w eigh t over
15 m in utes, follow ed by a 45-m in u te pause, an d th en a 23-h our
con t inu ous in fusion of 5.4 m g/kg/h if th e pat ien t presen t s < 3 h ours
after inju r y.

9 Evaluation and Managem ent of Spinal Cord Injury 121

(3) If th e pat ien t presen ts bet w een 3 an d 8 h ours after injur y, th e steroid
in fusion is con t in ued for a tot al of 48 h ou rs.
b. Th e NASCIS II Trials advocated for th e adm in ist rat ion of h igh -dose
steroids w ith in 8 h ou rs of inju r y if th e follow ing con t rain dicat ion s are
absen t:
(1) Cauda equin a syn drom e.
(2) Ner ve root injur y.
(3) Life-th reaten ing pat ien t st at us.
(4) SCI secon dar y to gun sh ot .
(5) Pregn an cy.
(6) Pat ien t younger th an 13 years of age.
(7) Subst an ce addict ion .
(8) Ch ron ic steroid use.
c. Num erous auth ors h ave quest ion ed th e validit y of th e st udy design an d
h ave refu ted th e n dings of th e NASCIS t rials.
d. In 2013, th e Congress of Neurological Surgeon s an d th e Am erican
Associat ion of Neurological Surgeon s recom m en ded again st th e use of
steroids follow ing an SCI.
(1) Lack of eviden ce th at dem on st rates ben e cial ou tcom es.
(2) Greater risk of poten t ial side e ect s (gast roin test in al bleeding,
in fect ion , avascu lar n ecrosis of th e fem oral h ead).
4. Surgical t im ing:
a. Data from th e Surgical Tim ing in Acute Spin al Cord Injur y St udy (STASCIS)
t rials suggest that early in ter vent ion w ith decom pression and stabilization
m ay poten t iate bet ter n eurological recover y follow ing an SCI.
(1) Prim ar y injur y from physical com pression or con t usion .
(2) Secon dar y injur y from th e dow nst ream cascade of even t s th at result
follow ing th e prim ar y in su lt:
(a) Neuroprotect ion involves th e preven t ion of secon dar y inju r y
w ith th e expedit ious decom pression of n eural elem en t s.
(b) Th e p oten t ial for n eu rop rotect ion varies inversely w ith t im e.
(3) Decom pression w ith in 24 h ours of injur y results in im proved
n eu rological ou tcom es at 6-m on th follow -u p .

Suggested Reading
Aarabi B, Hadley MN, Dh all SS, et al. Man agem en t of acu te t rau m at ic cen t ral cord syn drom e (ATCCS). Neu rosurger y 2013;72(Su ppl 2):195204
Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decom pression for t raum at ic
cer vical spin al cord inju r y: result s of th e Su rgical Tim ing in Acute Spin al Cord Injur y
St udy (STASCIS). PLoS ONE 2012;7(2):e32037
Halpern CH, Milby AH, Guo W, Schuster JM, Gracias VH, Stein SC. Clearan ce of th e cervical
spine in clinically unevaluable traum a patients. Spine 2010;35(18):17211728
Row lan d JW, Haw r yluk GW, Kw on B, Feh lings MG. Curren t st at us of acute spin al cord in ju r y p ath ophysiology an d em erging th erap ies: p rom ise on th e h orizon . Neu rosu rg
Focu s 2008;25(5):E2

10 Cervical Spine Trauma

10.1 General Considerations


I. In t rodu ct ion .
A. Fift y th ou san d cer vical spin al colum n or cord injuries are repor ted yearly in th e
Un ited States.
B. Most spinal colum n or cord injuries occur in m ales bet ween the ages of 15 and 24.
C. Mech an ism :
1. Motor veh icle acciden ts are th e m ost com m on cause (4056%) (Fig. 10.1).
2. Falls (2030%).
3. Gu n sh ot s (1221%).
4. Spor ts (613%).
D. Th e m idcer vical sp in e (C4C6) is th e m ost com m on ly a ected an atom ical
region .
II. Pat ien t evalu at ion .
A. A det ailed h istor y, in cluding th e m ech an ism of injur y as w ell as associated
inju ries, is requ ired.
B. Early recogn it ion of th e inju r y begin s in th e eld .
1. A cer vical collar an d spin e board are applied to th e pat ien t .
2. Th e pat ien t is t ran sferred to an em ergen cy depart m en t .
a. Th e t rau m a resu scitat ion team evalu ates air w ay com peten cy, breath ing,
an d circu lat ion .
3. An teroposterior an d lateral radiograph s of th e en t ire spin e can be obt ain ed.
4. Com puted tom ography (CT) is th e m ost sen sit ive an d speci c im aging st udy
to diagn ose cer vical spin e injuries (Fig. 10.2).
a. In t raven ou s con t rast is u sefu l to determ in e ver tebral ar ter y inju r y.
C. Cer vical sp in e t ract ion :
1. In dicat ion s.
a. Un st able fract u res or fract u re dislocat ion s of th e cer vical sp in e w ith or
w ith ou t n eurological de cits.
b. Dam age con t rol th erapy for cer vical spin e fract ures w h ile th e pat ien t is
being t reated for oth er injuries.
2. Con t rain dicat ion s.
a. Com p lete perm an en t qu adrip legia.
b. Un stable fract ures w ith deteriorat ing n eurological sign s.
c. St able fract ures.
d. A pat ien t w h o is n ot aw ake, aler t , an d cooperat ive.
3. Tech n iqu e: Gardn er-Wells tongs (Fig. 10.3).
a. Th e skin over th e tem p oral fossa is in lt rated w ith a local an esth et ic
agen t . Th e pin s are p osit ion ed 2 cm above th e extern al aud itor y can al
an d below th e tem p oral ridge. Th e p in s are t igh ten ed u n t il th e spring122

10 Cervical Spine Traum a 123

Fig. 10.1

Mechanism of whiplash injuries of the head and neck.

loaded in dicator p rot ru des 1 m m above th e surface. In it ially, 10 lb of


t ract ion -w eigh t is used. Weigh ts are added at 10 lb in crem en t s ever y 20
m in u tes. Serial n eu rological exam s are perform ed an d rad iograp h s are
t aken after each w eigh t is placed.
4. Com plicat ion s.
a. Failu re to redu ce: a bilateral, irredu cible facet dislocat ion is u n st able an d
sh ou ld be t reated w ith u rgen t open redu ct ion after m agn et ic reson an ce
im aging (MRI) is perform ed.
b. Ch ange in th e n eu rological stat u s: w ith any ch ange in th e n eu rological
st at u s of th e p at ien t , th e w eigh t s sh ou ld be rem oved im m ediately an d an
MRI scan sh ou ld be obt ain ed em ergen tly.

124 10 Cervical Spine Traum a

Fig. 10.2 (a) Sagit tal computed tom ographic


(CT) im ages of the cervical spine demonstrating spinal stenosis and spondylosis. (b) Axial CT
im ages of the cervical spine dem onstrating spinal stenosis and spondylosis at the level of the
C3 vertebrae. (c) Axial CT im ages of the cervical
spine dem onstrating spinal stenosis and spondylosis at the level of the C4 vertebrae.

III. Up p er cer vical inju ries.


A. Occipital con dyle fract ures.
1. Rare inju r y.
2. On e-th ird occur in conjun ct ion w ith atlan to-occipit al dislocat ion s.
3. Diagn osis is m ost com m on ly m ade in ciden tally w ith a h ead CT scan .
a. Ligam en tou s inju r y, in t racran ial h em atom a, an d n eu rological de cit m ay
accom p any th is inju r y.
4. Treat m en t:
a. Usu ally rigid orth osis or h alo vest for 3 m on th s.
b. A exion exten sion lm is obtain ed at 3 m on th s.
c. Occipit alcer vical ar th rodesis for result an t in stabilit y.
B. Occipu tC1 dislocat ion .
1. Un stable an d alm ost alw ays fat al.
a. Su r vivors u su ally h ave severe n eu rological de cits.
2. Violen t , t w ist ing, or exion -exten sion force on th e h ead.
3. Disrupt ion of all ligam en tou s at t ach m en t s.
4. Radiograph ic diagn osis.
a. Harris radiograp h ic lin es.
5. Treat m en t .
a. Closed redu ct ion .
b. Occipit al-cer vical fusion .

10 Cervical Spine Traum a 125

Fig. 10.3

Gardner-Wells tongs in place with traction.

C. C1C2 su blu xat ion .


1. More com m on in ch ildren th an in adu lt s.
2. Com m on com plain t s.
a. Neck pain w ith eviden ce of tor t icollis.
b. Suboccipital pain .
c. Lim ited cer vical rot at ion .
D. May be associated w ith odon toid or atlas fract u res.
1. Rupt ure of t ran sverse ligam en t .
a. An terior atlan tod en s in ter val (ADI).
(1) Th ree to 5 m m in dicate rupt ure of th e t ran sverse an d alar ligam en ts.
(2) Seven to 8 m m in dicate com plete ligam en tous disrupt ion .
(3) Greater th an 10 m m causes spin al cord com pression .

126 10 Cervical Spine Traum a

b. Treat m en t .
(1) If in stabilit y is 3 to 5 m m , h alo or rigid orth osis is used for 2 to 3
m on th s.
(2) If in stabilit y is > 5 m m , th en fuse C1C2.
2. Atlan toaxial rot ator y xat ion .
a. Th e h ead is t ilted tow ard th e side of xat ion an d th e ch in an d C2 sp in ou s
p rocess are p oin ted tow ard th e opp osite direct ion .
E. Fract ure of atlas (C1) (Fig. 10.4).
1. Axial loading disrupts th e atlan t al ring.
2. Neu rological inju r y is rare because of th e w ide spin al can al.
a. Cran ial n er ve inju ries m ay be obser ved .

Fig. 10.4 Levine and Edwards classi cation of atlas fractures. (a) Normal anatomy. (b) Posterior arch
fracture. (c) Classic Je ersons or burst fracture. (d) Avulsion fracture of the anterior arch. (e) Lateral
mass fracture. (f) Unilateral ring fracture.

10 Cervical Spine Traum a 127

3. An an teroposterior open -m outh odon toid view to assess th e lateral m asses


of C1 relat ive to th e lateral m ass of C2:
a. Greater th an 6.9 m m w id en ing of th e lateral m ass in dicates a t ran sverse
ligam en tous rupt ure.
(1) Allow atlas fract u res to h eal rst w ith h alo im m obilizat ion for 2 to 3
m on th s.
(2) C1C2 fusion m ay be don e if in stabilit y is > 5 m m .
4. Treat m en t:
a. Cer vical or th osis for 3 m on th s if n on disp laced.
b. Halo vest for 3 m on th s if displaced or delayed un ion .
c. Posterior C1C2 fusion for n on un ion .
F. Fract u res of th e odon toid (Fig. 10.5).
1. Type I.
a. Rare avu lsion fract u res of th e t ip .
(1) Stable an d t reat m en t is w ith a cer vical collar.
2. Type II.
a. Fract u res at th e base of th e odon toid :
(1) An terior displacem en t ( exion injur y).
(a) More com m on th an posterior displacem en t (exten sion injur y).

Fig. 10.5 Anderson and DAlonzo classi cation of odontoid fractures. (a) Odontoid tip avulsion.
(b) Fracture at the base of the dens. (c) Fracture within the body of C2. (d) Lateral view of a fracture
at the base of the dens.

128 10 Cervical Spine Traum a

b. Th e n on u n ion rate is 20 to 80%.


(1) Risk factors for n on un ion .
(a) Age over 50 years.
(b) More th an 4 m m disp lacem en t .
(c) Posterior angulat ion .
c. Treat m en t:
(1) Halo t ract ion for redu ct ion of fract ure.
(a) If acceptable reduct ion is ach ieved, th en a h alo jacket is applied
for 12 w eeks an d a cer vical collar for 6 w eeks.
(b) In dicat ion s for C1C2 fu sion :
i. Delayed u n ion or n on u n ion .
ii. Redisplacem en t follow ing h alo placem en t .
iii. Fract ures at h igh risk for n on u n ion (> 4 m m displacem en t ,
older pat ien t).
(c) Treat m en t opt ion s for odon toid fract u res associated w ith C1 ring
fract u re:
i. Con sider posterior C1C2 screw xat ion or an terior odon toid
screw xat ion .
ii. Halo in it ially to let C1 h eal, th en C1C2 fusion if C2 n on u n ion
develops.
3. Type III.
a. Fract u re th rough th e body.
(1) Non displaced.
(a) Treat w ith a cer vical orth osis or h alo.
(2) Displaced.
(a) Halo jacket for 3 m on th s.
G. Traum at ic spon dylolisth esis of th e axish angm ans fract ure (Fig. 10.6).
1. Mech an ism .
a. Acu te hyp erexten sion inju r y.
2. Types (Table 10.1).
3. Treat m en t .
a. Typ e I.
(1) Halo jacket for 12 w eeks.
b. Type II.
(1) Cer vical t ract ion to reduce displacem en t an d allow callus form at ion .
(2) Halo jacket for 10 to 12 w eeks.
c. Type IIA.
(1) Reduct ion in exten sion follow ed by h alo vest im m obilizat ion .
d . Typ e III or late in st abilit y/n on u n ion .
(1) An terior C2C3 fusion .
(2) Posterior screw xat ion (C2C3 plat ing).
H. Su baxial cer vical t rau m a.
1. Allen Ferguson classi cat ion of su baxial t raum a.
a. Classi cat ion is based on th e m ech an ism of inju r y.
b. Provides a biom ech an ical un derstan ding of th e injur y pat tern .
c. Classi cat ion (Allen) (Fig. 10.4, Fig. 10.5, Fig. 10.6, Fig. 10.7, an d Fig. 10.8)
(Table 10.2).

10 Cervical Spine Traum a 129

Fig. 10.6 E endin classi cation of hangm ans fracture. (a) Norm al anatomy. (b) Type I nondisplaced
(< 3 m m of displacem ent). (c) Type IIano translation, signi cant angulation, anterior longitudinal
ligament intact, posterior longitudinal ligament and C2C3 disk space disrupted. (d) Type IIIanterior
C2C3 displacem ent, angulation, and facet dislocation.

2. Suba xial cer vical spin e injur y classi cat ion (SLIC) system for cer vical spin e
inju ries (Table 10.3).
a. Classi cat ion is based on th e m orph ology of th e fract u re, th e st abilit y of
th e posterior ligam en tous com plex, an d th e pat ien ts n eurological st at us.
b. A score < 4 can be t reated n on operat ively, w h ereas a score > 4 requ ires
su rgical in ter ven t ion . A score of 4 is su rgeons ch oice.
IV. Treat m en t of sp eci c inju ries.
A. Un ilateral or bilateral facet dislocat ion s.
1. Cer vical t ract ion to reduce dislocat ion as soon as possible follow ed by
cer vical arth rodesis.
a. In an aw ake, cooperat ive p at ien t , MRI can be perform ed after at tem pted
redu ct ion .
(1) If th e pat ien t is obt un ded/in toxicated, obt ain a prereduct ion MRI to
ru le ou t an associated disk h ern iat ion .

130 10 Cervical Spine Traum a

Table 10.1
fracture)

Levine classi cation of traum atic spondylolisthesis of the axis (hangm ans

Type

Displacement and angulation

Other characteristics

Minim al displacem ent < 3 m m


without angulation

Bilateral pars fracture


C2C3 ligamentous structures are intact

IA

Minim al displacem ent with lit tle


or no angulation

Fracture lines extend through foramen


transversarum on computed tomography
(possible vertebral artery injury)

II

Signi cant displacem ent > 3 mm


and angulation > 11

Most com m on fracture subt ype


Posterior longitudinal ligam ent is
disrupted
Anterior longitudinal ligam ent is usually
intact

IIA

Minim al displacem ent (< 3 m m )


and angulation > 11

Additional widening of posterior part of


C2C3 disk space

III

Associated C2C3 facet dislocation

Unilateral or bilateral facet dislocation

Steven C. Kirshblum , Stephen P. Burns, Fin Biering-Sorensen, et al. International standards for neurological classi cation of spinal cord injury (Revised 2011). The Journal of
Spinal Cord Medicine, 2011; 34(6): 535-546. Used with perm ission.

B. Facet d islocat ion s w ith h ern iated disk.


1. Closed reduct ion m ay be dangerou s, produ cing fur th er n eurological de cit s.
a. An terior diskectom y an d fu sion m ay be p erform ed rst .
(1) Cervical fusion and stabilization m ay be accom plished by either anterior
grafting and plate xation or anterior grafting and posterior xation.
(2) If radiculopathy is presen t w ith an associated facet fract ure, rem oval
of th e fract ure fragm en t is recom m en ded during posterior fusion .
C. Fract u res of C3C7 vertebral bodies.
1. Wedge com pression fract u res.
a. Cer vical collar for 6 w eeks if p osterior elem en t s are in tact .
b. Halo jacket im m obilizat ion if th ere is sign i can t com pression or posterior
elem en t s are disrupted.
c. Posterior fusion m ay be n ecessar y in cases w ith severe kyph ot ic
angu lat ion or in cases of late in stabilit y (Fig. 10.7 an d Fig. 10.8).
2. Teardrop fract u res.
a. Alw ays u n st able du e to sign i can t bony com m in u t ion an d associated
d isru pt ion of th e an terior ligam en tou s com plex.
b. Posterior ligam en t s are frequen tly injured as w ell.
c. Treat m en t: posterior fusion .
3. Fract ures of th e spin ous process (clay-sh ovelers fract ure).
a. St able exion inju r y w ith avu lsion fract u re.
b. Treat m en t .
(1) Cer vical collar.

10 Cervical Spine Traum a 131


Fig. 10.7 Anteroposterior cervical spine
radiograph dem onstrating a unilateral C5
C6 facet dislocation with the spinous process of C5 rotated toward the right.

Fig. 10.8 Magnetic resonance


im aging of a 32-year-old m an who
sustained a bilateral C5C6 facet
dislocation with signi cant cord
comprom ise.

132 10 Cervical Spine Traum a

Table 10.2

Mechanistic classi cation (AllenFerguson)

Category

Findings

Compression- exion

Failure of the anterior colum n via compression


Posterior colum n distraction

Vertical compression

Burst fractures

Distraction- exion

Facet dislocations

Compression-extension

Posterior colum n compression


Anterior colum n distraction

Lateral- exion

Uncom m on

Distraction-extension

Associated with disk space widening and/or retrolisthesis

Table 10.3 The subaxial cervical spine injury classi cation system (SLIC)
for cervical spine injuries
Morphology
No abnorm alit y

Compression

Burst

+1 = 2

Distraction (e.g., facet dislocation, unstable teardrop


or advanced-stage exion compression injury)

Diskoligamentous complex
Intact

Indeterm inate (e.g., isolated interspinous widening,


m agnetic resonance im aging signal change only)

Disrupted (e.g., widening of disk space, facet perch


or dislocation)

Neurological status
Intact

Root injury

Complete cord injury

Incomplete cord injury

Continuous cord compression in set ting of neurological


de cit (neuro m odi er)

+1

10 Cervical Spine Traum a 133

4. Soft t issue inju r y.


a. Exten sion -accelerat ion w h ip lash .
(1) Involves an terior longit udin al ligam en t , an terior m usculat u re, an d
in ter ver tebral disk.
(2) Sym ptom s.
(a) Pain in th e n eck; referred pain to th e h ead, sh ou lder, an d
arm ; dysph agia; ocu lar sym ptom s; dizzin ess; an d tem p oral
m an d ibu lar p roblem s.
(b) Treat m en t .
i. Brace acutely an d m ay n eed surger y later if cer vical
sp on dylosis is problem at ic.
b. Flexion -decelerat ion injur y.
(1) Muscle st rain an d greater auricu lar n er ve st retch, in terspin ous
ligam en t , capsular tear, posterior longit udin al ligam en t , an d posterior
aspect of th e d isk.
(2) Treat m en t .
(a) Con ser vat ive rst an d if un stable by W h ites criteria an d
sym ptom at ic, th en posterior w iring an d fu sion .

Suggested Reading
Boldin C, Raith J, Fan kh au ser F, Hau n sch m id C, Sch w an t zer G, Sch w eigh ofer F. Predicting n eurologic recover y in cer vical spin al cord inju r y w ith postoperat ive MR im aging.
Sp in e 2006;31(5):554559
Bon o CM, Vaccaro AR, Feh lings M, et al. Measu rem en t tech n iqu es for low er cer vical
spin e inju ries: con sen su s statem en t of th e Spin e Trau m a St u dy Grou p . Sp in e 2006;
31(5):603660
Coe JD, Vaccaro AR, Dailey AT, et al. Lateral m ass screw xat ion in th e cer vical spin e: a
system at ic literat u re review. J Bon e Join t Su rg Am 2013;95(23):21362143
Moore TA, Vaccaro AR, An derson PA. Classi cat ion of low er cer vical sp in e inju ries. Sp in e
2006;31(11, Su ppl):S37S43, discu ssion S61
Plat zer P, Jain dl M, Th alh am m er G, et al. Clearing th e cer vical sp in e in crit ically inju red
pat ien t s: a com preh en sive C-sp in e protocol to avoid u n n ecessar y delays in diagn osis.
Eur Spin e J 2006;15(12):18011810

11 Thoracolumbar Spine Fractures

11.1 General Considerations


I. In t rodu ct ion .
A. Th e th oracolum bar spin e is th e m ost com m on site of spin al injuries.
1. Tran sit ion from less m obile spin e segm en ts in th e th orax to relat ively
hyperm obile spin al segm en t s in th e lum bar spin e.
B. Most inju ries occu r in m ales (age 1529) an d are m ost com m on ly th e resu lt of a
m otor veh icle acciden t (50%) or a fall from > 6 feet (25%).
C. Most inju ries occu r bet w een T11 an d L1 (52%).
1. L1L5 (32%).
2. T1T10 (16%).
D. Associated inju ries are com m on an d m ay occu r in u p to 50% of p at ien t s, u su ally
th e result of a dist ract ive force.
1. In t ra-abdom in al bleeding from liver an d splen ic injuries.
2. Ar terial or ven ous vessel disru pt ion .
3. Pu lm on ar y injuries.
a. Hem oth orax.
b. Pulm on ar y con t usion .
4. Non con t igu ous spin e injuries (5%).
II. Pat ien t evalu at ion .
A. Gen eral assessm en t .
1. Respirator y, cardioth oracic, abdom in al, urological evaluat ion .
2. Head/cer vical spin e st at us.
B. Neu rological assessm en t .
1. Fran kel scale an d Am erican Spin al Injur y Associat ion (ASIA) m otor in dex.
2. Spin al cord, con us, cauda equ in a, root injuries.
C. Rad iological evalu at ion .
1. All pat ien t s w h o h ave injuries suspicious for spin al t raum a sh ould un dergo
p lain rad iograph ic im aging (an teroposterior or lateral) of all ver tebral levels.
2. Plain X-ray is th e in it ial screen ing m odalit y:
a. Com p u ted tom ograp hy.
(1) Best im aging m odalit y for evaluat ion of th e m iddle colum n , especially
w ith sagit t al recon st ruct ion s.
b. Magn et ic reson an ce im aging.
(1) Most usefu l in evaluat ing th e spin al cord an d soft t issue disru pt ion
(disk/ligam en tous inju r y).
III. Classi cat ion m eth ods.
A. Spin e st abilit y (Den is classi cat ion ) (Fig. 11.1).
1. Th ree colum n s:
a. An terior colu m n .
134

11 Thoracolum bar Spine Fractures 135

a
Fig. 11.1

(a,b) The three colum ns of the spine as described by Denis.

(1) An terior longit udin al ligam en t , an terior an n ulus brosus, an d


an terior h alf of th e vertebral body.
b. Middle colum n .
(1) Posterior longit u din al ligam en t , posterior an n ulus brosis, posterior
h alf of th e vertebral body.
c. Posterior colum n .
(1) Pedicles, facet join ts, lam in a, spin ous processes, an d in terspin ous an d
su praspin ou s ligam en t s.
2. Clinical applicat ion :
a. In st abilit y is d e n ed as a disru pt ion of t w o or m ore of th e th ree sp in al
colum n s.
b. If th e m iddle colum n is disru pted, th en th e spin e is un stable except in th e
follow ing:
(1) Th oracic ver tebrae above T8 (stabilit y provided by th e ribs).
(2) L4L5 w h ere th e posterior colum n is in t act (sign i can t w eigh t
bearing th rough th e posterior colum n because of lordosis).
(3) Distraction injuries w here fractures occur through the cancellous bone.
3. St abilit y is n ot black an d w h ite; it is a gray zon e (Den is).
a. St able fract u res.
(1) Tran sverse process.
(2) Spin ous process.
(3) Ar t icular process.
(4) Pars in terart icularis.
(5) Com pression fract ures.
B. Th oracolu m bar inju r y classi cat ion an d severit y (TLICS) score.
1. Operat ive t reat m en t is based on th ree factors (Table 11.1).
a. Morp h ology of th e fract u re.
(1) Com pression .
(2) Burst .

136 11 Thoracolum bar Spine Fractures

Table 11.1 Components of the Thoracolum bar


Injury Classi cation and Severit y Score
Morphology of the fracture
1. Compression
2. Burst
3. Translational/rotational
4. Distraction
Posterior ligamentous complex
1. Intact
2. Indeterminate/suspected
3. Injured
Neurological status
1. Intact
2. Root injury
3. Cord
a. Incomplete
b. Complete
4. Cauda equina syndrome

(3) Tran slat ion al/rot at ion al.


(4) Dist ract ion .
b. Posterior ligam en tous com plex.
(1) In t act .
(2) In determ in ate/su spected.
(3) Injured.
c. Neurological stat us.
(1) In t act .
(2) Root injur y.
(3) Cord.
(a) In com plete.
(b) Com plete.
(4) Cauda equin a syn drom e.

11 Thoracolum bar Spine Fractures 137

IV. Treat m en t .
A. Gen eral considerat ion s.
1. Mult ifactorial.
a. Neu rological stat u s of th e pat ien t .
(1) An an terior approach is preferred in pat ien t s w ho are n eurologically
com prom ised an d h ave an terior-based com pression (i.e., ret ropu lsed
vertebral body fragm en t s).
b. Posterior ligam en tous com plex in tegrit y.
(1) If disrupted, requires reconst ruct ion of th e posterior ten sion band.
c. Fract ure m orph ology.
2. Tim ing of surger y.
a. Im m ediate op erat ive in ter ven t ion th eoret ically gives th e best ch an ce for
redu ct ion an d n eural recover y but is n ot clin ically proven .
b. In dicat ion s for acute surgical in ter ven t ion :
(1) Progressive n eurological de cit .
(2) Irreducible dislocat ion s.
(3) Open or con t am in ated injuries.
c. Early surger y (23 days):
(1) Easier redu ct ion an d decom pression via ligam en tot axis.
(2) Earlier m obilizat ion of th e pat ien t .
(3) Poten t ial operat ive com plicat ion s.
(a) Tran sport at ion issu es regarding pat ien t s w ith severe spin al
in st abilit y.
d . Late su rger y (710 days):
(1) Argum en t s for delayed in ter ven t ion in clude providing a ch an ce for
th e spin al cord to recover from t raum a an d edem a.
(a) Skelet al t ract ion an d closed reduct ion an d m otorized rotat ing
bed for pat ien t s w ith deform it y or dislocat ion s.
3. Extern al im m obilizat ion .
a. Above T5: cer vicoth oraciclu m bosacral orth osis.
b. T6L4: Jew et t hyperexten sion or th oracolum barsacral or th osis (TLSO)
braces.
c. L5S1: pan taloon cast .
B. Neu rological st at u s an d stabilit y.
1. Neurologically in t act w ith a st able spin e.
a. Com m on in com p ression fract u res, seat beltt ype inju ries an d bu rst
fract u res of th e low er lu m bar sp in e.
b. Orth osis or body cast .
2. Neurologically in t act w ith an un st able spin e.
a. Com m on in bu rst fract u res an d severe com p ression fract u res.
b. Operat ive st abilizat ion to preven t n eurological loss.
c. Early reh abilitat ion is preferred.
3. Neurologically com prom ised an d spin e u n stable.
a. Bu rst fract u res or fract u re dislocat ion s of th e low er th oracic sp in e an d
lum bar sp in e (Fig. 11.2).
b. An terior decom pression w ith or w ith out posterior stabilizat ion .

138 11 Thoracolum bar Spine Fractures

Fig. 11.2 (a) Sagit tal m agnetic resonance im aging


(MRI) of a 34-year-old m an who sustained a burst fracture to the T12 vertebral body. Note the retropulsion
of the posterior vertebral body with compression of
the anterior thecal sac. (b) A postoperative anteroposterior radiograph following an anterior L1 corpectomy
and fusion using a titanium Harm s m esh cage and an
anterior plate and screw construct.

C. Speci c fract u re t reat m en t .


1. Com pression - exion injuries.
a. An terior colu m n inju r y alon e u su ally does n ot cau se n eu rological de cit s.
(1) Factors suggest ive of in st abilit y an d disrupt ion of th e posterior
ligam en tou s com plex.
(a) Greater th an 50% collapse.
(b) Th ir t y-degree angu lat ion .
(c) Th ir t y-degree kyph osis.
b. Treat m en t:
(1) Con ser vat ive if an terior colum n failure alon e.
(a) Hyperexten sion orth osis.
(2) Middle colum n failure.
(a) Operat ive in ter ven t ion if un stable.
2. Dist ract ion exion injuries (seat belt inju r y) (Fig. 11.3).
a. Bony Ch an ce fract u re w ith ou t su blu xat ion or dislocat ion .
(1) Hyperexten sion body cast .

11 Thoracolum bar Spine Fractures 139

Fig. 11.3 (a) A sagit tal computed tomographic


reconstruction of a fracture-dislocation of the thoracolum bar spine dem onstrating m arked vertebral
body displacem ent and canal narrowing. (b) Sagit tal m agnetic resonance im aging of the thoracolum bar spine of the sam e patient dem onstrating
m arked canal narrowing. Note the draping of the
spinal cord over the posterosuperior edge of the
caudal thoracic vertebrae. (c) A postoperative lateral radiograph of the sam e patient dem onstrating reduction of the spinal deform it y followed by
a fusion and stabilization with segm ental pedicle
screw anchors spanning three levels above and
below the level of injury.

140 11 Thoracolum bar Spine Fractures

b. Ligam en tous exion -dist ract ion injur y.


(1) Posteriorly in st rum en ted ar th rodesis.
(2) Inju r y is th rough soft t issue st ruct ures w ith a decreased likelih ood of
h ealing.
3. Torsion al exion injuries (fract ure-dislocat ion s) (Fig. 11.4).
a. Frequ en tly cau se com p lete p arap legia.
b. Surgical posterior st abilizat ion an d fu sion are n ecessar y for early
reh abilit at ion .
4. Vert ical com pression injuries (burst fract ures).
a. Neu rological involvem en t is com m on secon dar y to a ret ropu lsed
p osterior vertebral body fragm en t .
b. Treat m en t for pat ien t s w ith out n eurological com prom ise:
(1) Con ser vat ive t reat m en t w ith acute bed rest an d TLSO orth osis
m ay be o ered for p at ien ts w h o h ave n o n eu rological d e cit s w ith
m in im al deform it y.
(2) Vertebral body cem ent augm en tat ion (kyph oplast y):
(a) Recom m en ded for osteoporosis-related fract ures w ith out
n eu rological com p rom ise.
(b) E cacy of th ese procedures rem ain s con t roversial.
(c) May h elp restore ver tebral body h eigh t an d alleviate pain .
(d) Risks: cem en t leak, adjacen t body fract ures.
c. Surgical opt ion s for n eurologically com prom ised pat ien t s:
(1) An an terior approach is preferred in cert ain sit uat ion s.
(a) Large ret ropulsed an terior fragm en t w ith sign i can t n eu rological
de cits.
(b) In ter ven t ion delayed > 2 w eeks.
(2) A posterior approach is preferred if th e com pressive fragm en t
(i.e., fract u re lam in a or in fold ed ligam en t u m avu m ) is located
p osterolaterally, w ith m in or n eurological de cit s.
(a) A posterior approach is required for fract ure-dislocat ion s an d in
sit u at ion s associated w ith t rau m at ic du ral tears.
(b) Both an terior an d posterior approach es m ay be n eeded in th reecolum n injuries.
i. Part icularly in sit u at ion s w ith n eurological com prom ise an d
posterior ligam en tou s inju ries.

11 Thoracolum bar Spine Fractures 141

a
Fig. 11.4 (a) Sagit tal T2-weighted m agnetic
resonance imaging dem onstrating a com plete fracture-dislocations through the L5
vertebral body due to a distraction-extension
injury m echanism. (b) A lateral postoperative
radiograph of the lum bosacral spine following
reduction of the fracture-displacement and
stabilization with pedicle screw instrumentation from L4 to S1.

Suggested Reading
Bellabarba C, Fish er C, Ch apm an JR, Det tori JR, Nor vell DC. Does early fract u re xat ion
of th oracolum bar spin e fract ures decrease m orbidit y or m ort alit y? Spin e 2010;
35(9, Suppl):S138S145
Gh obrial GM, Jallo J. Th oracolum bar sp in e t rau m a: review of th e eviden ce. J Neurosu rg Sci
2013;57(2):115122
Woodall JW Jr, McGuire RA. Eviden ce for th e t reat m en t of th oracolum bar bu rst fract ures.
Curr Orth op Pract 2012;:23
Xing D, Ch en Y, Ma JX, et al. A m eth odological system at ic review of early versus late stabilizat ion of th oracolu m bar spin e fract u res. Eur Sp in e J 2013;22(10):21572166

12 Spinal Rehabilitation and


Disability Evaluation
12.1 Rehabilitation of Back and Neck Pain
I. Gen eral con siderat ion s.
A. It is est im ated th at 80% of th e gen eral populat ion su ers at least on e disabling
episode of back or n eck p ain in th eir lifet im e.
B. Th e m ajorit y of pat ien t s recover w ith ou t sequ elae.
C. Many p at ien t s w h o do n ot recover h ave n o clear path ophysiological diagn osis as
a basis for con t in u ed p ain .
D. Advan ces in m edical tech n ology h ave con t ribu ted to in creased cost s associated
w ith th e evaluat ion an d t reat m en t of persisten t back or n eck pain .
E. It is w ell est ablish ed th at if disabilit y involves lit igat ion (w orkers com pen sat ion
or person al injur y), th e outcom e is less predictable an d th e problem is less
likely to resolve quickly.
II. Treat m en t of acu te n eck or low back p ain .
A. Evaluate for a neurological de cit that m ay necessitate urgent surgical intervention.
B. Diagn ost ic im aging is rarely n ecessar y for acu te episodes w h en n o t rau m a is
involved . (Th e except ion to th is is an occup at ion al injur y w h ere m edicolegal
issues m ay n eed to be addressed at a later t im e.)
C. Th e in it ial goal is pain relief, becau se th ese p at ien t s often exp erien ce severe,
disabling pain an d spasm .
D. Ap prop riate m ed icat ion in clu des n on steroidal an t i-in am m ator y drugs
(NSAIDs), sh ort-term n arcot ic an algesics (24 days on ly), an d m uscle relaxan t s
if spasm is a sign i cant p hysical n ding.
E. Nonph arm acological pain -reducing m odalit ies in clude h eat , ice, rest ,
p osit ion ing, relaxat ion , an d m assage.
F. Th e m ost im port an t early in ter ven t ion is p at ien t ed u cat ion .
G. Pat ien t s w ith low back or n eck pain em brace m any m yth s th at m ay in terfere
w ith recover y. Th e ext ra t im e spen t on in it ial educat ion w ill pay o in term s of
a qu icker recover y.
H. Essen t ial com p on en t s of pat ien t edu cat ion in clu de th e follow ing:
1. Likely causes of curren t con dit ion based on a discussion of sim ple an atom y
(m odels or pict ures are often h elpful).
2. Nat ural h istor y of th e injur y.
3. Ben e t s of m ain tain ing act ivit y w ith a brief discussion of speci c
aggravat ing act ivit ies.
4. Inst ruct ion on progressive exercise program s em phasizing both endurance
(cardiovascular condit ioning) and strength (isom et rics and core stabilization).
5. On ce th e acute episode h as subsided, educat ion on h ealth prom ot ion an d
lifest yle ch anges (w eigh t loss, m aintenan ce exercise, sm oking cessat ion ,
an d st ress m an agem en t) m ay h elp p reven t recu rren ces or decrease th eir
frequ en cy an d severit y.
142

12 Spinal Rehabilit ation and Disabilit y Evaluation 143

6. Form al physical th erapy m ay be in st it uted in it ially or reser ved for later if


n ecessar y, dep en d ing on th e in dividu als p reinju r y p hysical con dit ion ing,
m ot ivat ion , an d p hysical dem an d s of daily act ivit ies, in clu ding job
requ irem en t s.
III. Reh abilitat ion of ch ron ic inju r y.
A. Gen eral con siderat ion s.
1. Con t roversy exist s as to w h en acute pain becom es ch ron ic.
2. It is gen erally accepted th at th ere is a lack of progress tow ard
recover y, despite assu m ed con t in ued t issue h ealing, an d n o speci c
p ath op hysiological d iagn osis.
3. Chronic pain involves psych osocial as w ell as physical com ponents (Fig. 12.1).
4. Th e goal is to im prove fun ct ion an d m axim ize qualit y of life, n ot n ecessarily
to elim in ate th e pain .
B. Role of p sych iat ric disease.
1. Th e frequen cy of depression , an xiet y, an d sch izoph ren ia am ong su rgical
can didates for spin e surger y is in creasing.
2. Depression is m ore likely to be en coun tered am ong fem ale surgical
can didates, w h ereas sch izoph ren ia is m ore com m on am ong m ale pat ien t s.
a. Dem en t ia h as n o gen d er p referen ce am ong sp in e su rger y can didates.

Fig. 12.1

The psychological e ect s of chronic pain.

144 12 Spinal Rehabilit ation and Disabilit y Evaluation

3. Th ere is con siderable eviden ce th at suggests th at psych iat ric com orbidit ies
are an in depen den t risk factor for adverse in -h ospit al even t s follow ing sp in e
su rger y.
a. Dem en t ia is associated w ith a h igh er risk of p eriop erat ive m ort alit y.
4. Recen t m et a-an alyses recom m en d, w ith w eak eviden ce, th at pat ien t s w ith
ch ron ic low back pain w h o h ave psychiat ric com orbidit ies sh ould be t reated
w ith n on operat ive m an agem en t .
C. Fu n ct ion al restorat ion program s.
1. Repeated m easures of factors related to th e inju r y or disabilit y, such as
st rength , en du ran ce, an d coordin at ion .
2. Use fun ct ion al capacit y m easures as a basis of m on itoring progress an d goal
at t ain m en t .
3. Ou tcom es var y an d m ay be secon darily m easured by subscores of im proved
qualit y-of-life scales, sym ptom in terferen ce scales, object ive st rength or
en du ran ce m easu res, an d decreased u se of m ed icat ion .
4. Factors fou n d to con t ribute to poorer outcom es (in term s of ret urn to w ork
on ly) in clude h igh pret reat m en t self-repor ted scores for pain , depression ,
an d disabilit y; relat ively sh or t w ork h istor y p rior to inju r y; p reviou s su rgical
failu re; an d job dissat isfact ion .
5. Pat ien t s w ith ch ron ic n eck pain m ay ben e t from sim ilar program s.
6. Form al fun ct ion al restorat ion program s sh ou ld be reser ved for carefully
selected p at ien t s d u e to th e h igh cost an d th e variabilit y of ou tcom es.
D. Pain cen ters.
1. Mult idisciplin ar y program s are gen erally based on a m edical m odel.
2. Use a variet y of passive an d/or invasive pain -redu cing m odalit ies, in cluding
h eat , cold , u lt rasou n d, m assage, t ran scu t an eou s elect rical n er ve st im u lator
(TENS) un it , acupu n ct ure, an d inject ion s.
3. In corporate con cept s of beh avior m odi cat ion , such as biofeedback, st ress
m an agem en t , cop ing st rategies, an d rela xat ion tech n iqu es.
4. Address occupat ion al issu es, such w orkplace m odi cat ion .
5. Th is m ay be th e m ost appropriate environ m en t for detoxi cat ion from
n arcot ics w h en th is is n ecessar y.
6. Treat m en t of ch ron ic pain w ith invasive m eth ods, such as im plan t able
m orp h in e p u m p , sp in al cord st im u lator, sym p ath ectom y, an d rh izotom y, is
con t roversial.
E. Inject ion s for t reat m en t of back an d n eck pain .
1. Medicat ion s, su ch as local an esth et ics an d steroids, are injected in to various
locat ion s w ith in th e vertebral colu m n for both diagn ost ic an d th erapeut ic
reason s.
2. In dicated as an adjun ct m odalit y for tem porar y pain relief so th at exercises
an d reh abilitat ion can en su e.
3. May be used in respon se to a speci c diagn osis est ablish ed by im aging or
based on a clin ical diagn osis based on h istor y an d physical alon e.
4. Th e placebo e ect is alw ays possible an d di cult to prove.
5. Types of th erapeut ic inject ion s:
a. Local t rigger p oin t inject ion can be u sed in p at ien ts w ith m u scu lar,
ten din ous, or m yofascial pain w ith m arked poin t ten dern ess.

12 Spinal Rehabilit ation and Disabilit y Evaluation 145

b. An epidural steroid is in dicated for persisten t radiculopathy despite


NSAIDs in pat ien t s w ith a h ern iated disk or spin al sten osis.
c. A n er ve root block is in dicated for diagn osis of foram in al n er ve root
com pression an d for relief of radicular sym ptom s due to foram in al
sten osis.
d. Facet joint injection is indicated for sym ptom atic facet joint pain syndrom e.
(1) Most pat ien t s sh ould h ave pain ful exten sion an d spin al im aging
sh ow ing facet join t ar th rit is.
(2) Facet join t syn drom e is di cu lt to diagn ose, an d inject ion is
u npredict able for pain relief.
e. In t radiskal steroid inject ion is con t roversial an d m ay be in dicated for
p at ien t s w ith diskogen ic back pain .

12.2 Impairment and Disability Evaluation


I. Gen eral con siderat ion s.
A. Physician s are called upon to determ in e physical im pairm en t to sat isfy in surers,
em p loyers, an d govern m en t agen cies.
B. Im pairm en t rat ings are often requ ired in w orkers com pen sat ion , person al
inju r y, or ap p licat ion s for Social Secu rit y disabilit y.
C. De n it ion s:
1. Im pairm ent is a fu n ct ion al or an atom ical loss.
a. It resu lt s from a m edical con dit ion an d can be tem porar y or p erm an en t .
2. Disabilit y is th e exten t to w h ich a p erson can con t in u e to fu n ct ion w ith th e
im p airm en t con sidering th e occu pat ion al dem an ds, t rain ing, edu cat ion , an d
oth er psych osocial factors.
3. W hole person refers to th e p erson prior to th e illn ess or inju r y.
a. Describes th e person as a su m of all p ar ts (both an atom ical an d
p sych ological. Im pairm en t is determ in ed by th e loss of on e par t as
com pared w ith th e w h ole, th us th e term part ial disabilit y.
b. Th e exact im plem en t at ion of th is prin ciple varies st ate by st ate.
4. Healing period is de n ed as th e t im e w h en p rogress is being m ade tow ard
im p rovem en t of pain or fun ct ion an d t reat m en t con t in u es.
5. Healing plateau is d e n ed as th e t im e w h en t reat m en t is for m ain ten an ce,
an d fu r th er sign i can t ch anges in stat u s are n ot an t icipated; th is is also
kn ow n as m axim um m edical im provem en t .
II. Determ in at ion of disabilit y an d im p airm en t .
A. Four com pon en t s for determ in ing im pairm en t an d disabilit y.
1. Determ in e causalit y:
a. Requ ires an op in ion abou t th e relat ion sh ip bet w een th e circu m st an ces
th at caused th e im pairm en t an d th e resultan t im pairm en t itself.
2. Apport ion m en t:
a. Determ in e th e role of p reexist ing con dit ion s, su ch as degen erat ive join t
disease, in determ in ing im pairm en t from an injur y.
b. Th e Am erican Medical Associat ion h as ve t ypes of apport ion m en t:
(1) An occupat ion al disorder aggravated by a su per ven ing occupat ion al
disorder.

146 12 Spinal Rehabilit ation and Disabilit y Evaluation

(2) An occupat ion al disorder aggravated by a super ven ing oth er


occupat ion al con dit ion arising out of or in th e course of em ploym en t
by th e sam e em ployer.
(3) An occupat ion al disorder aggravated by a super ven ing oth er
occupat ion al con dit ion arising in th e course of em ploym en t by a
di eren t em ployer.
(4) An occupat ion al disorder aggravated by a preexist ing
n on occu pat ion al con dit ion .
(5) An occupat ion al disorder aggravat ing a preexist ing n on occupat ion al
con dit ion .
3. Determ in e en d of h ealing:
a. Often an arbit rar y p eriod based on th e in dividu al clin icians p ract ice,
p at ient p opu lat ion , local cu lt ure, an d exp erien ce (Maxim um Medical
Im provem en t).
4. Assign im pairm en t rat ing.
a. May be tem p orar y or perm an en t .
b. En com passes both residual sym ptom s as w ell as perm an en t rest rict ion s.
c. Ult im ately sh ou ld be based on an object ive assessm en t of th e pat ien ts
abilit y to p erform cer t ain fu n ct ion al t asks, su ch as sit t ing, lift ing,
grip ping, an d p u sh ing.
d. Form al evaluat ion m eth ods are evolving.
(1) Non e are yet proven to be m ore object ive or reliable th an th e t reat ing
p hysicians com plet ion of th e w ork cap acit y evaluat ion form based
on h is or h er est im at ion of th e pat ien ts curren t abilit ies.
III. Sp in al im pairm en t rat ing.
A. Th ere are m any rat ing system s available, in cluding on es developed by th e
Am erican Medical Associat ion an d th e Am erican Academ y of Orth opaedic
Su rgeon s.
B. Elem en t s for determ in ing im pairm en t in clu de th e follow ing:
1. Range of m ot ion .
a. Measu red w ith gon iom eter or in clin om eter.
2. Neurological im pairm en t .
a. In clu des sen sor y ch anges, loss of re ex, an d loss of m otor fu n ct ion
(w eakn ess to paralysis).
3. Speci c diagn osis or surgical in ter ven t ion .
4. Psych osocial im pairm en t .
a. In clu des su ch item s as act ivit ies of daily living, social fu n ct ion ing,
con cen t rat ion, an d coping.
C. Th e clin ician w ill ben e t from n d ing on e rat ing system an d u sing it
con sisten tly so as to becom e m ost pro cien t .
D. Treat ing p hysician s m u st n ot view im p airm en t rat ings as re ect ion s of
t reat m en t failure.

12 Spinal Rehabilit ation and Disabilit y Evaluation 147

Suggested Reading
Daubs MD, Nor vell DC, McGu ire R, et al. Fusion versu s n on operat ive care for ch ron ic
low back pain : do psych ological factors a ect outcom es? Sp in e 2011;36(21, Su pp l):
S96S109
Fu rlan JC, Noon an V, Singh A, Feh lings MG. Assessm en t of disabilit y in pat ien t s w ith acu te
t rau m at ic sp in al cord inju r y: a system at ic review of th e literat u re. J Neu rot rau m a
2011;28(8):14131430
Ron din elli RD. Changes for the n ew AMA Guides to im pairm en t rat ings, 6th Edit ion : im plicat ion s an d ap plicat ion s for p hysician disabilit y evalu at ion s. PM R 2009;1(7):643656
Ron din elli RD, Gen ovese E, Brigh am CR, eds. Guides to th e Evaluat ion of Perm an ent Im pairm en t . Ch icago, IL: Am erican Medical Associat ion ; 2008
Sin ikallio S, Aalto T, Airaksin en O, Leh to SM, Krger H, Viin am ki H. Depression is associated w ith a poorer ou tcom e of lu m bar sp inal sten osis surger y: a t w o-year prosp ect ive
follow -up st udy. Spin e 2011;36(8):677682

13 Biochemical Aspects of
Intervertebral Disk Degeneration
13.1 General Considerations
I. In ter vertebral disk.
A. Cells.
1. Notoch ordal cells:
a. Presen t em br yologically an d disap pear by adu lt life.
2. Ch on drocyte-like cells.
3. Likely origin ate from ch on drocytes in th e car t ilagin ous en d plate.
4. No sign i can t cell t urn over.
5. Th ese cells un dergo apoptosis w ith aging an d disk degen erat ion .
B. Gross st ru ct u res (from p erip h eral to cen t ral) (Fig. 13.1).
1. Outer brous an n u lus brosus.
a. Prim arily collagen brils th at are align ed in obliqu e layers.
b. Lim ited vascular an d n er ve supply.
c. Sin uver tebral n er ve run s posteriorly.
d . Sym p ath et ic bers run an teriorly.
2. In n er an n ulu s brosus.
a. Fibrocart ilagin ou s t issu e.
(1) Gradually blen ds w ith th e n ucleus pulposus.
(2) Posterolaterally th e an n ulus is th in n er an d h as m ore disorgan ized
collagen an d a greater proport ion of ver t ical bers.
(a) Weakest part of an n ulus.
(b) Con t ribu tes to a greater prop or t ion of disk h ern iat ion s.
3. Tran sit ion zon e.
a. Th in zon e of brou s t issu e bet w een th e in n er an n u lu s an d th e n u cleu s
pu lposus.

Fig. 13.1 Basic anatom ical structures of the


disk in relationship to the neural elem ents.

148

13 Biochem ical Aspect s of Intervertebral Disk Degeneration 149

4. Nucleus pu lposus.
C. Mat rices (Table 13.1).
1. Collagen s.
D. Disk degen erat ion .
1. Collagen syn th esis an d con ten t in crease in th e n ucleu s.
2. Decreased con cen t rat ion of cross-lin king in th e an n ulus.
3. Decreased w ater con ten t .
E. Proteoglycan s (PGs).
1. PG aggregates con st it uen t s.
a. Cen t ral hyalu ron an lam en t .
b. Lin k protein s at t ach m ult iple glycosam in oglycan m olecules.
c. Large PGs.
(1) Aggrecan .
(a) Sim ilar to art icular car t ilage.
(b) Half th e size of PGs foun d in cart ilage.
(c) High er kerat in sulfate:ch on droit in sulfate rat io.
(d) High er m olecular w eigh t s of kerat in sulfate.
(e) In creased hyaluron an con ten t .
(f) Im p or tan t in w ater reten t ion .
(g) Provides com p ressive st rength .
d . Sm all PGs.
(1) Biglycan , decorin , lu m ican , brom odulin .
(2) Involved in organ izat ion of collagen an d brillin form at ion .
(3) PG con ten t an d syn th esis var y depen ding on age, region , an d
d egen erat ion .
(a) PG act ivit y in a n orm al adult an n ulus is approxim ately on e-th ird
low er th an in a you ng n ucleu s.
(b) Syn th et ic act ivit y is greatest in th e in n er an n u lus.

Table 13.1

Components of the intervertebral disk

Annulus (70%)
1. Predom inantly t ype I
2. Type I, II, III, V, VI, IX, XI
3. Predom inantly t ype II
4. Type II, VI, IX, and XI provide tensile strength
Collagen cross-linking by covalent bonds via modi cation of lysine/hydroxylysine residues
Highest concentration of cross-linking in nucleus
Nucleus (20%)
1. Predom inantly t ype II
2. Type II, VI, IX, and XI

150 13 Biochem ical Aspect s of Intervertebral Disk Degeneration

F. Aging an d degen erat ion (Fig. 13.2).


1. Th e kerat in sulfate:ch on droit in su lfate rat io in creases w ith age.
2. Non aggregat ing PGs or PGs th at can n ot bin d to hyaluron ic acid in crease.
G. Hom eost asis of in ter ver tebral disk m et abolism .
1. An abolic en zym es, grow th factors, an d cytokin es.
a. Grow th factors.
(1) Transform ing grow th factor-b (TGF-b), b broblast grow th factor
(FGF), insulin -like grow th factor-1 (IGF-1), platelet-derived grow th
factor (PDGF), bon e m orph ogen et ic protein -2 (BMP-2), BMP-4, BMP-7.
(2) IGF-1, epiderm al grow th factor (EGF), FGF, an d TGF-b st im ulate
m at rix syn th esis.
(3) FGF prom otes proliferat ion of ch on drocytes in degen erat ive disks.
(4) IGF-1 st im ulates proteoglycan syn th esis in th e n ucleus.
(5) BMPs, such as BMP-2, BMP-7, an d laten t m em bran e protein (LMP)-1,
h ave been sh ow n to u p regu late PG syn th esis in vit ro an d in vivo.
2. Catabolic en zym es an d cytokin es.
a. En zym at ic degradat ion of th e m at rix:
(1) Mat rix m etalloprotein ases (MMPs):
(a) Collagen ase, gelat in ase, st rom elysin .
(2) Proin am m ator y cytokin es and free radicals in crease in degen erat ive
d isks.
(a) Nit ric oxide, prost aglan din E2 (PGE2), an d in terleukin (IL)-6 are
in creased in degen erated disks.
(b) Ph osph olipase A2, t u m or n ecrosis factor alph a (TNF-a), an d IL-1
are in creased in h ern iated disks an d radicu lop athy.
b. Cytokin e blockers su ch as IL-1, TNF blockers, an d t issue in h ibitors of
m etallop rotein ase can u p regu late PG syn th esis by blocking cat abolic
p rocesses.
H. Nu t rit ion by di u sion th rough th e en d p lates (Fig. 13.3).
1. Blood supply to th e en d plates an d outer an n ulus decreases w ith aging.
a. Lact ate con cen t rat ion in creases.
b. pH decreases.
c. Cellular m et abolism is a ected w ith decreased n ut rit ion (Fig. 13.4).
I. Biologic st rategies for in ter vertebral disk (IVD) d egen erat ion rep air or
regen erat ion .
1. Grow th factors.
a. BMPs.
b. Blocking cytokin e path w ays.
2. Th erapeut ic gen e t ran sfer.
a. Viral.
b. Nonviral.
3. Cell t ran splan tat ion .
a. IVD cells.
b. Ch on drocytes.
c. Mesen chym al stem cells.

13 Biochem ical Aspect s of Intervertebral Disk Degeneration 151


a

Fig. 13.2 Varying stages of disk degeneration (IV) categorized via the Thompson grading scale. (a)
Cadaveric specim ens and corresponding (b) m agnetic resonance im ages. Grade I represents a healthy
disk, and grade V represents a disk with osteophytic end plate changes, loss of disk height, and loss
of water content.

152 13 Biochem ical Aspect s of Intervertebral Disk Degeneration


Fig. 13.3 Diagram dem onstrating the
di usion of nutrient s into the intervertebral disk space.

Fig. 13.4

Therapeutic approach for repair of intervertebral disk degeneration.

13 Biochem ical Aspect s of Intervertebral Disk Degeneration 153

4. Cells an d m at rix t ran splan t at ion .


5. Molecules (pept ides or oth er com pou n ds) th at upregulate th e an abolic
p ath w ay an d dow n regulate in am m ator y or pain path w ays.
J. Biologic disk regen erat ion .
1. In creases th e syn th esis an d con ten t of PG an d collagen .
2. May im prove biom ech an ical propert ies of th e disk or th e m ot ion segm en t in
early st ages of d isk d egen erat ion .
a. May n ot be e ect ive if d isk d egen erat ion is severe an d th e p osterior
st ru ct u res are com p rom ised.
b. Use of grow th factor st im ulat ion to restore n ucleu s h eigh t an d m et abolic
fu n ct ion .
3. May n ot address pain percept ion .
K. Poten t ial lim itat ion s or u n an sw ered qu est ion s of grow th factor for IVD repair.
1. Durat ion of th erapeut ic e ect in vivo.
2. Opt im al dosage.
3. Opt im al deliver y system .
a. Inject ion .
b. Prolonged deliver y system s.
c. Carriers.
d . Mu lt iple p rotein s.
4. E ect of biom ech an ical st resses on disk m etabolism an d in uen ce of grow th
factors on cells.
5. E cacy of n on surgical pain -relieving procedures.
a. Ch em on u cleolysis.
(1) Min im ally invasive procedure involving th e inject ion of an en zym e
from papayas called chym op ap ain .
(2) Th e en zym e m et abolizes disk m aterial th at h as bulged to reduce
n er ve root com p ression .
(3) In 2003, th e Food an d Drug Adm in ist rat ion discon t in ued th e sale of
chym opapain due to grow ing repor ts of h em orrh age, pain , paralysis,
allergic react ion s, fat al an aphylact ic sh ock, an d t ran sverse m yelit is.

Suggested Reading
Colom bin i A, Lom bardi G, Corsi MM, Ban G. Path ophysiology of th e h um an in ter ver tebral
disc. In t J Bioch em Cell Biol 2008;40(5):837842
Raj PP. In ter vertebral d isc: an atom y-p hysiology-path ophysiology-t reat m en t . Pain Pract
2008;8(1):1844
Singh V, Manchikanti L, Calodney AK, et al. Percutan eous lum bar laser disc decom pression:
an update of curren t eviden ce. Pain Physician 2013;16(2, Suppl):SE229SE260
Wardlaw D, Rith ch ie IK, Sabbou beh AF, Vavd h a M, East m on d CJ. Prospect ive ran d om ized t rial of ch em on ucleolysis com pared w ith surger y for soft disc h ern iat ion w ith
1-year, in term ediate, an d long-term ou tcom e: par t I: th e clin ical outcom e. Sp in e
2013;38(17):E1051E1057

14 Degenerative Cervical Spine Disorders

14.1 Cervical Degenerative Disease


I. Clin ical categories.
A. Diskogen ic axial pain w ith or w ith out referred pain .
B. Disk h ern iat ion .
1. Myelopathy.
2. Radiculopathy.
C. Cer vical spon dylosis (Table 14.1).
1. Radiculopathy (foram in al sten osis).
2. Myelopathy (spin al cord com pression ).
II. Histor y an d exam in at ion .
A. Cer vical radicu lopathy.
1. Derm atom al pain dist ribut ion (Fig. 14.1).
a. Sp u rlings sign .
(1) Pain exacerbated by n eck exten sion an d rotat ion tow ard th e
sym ptom at ic side.
b. Sh ou lder abduct ion relief sign .
(1) Pain am eliorated by sh oulder abduct ion (m ore often presen t w ith
soft disk h ern iat ion s).
2. Neurological n dings (n er ve root dist ribut ion ).
a. Nu m bn ess.
b. Paresth esias.

Table 14.1

154

Dem ographics of cervical spine disease


Cervical spondylosis

Disk herniation

Age

> 50

< 50

Sex

Male > fem ale

Male = fem ale

Onset

Insidious

Acute

Location of pain

Neck and arm

Arm

Neck sti ness

Yes

No

Weakness

Yes

Yes or no

Myelopathy

More comm on

Less com m on

Derm atom al distribution

Multiple

Single

14 Degenerative Cervical Spine Disorders 155

Fig. 14.1

Derm atom al distribution of cervical and thoracic nerve roots.

c. Weakn ess.
d. Hypore exia.
B. Cer vical m yelopathy.
1. Pain is usu ally absen t .
a. Discom for t varies from a du ll ach e to sh arp p ain .
2. Sym ptom s:
a. Wide, at axic gait p at tern .
b. Poor h an d dexterit y.
(1) But ton ing sh irt .
(2) Writ ing.
(3) Holding on to a co ee m ug.

156 14 Degenerative Cervical Spine Disorders

3. Physical exam n dings:


a. Hyp erre exia.
b. Posit ive Ho m ans sign : pressing th e dorsal su rface of th e m iddle nger
elicit s a re ex con t ract ion of th e th u m b an d in dex ngers.
c. Inver ted brach ioradialis re ex: brach ioradialis ten don t ap elicits a re ex
exion of th e ngers.
d. Posit ive Babin skis sign : lateral st im ulat ion of th e plan tar surface of th e
foot elicits toe exten sion .
e. Posit ive Lh erm it tes sign : t ap p ing th e posterior n eck in n eck exion
elicit s paresth esia dow n th e back an d in to th e ext rem it ies.
f. Myelop ath ic h an d syn drom e:
(1) Th en ar at rophy.
(2) Posit ive nger escape sign : th e pat ien t can n ot keep th e fourth an d
fth digit of th e h an d in exten sion .
(3) Posit ive grip release test: pat ien t h as t rouble m aking a st an d fully
exten d ing ngersn orm al is 20 t im es in 10 secon ds.
(4) Dysdiadoch okin esia: loss of coordin at ion an d dexterit y of th e h an ds
during rapid m ovem en t .
III. Diagn ost ic im aging (Fig. 14.2 an d Fig. 14.3).
A. Plain radiograph s.
1. An teroposterior, lateral, an d oblique view s.
a. Overall align m en t:
(1) Pat ien t s w ith spon dylosis m ay h ave a loss of lordosis or a
sp on dylolisth esis.

Fig. 14.2 Schem atic of an axial cut through the cervical spine. The shaded area in section I represent s
the lamina that is rem oved in a lam inectomy. Section II represents the bone rem oved to perform a
thorough foram inotomy.

14 Degenerative Cervical Spine Disorders 157

Fig. 14.3 Cross-sectional view of a cervical vertebra. The neuroforamen is divided into three areas:
the medial zone, the middle zone, and the lateral zone.

b. Narrow ing of th e in ter ver tebral disk space.


c. Degen erat ive ch anges in th e zygapophyseal join t s an d th e presen ce of
osteophytes.
d. Foram in al n arrow ing is obser ved on th e oblique view s (Fig. 14.4).
B. Com p u ted tom ograp hy w ith m yelograp hy.
1. Modalit y of choice for th ose w h o can n ot u n dergo m agn et ic reson an ce
im aging (MRI).
2. Good for postoperat ive im aging if in st rum en tat ion presen t .
3. Invasive procedure th at involves in t radu ral inject ion of radiopaque dye.
C. MRI (Fig. 14.5).
1. Im aging m odalit y of ch oice for cer vical disk disease.
2. Good for evaluat ing space available for th e cord:
a. Less th an 13 m m is relat ive sten osis.
b. Less th an 10 m m is crit ical sten osis.
3. Part icularly useful to rule out spin al cord lesion s, su ch as syringom yelia,
t um ors, an d m yelom alacia.
4. Correlat ion w ith clin ical sym ptom s is crit ical, because th e false-posit ive rate
is h igh .

158 14 Degenerative Cervical Spine Disorders


Fig. 14.4 An oblique cervical spine
radiograph demonstrating neuroforaminal stenosis secondary to osteophyte
formation at the uncinate processes.

IV. Di eren t ial diagn osis (Table 14.2).


V. Treat m en t for cer vical radiculopathy.
A. Con ser vat ive t reat m en t: a 70 to 80% successful outcom e is expected w ith 2 to 3
m on th s of con ser vat ive t reat m en t .
1. Acute ph ase ( rst 2 w eeks).
a. Non steroidal an t i-in am m ator y m edicat ion s.
b. Oral steroids.
c. Short-term an algesics (lim ited u se of n arcot ics).
d. Ice or h eat applicat ion .
e. Act ivit y m odi cat ion .
(1) Soft collar.
(2) Hom e t ract ion .
2. In term ediate h ealing ph ase (34 w eeks).
a. St retch ing an d isom et ric exercises.
b. Physical th erapy:
(1) Modalit ies if th e pat ien t is n ot im proving.
c. Epidural steroids m ay be con sidered for persisten t radicular pain .
3. Reh abilit at ion ph ase (> 4 w eeks).
a. Cardiovascu lar con dit ion ing.
b. Vigorous st rength en ing exercise program .
B. Operat ive in dicat ion s:
1. Progressive sign s of root or cord dysfun ct ion .
2. Failure of con ser vat ive t reat m en t in relieving radicu lar pain or n eu rological
de cit s.

14 Degenerative Cervical Spine Disorders 159

Fig. 14.5 (ac) Sagit tal magnetic resonance imaging of the cervical spine. (From
Uhlenbrock D. MR Imaging of the Spine
and Spinal Cord. Stut tgart, Germany: Georg
Thieme Verlag; 2004: Fig. 4.70. Reproduced
with permission.)

3. Axial pain w ith out radicu lopathy sh ould be t reated con ser vat ively as long as
p ossible, becau se su rgical resu lt s are less predict able.
VI. Surgical tech n iques.
A. An terior cer vical surger y.
1. In dicat ion s.
a. Cen t ral soft disk h ern iat ion .
b. Bilateral radiculopathy at th e sam e level.
c. Un ilateral soft disk or foram in al sten osis.
(1) An terior approach is preferred in pat ien ts w ith sign i can t n eck pain
in ad dit ion to radiculop athy.
d. On e- or t w o-level spon dylot ic m yelopathy.
e. Kyph ot ic sagit t al align m en t .

160 14 Degenerative Cervical Spine Disorders

Table 14.2

Di erential diagnosis of cervical spine pathology

Pathology

Di erential

Trauma

Cervical sprain
Traum atic neuritis (brachial plexus)
Post traum atic instabilit y

Tum or

Superior sulcus (Pancoast) tum or with C8 radiculopathy and


Horners syndrom e
Spinal cord tum ors
Metastatic disease
Prim ary bone tum ors

In amm atory
conditions

Rheum atoid arthritis


Ankylosing spondylitis

Infections

Diskitis
Osteomyelitis
Soft tissue abscess
Shoulder disorders
Rotator cu tears
Impingem ent syndrom e

Neurological
conditions

Demyelinating disease (GuillainBarr syndrom e)


Amyotrophic lateral sclerosis

Others

Thoracic outlet syndrom e


Re ex sympathetic dystrophy
Angina pectoris
Peripheral nerve entrapm ents
Multiple sclerosis
Acute brachial neuritis (ParsonageTurner syndrom e)

2. An terior cer vical diskectom y an d fu sion (ACDF).


a. Allograft w ith local au tograft m ay be u sed for fu sion w ith
in st rum en tat ion .
(1) No iliac crest graft site m orbidit y.
(2) Recom bin an t h um an bon e m orph ogen et ic protein -2 (rh BMP-2) w as
u sed o label as an allograft to adjun ct ar th rodesis in th e an terior
cer vical spin e.
(a) In 2007, th e Food an d Drug Adm in ist rat ion (FDA) issued public
h ealth n ot i cat ion s regard ing th e risk of dysp h agia an d severe,
som et im es fatal, soft t issu e sw elling cau sing air w ay com p rom ise
w ith th e use of rh BMP-2 in th e set t ing of an ACDF.
(b) Su bsequ en tly, th e rate of rh BMP-2 u se in th e an terior cer vical
sp in e h as declin ed su bst an t ially.

14 Degenerative Cervical Spine Disorders 161

b. In terbody cage devices:


(1) Can h old graft m aterials.
(2) Provide st ruct ural st abilit y.
(3) Main t ain foram in al h eigh t .
(4) Titan ium an d carbon ber cages w ere popularized.
(a) Th ese m et allic cages had a greater m odulus of elast icit y th an
bon e, result ing in cage subsiden ce.
(b) Disk h eigh t collapse an d kyph ot ic deform it y.
(5) Polyeth ereth erketon e (PEEK) cages w ere subsequen tly in t roduced
(Fig. 14.6):
(a) Radiolucen t .
(b) Non absorbable an d biocom p at ible.
(c) Com parable m odus of elast icit y to bon e.
(d) Redu ced risk of cage subsiden ce.
(6) PEEK cages are produced as n on expan dable, expan dable, an d
st ackable m odels.
(a) Non expan dable PEEK cages h ave prede n ed dim en sion s, en d
p late angles, an d h eigh t s.
i. Risk for im plan t displacem en t .

Fig. 14.6 Illustration of a polyetheretherketone


(PEEK) cage. (From Albert TJ, Lee JY, Lim MR. Cervical Spine Surgery Challenges. New York, NY:
Thiem e Medical Publishers; 2008: Fig. 18.5. Reproduced with perm ission.)

162 14 Degenerative Cervical Spine Disorders

(b) Exp an dable PEEK cages con tou r to th e p at ien ts an atom y w ith
m in im al in t raop erat ive m odi cat ion s.
i. Par t icu larly advan t ageou s for corpectom y defect s.
c. Use of an terior in st rum en tat ion (plat ing):
(1) Single-level in terbody fusion is qu ite stable, an d fusion rates are
excellen t , w ith n o n eed for postoperat ive bracing.
(2) In st ru m en t at ion is recom m en ded in th e follow ing:
(a) Single-level fusions w ith allograft .
(b) Avoid p ostop erat ive bracing.
(c) Mult iple-level in terbody fusion s.
(d) High -risk pat ien t s:
i. Revision fu sion .
ii. Sm okers.
3. An terior cer vical corpectom y an d fusion .
a. St rut allograft an d an terior p late in st ru m en t at ion for st abilit y.
(1) Avoids postoperat ive h alo vest .
b. Expan dable cages (PEEK/t it an ium ).
(1) Easier to con tour an d t to th e corpectom y t rough .
B. Cer vical disk ar th rop last y (CDA).
1. Replacem en t of an in ter ver tebral disk w ith an art i cial disk device.
2. Pu rpose w as to design m ot ion -sparing devices in an e ort to reduce
adjacen t segm en t d egen erat ion .
3. Curren tly ve are FDA-approved:
a. Br yan Disc (Medt ron ic Sofam or Dan ek).
b. Prest ige Disc (Medt ron ic Sofam or Dan ek).
c. ProDisc-C (Syn th es Spin e).
d . Secure C disc (Globu s Medical, In c.).
e. PCM disc (Nu Vasive, In c.).
4. Several FDA investigative device exem ption t rials as w ell as oth er prospect ive
st udies h ave dem on strated th e long-term n on in feriorit y of CDA w h en
com pared w ith ACDF for the m anagem ent of degenerat ive disk disease.
5. Th e rates of adjacen t segm en t degen erat ion bet w een CDA an d ACDF are st ill
su bject to con t roversy.
a. Sim ilarly, th e rates of revision an d reop erat ion h ave also been scru t in ized
due to auth or an d in dust r y bias.
C. Posterior cer vical su rger y.
1. In dicat ion s.
a. Un ilateral soft disk h ern iat ion or foram in al sten osis in p at ien t s w ith
radicu lopathy an d n o sign i can t axial sym ptom s (posit ive Spurlings sign
an d n o segm en tal kyp h osis).
b. Cer vical spon dylot ic m yelopathy (m ore th an th ree levels of path ology).
c. Ossi cat ion of th e posterior longit udin al ligam en t (OPLL).
d. Neut ral or lordot ic sagit tal align m en t .
2. Lam in oforam in otom y (Fig. 14.7).
a. Mot ion -preser ving p rocedu re.
b. Treat m en t of cer vical radiculopathy w ith m in im al axial sym ptom s.

14 Degenerative Cervical Spine Disorders 163

c
Fig. 14.7 Step-by step m ethodology for perform ing a posterior cervical foraminotomy. (a) A cut ting
bur is used to thin the lamina (labeled I) at the junction of the lateral m asslam ina. (b) Twent y- ve
percent of the lateral mass is rem oved, exposing the lam ina (II), superior articular process of the inferior lamina (V), facet joint (IV), and ligam entum avum (VI). (c) A curet te is used to rem ove the superior articular process overlying the nerve root.

3. Lam in oplast y (Fig. 14.8).


a. Com parable ou tcom es an d com p licat ion s w h en com pared w ith
lam in ectom y an d fu sion an d ACDF.
b. Mot ion -preser ving procedure.
c. Sam e in dicat ion s as lam in ectom y an d fusion (lam in oplast y is preferred
in p at ien ts w ith m in im al axial n eck p ain an d n o sign i can t in stabilit y).
d. Tech n ique w ith or w ith ou t in st ru m en tat ion : in st rum en tat ion allow s for
earlier m obilizat ion an d th eoret ically redu ced rates of p ostop erat ive axial
n eck pain .
(1) Fren ch door.
(a) Midlin e open ing.
(b) Bilateral h inges.
(2) Open door (m ore com m on ).
(a) Open ing side.
(b) Hinge side.

164 14 Degenerative Cervical Spine Disorders

Fig. 14.8 (a) Preoperative cervical magnetic resonance imaging demonstrating spinal stenosis extending from C3 to C7. (b) A laminoplast y from C3 to C7 was performed (postoperative lateral radiograph
demonstrating the placement of titanium cervical plates and allograft). (c) Postoperative axial computed
tomography demonstrating placement of the titanium plate. (d) Postoperative axial computed tomography demonstrating placement of the machined allograft.

4. Lam in ectom y an d fusion w ith inst rum en tat ion (sam e in dicat ion s as
lam in oplast y an d preferred for pat ien ts w ith sign i can t n eck pain , bilateral
foram in al sten osis requ iring foram in otom ies in addit ion to lam in ectom y an d
in st abilit ies su ch as spon dylolisth esis).
a. St abilizat ion is recom m en ded w h en perform ing lam in ectom y to p reven t
postlam in ectom y kyph osis.
(1) Lateral m ass screw xat ion .
(2) Pedicle screw (C2, C7, T1).

14 Degenerative Cervical Spine Disorders 165

(3) C2 Tran slam in ar screw xat ion .


(a) Screw s are placed in bet w een th e in n er an d ou ter tables of th e
lam in a.
(b) Poten t ial opt ion if th e p osterior elem en ts of C2 are in t act .
(c) In dicat ion s in clude th e follow ing:
i. Atlan toaxial in st abilit y.
ii. Osteoar th rit is.
iii. Failed C1C2 ar th rodesis.
VII. Com plicat ion s.
A. An terior cer vical surger y.
1. Pseudarth rosis.
2. Graft dislodgm en t , resorpt ion , or collapse.
3. Dysph agia.
4. Hoarsen ess.
5. Vertebral or carot id ar ter y injur y.
6. Du ral tears.
7. Esoph ageal or t rach eal injur y.
8. Ner ve injur y: C5 n er ve root palsy also occurs in an terior surger y; th e rates of
C5 palsy are sligh tly decreased relat ive to posterior cer vical surger y.
B. Posterior cer vical su rger y.
1. Neurological de cit .
2. Axial n eck pain .
3. C5 ner ve root palsy.
a. Believed to occu r secon dar y to posterior cord m igrat ion an d st retch
inju r y to th e C5 n er ve root .
b. C5 palsy occurs w ith all cer vical approach es, in cluding an terior
tech n iqu es. Th e rates of C5 palsy are greatest w ith posterior
lam in ectom y/fusion an d lam in oplast y. Neverth eless, C5 palsy m ay occu r
follow ing an terior cer vical fu sion s.
VIII. Postoperat ive m an agem en t .
A. No rigid collar is n eeded after in st rum ented procedu res.
1. Th e pat ien t m ay begin range of m ot ion exercises in th e im m ediate
postoperat ive period.
2. Soft collars m ay be used for pat ien t com for t .

Suggested Reading
An d erson PA, Mat z PG, Gro MW, et al; Join t Sect ion on Disorders of th e Spin e an d Periph eral Ner ves of th e Am erican Associat ion of Neurological Su rgeon s an d Congress of
Neurological Surgeon s. Lam in ectom y an d fusion for th e t reat m en t of cer vical degen erat ive m yelop athy. J Neu rosurg Sp in e 2009;11(2):150156
Hear y RF, Kh eterpal A, Mam m is A, Ku m ar S. St ackable carbon ber cages for th oracolu m bar in terbody fusion after corpectom y: long-term ou tcom e an alysis. Neu rosu rger y
2011;68(3):810818, d iscu ssion 818819
Kan dziora F, P ugm ach er R, Sch aefer J, et al. Biom ech an ical com parison of expan dable
cages for ver tebral body rep lacem en t in th e cer vical sp in e. J Neu rosu rg 2003;99(1,
Su ppl):9197

166 14 Degenerative Cervical Spine Disorders


Mat z PG, An derson PA, Gro MW, et al; Join t Sect ion on Disorders of th e Spin e an d Perip h eral Ner ves of th e Am erican Associat ion of Neu rological Su rgeon s an d Congress
of Neurological Surgeon s. Cer vical lam in oplast y for th e t reat m en t of cer vical degen erat ive m yelopathy. J Neu rosurg Sp in e 2009;11(2):157169
Mat z PG, Holly LT, Gro MW, et al; Join t Sect ion on Disorders of th e Spin e an d Periph eral
Ner ves of th e Am erican Associat ion of Neurological Su rgeon s an d Congress of Neu rological Surgeon s. In dicat ion s for an terior cer vical d ecom p ression for th e t reat m en t of
cer vical degen erat ive radicu lopathy. J Neu rosu rg Spin e 2009;11(2):174182
Singh K, Nan dyala SV, Marqu ez-Lara A, Fin eberg SJ. Ep idem iological t ren ds in th e u t ilizat ion of bon e m orph ogen et ic protein in spin al fu sion s from 2002 to 2011. Sp in e
2014;39(6):491496

15 Degenerative Thoracic Spine


Conditions
15.1 General Considerations
I. In t rodu ct ion .
A. Th oracic pain m ay be due to several di eren t et iologies (Table 15.1).
1. Th e in ciden ce is ~ 15%.
2. It frequen tly presen t s in th e four th to sixth decade of life.
3. Clin ical presen t at ion :
a. May be eith er radicu lar or m yelop ath ic.
(1) Th e th oracic can al is relat ively sm all.
(2) Subtle m yelopath ic sym ptom s are sign i can t .
(3) Radiculopathy involves radiat ing pain aroun d th e associated rib.
B. Diagn osis:
1. Thoracic disk herniation is frequently seen on m agnetic resonance im aging (MRI).
a. MRI is m ost u sefu l becau se of th e w ide eld of view.
(1) Provides in form at ion regarding th e st at us of disk degen erat ion an d
sp in al can al im p ingem en t (Fig. 15.1).
(2) High false-posit ive rate.
(3) Also useful in ruling out in fect ion s an d t um ors.
b. Com puted tom ography (CT) w ith m yelography:
(1) More accurate assessm en t of spin al cord im pingem en t (Fig. 15.2).
(2) Invasive im aging st udy.
2. Th oracic sten osis:
a. Ossi cat ion of p osterior longit u din al ligam en t .
(1) Com m on in Asian populat ion s.

Fig. 15.1 (a) T2-weighted sagittal magnetic resonance imaging (MRI) demonstrates a herniated disk at T12
L1. (b) A T2-weighted axial MRI demonstrates a left paracentral disk herniation with foraminal impingement.

167

168 15 Degenerative Thoracic Spine Conditions

Table 15.1

Di erential diagnosis of thoracic pain

Category

Etiologies

Cardiovascular

Angina pectoris
Myocardial infarction
Mitral valve prolapse
Pericarditis
Aortic aneurysm

Pulm onary

Pneum onia
Carcinom a
Pneum othorax
Pulmonary em bolus
Pulmonary e usion

Mediastinal

Esophagitis
Tum ors

Intra-abdom inal

Hepatitis
Abscess
Cholecystitis

Gastrointestinal

Peptic ulcer disease


Hiatal hernia
Pancreatitis

Retroperitoneal

Pyelonephritis
Ureteral stone
Aneurysm

Neurological

Intraspinal cyst/tum or
Demyelinating disease
Transverse myelitis

Infectious

Osteomyelitis
Diskitis
Epidural abscess
Tuberculosis

15 Degenerative Thoracic Spine Conditions 169

Category

Etiologies

Traum atic

Compression fractures
Rib fractures

Neoplastic

Metastatic disease
Multiple myelom a
Intradural tumors

Metabolic

Osteoporosis
Osteom alacia
Pagets disease

Miscellaneous

Herpes zoster
In amm atory disease
Polymyalgia rheum atica

Fig. 15.2 Computed tom ographic myelography of the disk herniation in Fig. 15.1, dem onstrating
e acem ent of the spinal cord.

170 15 Degenerative Thoracic Spine Conditions

b. Ossi cat ion of ligam en t um avu m .


(1) Posterior spin al cord com pression .
(2) Treated w ith posterior th oracic decom pression .
c. Spon dylosis.
II. Treat m en t of th oracic disk disease.
A. Conser vat ive m odalit ies.
1. Non steroidal an t i-in am m ator y drugs.
2. Exercise program .
3. Muscle st rength en ing an d cardiovascular t n ess.
4. Physical th erapy an d m odalit ies as n ecessar y.
5. Con ser vat ive t reat m en t sh ould be t ried for at least 6 m on th s in pat ien t s
w ith out m yelopathy.
B. Su rger y.
1. In dicat ion s.
a. Th oracic disk h ern iat ion w ith m yelop athy.
b. Th oracic radicular pain w ith out m yelopathy th at becom es un relen t ing
an d resist an t to con ser vat ive t reat m en t for at least 6 m on th s.
2. Surgical tech n iques.
a. Lam in ectom y alon e m ay address on e- or t w o-level path ology.
(1) Instrum ented fusion after lam inectom y is recom m ended for m ultilevel
cases or high-risk patients to prevent postoperative kyphosis.
b. Costot ran sversectom y:
(1) An opt ion in posterolateral h ern iated disk cases.
c. Most cases requ ire an an terior approach w ith or w ith ou t fu sion .
(1) Fusion is advocated in pat ien ts w ith th e follow ing:
(a) Sign i can t back pain .
(b) Eviden ce of spin al in st abilit y.
(c) Iat rogen ic in st abilit y secon dar y to rem oval of bon e/disk for
decom p ression .
(d) Kyph ot ic deform it y.
d . An terior in st ru m en t at ion m ay be used in kyph ot ic cases.
e. Thoracoscopic diskectom y is an option that m ay decrease surgical m orbidit y.
(1) Ver y surgeon depen den t .
(2) Sh arp learn ing cur ve.
f. Min im ally invasive th oracic app roach es h ave gain ed p op u larit y.
(1) Retropleural approach: m inim izes the need for postoperative chest tube.

Suggested Reading
Am ato V, Giannachi L, Irace C, Corona C. Thoracic spinal stenosis and m yelopathy: report of
t wo rare cases and review of the literature. J Neurosurg Sci 2012;56(4):373378
Hsieh PC, Lee ST, Chen JF. Low er th oracic degen erat ive spon dylolith esis w ith con com itan t
lum bar sp on dylosis. Clin Neu rol Neurosu rg 2014;118:2125
Park BC, Min W K, Oh CW, et al. Su rgical ou tcom e of th oracic m yelopathy secon dar y to
ossi cat ion of ligam en t u m avu m . Join t Bon e Sp in e 2007;74(6):600605

16 Lumbar Disk Disease :


Pathogenesis and Treatment Options
16.1 General Considerations
I. In t rodu ct ion .
A. In ciden ce.
1. Eigh t y percen t of th e populat ion w ill experien ce back pain .
2. Tw o to 3% w ill experien ce con com itan t low er ext rem it y radiculopathy.
B. Age:
1. Mean age of on set is 35 years.
2. Un usual in pat ien ts un der 20 years an d over 60 years of age.
3. Hern iated disks in ch ildren are rare.
a. Slipp age of an en t ire disk an d ver tebral en d p late or slipp ed ver tebral
apop hyses m ay m im ic a h ern iated disk.
4. Hern iated disk in th e elderly is also un com m on .
a. May be associated w ith sp in al sten osis.
C. Gen der rat io is ap p roxim ately equ al.
1. Fem ales t ypically presen t a decade later.
D. Nat u ral h istor y of low back p ain an d radicu lop athy:
1. Low back pain resolut ion :
a. Fift y to 60% recover w ith in 1 w eek.
b. Nin et y- ve percen t recover in 3 m on th s.
2. Radiculopathy resolu t ion :
a. Fift y p ercen t recover in 1 m on th .
b. Seven t y- ve percen t recover in 1 year.
3. Surgical result s are bet ter after 1 year an d m ay persist for up to 4 years
(Spin e Pat ien t Outcom es Research Trial [SPORT]).
E. Epidem iological risk factors:
1. Gen et ic predisposit ion .
a. Cu rren tly th ough t to h ave th e m ost im p act on degen erat ive disk disease,
th an ks to con t ribut ion s by th e Tw in Spin e St udy by Bat t ie et al.
2. Cigaret te sm oking.
3. Depression .
4. Seden tar y lifest yle.
5. Obesit y.
6. Occupat ion al (th eoret ical).
a. Th e Tw in Sp in e St u dy d em on st rated th at occu p at ion (repet it ive h eavy
lift ing, driving) h ad lit tle e ect on disk degen erat ion .
II. Path ogen esis.
A. In ter vertebral disk (IVD) degen erat ion (Fig. 16.1).
1. Decreased n ut rit ion to th e IVD.
a. En d p late sclerosis.
b. Decreased vascularit y.

171

172 16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options

Fig. 16.1 Schem atic demonstrating the morphological changes associated with degeneration in the
intervertebral disk. Signal intensit y (magnetic resonance im aging) decreases as degeneration progresses with loss of disk height.

(1) O2 ten sion decreases.


(2) Lact ate in creases.
(3) pH decreases in th e cen ter of th e n ucleus pu lposus.
2. Decreased w ater con ten t .
a. Norm ally 88%; decreases to 60% by th e eigh th decad e.
3. In creased likelih ood of an n ular tears w ith aging.
a. Decreased p roteoglycan con ten t of th e n u cleu s p u lp osu s leads to greater
peripheral an n u lar loading an d less cen t ral n ucleu s pulposu s resist an ce.
b. An an nular tear m ay cause low back pain w ithout radiculopathy.
(1) This associat ion is st ill con t roversial.
c. Nociceptors are foun d on th e outer an n ulus an d posterior longit u din al
ligam en t .
(1) The posterolateral corn er is m ost su scept ible to a tear from exion /
rotat ion or torsion al st resses.
4. Hern iat ion .
a. Typ es of d isk h ern iat ion (Table 16.1).
b. Locat ion s.
(1) Most com m on at L4L5 an d L5S1, less com m on at h igh lum bar an d
th oracic region s.

16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options 173

Table 16.1

Morphology of disk herniations

Type

Findings

Protrusion

Broad-based disk bulge

Extrusion

Disk herniation through the posterior longitudinal ligam ent;


the fragm ent is larger than its base but still in continuit y

Sequestered

Complete displacem ent of the disk with no continuit y of the


fragm ent and the intact disk

Fig. 16.2 (a) Schematic demonstrating the anatomical orientation of the exiting and traversing
nerve root in relation to the intervertebral disk.
Note that the exiting nerve root can be a ected
only by a far lateral disk herniation. (b) Typically,
posterolateral disk herniations a ect the traversing nerve root. A magnetic resonance imaging
scan shows a posterolateral L5S1 disk herniation
impinging on the left S1 nerve root.

(2) Classically posterolateral w ith im pingem en t of th e t raversing n er ve


below (i.e., L4L5 h ern iated n ucleus pu lposus [HNP] a ect s th e
t raversing L5 n er ve root) (Fig. 16.2).
(3) Axillar y hern iat ion :
(a) Usually due to ceph alad an d m edial m igrat ion of th e disk
fragm en t .
(b) Medial ret ract ion becom es di cu lt an d dangerou s (Fig. 16.3).

174 16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options

Fig. 16.3 Illustrations and m agnetic resonance imaging dem onstrating various t ypes of lum bar
disk herniations. (a,b) Left paracentral L5S1 disk herniation. (c,d) Sequestered disk fragm ent that
m igrated inferiorly to the level of the S1 pedicle. (e,f) L5S1 axillary disk herniation.

(4) A sm all cen t ral disk h ern iat ion m ay cause back pain w ith out
radiculop athy or cauda equin a syn drom e.
(5) Ext rem e lateral or foram in al h ern iat ion :
(a) Im pinges upon th e exit ing n er ve root above th e disk level.
(b) More com m on in older p at ien t s.
(c) Typically fou n d at L3 an d L4 (Fig. 16.4).
(6) In t radu ral h ern iat ion is ext rem ely rare.
B. Ner ve root s.
1. An atom y.
a. Each lu m bar n er ve root exits below th e pedicle an d above th e d isk.
(1) For exam ple, th e L5 n er ve exit s below th e L5 pedicle an d above th e
L5S1 disk.
b. Th e dorsal root ganglion lies in th e in ter ver tebral foram en in ferior to th e
pedicle, w h ich m ay be th e m ain source of pain .
c. Each n er ve root h as th ree bran ch es.
(1) Ven t ral ram us for m otor fun ct ion

16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options 175
Fig. 16.4 An axial m agnetic resonance imaging scan demonstrating
a large far lateral disk herniation at
L5S1 causing impingem ent on the
right L5 nerve root.

(2) Sin uvertebral n er ve.


(a) In n er vates th e outer layer of th e posterior an n ulus brosus.
(b) An terior p ar t of th e an n u lu s brosu s h as sym p ath et ic
in n er vat ion , an d th e a eren t bers con n ect w ith th e
sin uver tebral n er ves.
(3) Dorsal ram us bran ch .
(a) In n er vates th e facet s an d posterior m uscles.
C. Bioch em ical p ath ology of disk h ern iat ion .
1. An nulus brosus an d n ucleus pu lposus cells produce th e ext racellular
m atrix.
a. Prim arily collagen an d proteoglycan s.
b. With aging an d disk degen erat ion , th e cells die (apoptosis), an d th e
m at rix con ten t is decreased .
c. Both an abolic an d cat abolic processes m ain t ain th e in tegrit y of th e
m at rix.
(1) Proin am m ator y cytokin es regulate th e cat abolic processes.
(a) Tum or n ecrosis factor alph a, in terleu kin -1, ph osph olipase A2,
p rostaglan din s.
(2) Grow th factors regu late th e an abolic processes.
(a) Bon e m orph ogen et ic protein (BMP).
2. Di usion th rough th e en d plates or n ut rit ion al path w ay is also altered by
degen erat ive ch anges.
3. An an n ular tear or HNP is in it ially associated w ith sign i can t in am m at ion .
a. Cytokin e leakage th rough th e an n u lar defect m ay cau se radicu lop athy.
b. Nucleus pulposus fragm en t s elicit in am m ator y an d n eurotoxic ch anges
w ith out sign i can t m ech an ical com pression .
(1) Rest , an t i-in am m ator y drugs, or epidural steroids frequen tly
alleviate th e sym ptom s by decreasing th e in am m ator y react ion .
4. Th e HNP fragm en t elicit s sign i can t in am m ator y react ion an d un dergoes
su bsequ en t resorpt ion .

176 16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options

III. Clin ical evalu at ion .


A. Histor y.
1. Sciat ica or radiculopathy.
a. Frequ en tly becom es greater th an back pain in large ext ru d ed or
sequ estered disk h ern iat ion s.
b. Typically resolves w ith t im e in m ost prot ruded disk h ern iat ion s.
c. Derm atom al dist ribut ion .
(1) Pain is classically w orse w ith sit t ing, cough ing, sn eezing, an d for w ard
exion .
(2) Pain is usu ally alleviated by lying an d rest .
B. Physical exam in at ion .
1. Obser vat ion of th e pat ien ts beh avior, pain respon se, spin e balan ce, gait ,
m u scle spasm , m u scle at rop hy is im p or tan t .
2. Bony an d soft t issue palpat ion :
a. Midlin e ten dern ess is frequ en t at th e involved level.
b. Sciat ic n otch an d ten dern ess along th e course of th e sciat ic n er ve m ay be
p resen t in radiculopathy.
c. Paraspin al m uscle spasm m ay be palpable.
3. Range of m ot ion :
a. Norm al range of m ot ion is ext rem ely variable am ong in divid u als an d
even ch anges from m orn ing to even ing.
(1) Pain reproduct ion at ext rem es of m ot ion is a h elpful sign .
(a) Pain fu l lu m bar exion suggests diskogen ic et iology.
(b) Pain fu l lu m bar exten sion suggest s facet disease.
b. Lateral ben ding m ay cause ipsilateral low er ext rem it y pain in pat ien ts
w ith posterolateral or lateral h ern iated disks.
(1) Lateral ben ding aw ay from th e sym ptom at ic lim b m ay aggravate pain
in pat ien ts w ith an axillar y h ern iated disk.
c. Pain fu l dysrhyth m ic range of m ot ion m ay in dicate m ech an ical in st abilit y,
p art icularly w h en st raigh ten ing from for w ard exion .
4. Neurological exam in at ion :
a. Motor, sen sor y, an d re ex d e cit s m ay be presen t along a sp eci c n er ve
root d ist ribu t ion .
b. Special test s:
(1) St raigh t leg raise.
(a) Elevat ion of a pain ful lim b cau ses radicular lim b pain .
i. Record th e degree of elevat ion th at reproduces pain .
(b) Dorsi exion of th e foot w h ile raising th e leg also st retch es th e
sciat ic n er ve an d cau ses p ain .
(2) Con t ralateral leg raise test .
(a) Posit ive if elevat ion of a n onpain ful lim b causes back an d lim b
pain on th e opposite side.
i. Usu ally im plies sequestered or large ext ruded h ern iated disk.
(3) Reverse st raigh t leg raise test (fem oral n er ve st retch test).
(a) Fem oral exten sion in a pron e posit ion st retch es th e fem oral
n er ve rep rodu cing pain in th e L3 or L4 dist ribu t ion .
5. Di eren t ial diagn osis of low back pain (Table 16.2):

16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options 177

Table 16.2

Di erential diagnosis of low back pain

Type

Di erential

Viscerogenic

Abdom inal and renal

Neoplastic

Prim ary and metastatic bone tumors

Neurogenic

Spinal cord tum ors or cysts

In amm atory
diseases

Ankylosing spondylitis, Reiters syndrom e, in am m atory bowel


diseases, and psoriatic arthritis (sacroiliitis)

Infectious

Diskitis, osteomyelitis, psoas abscess

Spondylogenic

Myofascial syndrom es
Iliolum bar syndrome, piriform is syndrom e, quadratus
lum borum syndrom e, and brositis (trigger point syndrom e)
Motion segm ent disorders
Disk disease, facet syndrom e, spinal stenosis
Bony problem s
Fractures, including osteoporotic compression fractures
Spondylolisthesis
Sacral lesions, coccyx pain
Psychogenic

6. Dist inguish ing spon dylogen ic causes of low back pain :


a. Diskogen ic.
(1) HNP.
(a) Leg pain , ten sion sign s, n eurological de cit s.
b. An n ular tears.
(1) Back pain an d referred pain to th e bu t tock (con t roversial).
(2) Midlin e ten dern ess, pain ful for w ard exion , back pain in creased w ith
st raigh t leg raising test .
c. Myofascial syn drom es.
(1) Ten dern ess on th e a ected m uscles rath er th an in th e m idlin e.
(2) Pain w ith act ive con t ract ion an d w ith passive st retch (con t ralateral
ben ding).
d. Posterior elem en t s.
(1) Spon dylolysis.
(a) Pain ful exten sion an d rot at ion tow ard opposite side.
(2) Facet syn drom e.
(a) Ten dern ess un ilaterally over th e join t .
(b) Pain fu l hyp erexten sion an d ben ding.
(3) Spin al sten osis.
(a) Neurogen ic clau dicat ion .
(b) Pain fu l exten sion of th e back.

178 16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options

7. Diagn ost ic st udies:


a. Plain X-rays.
(1) Detect spon dylolysis/spon dylolisth esis.
(2) Disk space n arrow ing.
(3) Scoliosis.
(4) Tum ors.
(5) In fect ion .
b. Magn et ic reson an ce im aging (MRI).
(1) Im aging m odalit y of ch oice for h ern iated disks an d for spin al sten osis.
(2) Use of gadolin ium con t rast in creases accuracy w h en evaluat ing
p ostoperat ive disk h ern iat ion s an d m ay be h elpfu l in evalu at ing for
t um or or in fect ion (Fig. 16.5).
(3) Gadolin iu m (on T1-w eigh ted im ages) en h an ces in vascular scar t issue
an d does n ot en h an ce in a recu rren t d isk h ern iat ion .
(4) Com puted tom ograph ic (CT) scan or CT m yelography:
(a) If MRI is con t rain dicated.
(b) CT m ay be bet ter in p at ien t s w ith degen erat ive scoliosis or in
pat ien t s w ith m et al im p lan t s.
c. Diskography.
(1) Perform ed in pat ien t s w ith suspected diskogen ic back pain w ithout
radicu lopathy.
(2) Reproduct ion of back pain w ith inject ion of dye in to th e suspected
disk an d eviden ce of an an n ular tear are con sidered posit ive n dings.
(a) Posit ive n dings m ust take in to con text th e pat ien ts sym ptom s
an d psych osocial stat u s (e.g., som at izat ion , ch ron ic p ain ).
(b) Con t roversial as th e accu racy also d ep en ds on th e p hysician
perform ing diskography, an d th e n eedle pun ct ure of th e disk m ay
accelerate d egen erat ion over t im e.

Fig. 16.5 Sagittal T1-weighted magnetic resonance imaging demonstrating enhancement of lesions following
administration of gadolinium contrast.
(From Chen C, Chen WL, Yen H. Candida
albicans lumbar spondylodiscitis in an
intravenous drug user: a case report.
BMC Res Notes 2013;6:529. Reproduced with permission.)

16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options 179

d. Bon e scan .
(1) Perform a bon e scan if su spicious for t um or or in fect ion .
IV. Con ser vat ive t reat m en t .
A. Proven m eth ods.
1. Pat ien t educat ion (back sch ool).
a. Decreased m ech an ical st ress an d exp ect at ion .
2. Cardiovascular t n ess program s.
3. Sm oking cessat ion .
4. Main ten an ce of ideal body w eigh t .
B. Unproven m eth ods.
1. Prolonged bed rest , m uscle rela xan t s, t ract ion , bracing, an d m an ipulat ion
2. Narcot ics an d t ran quilizers h ave n ot been sh ow n to im prove outcom es.
a. Th ey m ay be u sed for acu te sym ptom s (15 days).
3. Epidural steroids h ave n ot been proven to be h elpful.
a. Use in selected p at ien ts w ith p ersisten t leg p ain to h elp w ith
reh abilit at ion .
V. Operat ive m an agem en t .
A. In dicat ion s.
1. Failu re of con ser vat ive t reat m en t for at least 6 w eeks.
2. Progressive n eu rological de cit s.
3. Presen ce of n eurological n dings.
a. Radicu lar pain .
b. Posit ive ten sion sign or n eurological de cit s.
c. Posit ive im aging st u dy w ith clin ical correlat ion .
B. Su rgical tech n iqu es (Fig. 16.6 an d Fig. 16.7) (Table 16.3).
VI. SPORT.
A. Pat ien t populat ion s.
1. Clinical an d radiograph ic diagn osis of HNP.
a. Persisten t sym ptom s d esp ite 6 w eeks of n on op erat ive t reat m en t .
b. Ran dom ly assign ed to operat ive an d n on operat ive coh or t s.
B. Operat ive versu s n on operat ive t reat m en t ou tcom es.
1. In ten t-to-t reat an alysis: both operat ive an d non operat ive t reat m en t
dem on st rated sim ilar im provem en t of sym ptom s at 1 an d 2 years.
a. Su rgical t reat m en t w as associated w ith a faster recover y, bet ter p hysical
fu n ct ion , an d overall sat isfact ion .
2. As-t reated an alysis: pat ien t s t reated surgically dem on st rated greater
im provem en t in pain an d fu n ct ion after 2 years com pared w ith th ose
t reated n on operat ively.
C. Con t roversies.
1. High crossover rate.
a. Fort y- ve percent of patients in the nonoperative cohort underwent surgery.
b. For t y percen t of pat ien t s in th e surgical coh ort did n ot un dergo su rger y.
2. Non operat ive m an agem en t .
a. Not stan dardized.
b. Pat ien t s w ere required to h ave h ad a 6-w eek course of n on operat ive
m an agem en t for en rollm en t , w h ich likely a ected th e crossover rate.

180 16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options

Fig. 16.6 A t ypical L5S1 lam inotomy and diskectomy. (a) The interlam inar exposure starts with
removal of the ligam entum avum . (b) Additional removal of lam inar bone is perform ed until the
lateral portion of the nerve root is visualized. (c) The nerve root is gently retracted m edially, and the
herniated disk is rem oved with the aid of a pituitary rongeur.

Table 16.3

Various techniques of disk treatm ent

Surgical technique

Findings

Open diskectomy

Bet ter visualization of nerve


More m uscle dissection
Longer hospital stay
Potential for iatrogenic instabilit y

Microscopically assisted
diskectomy

Lim ited m uscle dissection


Improved visualization and lighting

Percutaneous diskectomy

Techniques include chem onucleolysis, percutaneous


diskectomy, and laser diskotomy
Inferior results when compared with m icroscopically
assisted diskectomy

Intradiskal electrotherm al
therapy

Intradiskal procedure for prim ary diskogenic back pain


Results dem onstrate equivocal results when compared
with placebo

3. In ten t-to-t reat versus as-t reated an alysis.


a. In ten t-to-t reat an alysis com p ared p at ien t s according to th eir assign ed
coh ort .
(1) Th is dem on st rated n o di eren ce in prim ar y outcom es bet w een
grou p s in p at ien ts w ith d isk h ern iat ion ; th at is, p at ien t s assign ed to
n on op erat ive t reat m en t w ere cou n ted as n on op erat ive p at ien t s if
th ey crossed over an d h ad surgical in ter ven t ion .
b. As-t reated an alysis com pared pat ien ts according to th e t reat m en t
u lt im ately received.
(1) Pat ien ts w h o un der w en t surger y dem on st rated im proved an d
su stain ed ou tcom es com p ared w ith th ose t reated n on operat ively.

16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options 181
Fig. 16.7 (a) A Wiltse paraspinal
approach for excision of a lateral
disk herniation. (b) Interm uscular
dissection is bet ween the multi dus and longissim us.

182 16 Lum bar Disk Disease: Pathogenesis and Treatm ent Options

Suggested Reading
Bat t i MC, Videm an T, Kaprio J, et al. Th e Tw in Spin e St u dy: con t ribu t ion s to a ch anging
view of disc degen erat ion . Spin e J 2009;9(1):4759
Bat t i MC, Videm an T. Lum bar d isc degen erat ion : epidem iology an d gen et ics. J Bon e Join t
Surg Am 2006;88(Su pp l 2):39
Lurie JD, Tosteson TD, Tosteson AN, et al. Su rgical versu s n on operat ive t reat m en t for lu m bar disc h ern iat ion : eigh t-year resu lt s for th e spin e p at ien t outcom es research t rial.
Spin e 2014;39(1):316
Mazan ec D, Okereke L. In terp ret ing th e Sp in e Pat ien t Ou tcom es Research Trial. Medical vs
su rgical t reat m en t of lu m bar disk h ern iat ion : im plicat ion s for fu t u re t rials. Cleve Clin
J Med 2007;74(8):577583
Wein stein JN, Lurie JD, Tosteson TD, et al. Surgical versus n on operat ive t reat m en t for lum bar disc h ern iat ion : fou r-year resu lt s for the Spin e Pat ien t Ou tcom es Research Trial
(SPORT). Spin e 2008;33(25):27892800
Wein stein JN, Tosteson TD, Lurie JD, et al. Surgical vs n on operat ive t reat m en t for lu m bar
disk h ern iat ion : th e Spin e Pat ien t Outcom es Research Trial (SPORT): a ran dom ized
t rial. JAMA 2006;296(20):24412450

17 Surgical Management of Lumbar


Degenerative Disk Disease
17.1 General Considerations
I. In t rodu ct ion .
A. Lifet im e in ciden ce of low back pain is est im ated to a ect 80% of th e gen eral
p op u lat ion .
1. Fourteen percent of new patient visits to physicians are related to low back pain.
2. Second only to respiratory infections as the m ost com m on cause of work absence.
B. On e h u n d red sixt y- ve lu m bar sp in e op erat ion s per 100,000 in dividu als occu r
each year in th e Un ited St ates.
C. Lu m bar fu sion for diskogen ic p ain an d lu m bar lam in ectom ies for radicu lar
sym ptom s are th e m ost com m on spin e su rgeries p erform ed .
D. Risk factors for low back p ain :
1. Prior h istor y of low back pain .
2. In creasing age.
3. Sm oking (n icot in e con sum pt ion ).
4. Medical com orbidit ies.
5. Low er socioecon om ic stat u s.
6. Psych ological dist ress (depression ).
II. Et iologies (Table 17.1).
A. Red ags in clin ical presen tat ion th at requ ire fur th er invest igat ion .
1. Histor y of sign i can t t raum a.
2. Histor y of previous m align an cy.
3. Age > 50 years.
4. System ic sym ptom s (fever, ch ills, an orexia, recen t w eigh t loss).
5. Severe progressive n eurological de cit .
a. Especially sadd le an esth esia or bow el/bladder dysfu n ct ion .
6. Ongoing in fect ion .
7. Histor y of im m un osuppression .
III. Diagn ost ic tools.
A. Est ablish ing a path oan atom ical diagn osis is th e key to successfu l surgical
outcom es (Table 17.2).
B. Arriving at a con clu sive diagn osis m ay be di cu lt; as m any as 85% of pat ien t s
are categorized as h aving idiop ath ic low back p ain .
C. Plain radiograph s:
1. Flexion -exten sion lm s.
D. May dem on st rate dyn am ic in stabilit y (spon dylolisth esis):
1. Obliqu e lm s.
E. Helpful in evalu at ing th e in tegrit y of th e pars in terart icularis in th e set t ing of
an isth m ic spon dylolisth esis:
1. Lu m bar spin e lm s are un n ecessar y for at least 4 w eeks in a pat ien t w ith
n ew -on set low back p ain w ith ou t any of th e p reviou sly m en t ion ed red ags.

183

184 17 Surgical Managem ent of Lum bar Degenerative Disk Disease

Table 17.1

Etiologies and di erential diagnosis for lower back pain

Type

Di erential

Idiopathic or nonspecif c (85%)


Degenerative disk disease

Diskogenic pain
Disk herniation
Degenerative scoliosis

Developm ental

Isthm ic spondylolisthesis
Idiopathic scoliosis

Congenital
Traumatic
Infectious

Osteomyelitis
Diskitis

In am m atory

Ankylosing spondylitis
Psoriatic spondylitis
Reiters syndrom e

Neoplastic
Metabolic

Osteoporosis
Pagets disease of bone

Referred

Dissecting aortic aneurysm


Renal vein throm bosis
Renal stones
Acute myocardial infarction
Pancreatitis
Duodenal ulcer
Pelvic disease

F. Com p u ted tom ograp hy (CT):


1. Allow s excellen t visualizat ion of th e bony an atom y of th e vertebral colu m n .
2. Not as sen sit ive as m agn et ic reson an ce im aging (MRI) for visualizat ion of
soft t issu e st ru ct u res.
3. CT m yelography is an excellen t im aging m odalit y for evaluat ing spin al
sten osis, bu t MRI is u sed becau se it is less invasive.
G. MRI:
1. Excellen t axial, coron al, an d sagit t al visualizat ion of th e soft t issues an d
n eu ral st ru ct u res both w ith in an d su rrou n ding th e vertebral colu m n .
2. Excellen t for th e evalu at ion of n eural com pression w ithin th e can al an d
foram en .
3. With disk degen erat ion , T2-w eigh ted MRI dem on st rates darken ing of th e
disks due to loss of w ater, but th is n ding does n ot predict th e developm en t
of back pain in asym ptom at ic pat ien ts.

17 Surgical Managem ent of Lum bar Degenerative Disk Disease 185

Table 17.2

Anatom ical sources of lum bar spine pain

Intervertebral disks

Primary pain generator in set ting of degenerative disk


disease; pain bers present in the outer third of the annulus
brosus
Biochem ical factors that can m ediate painful stim uli:
prostaglandins, lactic acid, substance P
During disk degeneration, nerve ingrowth has been
observed into deeper aspects of the annulus brosus and
even into the nucleus

Facet joints

Extensively innervated with pain bers.


Synovial folds of the joint lining also possess pain bers.
Proprioceptive nerve endings also present, which m ediate
protective m uscular re exes.

Musculoligam entous
structures

Both anterior and posterior longitudinal ligam ents (PLL)


possess sensory innervation. PLL has been found to have
bers containing substance P. Unencapsulated nerve bers
found in paraspinal m usculature respond to m etabolites
accumulated during prolonged m uscle contraction or
spasm .

Neural structures

Pain from m echanical nerve root compression is thought to


require the presence of in amm ation.
Dorsal root ganglion is sensitive to direct pressure and
vibratory forces.
Increase in genetic expression of neuropeptides (substance P)
in response to mechanical nerve root compression

H. Single-p h oton em ission CT (SPECT/CT):


1. Com bin at ion of SPECT (h igh sen sit ivit y an d speci cit y) an d CT (h igh
resolu t ion ).
2. Physiological im aging th at can detect in am m ator y ch anges in th e lum bar
sp in e.
3. SPECT im aging detects gam m a rays from radioisotopes injected in to th e
p at ien t .
4. Useful in detect ing facet join t ar th ropathy (Fig. 17.1).
5. Facet inject ion s (Fig. 17.2):
a. Rat ion alized by th e hypoth esis th at facet ar th rit is con t ribu tes to low back
p ain .
b. Th ere are few w ell-design ed st udies to evaluate e cacy; th us th e u se of
inject ion s to predict surgical outcom es for p at ien ts w ith low back pain is
n ot su pp orted .
I. Diskograp hy (Fig. 17.3):
1. Perform ed by th e in t rodu ct ion of a n eedle in to th e n ucleus pulposus an d
inject ion of con t rast to visualize in tern al ssures or tears.
2. Salin e m ay also be injected in to th e disk to reproduce pain .

186 17 Surgical Managem ent of Lum bar Degenerative Disk Disease

Fig. 17.1

Single-photon em ission computed tom ography (SPECT/CT).

3. Th e com bin at ion of pain w ith disk inject ion an d n dings of disk
d egen erat ion on CT-diskography in creases th e likelih ood th at a part icular
d isk is involved w ith th e pat ien ts pain .
a. Rem ain s con t roversial, esp ecially w ith ou t a con t rol.
4. Im por t an t n dings:
a. Re-creat ion of sim ilar pain w ith inject ion (con cordan ce).
b. Pain at low pressurizat ion .
(1) High pressurizat ion m ay result in a false posit ive.
c. Disk accept s > 2 m L of dye.
5. High ly con t roversial:
a. In 2009, Carragee et al rep or ted th at diskography w as associated w ith
accelerated d isk d egen erat ion , disk h ern iat ion , an d loss of disk h eigh t in
pat ien t s w ith out serious low er back pain .
b. Th e validit y of th is diagn ost ic in ter ven t ion h as n ot been proven .
(1) Th e lack of a gold st an dard diagn ost ic st udy for diskogen ic back pain
lim it s th e assessm en t of th e diagn ost ic validit y.
(2) Carragee et al repor ted th at n early 50% of pat ien t s w h o h ad su rger y
after a p osit ive diskograp hy reported sign i can t pain .
(a) Th us a posit ive diskography w as n ot h igh ly predict ive in
iden t ifying a disk lesion th at w as respon sible for th e pat ien ts
sym ptom s.
c. Diskography is associated w ith a variable false-posit ive rate in pat ien ts
w ith out low back pain .
(1) Pain -free pat ien t s10%.

17 Surgical Managem ent of Lum bar Degenerative Disk Disease 187

Fig. 17.2

A facet injection is perform ed in the lumbar spine.

(2) Ch ron ic pain (n ot in low er back)40%.


(3) Som at izat ion disorder75%.
d. In carefully selected pat ien ts w ith n orm al psych osom at ic st ates (n ot
involved in lit igat ion ), diskography m ay provide useful diagn ost ic
in form at ion in th e set t ing of n on sp eci c low er back p ain .
IV. Gen eral surgical in dicat ion s.
A. Mech an ical in st abilit y.
B. Neu rological d e cit s.
C. In dication s for pat ien t s w ith low back pain w ith ou t rad icu lar sym ptom s
1. Un rem it t ing back pain an d disabilit y for m ore th an 1 year.
2. Failu re of physical th erapy an d n on operat ive t reat m en t m odalit ies.
a. Non steroidal an t i-in am m ator y drugs (NSAIDs), h eat , ice, w eigh t loss,
act ivit y m odi cat ion .

188 17 Surgical Managem ent of Lum bar Degenerative Disk Disease

a
Fig. 17.3

b
(a,b) Contrast dye injection into the nucleus pulposus.

3. Absen ce of psych iat ric disorders an d com pen sat ion or ligat ion issues.
4. Isolated single-level disk degenerat ion on MRI w ith con cordan t pain on
diskography or single-level stat ic or dyn am ic in st abilit y.
V. Surgical procedures.
A. Gen eral prin ciples.
1. Low back pain m an agem en t largely focuses on spin al fusion .
2. Decom pression is in dicated in th e set t ing of leg pain an d n er ve root
com pression .
3. Mot ion preser vat ion procedure w ith lum bar tot al disk arth roplast y.
B. Sp in al fu sion p rin cip les.
1. Preven t s furth er segm en tal m ot ion .
a. More app ropriate for spin al in st abilit y.
C. Keys to at t ain ing a solid arth rodesis.
1. Met iculous preparat ion of th e graft site (decort icat ion ).
2. Supplem en tat ion w ith appropriate t ype an d am oun t of bon e graft .
3. Con siderat ion of lum bar spin e biom ech an ics.
a. Main tain ing or restoring th e n orm al lordosis in th e sagit t al align m en t of
th e lu m bar spin e.
4. Opt im izing system ic con dit ion s th at in uen ce bon e h ealing.
a. Nicot in e, cort icosteroids, NSAIDs, n u t rit ion , an d in fect ion .
b. Con cern for n ew or progressive degen erat ion of adjacen t levels to th e
fu sed segm en t s m an dates th at m in im u m n u m bers of levels be fu sed,
esp ecially in you nger in dividu als.
VI. Lum bar fusion tech n iques (Table 17.3).
A. Posterolateral (in tert ran sverse process) fusion (PLF).
1. Involves eith er a posterior or a posterolateral m uscle-split t ing approach .

17 Surgical Managem ent of Lum bar Degenerative Disk Disease 189

190 17 Surgical Managem ent of Lum bar Degenerative Disk Disease

2. Involves decort icat ion of t ran sverse processes an d placem en t of an


au togen ou s bon e graft along th e t ran sverse p rocesses.
3. Th e pseudar th rosis rate w ith ou t in st rum en t at ion is est im ated to be bet w een
25 an d 45%.
4. In st ru m en t at ion low ers th e pseu darth rosis rate (1525%).
5. Th ere is st ill som e preser ved m ot ion after th is procedure because of th e
in t act disk an teriorly.
a. If th e disk is th e m ain sou rce of p ain , pat ien t s m ay dem on st rate
p ersisten t back pain (con t roversial).
B. In terbody fu sion .
1. Prin ciples.
a. Resect ion of diseased in ter ver tebral disk:
(1) In appropriately selected pat ien ts w ith diskogen ic back pain ,
rem oving th e in ter vertebral disk sh ould resolve pat ien t sym ptom s.
b. Rigid in st rum en t at ion an d bon e graft s provide in it ial st abilit y to th e
an terior colu m n .
(1) Posterior xat ion w ith pedicle screw s provides addit ion al xat ion for
selected cases.
c. A solid in terbody fusion gen erally occurs at 6 m on th s to 1 year follow ing
su rger y.
2. Tech n iqu es.
a. Posterior lu m bar in terbody fu sion (PLIF) (Fig. 17.4 an d Fig. 17.5).
(1) Ext ract ion of th e disk th rough a posterior approach via a w ide
lam in ectom y w ith preser vat ion of th e facet join t .
(2) Th e approach can be w iden ed w ith th e rem oval of th e low er th ird of
th e in ferior facet an d m edial t w o-th irds of th e superior facet .
(3) Th is is follow ed by posterior in st rum en t at ion .

Fig. 17.4 Bony resection required in a (a) posterior lumbar interbody fusion and (b) transforaminal
lum bar interbody fusion.

17 Surgical Managem ent of Lum bar Degenerative Disk Disease 191

Fig. 17.5 Working zones of the (a) posterior lum bar interbody fusion and (b) transforam inal lum bar
interbody fusion in relation to the neurovascular structures.

b. Tran sforam in al lum bar in terbody fusion (TLIF) (Fig. 17.6 an d Fig. 17.7).
(1) Decreased/m in im al m an ipu lat ion of n eural elem en t s w h en com pared
w ith PLIF.
(2) A par t ial or com plete facetectom y is perform ed to en able access to
th e disk space.
(3) Can be perform ed bilaterally.
c. An terior lum bar in terbody fusion (ALIF) (Fig. 17.8 an d Fig. 17.9).
(1) In direct decom pression of th e exit ing roots w ith th e restorat ion of
disk space an d foram in al h eigh t .
(2) Lim ited decom pression of posterior elem en t s w h en com pared w ith
PLIF an d TLIF p roced u res.
(3) Fusion occurs readily w ith th is approach because of com pression on
th e graft .
(4) Can be u sed in a revision set t ing after a previous posterior surger y to
avoid dissect ion of scar t issue.
(5) Approach es:
(a) Open left ret roperiton eal approach .
(b) Op en t ran sp eriton eal app roach .
(c) Laparoscopic approach .
d. Lateral lu m bar in terbody fusion (Fig. 17.10).
(1) Lateral ret roperiton eal approach .
(2) Con sidered a varian t of ALIF.
(3) Can be u sed for th oracic an d lum bar in terbody fusion .
(4) Associated w ith a sign i can tly reduced risk of injur y to th e great
vessels.

192 17 Surgical Managem ent of Lum bar Degenerative Disk Disease

Fig. 17.6 Intraoperative photograph of the L4L5 interspace dem onstrating the dorsal root ganglion
of the L4 nerve root (exiting).

Fig. 17.7
material.

(ad) Rem oval of the disk material and placem ent of the interbody cage with bone graft

17 Surgical Managem ent of Lum bar Degenerative Disk Disease 193


Fig. 17.8 Postoperative lateral radiograph of an
anterior LT Cage (Medtronic) at L5S1.

Fig. 17.9

Anterior lum bar interbody fusion procedure.

194 17 Surgical Managem ent of Lum bar Degenerative Disk Disease


Fig. 17.10 Exposure for the lateral
lum bar interbody fusion.

(5) Th e disk space is reach ed th rough a t ran spsoas approach .


(a) Risk of inju r y to th e lum bar plexus.
(b) Th e gen itofem oral n er ve is m ost com m on ly inju red
(p ostop erat ive groin an d th igh p aresth esia).
(c) In t raoperat ive n eurom on itoring is crit ical during passage
th rough th e psoas.
e. Axial lu m bar in terbody fu sion (AxiaLIF).
(1) Min im ally invasive tech n ique th at u ses th e presacral space to create a
su rgical w orking plan e.
(2) Can on ly address L4 to S1 disk path ology.
(3) Risk of rectal injur y, sacral fract u re, an d pelvic h em atom a.
(4) Special im plan t s provide a xial com pression bet w een vertebral bodies.
(5) Lim ited eviden ce in th e pu blish ed literat ure h as dem on st rated
variable ou tcom es an d fu sion rates.
VII. Mot ion -preser ving procedures (tot al disk ar th roplast y).
A. Prin ciples.
B. Biom ech an ical st u dies h ave d em on st rated th at m ot ion -p reser vat ion devices
are associated w ith low er st resses on adjacen t segm en ts w h en com pared
w ith t radit ion al fusion tech n iques in an e or t to reduce adjacen t segm en t
degen erat ion .
C. In dication s:
1. In dicated for on e- or t w o-level diskogen ic back pain w ith out radiculopathy.

17 Surgical Managem ent of Lum bar Degenerative Disk Disease 195

D. Ou tcom es com p ared w ith lu m bar ar th rodesis:


1. Mid- an d long-term dat a are n ow available to com pare lum bar tot al disk
rep lacem en t (TDR) w ith fusion procedu res.
a. TDR h as dem on st rated com p arable safet y an d e cacy to lu m bar fu sion
p roced ures at 7 years.
b. Early experien ce w ith TDR h as dem on st rated sat isfactor y clin ical
outcom es w ith accept able com plicat ion (14.4%) an d reoperat ion (7.2%)
rates.
c. Superiorit y of TDR over lum bar fusion h as n ot been proven w ith regard
to adjacen t-level degen erat ion .
d. St udies h ave reported revision rates bet w een 7.7 an d 32.1% at 5 years (up
to 39.3% at 10 years), depen ding u pon th e device.
VIII. Con clusion s.
A. Low back pain is a m u lt ifactorial issue.
B. Carefu l pat ien t select ion is th e key to su ccessfu l clin ical ou tcom es in p at ien ts
w ith n on speci c low back pain .
1. Path ological n dings in im aging st u dies m ust be carefully assessed an d
correlated w ith th e pat ien ts h istor y an d physical exam n dings.
2. Psych osom at ic evalu at ion m ay play an im por t an t role in select ing pat ien t s
w h o un dergo surger y for low er back pain .
C. Non sp eci c low back pain rem ain s a con t roversial area w ith lim ited
u n derst an d ing of th e path oan atom y an d ben e ts of th e available t reat m en t
opt ion s.
D. Nu m erou s su rgical tech n iqu es exist for th e at t ain m en t of lu m bar arth rodesis.
E. Mot ion preser ving devices (TDR) h ave been dem on st rated to be a safe an d
e ect ive altern at ive to lu m bar fu sion su rger y. How ever, th e th eoret ical
advan t age of red u cing adjacen t-segm en t degen erat ion rem ain s u np roven .

Suggested Reading
Anderson PA, Sasso RC, Hipp J, Norvell DC, Raich A, Hashim oto R. Kinem atics of the cervical
adjacent segm ents after disc arthroplast y com pared w ith anterior discectom y and fusion: a system atic review and m eta-analysis. Spine 2012;37(22, Suppl):S85S95
Carragee EJ, Don AS, Hu r w it z EL, Cu ellar JM, Carrin o JA, Herzog R. 2009 ISSLS Prize Win n er: Does discograp hy cau se accelerated p rogression of degen erat ion ch anges in
the lum bar disc: a ten -year m atch ed coh ort st u dy [p u blish ed correct ion ap pears
in Spin e 2010 15;35(14):1414; Carrin o, Joh n corrected to Carrin o, Joh n A]. Spin e
2009;34(21):23382345
Carragee EJ, Lin coln T, Parm ar VS, Alam in T. A gold st an dard evalu at ion of th e d iscogen ic pain diagn osis as determ in ed by p rovocat ive discography. Sp in e 2006;31(18):
21152123
Carragee EJ, Tan n er CM, Kh u ran a S, et al. Th e rates of false-posit ive lu m bar discography in select pat ien t s w ith ou t low back sym ptom s. Spin e 2000;25(11):13731380,
discussion 1381

196 17 Surgical Managem ent of Lum bar Degenerative Disk Disease


Jacobs W, Van der Gaag NA, Tuschel A, et al. Total disc replacem ent for chronic back pain in
the presence of disc degeneration. Cochrane Database Syst Rev 2012;9:CD008326
Phillips FM, Slosar PJ, You ssef JA, An dersson G, Papath eofan is F. Lum bar spin e fusion for
ch ron ic low back p ain du e to degen erat ive disc disease: a system at ic review. Sp in e
2013;38(7):E409E422
Rodgers W B, Gerber EJ, Pat terson J. In t raop erat ive an d early p ostop erat ive com plicat ion s in ext rem e lateral in terbody fu sion : an an alysis of 600 cases. Sp in e 2011;36(1):
2632
Siep e CJ, Heider F, Wiech ert K, Hit zl W, Ish ak B, Mayer MH. Mid- to long-term resu lt s of
tot al lu m bar disc rep lacem en t: a prosp ect ive an alysis w ith 5- to 10-year follow -u p .
Spin e J 2014;14(8):14171431
Wei J, Song Y, Sun L, Lv C. Com p arison of art i cial tot al disc rep lacem en t versu s fu sion for
lum bar degen erat ive disc disease: a m et a-an alysis of ran dom ized con t rolled t rials. In t
Or th op 2013;37(7):13151325

18 Lumbar Spinal Stenosis

18.1 General Considerations


I. In t rodu ct ion .
A. De n it ion : n arrow ing of th e spin al can al (cen t ral sten osis), lateral recess (lateral
recess sten osis), or foram en (foram in al sten osis) w ith n eural im pingem en t th at
p rod u ces sym ptom s of n eurogen ic claudicat ion or radiculopathy.
B. Degen erat ive sp in al sten osis evid en ced on im aging st u dies is sign i can t on ly if
clin ically sym ptom at ic.
C. More com m on after th e fth d ecade.
D. Men m ore a ected th an w om en .
E. Associated w ith disk degen erat ion .
II. Classi cat ion .
A. Congenital: usually developm ental and prim arily central canal stenosis (Fig. 18.1).

Fig. 18.1 (a,b) Measurem ents of the bony


anatomy and spinal canal.

197

198 18 Lum bar Spinal Stenosis

1. Ch aracterist ics.
a. Earlier clin ical p resen t at ion (fou r th an d fth decade).
b. Mult ilevel involvem en t .
c. Few er degen erat ive ch anges on im aging.
d. Subtle an atom ical ch anges th at m ay com press th e th ecal sac.
2. Radiograph ic n dings.
a. Sm aller cross-sect ion al spin al can al area.
b. Sh or ter an terior-posterior (AP) pedicle length .
c. Th e m idlin e, axial AP can al diam eter, m ediallateral vertebral body
w idth , an d sagit t al AP can al diam eters are sm aller.
d. Sm aller AP pedicle length to ver tebral body rat io.
e. No d i eren ce in th e AP vertebral body diam eter, ver tebral body h eigh t ,
can al w idth , or pedicle w idth .
B. Acqu ired (m ost com m on in th e sixth decad e).
1. Degen erat ive sten osis.
a. Cen t ral sten osis.
(1) En largem en t of th e in ferior art icular process, ligam en t um avum ,
an d in ter vertebral disk prot ru sion or h ern iat ion .
b. Lateral sten osis.
(1) En largem en t of th e superior art icular process an d ligam en t u m
avu m .
c. Foram in al stenosis.
(1) Narrow ing of th e foram en secon dar y to far lateral disk h ern iat ion an d
p ars hyper t rophy in isth m ic sp on dylolisth esis.
2. Degen erat ive spon dylolisth esis.
a. For exam ple, at th e L4L5 level, th e L5 n er ve is en t rap p ed bet w een
th e in ferior art icular process of L4 an d th e posterior aspect of th e body
of L5.
3. Com bin ed.
a. Disk h ern iat ion , su p erim posed on a degen erat ive or congen itally sten ot ic
can al.
4. Iat rogen ic.
a. Postlam in ectom y, postfu sion , p ost disk su rger y.
5. Post t raum at ic.
a. Secon dar y to ret rop u lsion of bon e in a bu rst fract u re an d fract u re
dislocat ion .
6. Miscellan eous.
a. Pagets d isease, u orosis.
b. Dw ar sm (ach on droplast ic).
III. Path ogen esis.
A. Variat ion s of th e spin al can al m ay predispose to spin al sten osis.
1. Th ree t ypes of spin al can al.
a. Rou n d can al.
b. Oval can al.
c. Trefoil canal (15%).
(1) Napoleon h at sh ape.
(2) A t refoil can al predisposes to lateral recess sten osis.

18 Lum bar Spinal Stenosis 199

B. Disk degen erat ion :


1. Aging versu s degen erat ion .
2. Ch anges in th e collagen , proteoglycan s, an d w ater con ten t .
C. Facet join t involvem en t:
1. Follow s disk degen erat ion .
2. Join t cart ilage loss, hypert rophy, osteophytes, an d su blu xat ion .
D. Th ree-join t com plex:
1. Tw o posterior facet join ts an d th e disk are all involved in th e path ogen esis.
2. Degen erat ive ch anges of th e th ree-join t com plex secon dar y to repeated
rotat ion al an d com pression inju ries.
3. In ter ver tebral disks develop circum feren t ial an d radial tears w ith a loss of
d isk h eigh t .
4. Posterior join t s un dergo syn ovit is, cart ilage dest ruct ion , an d osteophyte
form at ion .
a. Resu lts in cap su lar laxit y, ligam en t u m avu m hyp er t rop hy or bu ckling,
an d join t in st abilit y or su blu xat ion .
5. In stabilit y:
a. Degen erat ive sp on dylolisth esis.
b. Ret rolisth esis.
c. Degen erat ive scoliosis.
d . Rot ator y sublu xat ion .
E. L4 or L5 n er ves are m ore t ypically a ected:
1. Greater com pressive an d sh ear st resses.
2. Pedicles of th e low er lum bar spin e h ave convex in ferior borders as com pared
w ith th e con cave in ferior border in th e upper lum bar spin e.
3. Disk degen erat ion is m ost com m on at L4L5 an d L5S1.
F. Neu ral com pression :
1. An atom ical site of com pression :
a. Cau da equ in a an d th ecal sac (cen t ral can al).
b. Traversing n er ve root (lateral recess).
c. Dorsal root ganglion (in ter ver tebral foram en ).
d. Spin al n er ve (ext raforam in al).
2. Th e cau da equin a is com pressed cen t rally from th e an teroposterior direct ion
at th e in ter vertebral disk level..
a. Bu lging disk an teriorly.
b. Ligam en t um avum an d facet join t s posteriorly.
3. The nerve root can be com pressed at m ultiple anatom ical locations (Fig. 18.2).
a. En t ran ce zon e.
(1) Posterolateral h ern iated disk.
(2) Hypert roph ic superior art icu lar process.
b. Middle zon e.
(1) Pars in terart icularis (spon dylolysis).
4. Exit zon e (foram en ) (Fig. 18.3):
a. An atom y.
(1) Boun ded by vertebral body an d disk an teriorly, pedicles superiorly
an d in feriorly, an d pars, ligam en t u m avu m , an d t ip of su p erior
art icu lar process p osteriorly.

200 18 Lum bar Spinal Stenosis

Fig. 18.2

Various anatom ical locations for nerve root compression.

18 Lum bar Spinal Stenosis 201

Fig. 18.3 (a) Anatom ical location of the nerve root within the neuroforam en. (b) Neuroforaminal
stenosis with nerve root impingement secondary to facet hypertrophy and osteophytic compression
secondary to the superior articular process.

(2) Laterally h ern iated disk or an n ulu s.


(3) Superior facet sublu xat ion m ay com press th e n er ve again st th e
pedicle, body, or bulging an n ulus.
b. Ext raforam in al com pression .
(1) Ext rem e lateral or ext raforam in al h ern iated disk.
(2) Also kn ow n as far-out syn drom e.
(a) Th e exit ing n er ve root is com pressed bet w een th e t ran sverse
processes of L5 an d th e sacral ala in spon dylolisth esis (L5S1).
(3) Tran sverse process fract ure or bone graft an terior to th e t ran sverse
processes.
5. Dim en sion s of sten osis (Fig. 18.4):
a. Cen t ral.
(1) Absolute sten osis: m idsagit t al lu m bar diam eter < 10 m m .
(2) Relat ive sten osis: 10 to 13.5 m m .
b. Lateral recess.
(1) Less th an 3 to 4 m m .
c. Foram en .
(1) Foram in al h eigh t < 15 m m .
(2) Posterior disk h eigh t < 3 m m (80% likelih ood of n er ve root
com pression ).
6. Pathophysiology of radiculopathy:
a. Com bin at ion of com p ression an d in am m at ion .
(1) Com pression alon e m ay n ot cause pain .
(2) In am m ator y m ediators:
(a) Ph osph olipase A2.
(b) Neu rop ept ides.
b. Dyn am ic in stabilit y.
(1) Spin al can al an d foram en .

202 18 Lum bar Spinal Stenosis

Fig. 18.4 (a) Cross-sectional view of the norm al anatomy of the neural structures within the spinal
canal. (b) Computed tom ographic myelography demonstrating central stenosis with signi cant ligamentum avum hypertrophy.

c. Ven ous st asis.


d. Arterial isch em ia.
e. Nu t rit ion al de cit .
(1) Abn orm al cerebrospin al ow.
f. Percen t con st rict ion of cau da equ in a.
(1) Tw en t y- ve percen t: n o de cit s.
(2) Fift y percen t or greater: m otor de cit s an d com plete loss of
som atosen sor y evoked p oten t ials (SSEPs).
IV. Clin ical n dings.
A. Pain.
1. Variable:
a. Mon oradicu lop athy.
b. Bilateral n eu rogen ic claudicat ion .
c. At ypical leg pain .
d . Cauda equ in a sym ptom s.
2. Typically in th e low er back, but tock, an d low er ext rem it ies.
3. Pain is w orse w ith st an ding an d w alking.
4. Relieved by rest , exed post ure, an d sit t ing.
5. Th e h istor y is th e key in m aking th e diagn osis of spin al sten osis.
B. Claudicat ion -like sym ptom s in 50%.
1. On e m ust rule out vascular claudicat ion .
2. In vascular claudicat ion :
a. Relief after rest is m ore p rom pt .
b. Flexion of th e spin e does n ot relieve sym ptom s.
(1) For exam ple, bicycling an d w alking uph ill m ay n ot cause n eurogen ic
claudicat ion because th e spin e is exed.
3. Vascu lar an d n eurogen ic claudicat ion m ay coexist .

18 Lum bar Spinal Stenosis 203

C. Physical exam in at ion .


1. Paucit y of object ive n dings.
2. Th e sciat ic ten sion sign is often n egat ive.
3. Neurological de cit s m ay or m ay n ot be presen t .
4. Th e m ost im port an t sign is pain ful an d lim ited exten sion .
5. Th orough abdom in al an d vascular exam in at ion sh ould be don e rou t in ely.
a. Vascu lar ch anges m ay d em on st rate low er ext rem it y u lcer form at ion , h air
loss, edem a, an d skin m ot tling.
D. Diagn ost ic tools.
1. Plain radiograph s.
a. Disk sp ace n arrow ing or degen erat ive disk disease.
b. En d plate osteophytes an d sclerosis.
c. Facet en largem en t or osteophyte form at ion .
d . Narrow ed n euroforam in al can al.
e. Loss of lu m bar lordosis.
2. Magn et ic reson an ce im aging (Fig. 18.5).
a. Best m odalit y for evalu at ing lu m bar sp in al sten osis.
b. Excellen t for soft t issue det ails, but bony m argin s are bet ter
d em on st rated by CT scan s.
E. Congen it al sten osis.
1. Lum bar spin al sten osis t ypically a ect s in dividuals over 60 years of age, but
you nger p at ien t s w ith congen it al sten osis presen t in th e fou rth an d fth
d ecades.
2. Th e presen t ing sym ptom s are som ew h at di eren t in th at m any su er w ith
low back pain (LBP) w ith or w ith out n eurogen ic claudicat ion .

Fig. 18.5 Magnetic resonance imaging demonstrating spinal stenosis secondary to a herniated
lumbar disk. (From Imhof H, ed. Spinal Imaging
[Direct Diagnosis in Radiology]. Stut tgart, Germany: Georg Thieme Verlag; 2008: Fig. 3.35.
Reproduced with permission.)

204 18 Lum bar Spinal Stenosis

3. LBP is t ypically w orse w ith st an ding an d w alking as com pared w ith


diskogen ic LBP, w h ich is t ypically w orse w ith sit t ing.
4. Th e spin al can al is n arrow at m ult iple levels w ith sh ort pedicles. Th e sagit tal
can al to ver tebra rat io is < 0.4 (Singh et al).
5. Th e pat ien t s w ith congen it al sten osis presen t ing w ith n eurogen ic LBP
are frequ en tly m isdiagn osed as diskogen ic LBP an d are given in ap p ropriate
t reat m en t .
6. Treat m en t is in it ially con ser vat ive as for oth er sten ot ic pat ien ts, but if th ere
is n o respon se, m u lt ilevel lam in ectom y is recom m en ded rath er th an fusion .
V. Di eren t ial diagn oses.
A. Traum a (sprain s, st rain s, com pression fract ures).
B. In fect ion s (ver tebral osteom yelit is).
C. In am m ator y disord ers.
D. Congen ital defect s (ach on d rop lasia).
E. Met abolic (osteoporosis, Pagets disease).
F. Degen erat ive (d isk h ern iat ion , facet syn drom e).
G. Neop lasm s (in t raspin al, bon e t u m ors, an d m et ast asis).
H. Neu rological d isorders (p eriph eral n eu ropath ies).
I. Circu lator y (abdom in al aort ic an eu r ysm , vascu lar clau dicat ion ).
J. Myofascial syn drom es.
K. Psych on eu rot ic p roblem s.
VI. Treat m en t .
A. Con ser vat ive.
1. Non steroidal an t i-in am m ator y drugs.
2. Lum bosacral corset s.
3. Flexion exercises.
4. Epidural or foram in al inject ion .
B. Su rger y.
1. In dicat ion s.
a. Cau da equ in a syn drom e.
b. Progressive m otor w eakn ess.
c. Lim b pain th at is un respon sive to con ser vat ive t reat m en t an d if
sym ptom s sign i can tly a ect qu alit y of life.
2. Su rgical tech n iques (Fig. 18.6).
a. Decom p ression : th e key is adequ ate decom p ression w h ile preser ving
stabilit y of th e m ot ion segm en t by u n d ercu t t ing th e facet join t an d
preser ving th e pars in terart icularis. For m ult ilevel decom pression, care
m u st be t aken to p reser ve th e p ars in terart icu laris in th e u p p er lu m bar
spin e, becau se th e pars is m ore m edial. Th erefore, lam in ectom y is m ore
lateral at th e facet s, w h ich is th e locat ion for lateral recess sten osis, an d
m ore m edial or n arrow er at th e p ars.
(1) Cen t ral sten osis:
(a) Lam in ectom y (Fig. 18.7).
(2) Lateral recess:
(a) Rem ove an overgrow n superior facet by un dercu t t ing.
(3) Foram inal decom pression: foram inal decom pression requires m ore
facet rem oval, but ever y e ort m ust be m ade to preserve the facet joint

18 Lum bar Spinal Stenosis 205

Fig. 18.6

Steps for a lum bar laminectomy.

as m uch as possible by undercut ting an d using special instrum en ts,


such as a cur ved foram in otom y rongeur or rasp (Fig. 18.8).
(a) If th e n er ve root is t igh t after lam in ectom y an d facet
u n dercu t t ing, addit ion al sites m ay be respon sible for n er ve
com pression .
i. Su perior facet again st p osterior vertebral body.
ii. Su perior facet again st p edicle.
iii. Su perior facet or pedicle again st bulging lateral an n ulu s.
iv. In ferior facet an d ver tebral body (degen erat ive
sp on dylolisth esis).
v. Tran sverse processes of L5 an d sacral ala (far-out syn drom e).
b. Lu m bar fu sion :
(1) Approach es.
(a) Posterior: posterolateral fusion , posterior lum bar in terbody
fu sion , an d t ran sforam in al lu m bar in terbody fu sion .
(b) An terior: an terior lu m bar in terbody fu sion , ext rem e lateral
lu m bar in terbody fu sion .
(2) Fusion is recom m en ded w h en there is sten osis in conjun ct ion w ith
th e follow ing con dit ion s:
(a) Un st able degen erat ive scoliosis or kyph osis.
i. Progressive cur ves.
ii. Cu r ves > 20.
iii. Loss of sagit t al balan ce an d lum bar lordosis.

206 18 Lum bar Spinal Stenosis

18 Lum bar Spinal Stenosis 207

Fig. 18.7 (a) Standard midline incision m ade for a lum bar lam inectomy. (b) The spinous processes
have been rem oved. The shaded area depicts the lam ina needed to be rem oved to accomplish a central decompression. (c) A curet te is used to rem ove the ligam entum avum from the undersurface of
the lamina to gain access to the spinal canal. (d) A Kerrison rongeur is used to rem ove the lam ina in a
piecem eal fashion. (e) The Kerrison rongeur is then used to undercut and rem ove bone and the ligamentum avum within the lateral recess. (f) A Kerrison rongeur is gently placed into the neuroforamen
to undercut the superior-articular process to create space for the exiting nerve root. (g ) The shaded
areas represent the area of bone and soft tissue needed to be rem oved to ensure a thorough central
and lateral recess decompression.

iv. Lateral listh esis.


v. Flexible cur ves.
vi. Pat ien ts w ith radicu lar sym ptom s on th e con cave side of th e
cur ve.
(b) Degen erat ive sp on dylolisth esis.
(c) Iat rogen ic in stabilit y.
i. Greater th an 50% facet resect ion bilaterally.
ii. Rem oval of on e com plete facet com plex.
(d) Recurren t sam e-level or adjacen t-level decom pression s.
(3) Mot ion preser vat ion .
(4) In terspin ous spacers.
(a) Approved by th e Food an d Drug Adm in ist rat ion .
(b) Th e m ech an ism of act ion is local dist ract ion an d kyph osis th at
th eoret ically reduces soft t issu e in folding in to th e cen t ral can al
(ligam en t u m avu m ).
(c) In dicat ion s:
i. Neurogen ic clau dicat ion p ain th at is relieved w h en th e spin e
is exed .
ii. Spon dylolisth esis up to grade 1.5 (Table 18.1).

208 18 Lum bar Spinal Stenosis

Table 18.1

Comparison of vascular and neurogenic claudication

Findings

Vascular

Neurogenic

Claudication distance

Fixed

Variable

Relief after cessation of activit y

Im m ediate

Delayed

Relief of pain

Standing

Flexion or sit ting

Uphill walking

Pain

No pain

Bicycling

Pain

No pain

Location and radiation

Distal to proxim al

Proxim al to distal

Atrophy

Rare

Occasional

Back pain

Uncom m on

Com m on

Skin

Loss of hair

Norm al

Fig. 18.8 (a.b) Magnetic resonance im aging following a foram inal decompression in the lum bar
spine.

C. Spin e p at ien t ou tcom es research t rials (SPORT).


1. Pat ien t popu lat ion s.
a. Spin al sten osis w ith ou t sp on dylolisth esis.
b. Min im um 12 w eeks of sym ptom s.
c. Ran dom ly assign ed to operat ive an d n on operat ive coh ort s.
2. Operat ive versus n on operat ive outcom es in pat ien ts w ith spin al sten osis.
a. Th e m ajorit y of pat ien t s (89%) u n der w en t decom p ression su rger y
w ith out fu sion .

18 Lum bar Spinal Stenosis 209

b. As-t reated an alysis dem on st rated th at pat ien t s t reated surgically


reported greater im provem en t in pain an d fu n ct ion th rough 2 years
com pared w ith th ose t reated n on operat ively.
3. Con t roversies.
a. High crossover rate:
(1) For t y-n in e percen t of pat ien t s in th e n on operat ive coh ort un der w en t
su rger y.
(2) Th irt y-t w o percen t of pat ien t s in th e surgical coh ort did n ot un dergo
su rger y.
b. Non operat ive m an agem en t w as n ot st an dardized.
(1) In cluded physical th erapy, ch iropract ic, inject ion s.
c. In ten t-to-t reat versus as-t reated an alysis:
(1) Th e in ten t-to-t reat an alysis com pared pat ien t s according to th eir
assign ed coh or t .
(a) Th is dem on st rated n o di eren ce in prim ar y outcom es bet w een
grou p s in p at ien ts w ith d isk h ern iat ion .
(b) In th is an alysis, if a p at ien t w as assign ed to th e n on op erat ive
t reat m en t arm , but w en t on to h ave surger y, th at pat ien t w as
cou n ted as a n on operat ive pat ien t .
(2) Th e as-t reated an alysis com pared pat ien ts according to th e t reat m en t
u lt im ately received regardless of th eir assign ed t reat m en t arm .
(3) Pat ien t s w h o un der w en t surger y dem on st rated im proved an d
su st ain ed ou tcom es com p ared w ith th ose t reated n on operat ively at
4 years.

Suggested Reading
Krein er DS, Sh a er WO, Baisden JL, et al; North Am erican Spin e Societ y. An eviden ce-based
clin ical gu idelin e for th e diagn osis an d t reat m en t of degen erat ive lu m bar sp in al sten osis (u pdate). Sp in e J 2013;13(7):734743
Pearson A, Lu rie J, Tosteson T, Zhao W, Abdu W, Wein stein JN. W h o sh ou ld h ave surger y for spin al sten osis? Treat m en t e ect predictors in SPORT. Sp in e 2012;37(21):
17911802
Skidm ore G, Ackerm an SJ, Bergin C, et al. Cost-e ect iven ess of th e X-STOP in terspin ou s
spacer for lu m bar spin al sten osis. Spin e 2011;36(5):E345E356
Wein stein JN, Tosteson TD, Lurie JD, et al; SPORT Invest igators. Surgical versus n on su rgical
therapy for lu m bar sp in al sten osis. N Engl J Med 2008;358(8):794810
Wein stein JN, Tosteson TD, Lurie JD, et al. Surgical versus n on operat ive t reat m en t for
lum bar spin al sten osis four-year resu lt s of th e Spin e Pat ien t Ou tcom es Research Trial.
Sp in e 2010;35(14):13291338

19 Lumbar Spondylolisthesis

19.1 General Considerations

210

I. In t rodu ct ion .
A. De n it ion s.
1. Spondylolisthesisd isp lacem en t of on e vertebra on an oth er.
2. Spondylolysislyt ic defect in th e p ars in terar t icu laris.
a. Bon e bet w een th e su p erior an d in ferior art icu lar p rocesses.
II. Gen eral con siderat ion s.
A. Hereditar y factors.
1. Th e fam ilial ten den cy is st ronger in dysplast ic t ype (94%) com pared w ith
isth m ic t ype (32%).
2. More com m on in w h ite m ales (6.4%), less com m on in black fem ales (1.1%).
a. High er in ciden ce am ong Eskim o p opu lat ion (u p to 45%).
3. Associat ion w ith spin a bi da of th e sacrum an d dysplast ic ch anges of th e
bony elem en t s in h igh dysplast ic t ypes.
B. Epidem iology.
1. More com m on in m en th an in w om en .
2. High er in ciden ce am ong football players, fem ale gym n ast s, an d soldiers
carr ying heavy backpacks.
3. Low er in ciden ce am ong n on am bulator y pat ien t s.
III. Biom ech an ics.
A. Abrupt ch ange in st i n ess across th e lu m bosacral jun ct ion .
1. Th e pars in terar t icularis is st rong but su scept ible to fat igue fract u res.
a. Esp ecially w ith exten sion inju ries.
2. Sh ear st ress at th e pars can be in creased by exion con t ract ures of the h ip
an d secon dar y hyp erlordosis.
a. Pin cerlike e ect on L5 p ars from th e su perior art icu lar process of S1 an d
in ferior art icu lar process of L4.
IV. Classi cat ion s.
A. Modi ed Wilt se (Table 19.1).
B. Sp in al d eform it y st u dy grou p L5S1 classi cat ion (Fig. 19.1).
1. Based on th e sacropelvic m orph ology, slip grade, an d spin al balan ce.
2. Type 1 an d 2 spon dylolisth esis carr y a low er risk of progression com pared
w ith t ype 3.
3. Reduct ion is likely w arran ted for t ypes 5 an d 6.
C. Classi cat ion of sp on dylolisth esis (March et t iBar tolozzi).
1. Developm en t al.
a. De cien t bony h ook, an atom ical abn orm alit ies of th e L5 p edicle, p ars,
in ferior facet s.
(1) High dysplasia.
(a) Severe bony an om alies w ith sign i can t kyph osis.

19 Lum bar Spondylolisthesis 211

Table 19.1

Wiltse spondylolisthesis classi cation

Type

Name

Description

A ected level

Congenital/dysplastic

Dysplasia of the sacrum, fth


lum bar arch, facets, or both

L5S1

II

Isthm ic/spondylolytic

Pars interarticularis defect

L5S1

III

Degenerative

Degeneration of the facets


and disk

L4L5 (90%)
L3L4 or L5S1 (10%)

IV

Traum atic

Fracture of the neural


arch excluding the pars
interarticularis

L5S1

Pathological

Pathological lesion or
generalized m etabolic
disturbance

Any level

VI

Iatrogenic

Iatrogenic disruption of the


facet, ligament, disk, or bone

Any level

Fig. 19.1

Spinal deformit y study group L5S1 classi cation for spondylolisthesis.

212 19 Lum bar Spondylolisthesis

(b) Com m on du ring 7 to 20 years of age.


(c) Com pen sator y lum bar hyperlordosis.
(2) Low dysplasia.
(a) Slow er progression .
(b) Frequ en tly asym ptom at ic.
(c) Disk degen erat ion aggravates th e m ot ion segm en t in st abilit y.
(3) Acquired.
(a) Traum at ic (acute vs. ch ron ic st ress fract ures).
(b) Post su rgical.
(c) Pathological.
(d) Degen erat ive.
(e) Speci c en t it ies (m odi ed Wilt se classi cat ion ).
2. Congenital or dysplast ic (14%).
a. Ep idem iology.
(1) Displacem en t occurs early.
(a) Typically during th e adolescen t grow th spurt .
(b) Tw o:on e fem ale:m ale rat io.
(c) Gen et ic com pon en t .
i. In creased risk am ong all a ected rst-degree relat ives.
b. Et iology.
(1) Congen ital or dysplast ic abn orm alit y of th e L5S1 facet join t:
(a) Preven t s proper art iculat ion .
(b) Displacem en t is early but lim ited based on th e in t act posterior
n eu ral arch .
i. In creased rate of n eu rological sym ptom s (2535%).
(2) Th e pars in terart icu laris is in tact bu t poorly developed or elongated.
c. Clin ical n dings.
(1) Pain radiat ing in to low er ext rem it ies.
(a) Lit tle or n o back pain .
(2) Cauda equin a.
d . Treat m en t .
(3) Most congen it al spon dylolisth esis pat ien t s w ith progression of th e
slip requ ire decom p ression an d ar th rodesis.
3. Isth m ic spon dylolisth esis.
a. Ep idem iology.
(1) Most com m on spondylolytic disorder am ong children and young adults.
(a) Com m on from 7 to 20 years.
(b) On set usually coin cides w ith adolescen t spurt , an d progression
occu rs bet w een 10 an d 15 years of age.
(2) Most com m on at L5 over S1 vertebrae (95%).
(3) Most often asym ptom at ic.
(a) Low back pain an d radiculopathy (L5 n er ve root) m ay develop.
b. Clin ical n dings.
(1) Rest ricted for w ard exion of th e h ips an d back.
(2) Tigh t h am st rings.
(3) Flat but tock (ver t ical sacrum ).

19 Lum bar Spondylolisthesis 213

(4) Lum bosacral kyph osis.


(5) Com pen sator y lordosis.
(6) An terior prot rusion of the pelvis.
(7) Pelvic w addle gait .
c. Roen tgen ograph ic n dings (Fig. 19.2).
(1) Defect at th e pars in terar t icularis:
(a) Seen at th e n eck of th e Scot t ie dog project ion on oblique view.
(2) Trapezoidal L5 ver tebral body:
(a) Roun ded sacral dom e.
i. On an an terop osterior (AP) view th is appears as th e reverse
Napoleons h at sign .
(3) Com puted tom ographic scan dem onstrates the pars defects and stenosis.
(a) Single-photon em ission com puted tom ography (SPECT) can detect
m etabolic act ivit y in th e region of th e pars in terarticularis defect .
(4) Magn et ic reson an ce im aging (MRI) is th e st udy of ch oice for assessing
sp in al sten osis.
(a) May dem on st rate w ide can al sign .
i. Suggest ive of a bilateral pars d efect .
(5) Radiograph ic m easurem en t s:
(a) Meyerding classi cat ion .
i. Grade I: 0 to 25% slip.
ii. Grade II: 26 to 50% slip .
iii. Grade III: 51 to 75% slip.
iv. Grade IV: 76 to 100% slip.
v. Grade V: spon dyloptosis or > 100% slip.

Fig. 19.2 An L4L5 spondylolisthesis with neuroforaminal impingement of the L4 nerve root
within the foram en.

214 19 Lum bar Spondylolisthesis

(b) Slip angle (Fig. 19.3).


i. Th e angle of kyph osis is m easu red as th e angle bet w een
th e superior en d plate of L5 an d a lin e perpen dicu lar to th e
posterior bord er of th e sacru m .
ii. Most sen sit ive in dicator of p oten t ial in stabilit y.
iii. Correct ion of th e slip angle is th e m ost im por tan t goal of
su rgical redu ct ion .
iv. Correct ion of th e slip is n ot im por tan t in ach ieving clin ical
su ccess.
v. In h igh -grade spon dylolisth esis, an in terbody m ay h elp
ach ieve redu ct ion .
(c) Lum bar in dex.
i. Measurem en t of th e w edging of th e an terior L5 vertebral body
Rat io of th e p osterior an d an terior h eigh t of th e slipp ed
vertebra.
d. Treat m en t
(1) Act ivit y m odi cat ion (n on operat ive).
(a) Back an d abdom in al st rength en ing exercise.
(b) Ham st ring st retch ing.
(c) Brace if persisten t pain despite act ivit y m odi cat ion .
(d) A posit ive bon e scan or SPECT scan im plies th e poten t ial for
osseous h ealing via im m obilizat ion .

Fig. 19.3

Measurem ent of slip angle.

19 Lum bar Spondylolisthesis 215

(2) Operat ive.


(a) Goals of surger y.
i. Pain reduct ion .
ii. Preven t ion of fu r th er slip page.
iii. Restorat ion of n orm al post ure.
iv. Preven t ion of n eurological de cit s.
(b) Su rgical tech n iqu es.
i. Direct pars repair.
ii. Posterolateral fusion w ith or w ith out decom pression .
Possible slip redu ct ion .
Possible in st ru m en t at ion .
iii. Possible in terbody fu sion (an terior lum bar in terbody fusion ,
p osterior lum bar interbody fu sion , t ran sforam in al lu m bar
in terbody fu sion ) (Fig. 19.4).
(c) Pseu darth rosis.
i. Fu sion rate decreased in sm okers (57%) versu s non sm okers
(95%).
ii. Com m on in in sit u fusion s w ith out in st ru m en tat ion .
In creased st ress across fu sion m ass.
Di cu lt y in exp osing L5 t ran sverse process.
(d) Slip progression .
i. Occu rs in 33% of cases regardless of th e presen ce of a solid
fu sion (u n in st ru m en ted).
ii. In creased risk of p rogression .
High -grad e slip s.
Gill lam in ectom y.
No p ostop erat ive im m obilizat ion .
(e) High -grade slip reduct ion .
i. May cause L5 n er ve root n eu rapraxia.
ii. Fu ll correct ion is n ot n eeded.
iii. Correct ion of th e kyph osis is m ost im port an t .
iv. Reduct ion im proves th e fusion rate.
D. Degen erat ive sp on dylolisth esis.
1. Epidem iology.
a. Most often occu rs at th e L4L5 level.
b. Five t im es m ore com m on in w om en .
c. Sym ptom s usually appear after age 40.
2. Clinical n dings.
a. Low back pain w ith bilateral low er ext rem it y radiat ion .
(1) Fift y percen t of pat ien t s h ave radiculopathy, m ost com m on ly in th e
L5 n er ve root dist ribu t ion .
b. St i n ess is n ot a com m on n ding.
(1) Most pat ien t s are hyper exible.
c. Associated com plain t s of sten ot ic sym ptom s.
(1) Proxim al m uscle w eakn ess.

216 19 Lum bar Spondylolisthesis

b
a

Fig. 19.4 Images demonstrating the minimally invasive


transforaminal lumbar interbody fusion and percutaneous
pedicel screw placement. (a) Intraoperative anteroposterior
(AP) uoroscopic image demonstrating placement of the
guidewires along the medial wall of the pedicle. (b) Intraoperative image demonstrating removal of the ligamentum
avum and coagulation of the epidural veins overlying the
disk space via the tubular retractor system. (c) Intraoperative bulls-eye view uoroscopic image demonstrating the
advancement of guidewires for percutaneous pedicle screw
placement. (d) Intraoperative lateral uoroscopic image
demonstrating pedicle screw placement in the L4 and L5
pedicles. (e) Postoperative lateral radiograph demonstrating pedicle screw placement in the L4 and L5 pedicles with
posterior instrumentation.

19 Lum bar Spondylolisthesis 217

(2) Neurogen ic claudicat ion .


(a) Sh opping car t sign .
i. Relief w ith for w ard exion .
3. Radiograph ic n dings.
a. Plain radiograp h s.
(1) A st an ding lateral radiograph is m ore sen sit ive th an a n on -w eigh tbearing view.
(2) Flexion exten sion view s:
(a) Greater th an 4 m m of m ot ion is con sidered in dicat ive of dyn am ic
in stabilit y.
(b) Greater th an 10 of m ot ion .
b. CT m yelogram .
(1) Determ in es am oun t of spin al sten osis.
(2) Evaluates degree of osteopen ia.
(3) Det ailed view of facet hypert rophy.
(4) Th e t raversing n er ve root is com pressed by th e superior art icu lar
p rocess of th e in ferior vertebrae.
c. MRI.
(1) Gold stan dard for evaluat ion of disk, ligam en ts, an d n eural st ru ct ures.
(2) Provides in form at ion regarding n eurological com pression .
(3) Delin eates syn ovial cyst s an d hyper t roph ic ligam en t um avu m .
4. Treat m en t .
a. Non operat ive.
(1) Short-term bed rest (12 days).
(2) Non steroidal an t i-in am m ator y drugs.
(3) Oral steroids.
(a) Best reser ved for acute exacerbat ion s of leg pain .
(4) Physical th erapy.
(a) Range of m ot ion .
(b) Aerobic con dit ion ing.
b. Operat ive (Fig. 19.5).
(1) In dicat ion s.
(a) Persisten t or recurren t severe leg pain .
(b) Progressive n eu rological de cit .
(2) Treat m en t opt ion s (Table 19.2).
5. Spine pat ien t outcom es research t rials (SPORT).
a. Pat ien t p op u lat ion s.
(1) Pat ien t s w ith degen erat ive spon dylolisth esis an d spin al sten osis.
(2) Persisten t sym ptom s (e.g., radicular leg pain , n eurological
claudicat ion ) for 12 w eeks.
(3) Assign ed ran dom ly to operat ive an d n on operat ive cohort s.
b. Operat ive versu s n on operat ive t reat m en t ou tcom es.
(1) Surger y con sisted of st an dard lum bar decom pression w ith or w ith ou t
single-level fu sion .
(a) Iliac crest bon e graft w ith or w ith out posterior pedicle screw
xat ion .

218 19 Lum bar Spondylolisthesis

d
Fig. 19.5 Im ages of an 18-year-old m an with a high-grade L5S1 isthmic spondylolisthesis and bilateral L5 radiculopathy. (a) Anteroposterior radiograph showing that the L5 transverse processes overlie
the sacrum due to the severe slip. (b) Lateral radiograph showing the grade 3 slip. (c) Magnetic resonance im aging scan shows t ypical changes at L5S1 rounding of the sacral dome. (d,e) Postoperative
radiographs dem onstrating the placement of interbody cages to increase the fusion rate with supplem entary pedicle screw xation.

(2) Th e su rgical coh ort dem on st rated greater im provem en ts in pain an d


fu n ct ion after 2 years com pared w ith th ose t reated n on op erat ively in
th e as-t reated an alysis.
c. Con t roversies.
(1) High crossover rate:
(a) For t y-n in e percen t of pat ien t s in th e n on operat ive coh ort
un der w en t su rger y.
(b) Th ir t y-six percen t of p at ien t s in th e su rgical coh ort did n ot
un dergo surger y.

19 Lum bar Spondylolisthesis 219

Table 19.2

Surgical options for adult spondylolisthesis

Procedure

Advantages

Disadvantages

Complications

Lam inectomy

Rapid pain relief


Avoids m orbidit y
of a fusion

Does not address


instabilit y

Slip progression
(2550%)

Lam inectomy
with
posterolateral
fusion

Decreased slip
progression if
fusion obtained

Possible failure of
fusion

Increased rate of
pseudarthrosis as
compared with
noninterbody
techniques

Instrum ented
fusion with
interbody graft

Increased fusion
rates
Partial reduction
of deform it y
Allows for m ore
aggressive
decompression

Improves slip
angle
Longer operative
tim es

Instrum ent
placem ent
Increased
infection rate
Implant migration
or failure

(2) Non operat ive m an agem en t w as n ot st an dardized.


(3) Surgical procedures w ere n ot stan dardized.
(a) Decom pression alon e.
(b) Decom p ression an d fu sion .
i. Autograft w ith iliac crest bon e graft (ICBG).
ii. Fu sion w ith or w ith ou t posterior in st rum en t at ion .
iii. Bon e m orph ogen et ic protein w as n ot used.
(4) In ten t-to-t reat versus as-t reated analysis:
(a) In ten t-to-t reat an alysis com pared pat ien ts according to th eir
assign ed coh ort .
i. Th is dem on st rated n o di eren ce in p rim ar y outcom es
bet w een groups in pat ien t s w ith spon dylolisth esis.
ii. Pat ien ts assign ed to n on op erat ive t reat m en t w ere cou n ted
as n on op erat ive p at ien ts even if th ey crossed over an d h ad
su rgical in ter ven t ion .
(b) As-t reated an alysis com p ared p at ien t s accord ing to th e t reat m en t
u lt im ately received.
(c) Pat ien ts w h o un der w en t surger y dem on st rated im proved an d
su stain ed ou tcom es com p ared w ith th ose t reated n on op erat ively
for 4 years.
E. Traum at ic spon dylolisth esis.
1. Extrem ely rare injuries.
2. A posterior fract ure m ay be part of a larger injur y.
a. Be su sp iciou s for a fract u re or dislocat ion of th e sp in e.

220 19 Lum bar Spondylolisthesis

F. Path ological sp on dylolisth esis.


1. Gen eralized bon e disease.
a. Osteop orosis an d osteom alacia.
(1) In st abilit y resu lt s from con t iguous st ress fract ures h ealing in an
elongated pat tern .
b. Pagets disease an d osteogen esis im perfect a.
c. Prim ar y or secon dar y n eoplasm .

Suggested Reading
Blum en th al C, Curran J, Ben zel EC, et al. Radiograph ic p redictors of delayed in stabilit y
follow ing decom p ression w ith ou t fu sion for degen erat ive grad e I lu m bar sp on dylolisthesis. J Neurosu rg Spin e 2013;18(4):340346
Longo UG, Loppin i M, Rom eo G, Ma ulli N, Den aro V. Eviden ce-based surgical m an agem en t of spon dylolisth esis: redu ct ion or ar th rod esis in sit u . J Bon e Join t Su rg Am
2014;96(1):5358
Pou ssa M, Rem es V, Lam berg T, et al. Treat m en t of severe spon dylolisth esis in adolescen ce
w ith reduct ion or fu sion in sit u: long-term clin ical, radiologic, an d fu nct ion al ou tcom e. Spin e 2006;31(5):583590, discussion 591592
Wat ters WC III, Bon o CM, Gilber t TJ, et al; North Am erican Sp in e Societ y. An evid en ce-based
clin ical gu id elin e for th e diagn osis an d t reat m en t of degen erat ive lu m bar sp on dylolisthesis. Spin e J 2009;9(7):609614
Wein stein JN, Lu rie JD, Tosteson TD, et al. Su rgical versu s n on su rgical t reat m en t for lu m bar degen erat ive spon dylolisth esis. N Engl J Med 2007;356(22):22572270
Wein stein JN, Lu rie JD, Tosteson TD, et al. Surgical com pared w ith n on operat ive t reatm en t for lum bar degen erat ive spon dylolisth esis. fou r-year resu lt s in th e Sp in e Pat ien t
Ou tcom es Research Trial (SPORT) ran dom ized an d obser vat ion al coh ort s. J Bon e Join t
Surg Am 2009;91(6):12951304

20 Adult Spinal Deformity

20.1 General Considerations


I. In t rodu ct ion .
A. Adult scoliosis is m ore rigid th an adolescen t spin al deform it y (ASD) an d is m ore
likely to be sym ptom at ic.
B. Th e cur ve m ay progress, especially if th e cu r ve is > 50 (Fig. 20.1).
1. Th e cur ve m ay progress 1 to 2 per year.
II. Risk factors for lu m bar cu r ve progression :
A. Lateral an d rotator y listh esis.
B. Large apical rot at ion .
III. Sp in al sten osis, disk disease, an d osteopen ia are associated p ath ologies.
A. Asym m et rical loss of disk h eigh t an d vertebra m ay con t ribute to th e in crease in
Cobb angle.
IV. Adu lt scoliosis is m ore likely to be sym ptom at ic, w ith p ain an d disabilit y.

a
Fig. 20.1

b
(a,b) Cobb angle m easurem ent.

221

222 20 Adult Spinal Deform it y

A. Pain often origin ates on th e convexit y of th e cur ve due to m uscle fat igue. Th is is
follow ed by facet degen erat ion on th e con cave side.
B. Th ere is in creased in ciden ce of low back pain if th e lum bar cur ve is > 45.
C. It is n ecessar y to ru le ou t oth er sou rces of pain , su ch as abdom in al an eu r ysm ,
ren al ston es, an d t um ors, as w ell as disk disease an d spin al sten osis.
D. Pain , in th e absen ce of a p rogressive cu r ve, is rarely an in dicat ion for su rger y.
E. Sciat ica m ay result from n er ve root com pression in th e con cavit y of th e cur ve.
V. Respirator y com prom ise m ay occur, resu lt ing in dyspn ea, pu lm on ar y hyperten sion ,
an d cor p u lm on ale.
VI. Adult s often h ave oth er m edical com orbidit ies th at m ake th e surger y m ore risky.
VII. Sacropelvic radiograph ic param eters (Table 20.1) (Fig. 20.2).
VIII. Classi cat ion :
A. Scoliosis Research Societ y (SRS)Sch w ab Adult Spin al Deform it y Classi cat ion
(Sch w ab et al).
1. Uses radiograph ic param eters an d pat ien t-reported fun ct ion al assessm en t
scores.
a. Radiograph ic p aram eters w ere correlated w ith fu n ct ion al ou tcom es.
2. Cur ve t ype involves th e assessm en t of coron al deform it y w ith added sagit tal
d eform it y m odi ers (Fig. 20.3).
a. Cu r ve Type T: th oracic m ajor cur ve > 30 (apical T9 or h igh er).
b. Cu r ve Type L: th oracolum bar or lum bar m ajor cur ve > 30 (ap ical T10 or
low er).

Table 20.1

Sacropelvic radiographic parameters

Radiographic
parameter

Measurement

Note

Pelvic incidence
(PI = PT + SS)

Angle between the straight line


from the femoral head to the
midpoint of the sacral plate and a
perpendicular line to the sacral plate

Will not change position


after skeletal m aturit y
(m orphological parameter)

Pelvic tilt (PT)

Angle bet ween the straight line


from the femoral head to the
midpoint of the sacral plate and a
vertical line from the femoral head

Changes with position and


increases with age due
to compensatory forces
(positional param etera )

Sacral slope (SS)

Angle bet ween the sacral plate


and the horizontal axis

Changes with position


(positional param etera )

Sagit tal vertical


axis

A plum b line is drawn in the


sagit tal axis from the C7 vertebral
body, and the distance from the
posterosuperior sacral end plate
to the plum b line is m easured

Measurem ent of global


alignm ent.
If plum b line is posterior to
the S1 vertebral body, it is
negative (norm al). If anterior,
it is referred to as positive.

If one positional param eter changes, it a ects all other param eters.

20 Adult Spinal Deform it y 223

a
Fig. 20.2

b
(a,b) Sacropelvic radiographic param eters.

Fig. 20.3 The SRSSchwab adult spinal deform it y classi cation: assessm ent and clinical correlations
based on a prospective operative and nonoperative cohort. (Neurosurgery 2013;73(4):559568.)

224 20 Adult Spinal Deform it y

c. Cu r ve Type D: double m ajor cu r ves > 30.


d. Cur ve Type N: n o m ajor coron al deform it y.
3. Sagit t al m odi ers (th ree t ypes).
a. All are correlated w ith p ain an d disabilit y an d are im p ort an t for
p reoperat ive p lan n ing an d determ in at ion of operat ive m an agem en t .
b. Pelvic in ciden ce (PI) LL.
c. Pelvic t ilt (PT) (pelvic ret roversion ).
d. Sagit t al vert ical axis (SVA).
IX. Evalu at ion :
A. Careful h istor y an d exam in at ion , in cluding previous evaluat ion s for scoliosis:
1. Assessm en t of kyph osis, lordosis, rib h um p, an d cur ve exibilit y.
2. Neurological exam in at ion .
B. X-rays: 36 in stan ding an terop osterior an d lateral to m easu re m agn it u de of th e
cur vat ures an d obtain radiograph ic param eters as already de n ed:
1. It is im port an t to m ake sure th at th e pat ien t is n ot exing th e kn ees, w h ich
w ill cause un derest im at ion of sagit t al im balan ce.
2. Pat ien t s w ith spin al sten osis an d deform it y m ay ex for w ard to relieve
spin al sten osis sym ptom s. It is im p or t an t to assess both st ru ct u ral atback an d fun ct ion al or exible kyph osis to avoid overest im at ing sagit t al
im balan ce.
C. Radicu lar p ain or sym ptom s of sp in al sten osis w arran t m agn et ic reson an ce
im aging to assess for n eural com pression .
X. Treat m en t:
A. Goals of t reat m en t in clude im provem en t of fun ct ion al im provem en t an d pain
an d restorat ion of coron al an d sagit t al align m en t .
B. Con ser vat ive t reat m en t is in dicated for n onp rogressive cu r ves causing localized
back pain . Th e t reat m en t plan in corporates th e gen eral prin ciples of t reat ing
back pain , in cluding a brief period of rest , n on steroidal an t i-in am m ator y
drugs, st retch ing, an exercise program , an d n er ve blocks.
C. Radiograp h ic param eters, as determ in ed by th e SRSSch w ab Classi cat ion ,
sh ou ld gu ide su rgical p lan n ing.
1. Goal param eters in clude the follow ing:
a. LL = PI 9.
b. PT < 20.
c. SVA < 50 m m .
XI. Tech n iques:
A. Operat ive m an agem en t is likely w arran ted w ith sym ptom at ic pat ien t s an d
sh ou ld be gu ided by th e target rad iograp h ic param eters as already st ated .
B. Relat ively exible th oracic cu r ves or balan ced dou ble m ajor cu r ves requ ire
posterior fu sion an d in st ru m en t at ion .
C. Rigid an d severe un balan ced thoracic cur ves (> 80 cur ves) m ay require an terior
release an d fusion follow ed by posterior fu sion an d in st rum en t at ion .
D. Relat ively exible th oracolu m bar or lu m bar cu r ves can be t reated by an terior
fu sion w ith in st ru m en t at ion (if th ere is n o kyp h osis an d th e cu r ve is lim ited to
T10 to L4).
E. Severe an d rigid th oracolum bar or lu m bar cu r ves > 75, redu n dan t statem en t ,
an d associated kyp h osis m ay requ ire an terior release an d fu sion follow ed by
posterior fu sion an d in st ru m en t at ion .

20 Adult Spinal Deform it y 225

F. Degen erat ive scoliosis w ith radicu lop athy requ ires posterior lam in ectom y
an d fu sion w ith t ran spedicu lar in st ru m en t at ion of th e lu m bar sp in e w ith or
w ith ou t an terior fusion .
XII. Com plicat ion s:
A. High er th an adolescen t spin e, especially pu lm on ar y problem s.
B. Pseu darth rosis is less for com bin ed an terior an d posterior app roach th an for
p osterior fu sion alon e.
C. Flat-back syn drom e (loss of lu m bar lordosis) m ay resu lt if th e posterior
su rgical tech n iqu es p rod u ce a d ist ract ive force or if th e an terior tech n iqu e
p rodu ces sign i can t com pression force along th e lum bar spin e. Segm en tal
in st ru m en tat ion an d p reser vat ion of th e lu m bar lordosis an d sagit tal balan ce
are crit ical.
D. Proxim al ju n ct ion al kyp h osis (PJK) (Fig. 20.4):
1. Postoperat ive adjacen t-segm en t path ology th at is de n ed as a kyph osis of
> 10 of th e ceph alad ver tebrae above a previously in st rum en ted segm en t:
a. If severe en ough , m ay w arran t a revision p rocedu re.

Fig. 20.4

Proximal junctional kyphosis.

226 20 Adult Spinal Deform it y

2. Risk factors:
a. In creased age.
b. Fusion to sacrum .
c. Circum ferent ial fusion .
d. Th oracoplast y.
e. Up p er in st ru m en ted vertebrae at T1T3.
3. Prevalen ce of 17 to 39%, m ostly at 2 years.
4. Th ere is m oderate eviden ce suggest ing th at PJK does h ave deleteriou s e ect s
on fun ct ion al outcom es.
E. In fect ion :
1. In ciden ce of 0.5 to 8%.
2. More com m on w ith posterior surger y.
F. Neu rological com plicat ion s:
1. In ciden ce of 1 to 5%.
2. Most com m on w ith com bin ed posterior an d an terior su rger y.
G. Pu lm on ar y em bolism :
1. In ciden ce of 1 to 20%.

Suggested Reading
Kim HJ, Len ke LG, Sh a rey CI, Van Alst yn e EM, Skelly AC. Proxim al ju n ct ion al kyp h osis
as a dist inct form of adjacen t segm en t path ology after spin al deform it y surger y: a
system at ic review. Sp in e 2012;37(22, Su p pl):S144S164
Klin eberg E, Gu pt a M, McCar thy I, Host in R. Detect ion of p seu dar th rosis in ad u lt sp in al d eform it y: Th e u se of h ealth -related qu alit y-of-life ou tcom es to pred ict pseu dar th rosis.
J Spin al Disord Tech 2013
Sch w ab FJ, Blon del B, Bess S, et al; In tern at ion al Spin e St u dy Grou p (ISSG). Rad iograph ical
spin op elvic p aram eters an d d isabilit y in th e set t ing of adu lt spin al deform it y: a p rospect ive m u lt icen ter an alysis. Spin e 2013;38(13):E803E812
Sch w ab F, Ungar B, Blon del B, et al. Scoliosis Research Societ y-Sch w ab adu lt sp in al deform it y classi cat ion : a validat ion st udy. Spin e 2012;37(12):10771082
Terran J, Schw ab F, Sha rey CI, et al; International Spine Study Group. The SRS-Schw ab adult
spinal deform it y classi cation: assessm ent and clinical correlations based on a prospective operative and nonoperative coh ort. Neurosurger y 2013;73(4):559568

21 Pediatric Spinal Deformity

21.1 General Considerations


I. Classi cat ion (Table 21.1).

21.2 Idiopathic Adolescent Scoliosis


I. Et iology.
A. Neurom uscu lar.
1. Ch anges in th e m uscle ber t ypes an d m u scle spin dles h ave been
dem on st rated.
2. In creased calm odulin level, w h ich is respon sible for th e regulat ion of m uscle
con t ract ion , an d decreased m elaton in levels (calm odulin an t agon ist) h ave
been dem on st rated in pat ien t s w ith idiopath ic adolescen t scoliosis (IAS).
B. Horm on al.
C. Con n ect ive t issu e.
1. Elast ic an d collagen bers are th e prim ar y elem en ts th at suppor t th e spin e.
2. Abn orm alit ies of th e collagen /proteoglycan in th e in ter ver tebral disks h ave
also been reported .
D. Gen et ic: 5:1 fem ale prep on deran ce (> 10 cur ves), fam ilial (20 t im es greater
likelih ood in fam ilies) w ith m on ozygot ic t w in con cordan ce rate of 73%, gen et ic
(sex-lin ked t rait w ith in com plete pen et ran ce an d variable expressivit y).
E. Melaton in or seroton in abn orm alit ies.
II. An atom ical ch aracterist ics.
A. Lateral cur vat ure or deform it y in th e coron al plan e.
B. Decreased th oracic kyp h osis or th oracic hypokyph osis (deform it y in th e sagit t al
p lan e):
1. Earlier accelerated spin al grow th as com pared w ith n orm al in dividu als m ay
be related.
C. Ver tebral rot at ion : th e sp in ou s process rot ates tow ard th e con cavit y (deform it y
in th e axial plan e) an d cau ses rib h um p.
D. Pat tern s of th oracic scoliosis:
1. King classi cat ion (Table 21.2): h elp s determ in e fu sion levels for su rger y
(n ot all cur ves t in to th is classi cat ion ).
2. Len ke classi cat ion : n ew er, m ore exten sive, classi es th e cur ves based on
cu r ve t ype, coron al lum bar m odi er, an d th oracic sagit t al pro le (Fig. 21.1).
a. Fou r series of plain lm sp in e radiograph s are u sed: u prigh t
posteroan terior, lateral, supin e righ t-ben ding, an d su pin e left-ben ding.
b. Cur ves can be classi ed in to six t ypes:
(1) Type 1: Main th oracic (MT).
(2) Type 2: Dou ble th oracic (DT).
(3) Type 3: Dou ble m ajor (DM).
(4) Type 4: Triple m ajor (TM).

227

228 21 Pediatric Spinal Deform it y

Table 21.1

Classi cation of pediatric spinal deform it y

Classif cation

Type

Subtypes

Nonstructural

Postural
Sciatic
In am m atory
Compensatory

Structural

Idiopathic

Infantile (< 3 years)


Juvenile (310 years)
Adolescent (10 years through
maturit y)

Neuromuscular
Neuropathic
Myopathic

Cerebral palsy
Syringomyelia
Poliomyelitis
Spinal m uscular atrophy
Friedreichs ataxia
Arthrogryposis
Muscular dystrophy
Myotonia dystrophica

Congenital

Diastem atomyelia, spina


bi da, hem ivertebra, wedge
vertebra, unsegmented
bar with contralateral
hem ivertebra, block vertebra

Neuro brom atosis


Mesenchym al disorders

Marfans syndrom e
EhlersDanlos syndrom e

Rheum atoid disease


Traum a
Extraspinal contracture
Osteochondral dystrophies
Infection
Metabolic disorders
Related to lum bosacral joint
Tum ors

Burns
Thoracic surgery

21 Pediatric Spinal Deform it y 229

Table 21.2

King classi cation system

Type

King classif cation

Notes

Double m ajor right thoracic


and left lum bar

Lum bar curve is larger than


the thoracic curve

Right thoracic and


compensatory left lum bar

II

Thoracic curve is larger


than the lum bar curve

Right thoracic

III

Left lum bar curve does not


cross the m idline

Right thoracolum bar

IV

Double thoracic

Fig. 21.1 Lenke classi cation. (From Lenke LG, Bet z RR, Harm s J, et al. Adolescent idiopathic scoliosis:
a new classi cation to determ ine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83-A:1169
1181. Reproduced with perm ission.)

230 21 Pediatric Spinal Deform it y

(5) Type 5: Th oracolum bar/lum bar (TL/L).


(6) Type 6: Th oracolum bar/lum barm ain th oracic (TL/L-MT).
c. Th e m ajor cur ve is th e largest cu r ve.
d. Min or cur ves are th en evaluated for st ruct ural criteria.
(1) St ruct ural cu r ve: coron al plan e rigidit y > 25 up on side-ben ding or
kyph osis > 20 on sagit t al radiograph s.
e. Spin al ar th rodesis sh ou ld in clu de on ly th e m ajor cu r ve an d th e st ru ct u ral
m in or cu r ves.
f. A lu m bar coron al m odi er is determ in ed.
(1) A cen t ral sacral ver t ical lin e (CSVL) is draw n vert ically from th e
m idp oin t of S1.
(a) Modi er A: th e CSVL t raverses bet w een th e pedicles of th e apical
vertebrae.
(b) Mod i er B: th e CSVL lies bet w een th e m edial border of th e
con cave pedicle an d th e lateral edge of th e apical ver tebral body.
(c) Modi er C: th e CSVL is n ot adjacen t to th e lateral border of th e
ap ical ver tebral body.
g. Th e last com ponent involves assessm en t of the sagit tal thoracic align m ent.
(1) Th e Cobb angle from T5 to T12 is m easured.
(2) If th e Cobb angle is +10 to +40, a n orm al m odi er is assign ed.
(3) A m in u s sign in dicates a Cobb angle < 10 (hypokyp h ot ic cur ve).
(4) A plus sign in dicates a Cobb angle > 40 (hyperkyph ot ic).
h . For t y-t w o di eren t t ypes of cu r ves are p ossible becau se t yp e 5 an d 6
cur ves are associated w ith a lum bar coron al m odi er of C.
3. Isolated lum bar or th oracolum bar cur ves.
III. Nat u ral h istor y an d p rogn osis.
A. Prevalen ce: 25/1,000 (2.5%) exh ibit > 10 cur ves an d (0.4%) 4/1,000 exh ibit
> 20 cu r ves (Table 21.3).
IV. Diagn osis.
A. Screening: gen erally occu rs in sch ool ch ildren aged 10 to 14:
1. Leads to a subst an t ial n um ber of referrals.
2. On e-th ird of all referrals h ave scoliosis to som e degree.
3. Genet ic test ing is available to determ in e th e risk of cu r ve progression in
p atien ts w ith AIS:
a. ScoliScore (Tran sgen om ic, In c.).
(1) Th ough t to determ in e th e risk of cu r ve progression past 40.
(2) Sh ould be used as an adjun ct to clin ical exam in at ion an d
rad iograp h ic n dings.
(3) Th ere is m ixed eviden ce regarding th e e cacy of th is gen et ic test .
B. Histor y: age, gen der, on set of m en arch e, p ain , fam ily h istor y.
1. Pain occurs in up to 30% of pat ien t s w ith AIS.
2. Peak grow th occurs in girls at age 11 to 12 an d in boys at age 13 to 14.
C. Physical exam in at ion :
1. Obser vat ion .
a. Asym m et r y of sh ou ld er level, breast s, w aist , or pelvis.
b. Prot ru ding scapula or ribs.
c. Loss of th oracic lordosis.

21 Pediatric Spinal Deform it y 231

Table 21.3

Factors contributing to curve progression

Curve
m agnitude

The greater the angulation and rotation, the greater the tendency
for progression. For example, a 20 curve has a 20% likelihood of
progression, and a 40 curve has a 60% likelihood of progression.

Age

Younger age is a more important prognostic factor than gender


or fam ily history. Ninet y percent of spinal growth has occurred at
pubert y; however, this age has the highest risk of progression.

Risser score

A score of 1 or less has a higher likelihood of progression.

Curve size

Shorter curves progress m ore

Location

The lower the curve is in the spinal colum n, the greater the
likelihood of progression (thoracic < lum bar).

Flexibilit y

Sti er curves in im m ature individuals and more exible curves in


m ature individual are m ore likely to progress.

Gender

Girls are m ore com m only a ected, especially for larger curves.

Fam ily history


Slender spine

d. Adam s for w ard ben d test .


(1) Th e p at ien t ben ds at th e w aist to 90.
(2) During th e process, assess for asym m et r y in ben ding an d rotat ion al
deform it y of th oracic an d lum bar cur ves.
2. Measurem en t s.
a. A scoliom eter is u sed to m easu re th e rib h u m p (rot at ion al deform it y on
for w ard ben ding).
b. A plum b lin e dropped from C7 in dicates coron al balan ce relat ive to th e
glu teal cleft .
c. Leg length discrepan cy.
3. Neu rological exam in at ion .
a. Deep ten don re exes.
b. Abdom in al re exes.
(1) Ch eck for sym m et rical um bilical m ovem en t upon lateral to m edial
ligh t st roke on th e abdom en .
(2) Asym m et rical m ovem en t correlates w ith n eural axis path ology.
D. X-ray exam in at ion :
1. Th e Cobb angle (Fig. 21.2) is u sed to determ in e th e m agn it u d e of th e cu r ve.
Th e u pper an d low er en d ver tebrae of each cur ve are iden t i ed. A lin e is
d raw n at th e u pp er en d of th e cran ial en d vertebra along th e en d plate or
by m arking th e u pper or low er m argin of th e pedicles. A lin e is th en draw n

232 21 Pediatric Spinal Deform it y

Fig. 21.2

(a,b) Cobb angle analysis for m anual adolescent idiopathic scoliosis measurem ents.

at th e low er en d of th e caudal vertebra of th e cu r ve, u sing th e en d plate or


p edicles. A righ t angle to th is lin e is th en draw n . Th e angle to be m easu red is
th e angle form ed by th e t w o lin es at th e en d vertebrae.
2. Bon e age determ in at ion can be u seful to h elp determ in e th e risk of spin al
cur ve progression .
a. Risser sign (Fig. 21.3): ossi cat ion of th e iliac epiphysis progresses from
th e an terior iliac spin e posteriorly. A Risser 0 h as th e least ossi cat ion
an d greatest risk of p rogression , w h ereas a Risser 5 in dicates th e
epip hysis h as fu sed w ith th e iliac crest , an d th e risk of p rogression is
m in im al.
b. A ring apophysis fusion in dicates cessat ion of all vertebral body grow th
p oten t ial.
c. Left w rist an d h an d: th e X-ray is com pared w ith st an dards in th e
Greu lich an d Pyle atlas.
E. Pu lm on ar y fu n ct ion test: > 70 cu r ves h ave decreased vit al capacit y,
p art icularly w ith hypokyph osis.
F. In dicat ion s for m agn et ic reson an ce im aging (MRI):
1. Neurological abn orm alit ies.

21 Pediatric Spinal Deform it y 233


Fig. 21.3 (ad) The Risser Sign: Ossi cation
of the iliac apophysis progresses from the
anterior iliac spine posteriorly. A Risser 0 has
the least ossi cation and greatest risk of progression, while a Risser 5 indicates the apophysis has fused with the iliac crest and the risk of
progression is m inimal.

234 21 Pediatric Spinal Deform it y

2. Congen it al vertebral abn orm alit ies.


3. Juven ile an d in fan t ile on set .
4. Rapid progression .
5. Cut an eous m an ifest at ion s of dysraph ism .
V. Managem en t .
A. Goals of t reat m en t .
1. Preven t progression an d m ain tain balan ce.
2. Main t ain respirator y fun ct ion .
3. Reduce pain an d preser ve n eurological st at us.
4. Cosm esis.
B. Non operat ive t reat m en t .
1. For m ost pat ien t s w ith scoliosis, progression m ay n ot be severe en ough to
w arran t t reat m en t .
2. Obser vat ion is in d icated for cur ves < 25 in im m at ure pat ien t s an d > 50 in
m at u re pat ien t s.
a. Obt ain X-ray 3 m on th s after th e rst visit an d th en ever y 6 to 9 m on th s
for cu r ves < 20 an d ever y 4 to 6 m on th s for cur ves > 20.
b. A sign i can t ch ange is de n ed as progression of > 10 in cu r ves < 20 an d
> 5 in cu r ves > 20.
3. Exercise is in dicated on ly as an adju n ct t reat m en t , especially for pat ien t s
w ith obesit y, back pain , lum bar hyperlordosis, exible kyph osis, an d t ru n k
an d ext rem it y m u scle t igh t n ess.
4. Orth osis: cu r ve > 30 to 45 ( rst visit) an d > 25 w ith docu m en ted
p rogression in im m at u re pat ien ts (Risser 3 or less):
a. Not for cer vicoth oracic cu r ves an d hypokyph ot ic th oracic cu r ves.
b. Th e goal is to preven t progression : ~ 85% of com plian t pat ien ts
d em on st rate progression cessat ion an d im p rove (~ 50% correct ion ), but
m ost pat ien t s ten d to ret u rn w ith in 5 of th e origin al cur ve after th e
brace t reat m en t is ceased.
c. Protocol: th e pat ien t m ust w ear th e brace 23 h ours a day un t il 2 years
after m en arch e or Risser 4 an d be w ean ed o in 1 year (part-t im e w ear is
also rep orted).
d . Orth osis t ypes:
(1) Th oracolum bar sacral orth osis (Boston overlap).
(a) Appropriate up to T8 apex.
(b) All cur ve t ypes.
(c) Medium com plian ce.
(2) Ben ding brace (Ch arleston ).
(a) Th oracolum bar an d lum bar cur ves (2535).
(b) Best com plian ce.
(3) Meh t a cast .
(a) Treat m en t opt ion for ver y young ch ildren .
(4) Cer vico Th oracolum bar Sacral Orth osis (CTLSO) (GB Or th opaedics).
(a) Th oracic cur ves w ith apex above T7.
(b) Low com plian ce.
5. Elect rical st im ulat ion t reat m en t h as been aban don ed.

21 Pediatric Spinal Deform it y 235

C. Op erat ive t reat m en t .


1. In dicat ion s for surger y.
a. Progressive cu r ves > 40 to 45 in grow ing ch ildren (Fig. 21.4).
b. Failu re of bracing.
c. Progressive cu r ves beyon d 50 in adu lt s.

Fig. 21.4 A 17-year-old girl with


adolescent idiopathic scoliosis.
(a) Anteroposterior radiograph
demonstrating a 49 right thoracolumbar curve with maintenance of the overall coronal
balance. (b) Lateral radiograph
demonstrates relatively preserved
sagittal alignment. Postoperative
(c) anteroposterior and (d) lateral
radiographs with an anteroposterior release and fusion.

236 21 Pediatric Spinal Deform it y

2. Goals of su rger y.
a. Spin al an d p elvic balan ce is m ore im p or tan t th an cu r ve correct ion .
b. Preven t respirator y com prom ise.
c. Preven t back pain .
d. Cosm esis.
3. Operat ive m an agem en t based on th e Len ke classi cat ion .
a. Typ e 1: posterior fu sion an d in st ru m en tat ion (PFI) is favored.
(1) Low er exten t ver tebrae (LEV) is con t roversial.
b. Type 2: requ ire PFI.
(1) Th e proxim al fusion level (T2 or T3) is determ in ed by th e size of th e
p roxim al th oracic cur ve an d sh oulder align m en t .
(2) LEV is con t roversial.
c. Type 3: PFI is w arran ted.
d. Type 4: Rare an d w arran t s fusion of th e proxim al th oracic cur ve, m ain
th oracic cur ve, an d th oracolum bar/lum bar cu r ves.
(1) May require an an terior release for rigid cur ves.
e. Typ e 5: On ly requ ire fu sion of th e th oracolu m bar/lu m bar cu r ve given
th at it is st ruct ural (an terior or posterior).
f. Typ e 6: PFI of th e m ajor th oracolu m bar/lu m bar an d th e m in or th oracic
cur ve.
VI. In strum en tat ion .
A. Con tem porar y system s.
1. Vertical Expandable Prosthetic Titanium Rib (VEPTR) (Synthes Spine) (Fig. 21.5).
a. Received h u m an it arian device exem pt ion st at u s to t reat ch est w all an d
spin al deform it y associated w ith th oracic in su cien cy syn drom e.
b. Maxim izes lung volum e by expan ding th e rib cage an d en abling grow th
an d correct ion of th e sp in al deform it y.
c. Long-term outcom es w ith VEPTR are pen ding, because sagit tal deform it y
rem ain s u n addressed.
2. Grow ing rod in st rum en t at ion .
a. Used in adolescen t ch ildren to en able n orm al grow th of th e sp in e w h ile
addressing sp in al deform it y correct ion .
b. Requires length en ing at periodic in ter vals.
VII. Surgical tech n ique.
A. In t raoperat ive cell saver system .
B. In t raoperat ive n eurom on itoring an d w ake-u p test or m otor evoked poten t ials.
C. Fu sion tech n iqu e:
1. Subperiosteal dissect ion out to th e t ips of th e t ran sverse processes.
2. Decort icat ion , facet cart ilage excision .
3. Iliac crest autograft or rib graft from th oracoplast y.
D. In st ru m en t at ion tech n iqu es: m ost deform it y correct ion s are n ow p erform ed
u sing th e ped icle screw based system s.
VIII. Post surgical care, outcom es, an d com plicat ion s.
A. Bracing after su rger y is n ot required.
B. Pat ien t s are slow ly advan ced in th eir act ivit ies u n t il fu ll recover y in 6 to 12
m on th s.

21 Pediatric Spinal Deform it y 237

i
Fig. 21.5

j
(aj) Vertical expandable prosthetic titanium rib in the pediatric spinal deform it y patient.

238 21 Pediatric Spinal Deform it y


Fig. 21.6 Types of congenital
scoliosis. (a) Unilateral unsegm ented bar. (b) Block vertebra.
(c) Fully segm ented hem ivertebra. (d) Sem isegm ented hem ivertebra. (e) Nonsegm ented
hemivertebra.

C. Dep en ding on in st ru m en t at ion u sed, correct ion p ercen t age varies from 50 to
75%.
D. Fu sion below L3 in creases th e in ciden ce of low er back p ain .
E. Posterior spinal in st rum en t at ion h as a reoperat ion rate of 5 to 19%.
F. Oth er com p licat ion s:
1. Delayed in fect ion .
a. In ciden ce of 1 to 7%.
b. Requ ires h ardw are rem oval an d an t ibiot ics.
2. Late-on set surgical pain .
a. In ciden ce of 5%.
b. Requires h ardw are rem oval.
3. Pseudarth rosis.
a. In ciden ce of 3%.
b. Com pression in st rum en t at ion or bon e graft n eeded for t reat m en t .

21 Pediatric Spinal Deform it y 239

21.3 Idiopathic Infantile and Juvenile Scoliosis


I. Idiop ath ic in fan t ile scoliosis.
A. Usually detected at 2 to 3 m on th s of age.
B. Greater in ciden ce in boys th an girls.
C. More com m on in Englan d .
D. Nin et y p ercen t of cases involve th e left th oracic.
E. Progn osis:
1. Sixt y to 70% of cases resolve spon tan eously.
F. Tw o t yp es of p rogressive cu r ves:
1. Ben ign cur ves are t ypically ch aracterized by > 1-year on set , double cur ves,
an d greater exibilit y.
2. Malign an t cur ves are ch aracterized by > 1-year on set , th oracic locat ion , an d
rigid cu r ves.
G. Good progn osis if Meh t a angle (ribvertebral angle) is < 20 an d th e convex rib
d oes n ot overlap th e vertebral body on th e posteroan terior radiograph (ph ase I).
In ph ase II, th ere is an overlap bet w een th e rib an d ver tebral body, an d th e
p rogn osis is w orse.
H. Th e t reat m en t con sist s of bracing for cur ves > 30. If th e cur ve is progressive,
su rger y is recom m en ded. Opt ion s in clu de su bcu tan eou s rod or telescoping rod
w ith out fusion or com bined an terior an d posterior fusion .
II. Idiopath ic juven ile scoliosis.
A. Th e righ t thoracic pat tern is th e m ost com m on .
B. Variable progression : on e-th ird are obser ved, on e-th ird are braced, an d on eth ird require surger y.
C. Brace if > 30.
D. Su rger y if p rogressive cu r ve > 45 desp ite brace t reat m en t , esp ecially during
p ubert y.

21.4 Other Type of Scoliosis


I. Congen it al scoliosis (Fig. 21.6).
A. Failu re of segm en tat ion or form at ion or both .
B. Associated an om alies: gen itou rin ar y (ren al agen esis, u reteral obst ru ct ion ).
C. Paralyt ic scoliosis.
D. Neu ro brom atosis.
II. Neu rom u scu lar scoliosis (Fig. 21.7).
A. Gen eral con siderat ion s.
1. Bracing does n ot preven t th e n at ural progression of th e scoliosis.
2. Di eren ces in surgical approach in clude th e length of fusion s an d operat ing
on sm aller cur ves.
3. Hooks an d screw s are used m ore frequen tly.
4. Segm en tal Lu que w ires are used.
5. In creased rates of com plicat ion s.
B. Cerebral p alsy.
1. Scoliosis a ected by th e im balan ce of th e paraspin al m uscles.

240 21 Pediatric Spinal Deform it y

Fig. 21.7 A 13-year-old boy with neuromuscular scoliosis. (a) Anteroposterior and (b) lateral radiographs. There appears to be lumbar hyperlordosis and a compensatory thoracic kyphosis. (c,d) Postoperative radiographs demonstrate a combination of pedicle screw, hook, and sublaminar wiring xation.

21 Pediatric Spinal Deform it y 241

2. Surger y.
a. Cur ves > 50.
b. Levels to be repaired:
(1) Am bu lator y pat ien t .
(a) Proxim al to dist al st able ver tebra.
(2) Non am bulator y pat ien t s.
(a) T2 to pelvis.
c. Usually posterior approach but an terior approach m ay n eed to be
p erform ed for cu r ves > 100.
C. Myelom en ingocele.
1. Secon dar y to bir th defect: exposure of th e m en inges an d spin al cord m ay
resu lt in bow el, bladder, m otor, an d sen sor y de cit s.
2. In ciden ce of 1 in 1,000: correlated w ith folate de cien cy in pregn an cy.
3. Fifteen percent of pat ient s w ith th is de cit are allergic to latex.
4. MRI is used for diagn osis due to th e n eurological com plicat ion s.
5. Surger y:
a. In dicated for p at ien ts w h o h ave di cu lt y w ith sit t ing or are at risk for
developing pressure sores.
b. A com bin ed posterior an d an terior approach is used.
D. Sp in al m u scu lar at rophy.
1. Progressive w eakn ess due to loss of an terior h orn cell n euron s.
2. Th ree t ypes.
a. Typ e I (Werdn igHo m an n disease).
(1) On set in n eon at al period an d death by age 2.
b. Type II.
(1) On set at ~ 5 to 6 m on th s of age.
c. Type III.
(1) On set before age 3 an d progressive w eakn ess w ith loss of am bu lator y
st rength by age 15.
(2) Surger y.
(a) In dicated in progressive scoliosis.
(b) Th e approach sh ould be an terior an d posterior for a young
p at ien t w ith large cur ves an d on ly posterior for th e older pat ien t
w ith sm aller cu r ves.
E. Duch en n es m uscular dyst rophy.
1. X-lin ked recessive disorder.
2. Spin al deform it y develops secon dar y to m uscle im balan ce on ly after loss of
am bu lat ion .
3. In creased in ciden ce of m align an t hyper ten sion w ith gen eral an esth esia.
4. Preoperat ive pu lm on ar y fu n ct ion an d cardiac con t ract ilit y assessm en t are
n ecessar y.
5. Surger y:
a. In dicated in progressive scoliosis > 25 to 30%.
b. A T2 to sacrum posterior approach is used.

242 21 Pediatric Spinal Deform it y

21.5 Kyphotic Deformities


I. Gen eral con siderat ion s of kyp h ot ic deform it ies.
A. An atom ical variat ion .
1. Cer vical lordosis, th oracic kyph osis, an d lum bosacral lordosis
2. Th e sagit t al plum b lin e (odon toid) should n orm ally cross C7T1, T12L1,
an d th e posterior aspect of th e sacru m (S1).
3. Norm al th oracic kyph osis:
a. Tw en t y to 45, m ean = 34.
4. Norm al lum bar lordosis:
a. Fort y to 60.
b. Tw o-thirds of lordosis occur bet w een L4L5 an d L5S1.
B. Biom ech an ics.
1. An terior colum n failure result s in com pression , an d posterior colum n failure
resu lt s in ten sion .
2. Posterior st ruct u res:
a. Th e lam in a an d ligam en t u m avu m are relat ively st ronger in resist ing
ten sion th an facet s, capsules, an d in terspin ou s ligam en ts.
3. Deform it y in creases th e m om en t arm , w h ich can result in fur th er
decom pen sat ion .
4. Eccen t ric loading can a ect cart ilagin ous grow th .
a. Com pression decreases grow th an teriorly.
b. Ten sion in creases grow th posteriorly, resu lt ing in in creased kyph osis.
C. Classi cat ion (Table 21.4).
D. Sp eci c kyph ot ic deform it ies.
1. Post ural kyph osis.
a. Most com m on in adolescen ts an d you ng adu lt s.
b. Roun d back deform it y.
c. Mod est kyp h osis (4060).
d. Sm ooth an d exible.
e. No radiograp h ic ch anges.
f. No sp eci c t reat m en tcon ser vat ive m an agem en t .
2. Congen it al kyph osis.
a. May be single or m u lt ilevel.
(1) Type I.
(a) Failure of form at ion (h em iver tebra).
(b) Worse p rogn osis for p rogression an d p arap legia.
(c) Upper spin al levels h ave a w orse progn osis th an low er levels.
(2) Type II.
(a) Failure of segm en tat ion (bar).
(3) Type III.
(a) Com binat ion of I an d II.
(4) Treat m en t .
(a) Non operat ive t reat m en t is in e ect ive.

21 Pediatric Spinal Deform it y 243

Table 21.4

Classi cation of kyphotic deform ities

Type

Notes

Postural
Congenital

Defect of form ation


Defect of segm entation
Mixed

Neurom uscular (Fig. 21.8)


Scheuerm anns disease (Fig. 21.9)
Myelom eningocele

Developm ental (late paralytic)


Congenital (present at birth)

Traum atic

Due to bone, ligam ent, and/or cord injury

Postsurgical

Postlam inectomy
Following excision of a vertebral body

Postirradiation
Metabolic

Osteoporosis
Senile
Juvenile
Osteom alacia
Osteogenesis imperfecta

Skeletal dysplasia

Achondroplasia
Mucopolysaccharidoses
Neuro bromatosis

Collagen disease

MarieStrmpell disease

Tum or

Benign
Malignant
Primary
Metastatic

In am m atory and infectious

(b) Su rger y:
i. Type I lesion s.
Posterior in sit u fu sion if < 50 at 1 to 5 years.
An terior an d p osterior fusion if > 50 an d older ch ildren .
Bet ter correct ion an d m ain ten an ce.
Low er rate of p seu dar th rosis.

244 21 Pediatric Spinal Deform it y

An terior decom p ression .


Release of all th e teth ering st ru ct u res:
An terior longit u din al ligam en t .
In ter vertebral disk an d en d plate.
Posterior longit udin al ligam en t .
In traoperat ive dist raction an d correct ion of th e deform it y:
Rib, bu la, or iliac crest st rut graft s.
Sim u lt an eou s or secon d -st age p osterior fu sion w ith
com pression in st rum en tat ion .
Postop erat ive bracing is recom m en d ed .
ii. Type II lesion s.
Posterior fusion on ly if kyph osis is < 55.
For severe deform it y, an an terior osteotom y an d
correct ion an d fusion m ay be at tem pted follow ed by a
posterior fusion .
Skelet al t ract ion is con t rain dicated as it m ay cau se
paraplegia.
3. Sch eu erm an ns disease (juven ile kyph osis).
a. Sch eu erm an n rst described radiological m an ifest at ion of th is disease in
1920.
(1) Th e in ciden ce is 0.4 to 8.3% of th e popu lat ion , but on ly 1% seek
m ed ical at ten t ion .
(2) Path ogen esis is un kn ow n .
(a) Fam ilial ten den cy w ith n o gen et ic lin k.
(b) Collagen w eakn ess an d st u n ted ossi cat ion of th e vertebral en d
plate are ch aracterist ic.
(c) Osteopen ia.
(d) Nutrit ion al de cien cies.
(e) Mech an ical alterat ion s an d m uscle w eakn ess h ave been
th eorized.
i. No scien t i c eviden ce exist s.
ii. Grow th cen ters adjacen t to th e ver tebral en d plate (n ot ring
ap op hyses):
An terior car t ilagin ou s colu m n s exp erien ce st u n ted grow th
w ith axial loading.
Posterior p hysis hypert rophy d u e to ten sile forces.
iii. With kyp h ot ic deform it y, spin al exors becom e st ronger th an
exten sors becau se of th e m om en t arm .
(3) Path oanatom y:
(a) Th icken ed an d con t racted an terior longit udin al ligam en t .
(b) Wedging of th e an terior vertebral bodies.
(c) Nucleus pu lposus.
i. Prot rusion an teriorly an d in to th e bony spongiosa (Sch m orls
nodes).
(4) Clin ical n dings:
(a) On set is com m on ly bet w een 12 an d 14 years of age.
(b) Equal m ale:fem ale rat io.

21 Pediatric Spinal Deform it y 245

(c) Deform it y is th e m ost com m on presen t ing com plain t .


(d) Pain occurs in ~ 50% am ong th ose w h o seek m edical at ten t ion .
i. Increased rate of sym ptom atology if the lum bar spine is involved
Som e p at ien t s develop lu m bar sp on dylolysis later.
(5) Physical exam in at ion :
(a) In crease in th oracic kyph osis (rigid).
(b) Com p en sator y lu m bar an d cer vical lordosis:
i. Roun d sh oulders.
ii. For w ard t ilt ing of th e h ead.
(c) Muscle tightness and contractures are seen, typically in the ham strings.
(d) Th ir t y percen t h ave an associated m ild scoliosis.
(6) Radiograph ic n dings:
(a) Early:
i. Disordered en doch on dral ossi cat ion .
ii. Irregu lar en d plates.
iii. Narrow ing of th e in ter ver tebral disk space.
iv. Sch m orls n odes.
(b) In term ediate:
i. Vertebral w edging.
ii. In creasing kyph osis > 45.
More th an 5 of an terior w edging in th ree or m ore
vertebrae at th e ap ex of th e kyp h osis (Soren sons criteria).
(c) Late:
i. Degen erat ive ch anges.
Osteophytes.
Facet hyp ert rop hy.
(d) St an ding lateral an d supin e hyperexten sion view s are used to
assess th e rigidit y of th e cu r ve.
(7) Treat m en t:
(a) Obser vat ion is in dicated for m ild deform it y w ith m in im al
sym ptom s.
(b) Bracing in dicat ion s:
i. Vertebral w edging > 5.
ii. Kyp h ot ic cur ves bet w een 45 an d 65 an d 1 to 2 years of
grow th rem ain ing:
Milw au kee brace for apex above T9.
Th oracolu m bar Sacral Or th osis (TLSO) for th e ap ex below
T9 an d th oracolum bar cur ves.
iii. Cu r ve correct ion an d w edging im provem en t of ~ 40% can be
exp ected after 6 to 12 m on th s.
iv. Th e brace sh ould be w ean ed w ith skelet al m at urit y, but loss of
correct ion is expected after 10 years.
(c) Exercise:
i. St ressing pelvic t ilt , abdom in al st rength en ing, spin al
exibilit y, an d th oracic sp in e exten sion exercises is an
im p or tan t part of th e t reat m en t plan .

246 21 Pediatric Spinal Deform it y

(8) Surger y:
(a) In dicat ion s.
i. Severe deform it y after grow th com plet ion w ith un relen t ing
pain .
Typically > 75 an d > 10 w edging in th ree or m ore
con t iguou s ver tebral bodies.
ii. Resist an ce to bracing after 6 m on th s.
iii. Neurological sign s or sym ptom s.
(b) Tech n iqu es.
i. Posterior-only in st ru m en ted fusion .
Cu r ves < 75 an d ben ding correct ion to < 50.
Posterior in st ru m en t at ion sh ou ld exten d th e en t ire
kyph ot ic region , an d distally it sh ould in clude on e lordot ic
vertebra (u su ally L1 or L2). Th e posterior sacral vert ical
lin e is a vert ical lin e th at crosses th e posterior su perior
corn er of the sacrum . Th e ver tebra th at bisect s th is lin e
is som et im es con sidered as th e en d ver tebra for fu sion to
preven t jun ct ion al deform it y.
ii. An terior fusion (t ran sth oracic approach ) follow ed by posterior
fu sion an d in st ru m en tat ion .
Cur ves > 75 w ith m in im al ben ding correct ion (> 50).
(c) Postoperat ive protocol.
i. TLSO for 6 to 9 m on th s un t il solid fu sion .
(d) Com plicat ion s.
i. Pseudarth rosis an d in st ru m en t at ion failure (greater in
posterior fusion alon e).
ii. Loss of correct ion .
iii. In fect ion .
iv. Pulm on ar y com plicat ion s.
v. Neu rological de cit s.
4. Neurom u scular kyph osis (Fig. 21.8).
a. Associated con dit ion s:
(1) Poliom yelit is.
(2) An terior h orn cell diseases (spin al m uscular at rophy).
(3) Cerebral palsy.
(4) Ch arcotMarieTooth disease.
(5) Mu scular dyst rophy.
(6) Friedreichs at axia.
b. Lack of th e exten sor m uscle st rength con t ribu tes to developm en t of a
kyph ot ic deform it y.
c. Th e n at u ral h istor y is progressive even after skeletal m at urit y.
d . Treat m en t:
(1) Bracing un t il th e pat ien t is ~ 11 to 12 years old to m axim ize t run cal
h eigh t .
(2) Posterior fusion w ith in st rum en t at ion in m ilder an d exible cur ves.
(a) Com pression in st rum en t at ion is preferred over Luqu e rods w ith
su blam in ar w ires for correct ion of kyp h osis.

21 Pediatric Spinal Deform it y 247

d
Fig. 21.8 Images of a 44-year-old m an with neuro brom atosis who presented with severe kyphoscoliosis and paraplegia. A sim ultaneous anterior and posterior approach was perform ed on this patient to
com bine anterior and posterior procedures. The steps of the procedures included a posterior osteotomy, anterior vertebrectomy, spinal cord decompression, anterior fusion with strut grafting, posterior
compression instrumentation, and anterior instrum entation, in this order. (a) Preoperative m agnetic
resonance im age showing 170 kyphosis with cord compression. (b) Computed tom ographic (CT)
myelogram demonstrating severe kyphotic deformit y with signal cuto distal to the T9 vertebra.
(c) Intraoperative photograph showing anterior vertebrectomy, bular strut graft, and anterior instrum entation. (d) Postoperative radiograph showing 65 of kyphosis.

(b) Com bin ed an terior an d posterior fusion w ith in st rum en t at ion in


severe xed deform it ies.
5. Myelom en ingocele.
a. Congen it al.
(1) It is gen erally n ot recom m en ded to correct deform it y at birth
because of th e lack of bon e stock an d associated problem s.
b. At 3 to 5 years of age, posterior resection followed by correction of kyphosis.
(1) Posterior in st rum en t at ion sh ould be applied t w o to th ree ver tebrae
proxim al to th e apex.
(2) Follow ed by 6 to 9 m on th s of bracing.

248 21 Pediatric Spinal Deform it y

Fig. 21.9 Preoperative radiographs of an 18-year-old woman with Scheuerm anns kyphosis. (a)
Anteroposterior radiograph demonstrating no coronal plane deform ities. (b) Lateral radiograph m easuring 80 of kyphosis from T1 to T12. (c,d) Because of the patients relative exibilit y, an all posterior
approach was perform ed, restoring her sagit tal balance.

21 Pediatric Spinal Deform it y 249

6. Developm en tal or paralyt ic kyph osis.


a. Th e deform it y is p rogressive becau se th e exten sors of th e sp in e
(sacrospin alis an d quadrat us lum borum m uscles) rotate an teriorly to
in crease exion force.
b. Treat m en t:
(1) Bracing is in dicated for young pat ien ts w ith m ild deform it y.
(2) Posterior fusion involving long fu sion to th e sacru m .
(3) An terior release an d fusion follow ed by posterior fusion w ith
com pression in st rum en t at ion s.
7. Post t raum at ic kyph osis.
a. Acu te or late secon dar y to severe com pression fract u res, bu rst fract u res,
or fract ure-dislocat ion s.
b. More com m on for un st able fract ures after con ser vat ive t reat m en t .
c. Sym ptom s in clude deform it y, pain , an d n eurological de cit .
d. Treat m en t:
(1) Obser vat ion an d con ser vat ive t reat m en t if th e deform it y causes m ild
p ain th at is con t rollable.
(2) Surger y is m ost com m on ly don e by a com bin ed an terior an d
p osterior fu sion.
(a) An terior decom pression w ith an terior in st rum en tat ion alon e
m ay be don e if adequ ate correct ion h as been ach ieved an d th e
in st rum en tat ion is stable.
(b) Posterior-on ly t ran spedicu lar osteotom y m ay be don e if th ere is
n o n eu rological com pression .
8. Post surgical kyph osis.
a. Usu ally obser ved after lam in ectom y for sp in al cord t u m ors an d
syringom yelia.
b. Fusion is recom m en ded at th e t im e of surger y w h en exten sive
lam in ectom y h as been perform ed.
c. Severe deform it y is approached w ith a com bin ed an terior an d posterior
fu sion .
9. In fect ious kyph osis (Fig. 21.10).
a. In fect ion m ay be cau sed by t u bercu losis an d pyogen ic osteom yelit is.
b. Th e th oracolu m bar jun ct ion is m ost com m on ly a ected.
c. Treat m en t:
(1) An t ibiot ic t reat m en t in cludes long-term in t raven ous an t ibiot ics an d
bracing.
(2) An terior debridem en t an d fusion in dicat ion s:
(a) Un respon sive to m edical t reat m en t .
(b) Mult iple-level involvem en t .
(c) Spin al cord com pression .
(d) Presen ce of an abscess.
(3) Progressive kyph osis n eeds an terior an d posterior procedures.
10. In am m ator y kyph osis (an kylosing spon dylit is).
a. Ch aracterized by loss of a lu m bar lordosis an d in creased cer vical an d
th oracic kyph osis.
b. Prim ar y locat ion of disabling deform it y sh ould be assessed.

250 21 Pediatric Spinal Deform it y

Fig. 21.10 A 65-year-old m an with old tuberculosis who had a posterior fusion 40 years prior.
Despite severe kyphosis, this patient was am bulatory with m inimal symptom s. (a) Lateral radiograph
showing severe angular kyphosis. (b) Sagit tal T2-weighted m agnetic resonance image (MRI) showing
an old granuloma and spinal cord compression at the apex of the kyphotic deformit y.

c. Hip exion con t ract ure sh ould be corrected rst .


(1) May avoid th e n eed for spin al surger y.
d. Lum bar osteotom y is in dicated for a sign i can t loss of lum bar lordosis.
(1) Types of osteotom y.
(a) Sm ith Petersen /Pon te open ing w edge exten sion osteotom y.
i. Typically p erform ed at L2L3 an d L3L4 jun ct ion follow ed by
in st rum en tat ion an d fusion .
ii. Th e angle of correct ion corresp on ds to th e spin e exion
deform it y on st an ding.
iii. Th e apex of th e osteotom y sh ould be an terior to th e n eural
t ube an d at th e jun ct ion of th e posterior longit udin al ligam en t
an d in ter ver tebral d isk.
(b) Pedicle su bt ract ion osteotom y.
i. Does n ot length en th e an terior colum n .
ii. A closing w edge osteotom y sh or ten s th e vertebral colum n an d
is safer n eurologically.
iii. Posterior resect ion of th e lam in a, pars, an d pedicles is
perform ed follow ed by a vertebral w edge resect ion .

21 Pediatric Spinal Deform it y 251

11. Flat back syn drom e.


a. Et iologies.
(1) Dist ract ion of th e lum bar spin e (Harrington in st rum en t at ion ).
(2) Lum bar fusion w ith loss of lordosis.
b. Clin ical n dings.
(1) Sagit t ally im balan ced post ure.
(2) Back pain w ith referred pain dow n to legs.
(3) Tran sit ion syn drom e above an d below kyph osis.
(4) Com pen sator y h ip an d kn ee exion con t ract ures.
c. Treat m en t .
(1) Con ser vat ive t reat m en t w ith n on steroidal an t i-in am m ator y drugs,
physical th erapy, range of m ot ion exercises, pain m an agem en t .
(2) Surger y.
(a) Lum bar osteotom y to balan ce th e sagit t al con tour of th e spin e.
i. Pedicle subt ract ion osteotom y.
ii. Sm ith Petersen osteotom y.

Suggested Reading
Kuklo TR, Pot ter BK, Sch roeder TM, OBrien MF. Com parison of m an ual an d digital m easurem en t s in adolescen t idiopath ic scoliosis. Spin e 2006;31(11):12401246
Len ke LG. Len ke classi cat ion system of adolescen t idiopath ic scoliosis: t reat m ent recom m en dat ion s. In st r Course Lect 2005;54:537542
Len ke LG, Bet z RR, Harm s J, et al. Adolescen t idiopath ic scoliosis: a n ew classi cat ion to determ in e exten t of sp in al arth rodesis. J Bon e Join t Su rg Am 2001;83-A(8):
11691181
Len ke LG, Edw ards CC II, Bridw ell KH. Th e Len ke classi cat ion of adolescen t idiopath ic
scoliosis: h ow it organ izes cur ve pat terns as a tem plate to perform select ive fusion s of
the spin e. Sp in e 2003;28(20):S199S207
Lu n din e KM, Lew is SJ, Al-Au baidi Z, Alm an B, How ard AW. Pat ien t ou tcom es in th e op erat ive an d n on op erat ive m an agem en t of h igh -grade sp on dylolisth esis in ch ildren . J
Pediat r Orth op 2014;34(5):483489
ONeill KR, Len ke LG, Bridw ell KH, et al. Clin ical an d radiograp h ic ou tcom es after 3colu m n osteotom ies w ith 5-year follow -up . Sp in e 2014;39(5):424432

22 Pediatric Cervical Spine Disorders

22.1 General Considerations


I. Develop m en tal an atom y.
A. Atlas.
1. Neu rocen t ral syn ch on drosis form s at 6 to 24 m on th s.
a. Fu sion begin s at 4 to 6 years.
b. Posterior syn ch on drosis fuses at 5 years.
B. Den s.
1. Tw o prim ar y ossi cat ion cen ters coalesce at 1 to 3 m on th s of age.
2. Separated from th e ver tebral body by a den tocen t ral syn ch on drosis th at
fu ses at 6 to 8 years.
C. Norm al varian t s.
1. Posterior bi d C1 arch .
2. Bipart ite superior ar t icular surface of th e atlas.
3. Pseudon otch of th e atlas.
4. Absen ce or part ial absen ce of th e posterior arch of th e atlas.
5. Posteriorly displaced spin olam in ar lin e of th e axis.
6. Posteriorly angulated den s.
7. Pseudosublu xat ion of th e axis (< 10 years old).
II. Physical exam in at ion .
A. Lim ited range of m ot ion .
B. Tor t icollis.
C. Facial asym m et r y.
D. Associated abn orm alit ies.
1. Scoliosis, ren al, cardiac, or oth er h ead an d n eck an om alies.
III. Diagn ost ic evalu at ion (Fig. 22.1 an d Fig. 22.2).
A. A exion -exten sion view is ver y im port an t to assess st abilit y.
B. Crit ical m easu rem en t s on exed lateral view :
1. Atlan toaxial in ter val: 4.5 m m (ch ildren ), com pared w ith 3 m m (adult s).
a. From th e p osterior aspect of th e an terior C1 arch to th e odon toid process.
2. Space available for spin al cord (SAC): 13 m m .
a. Determ in es th e m in im al am ou n t of sp ace requ ired w ith in th e sp in al
can al to accom m odate th e spin al cord.
IV. Sp eci c disorders.
A. Basilar invagin at ion (Fig. 22.3).
1. Deform it y of th e bon es at th e base of th e skull at th e m argin of th e foram en
m agn u m .
a. Th e odon toid is m igrated cep h alad .

252

22 Pediatric Cervical Spine Disorders 253

Fig. 22.1 Lateral illustration of the norm al relationship of the C1C2 articulation dem onstrating the
atlantodens interval (ADI) and the space available for cord (SAC).

2. Types.
a. Prim ar y.
(1) Congen ital.
(2) Associated w ith oth er n dings.
(a) Atlan to-occipital fusion .
(b) Hyp op lasia of atlas.
(c) Bi d posterior arch of th e atlas.
(d) Odon toid abn orm alit ies.
(e) KlippelFeil syn drom e.
b. Secon dar y.
(1) Developm en tal con dit ion w ith soften ing of th e base of th e skull.
(2) Associated w ith oth er clin ical disorders.
(a) Osteom alacia.
(b) Ricket s.
(c) Pagets disease.
(d) Osteogen esis im perfect a.
(e) Ren al osteodyst rophy.
(f) Rh eu m atoid arth rit is.
(g) Neu ro brom atosis.
(h ) An kylosing spon dylit is.
(i) Ach on droplasia.

254 22 Pediatric Cervical Spine Disorders

b
Fig. 22.2 (a) In exion, the space available for cord (SAC) may decrease bet ween the posterior aspect of
the dens and the anterior aspect of the C1 posterior ring. (b) In extension, the SAC may decrease bet ween
the posterior aspect of the dens and the anterior aspect of the C2 lamina or the foramen magnum.

3. Clin ical ndings.


a. Com m on ly becom e sym ptom at ic in secon d an d th ird decades.
(1) Sh ort n eck.
(2) Asym m et ric face.
(3) Tort icollis.
(4) Weakn ess/paresth esias.
(5) Cran ial n er ve palsies.
(6) Cerebellar sign s (un steady gait an d nyst agm us).
(7) Pain (h ead an d n eck).

22 Pediatric Cervical Spine Disorders 255

c
Fig. 22.3 An 18-year-old man with osteogenesis imperfecta and basilar invagination presented with
unrelenting headache, neck pain, and myelopathy. (a) Lateral radiograph demonstrating basilar invagination with the odontoid protruding into the foram en magnum . (b) Magnetic resonance im aging scan
showing the odontoid indenting the brain stem. (c) Postoperative lateral radiograph showing a triple
wire technique and posterior occipitalcervical fusion.

(8) Syn cope an d dizzin ess (vertebral arter y com pression ).


(9) Seizures/hydroceph alus (cerebrospin al obst ruct ion ).
4. Treat m en t .
a. Posterior im p ingem en t .
(1) Suboccipital cran iectom y an d decom pression of th e posterior ring of
C1 w ith posterior st abilizat ion .
b. An terior im pingem en t .
(1) Mobile odon toid:
(a) Occipitocer vical fusion in exten sion is recom m en ded.

256 22 Pediatric Cervical Spine Disorders

(2) If th e odon toid can n ot be redu ced, an terior excision of th e odon toid
an d posterior st abilizat ion are recom m en ded.
B. Klip pelFeil syn drom e (Fig. 22.4).
1. Congen it al fusion of cer vical vertebrae.
2. Failure of n orm al segm en t at ion of th e cer vical spin e during th e th ird to
eigh th w eek.

c
Fig. 22.4 A 55-year-old man with KlippelFeil syndrom e and basilar invagination. The patient presented with severe neck pain and headache. (a) Lateral radiograph showing congenital fusion bet ween
C3C4 and C5C6. (b) Magnetic resonance im aging also shows the congenitally fused vertebrae with
disk degeneration at C4C5. Basilar invagination is noted as well. (c) Postoperative radiograph showing an occiputC6 fusion with platescrew xation.

22 Pediatric Cervical Spine Disorders 257

3. Associated an om alies.
a. Gen itou rin ar y (35%).
b. Cen t ral n er vous system .
c. Cardiopulm on ar y.
d. Sprengels deform it ies (40%).
e. Up p er ext rem it y an om alies.
f. Scoliosis (60%).
4. Clin ical n dings.
a. Low p osterior n eck lin e.
b. Sh or t n eck.
c. Lim ited n eck m ot ion .
(1) Th e m ajorit y of pat ien t s h ave a n orm al appearan ce w ith m ild
rest rict ion of m ot ion .
5. Radiograph ic n dings.
a. Ver tebral syn ostoses.
b. Flat ten ing an d w iden ing of th e vertebral bodies.
c. Absen t disk spaces or hypoplasia.
6. Treat m en t .
a. Th e m ajorit y of p at ien ts are asym ptom at ic.
(1) Sym ptom s m ay appear later in life.
b. Con ser vat ive t reat m en t is in dicated for m ost pat ien t s.
(1) An t i-in am m ator y m edicat ion s.
(2) Exercise program .
c. Fu sion m ay be in dicated in select pat ien t s w ith in st abilit y an d spin al cord
im pingem en t .
C. An om alies of th e od on toid.
1. Et iology.
a. Trau m a.
(1) Salter I fract ure w ith a n on un ion (Fig. 22.5).
b. Congen it al.
(1) Failure to fuse (n orm ally fuses at 36 years).
2. Clin ical n dings.
a. Neck pain .
b. Tort icollis.
c. Neurological sym ptom s.
3. Treat m en t .
a. Con ser vat ive if stable.
b. Surgical in ter ven t ion .
(1) In dicat ion s for surgical stabilizat ion .
(a) More th an 7 to 10 m m of in stabilit y even w ith out sym ptom s.
(b) Atlan toden s in ter val (ADI) > 4.5 m m w ith exion -exten sion lm s
an d SAC < 13 m m .
(2) Tech n ique.
(a) C1C2 fu sion w ith w ire xat ion :
i. Th e vertebral arter y is p rop ort ion ally closer to th e m idlin e in
th e ch ild.

258 22 Pediatric Cervical Spine Disorders

Fig. 22.5

Illustration of the three t ypes of odontoid fractures.

(b) Preoperat ive t ract ion an d reduct ion m ay be n ecessar y.


(c) Postoperat ive h alo vest st abilizat ion .
(d) C1C2 fusion w ith C1C2 t ran sart icular screw xat ion :
i. More rigid an d avoids h alo vest postoperat ively.
(e) Occipu tC2 fusion is n ecessar y if th e C1 ring is de cien t .
D. Congen ital atlan to-occip it al fu sion .
1. Failure of segm en t at ion .
2. Most com m on ly recogn ized an om aly of th e cran iovertebral ju n ct ion .
3. Pron e to C1C2 in st abilit y if associated w ith C2C3 fusion or an om alies of
th e odon toid (70%).
4. Associated w ith dw ar sm , fun n el ch est , pes cavus, syn dact yly, cleft palate,
an d gen itou rin ar y an om alies.
5. Clin ical n dings.
a. Sh ort n eck, rest ricted n eck m ot ion , an d tort icollis.
b. Fift y percen t h ave relat ive basilar im pression s secon dar y to dim in ish ed
ver tebral h eigh t of th e atlas ring.
c. Neurological involvem en t , especially if th e odon toid is above th e foram en
m agn u m level.
6. Radiograph ic n dings.
a. Flexion -exten sion view.
(1) ADI > 3 to 4 m m .
(2) SAC < 13 m m .
7. Treat m en t .
a. Con ser vat ive t reat m en t .
(1) Cer vical collar.
(2) Tract ion .
b. Surger y.
(1) OcciputC1C2 fusion after t ract ion an d reduct ion if C1C2
in st abilit y is presen t .
(2) Posterior decom pression an d fusion if th ere is posterior com pression
of th e spin al cord.

22 Pediatric Cervical Spine Disorders 259

E. Tort icollis (w r y n eck).


1. Typically discovered in th e rst 6 to 8 w eeks of life.
2. Isch em ia an d con t ract ure of th e stern ocleidom astoid m uscle m ay be
p ath ogen ic.
a. Ven ou s occlu sion an d brou s replacem en t of t issu e secon dar y to
in t rau terin e p osit ion .
3. Clin ical n dings:
a. Tw en t y p ercen t associated in ciden ce of congen ital h ip dislocat ion .
b. Eigh t y- ve percen t of cases involve th e righ t side.
c. Th e h ead is t ilted tow ard th e involved side, an d th e ch in is rot ated to th e
opposite side.
d . Soft , n on tend er en largem en t ben eath th e skin resolves in 6 to 12 w eeks.
e. Con t ract u re of th e m u scle follow s w ith decreased range of m ot ion of th e
n eck.
f. Facial asym m et r y an d m ild d orsal com p en sator y scoliosis.
4. Di eren t ial diagn osis:
a. Congen it al cer vical sp in e an om alies.
b. Ext raocular m uscle im balan ce.
5. Treat m en t:
a. St retch ing exercise, p osit ion ing, an d brace.
(1) Eigh t y- ve to 90% respon se w ith in 1 year.
b. Su rgical in dicat ion s.
(1) After 1 year if persistent facial asym m et r y.
(2) Head t ilt ing.
(3) Decreased range of m ot ion .
c. Su rgical opt ion s.
(1) Un ipolar/bipolar release.
(a) Bipolar release w ith Z-length en ing gives th e best results.
i. Be carefu l of th e posterior au ricular n er ve an d spin al
accessor y n er ve.
F. Atlan toaxial in st abilit ies.
1. Et iologies.
a. In am m at ion .
(1) Ph ar yngeal in fect ion (Grisels syn drom e).
(2) Juven ile rh eum atoid ar th rit is.
b. Dow ns syn drom e.
(1) Tw en t y- ve percen t in ciden ce.
(2) Boys older th an 10 years are at greater risk for m yelopathy follow ing
ru pt u re of t ran sverse ligam en t .
c. Dysplasia.
(1) Ach on droplasia.
(2) Diast roph ic dysplasia.
(3) Spon dyloepiphyseal dysplasia.
(4) Morquios syn drom e.
(5) Larsens syn drom e.
d. Congen it al an om alies.

260 22 Pediatric Cervical Spine Disorders

e. Spon t an eou s rotator y su blu xat ion of C1C2.


(1) Fielding classi cat ion .
(a) Type I.
i. Sim ple sh ift w ith ou t d isplacem en t .
(b) Type II.
i. Less th an 5 m m of C1C2 displacem en t .
(c) Type III.
i. Greater th an 5 m m of C1C2 displacem en t .
2. Treat m en t .
a. Con ser vat ive.
(1) Mild rot ator y deform it y.
(a) Collar.
(b) An algesics.
b. Surgical.
(1) C1C2 fusion if n eurological sym ptom s presen t .
(2) SAC < 13 m m .
G. Traum at ic cer vical injuries.
1. Cer vical spin e fract ures.
a. Vertebral fract u res accou n t for 2 to 3% of all ch ildh ood inju ries.
b. Fifteen percen t of all spin al cord injuries occur in ch ildren .
c. Un der 10 years, bony injuries are less com m on .
d . Pat ien t posit ion ing m ay be a problem in ch ildren u n der 5 years.
(1) Th e h ead is larger th an th e t ru n k.
(a) Th e back board m ay displace th e fract ure.
(b) Keep th e h ead low er th an th e ch est .
2. Radiograph ic evaluat ion .
a. In terp ret at ion of cer vical radiograp h s is m ore di cu lt .
(1) In com plete ossi cat ion .
(2) Norm al an atom ical varian t s.
(a) Pseudosublu xat ion of C2C3.
b. Spin al cord injur y w ith out radiograph ic abn orm alit y (SCIWORA):
(1) Com m on in ch ildren un der 10 years.
(2) Magn et ic reson an ce im aging (MRI) is h elpful in iden t ifying th e
locat ion an d exten t of injur y.
3. Speci c inju ries.
a. Occip itoatlan t al in stabilit y.
(1) Most injuries are fat al.
(2) Radiograph s:
(a) More th an 1 m m in crease in dist an ce bet w een odon toid t ip an d
basion .
(b) Pow ers rat io (dist an ce from th e basion to th e p osterior arch of
C1:d ist an ce from th e opisth ion to th e an terior arch of C1).
i. Greater th an 1 is con sisten t w ith in st abilit y.
(3) Treat m en t:
(a) OcciputC1 fusion an d h alo brace.

22 Pediatric Cervical Spine Disorders 261

b. Je erson fract ure (Fig. 22.6).


(1) Axial loading injur y m ech an ism .
(a) Usually h ave an associated h ead injur y.
(b) More com m on ly recogn ized du e to th e in creased u se of
com pu ted tom ography (CT).
(2) Radiograph ic n ding.
(a) Widen ing bet w een odon toid an d lateral m ass of C1.
(b) Overh ang of th e lateral m ass of C1 m ay be n orm al in a ch ild du e
to di eren t ial ossi cat ion .
(c) CT is th e best for delin eat ing fract ures an d h elps to di eren t iate
th e follow ing:
i. Neurocen t ric syn ch on drosis (fused by 6 years).
ii. Posterior syn ch on drosis (fused at 5 years).
iii. Irregu lar ossi cat ion .
Esp ecially th e an terior arch m ay h ave m u lt iple ossi cat ion
cen ters.
(3) Treat m en t .
(a) Min er va orth osis or h alo brace, depen ding on displacem en t or
ru pt u re of th e t ran sverse ligam en t .
c. Odon toid fract ures.
(1) Usually occur in ch ildren < 4 years old because syn ch on drosis fuses
by 6 years.
(2) Radiograph s.
(a) Angulat ion of odon toid w ith displacem en t (ADI > 4.5 m m ).
(b) Flexion -exten sion radiograph s.
i. May dem on st rate in st abilit y an d displacem en t of th e fract ure.
ii. Great cau t ion sh ou ld be t aken during th e exion an d
exten sion exam in at ion .

Fig. 22.6 Axial computed tom ographic


im age of a Je erson fracture. (From Im hof
H, ed. Spinal Im aging [Direct Diagnosis
in Radiology]. Stut tgart, Germany: Georg
Thiem e Verlag; 2008: Fig. 2.16b. Reproduced with permission.)

262 22 Pediatric Cervical Spine Disorders

(3) Treat m en t .
(a) Reduct ion by posterior t ran slat ion an d m ild exten sion .
(b) Min er va or h alo vest .
i. Non un ion (rare).
Loss of con t in u it y bet w een th e od on toid an d body of C2 (os
odon toideum ).
ii. Malu n ion (com m on ).
d. Hangm ans fract u rebilateral fract ure of th e C2 pedicles (t raum at ic
sp on dylolisth esis of C2 on C3) (Fig. 22.7).
(1) Mech an ism of injur y:
(a) Exten sion or dist ract ion .
(b) Com m on ly associated w ith facial abrasion s or fract u res.
(2) Th e m ajorit y of pat ien t s rem ain n eurologically in tact .
(3) Radiograph s:
(a) Fract ures of th e pedicles an d displacem en t or angu lat ion m ay be
sign i can t .
(4) Treat m en t:
(a) Closed reduct ion .
i. Posterior t ran slat ion an d sligh t exten sion .
(b) Min er va or th osis or h alo vest .
e. Low er cer vical sp in e inju ries (Fig. 22.8).
(1) Bony injuries are less com m on in ch ildren un der 10 years.
(2) Cer vical dislocat ion s sh ould be reduced as soon as possible.
(3) St abilizat ion is perform ed using posterior spin ou s process w ires an d
fu sion u sing iliac crest bon e graft .

Fig. 22.7 Lateral radiograph of a hangm ans fracture (bilateral C2 pedicle fracture). (From Imhof H,
ed. Spinal Im aging [Direct Diagnosis in Radiology]. Stut tgart, Germ any: Georg Thiem e Verlag; 2008:
Fig. 2.18. Reproduced with permission.)

22 Pediatric Cervical Spine Disorders 263

Fig. 22.8 Cervical kyphosis. (a) Lateral radiograph of a 17-year-old patient with cerebral palsy who
presented with severe thoracic lordosis and cervical kyphosis with progressive myelopathy. This patient
underwent anterior vertebrectomy and fusion and subsequent surgical procedures for correction of
his thoracic lordosis. (b) Magnetic resonance imaging of a 14-year-old boy with postlaminectomy
kyphosis and myelopathy. Anterior corpectomy and fusion were required for correction.

Suggested Reading
Brockm eyer DL, Ragel BT, Kestle JR. Th e p ediat ric cer vical spin e in st abilit y st u dy. A p ilot
st u dy assessing th e p rogn ost ic valu e of fou r im aging m odalit ies in clearing th e cervical spin e for ch ildren w ith severe t raum at ic inju ries. Ch ild s Ner v Syst 2012;28(5):
699705
Jon es TM, An d erson PA, Noon an KJ. Pediat ric cer vical sp in e t rau m a. J Am Acad Orth op
Su rg 2011;19(10):600611
Mart u s JE, Gri th TE, Dear JC, Rath jen KE. Pediat ric cer vical kyph osis: a com p arison of
arth rodesis tech n iqu es. Spin e 2011;36(17):E1145E1153
McKay SD, Al-Om ari A, Tom lin son LA, Dorm an s JP. Review of cer vical sp in e an om alies in
gen et ic syn drom es. Sp in e 2012;37(5):E269E277

23 Spinal Tumors

23.1 General Considerations


I. Evalu at ion .
A. Histor y:
1. Pain (localized vs. radicular) is th e m ost com m on ch ief com plain t (85% of
p at ien ts).
a. Oth er com m on p resen t ing sym ptom s in clu de m otor w eakn ess (41%) an d
a p alp able m ass (16%).
2. Pain secon dar y to a spin al t u m or is t ypically localized, progressive,
u n relen t ing, n on m ech an ical, an d w orse at n igh t .
a. Pat ien t s do n ot h ave relief w ith rest .
3. System ic sign s an d sym ptom s:
a. Fevers/ch ills.
b. Leth argy.
c. Un explain ed w eigh t loss.
4. Neurological sym ptom s m ay be presen t , such as w eakn ess, sen sor y ch anges,
or bow el an d bladder ch anges.
5. Age m ay h elp to n arrow th e di eren t ial diagn osis.
a. In older pat ien t s, m et astasis an d m u lt iple m yelom a are m ore com m on .
6. A h istor y of a prim ar y t u m or elsew h ere in th e body raises th e con cern of
m et ast ases.
a. Met ast at ic t u m ors are m ore com m on th an prim ar y t u m ors in th e sp in e.
Table 23.1

Com m on m etastatic spine tum ors

Primary tumor

Risk factors

Breast cancer

First-degree relative
History of increased estrogen exposure (early menarche, late
menopause, nulliparity, prolonged hormone replacement therapy)
Radiation exposure

Prostate cancer

Increased age (> 45 years)


Bladder outlet obstruction

Thyroid cancer

Iodine excess/de ciency


Radiation exposure

264

Lung cancer

History of sm oking

Renal cell carcinom a

Tobacco use

23 Spinal Tum ors 265

b. Th e spin e is th e m ost com m on site of bon e m et astases.


c. See Table 23.1 for risk factors.
B. Physical exam in at ion of th e sp in e sh ou ld in clu de p alp at ion , range of m ot ion ,
an d n eu rological exam in at ion .
1. Neurological exam in at ion .
a. Det ailed m otor exam in at ion .
b. Sen sor y exam in at ion .
(1) Ligh t touch .
(2) Pinprick.
(3) Vibrat ion .
(4) Assessm en t of long t ract n dings.
(a) Re exes.
2. Physical exam in at ion of poten t ial m et ast at ic foci (Table 23.2).
C. Diagn ost ic st u dies:
1. Helpful in di eren t iat ing t um or from in fect ion :
a. W h ite blood cell cou n t (W BC), er yth rocyte sedim en t at ion rate, an d
C-react ive p rotein sh ou ld all be elevated w ith in fect ion an d n orm al or
sligh tly elevated w ith t u m or.
(1) Except ion is lym ph om a, w h ich is associated w ith an elevated W BC.
2. Mult iple m yelom a is associated w ith protein spikes on seru m or urin e
an alysis.
3. Thyroid-st im ulat ing h orm on e an d free T4 levels are u seful in iden t ifying
thyroid disease.
4. Prost ate-speci c an t igen (PSA) is usefu l for prost ate can cer.
5. Calcium an d ph osph ate are com m on ly associated elect rolyte abn orm alit ies
th at m ay n eed to be corrected.
6. Radiological evalu at ion (Table 23.3):
a. Osteolyt ic lesion s: breast (85%), ren al cell, thyroid, an d lu ng.
b. Osteoblast ic lesion s: breast (15%) an d prost ate (Fig. 23.1).
Table 23.2

Classic physical exam ndings in m etastatic spine tumors

Primary tumor

Physical exam f ndings

Breast cancer

Hard, xed, nontender breast m ass


Nipple retraction
Skin erythem a or edem a

Prostate cancer

Large, hard, nodular prostate on digital rectal exam ination

Thyroid cancer

Painless, palpable thyroid

Lung cancer

Baseline change in cough


Hem opt ysis

Renal cell carcinom a

Classic triad of hem aturia, ank pain, and abdom inal m ass
Tobacco use

266 23 Spinal Tum ors

Table 23.3

Diagnostic im aging of spine tum ors

Imaging study

Advantages

Disadvantages

Plain
radiography

Simple screening m ethod


Helpful in diagnosis (benign
vs. m alignant, osteolytic vs.
osteoblastic)

Low sensitivit y (> 50% of


cancellous bone loss is needed for
radiographic identi cation of bone
destruction)
Winking owl sign

Bone scan

Most sensitive tool for


m etastases (osteoblastic
lesions)

Low speci cit y (cannot


di erentiate fracture, infection,
and neoplasm )

Computed
tom ography

Best for evaluating bone


destruction
Important for preoperative
planning

Ine ective as a screening tool

Magnetic
resonance
im aging

High sensitivit y, especially


when used with gadolinium
Provides inform ation about
soft tissue component
Helpful in evaluating spinal
cord compression

Extent of cord compression does


not consistently correlate with
symptom s or outcom e

Myelography

Good visualization of
epidural m etastasis and cord
compression

Invasive

Angiography

Selective em bolization of
the neoplasm m ay decrease
bleeding during surgery

Invasive

Fig. 23.1 Osteoblastic lesions in the L3 and L4


vertebral bodies.

23 Spinal Tum ors 267

Table 23.4 Magnetic resonance im aging ndings in spinal infection versus tum ors versus
compression fractures
Diagnosis

T1

T2

Di erentiating f ndings

Vertebral
osteomyelitis

Decreased signal
within disk and
end plates
Loss of end plate
de nition

Increased signal
within disk and
end plates
Loss of end plate
de nition

Disk/end plate involvement


> vertebral body
Hyperintense abscesses
on T2
Tuberculous spondylitis
does not involve
contiguous levels
Soft tissue m ass is poorly
de ned

Osteoporotic
compression
fracture

Decreased
signal in the
involved body
Incomplete
m arrow
replacem ent

Increased signal
in the body
Incomplete
m arrow
replacem ent

Returns to isointensit y on
T1 and T2
Marrow preservation in
the posterior third of the
body

Neoplastic
disease

Decreased
signal
De ned area
of in ltrative
edem a
Pedicle
involvem ent

Increased signal
De ned area
of in ltrative
edem a
Pedicle
involvem ent

No disk or cartilaginous
involvem ent
Noncontiguous
involvem ent is frequent
No restoration of norm al
signal intensit y as in
fracture
Soft tissue m asses are
eccentric, large, and well
de ned

7. Magn et ic reson an ce im aging (MRI) di eren t iat ion of in fect ion , fract ure, an d
t um or (Table 23.4).
D. Prim ar y t u m or t yp es:
1. See Table 23.5, Table 23.6, Table 23.7, an d Table 23.8.
E. St aging:
1. Wein stein Borian iBiagin i system (Fig. 23.2) (Table 23.9).
a. Th ree-dim en sion al descript ion of t u m or invasion .
F. Treat m en t:
1. Goals:
a. Establish m en t of a de n it ive diagn osis.
b. Main ten an ce of n eurological fun ct ion .
c. Restorat ion of spin al st abilit y.
d . Pain relief.
e. Con t rol of local t u m or an d preven t ion of m etast ases.

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268 23 Spinal Tum ors

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272 23 Spinal Tum ors

Fig. 23.2

Table 23.9

The WeinsteinBorianiBiagini system for spinal tum or staging.

WeinsteinBorianiBiagini staging system

Type

Notes

Anatomical zones

Twelve pie-like zones starting at the spinous


process and rotating clockwise

Involvement of di erent vertebral


layers

Extraosseous soft tissue


Intraosseous (super cial)
Intraosseous (deep)
Extraosseous (extradural)
Extraosseous (intradural)

Speci cation of the spinal


segment(s) involved

2. Treat m en t is dict ated by diagn osis, locat ion of t um or, an d gen eral h ealth of
th e pat ien t .
3. Radiat ion versu s surger y:
a. In 2005, Patch ell et al rep or ted th e resu lts of a m u lt icen ter, ran dom ized,
con t rolled t rial th at com pared th e outcom es associated w ith surger y plus
radiat ion versu s rad iat ion alon e for p at ien ts w ith n er ve com p ression
from m et ast at ic can cer to th e spin e.

23 Spinal Tum ors 273

(1) Advan t ages of surger y plus postoperat ive radiat ion versus radiat ion
alon e.
(a) A greater n u m ber of pat ien t s w ere able to w alk after t reat m en t
(84% vs 57%).
(b) Longer m ain ten an ce of con t in en ce.
(c) Greater m uscle st rength , fun ct ion al abilit y, an d in creased
su r vival.
(d) Decreased requirem en t of cort icosteroid an d opioid m edicat ion
after t reat m en t .
(e) Th e st udy w as term in ated early due to th e sign i can t advan tage
of th e surgical t reat m en t over radiat ion alon e.
4. Radiat ion th erapy is recom m en ded for th e follow ing pat ien t s:
a. Cord com pression cau sed by a soft t issu e t u m or w ith ou t com p rom ise of
th e surroun ding bony arch itect ure.
b. Radiorespon sive t u m ors:
(1) Hem atopoiet ic.
(2) Prost ate.
(3) Breast .
c. Decom pression w ith con com itan t radiat ion th erapy is associated w ith
su perior ou tcom es w h en com pared w ith rad ioth erapy alon e for p at ien t s
w ith m et astat ic can cer causing spin al cord com pression .
d. Spin al radiat ion prior to su rgical in ter ven t ion is associated w ith greater
rates of w ou n d com p licat ion s (deh iscen ce, in fect ion , revision ) an d
adverse su rgical ou tcom es.
5. Surger y:
a. In dicat ion s.
(1) Diagn ost ic evaluat ion .
(2) Cu rat ive excision (ben ign t um ors an d cer t ain m align an t t um ors).
(3) Spin al in stabilit y or deform it y secon dar y to n eoplast ic bon e
dest ru ct ion .
(4) Neu rological deteriorat ion.
(5) Failure of previous radiat ion th erapy.
(6) Radiat ion -resistan t t u m ors.
(7) Un rem it t ing pain .
b. Surgical st rat i cat ion .
(1) Diagn osis of t um or.
(a) Ben ign versus m align an t (Fig. 23.3 an d Fig. 23.4).
(b) Prim ar y versu s m et ast at ic.
(2) St age.
(a) Degree of spin al involvem en t .
(b) Poten t ial m et astat ic spread.
(3) Neu rological stat u s.
(a) Prim ar y in dicator of postsurgical outcom e.
i. Rapid p rogression of sym ptom s (< 1 w eek) is a poor
p rogn ost ic in dicator.
ii. Pat ien t s w ith severe de cit s (in abilit y to w alk, loss of bow el/
bladder fun ct ion ) are less likely to recover.

274 23 Spinal Tum ors

Fig. 23.3 Examples of primary benign tumors of the spine. (a) Computed tomography (CT) scan demonstrating an osteoid osteoma with a central nidus and sclerotic rim at the posterior part of the vertebral
body. (b) Lateral radiograph demonstrating an osteoblastoma of C2 with an expansile sclerotic bone. (c)
Lateral radiographs demonstrating vertebra plana at C6 due to eosinophilic granuloma. (d) Lateral lumbar
radiograph showing a hemangioma with osteopenia and vertical striations of the vertebral body.

(4) Progn osis.


(5) St ruct ural stabilit y (Fig. 23.5).
(6) Pain st at us.
c. Surgical approach .
(1) Excise th e en t ire lesion if possible.
(a) Tot al en bloc spon dylectom y (Fig. 23.6 an d Fig. 23.7).
i. Accom p lish ed th rough a posterior approach .
ii. Par t icu larly u sefu l if excising th e lesion is curat ive.
Ch on drosarcom a.
(2) Approach an teriorly or posteriorly or both depen ding on th e locat ion
of th e t um or.
(a) A decom pressive lam in ectom y does not address an terior
path ology an d predisposes pat ient s to postoperat ive in st abilit y.

23 Spinal Tum ors 275

Fig. 23.4 Intradural neuro broma. (a) Anteroposterior myelography showing a myelographic block at
L1 due to a neuro broma. The myelographic block is smooth and meniscal in shape (arrows) due to the
intradural adhesions, whereas extradural lesions produce a ragged margin. (b) Computed tomographic
scans showing erosion of the vertebral body and pedicle due to expansion of intradural neuro bromas.

(3) Met ast at ic t um ors are usually approach ed an teriorly if th e spin al


cord com pression is an terior.
(a) Recon st ruct ion can be perform ed w ith autograft , allograft ,
m ethyl m eth acr ylate cem en t , or syn th et ic m aterials.
i. Autograft/allograft allow s poten t ial biologic in corporat ion .
ii. Methyl m ethacr ylate o ers instantan eous stabilit y but m ay fail
in pat ien ts w hose expected life span is prolonged (> 1 year).
iii. Pat ien ts w h o receive postoperat ive irradiat ion h ave decreased
ch an ces of ach ieving biological fusion .
d. Stereot act ic radiosurger y (SRS).
(1) Delivers ver y h igh doses of radiat ion to an ult raspeci ed locus of
t issue in an e ort to m in im ize dam age to th e surroun ding st ru ct ures.
(2) Coupled w ith robot ic n avigat ion to gu ide th e t rajector y of th e
radiat ion beam in six dim en sion s.
(3) Advan cem en ts in SRS, in clu ding in ten sit y-m odulated radioth erapy,
h ave fu r th er am pli ed th e p recision an d accu racy of radioth erapy to
lim it dam age to th e spin al cord.
(a) Th is h igh level of precision allow s for m ult iple t reat m en t s, if
n ecessar y.
(4) Can be used in conjun ct ion w ith su rgical decom pression .

276 23 Spinal Tum ors

c
Fig. 23.5 Im ages of a 17-year-old girl with giant cell tum or involving the sacrum. (a) Anteroposterior view of the spine and pelvis showing a destructive lesion involving the sacrum and left sacroiliac
joint. (b) Lateral radiograph showing a destructive lesion at S1S2. Note that the sacrum is not well
dem arcated. (c) Computed tom ographic scan showing the extent of the tum or with involvem ent of
the left sacroiliac joint.

23 Spinal Tum ors 277

f
Fig. 23.5 (Continued) Im ages of a 17-year-old girl with giant cell tumor involving the sacrum .
(d) T2-weighted sagit tal magnetic resonance im age showing a large tumor extension into the pelvis anteriorly and into the spinal canal posteriorly. (e,f) A posterior approach was used to perform a
lam inectomy of L5 and the sacrum with excision of the tum or. Reconstruction was performed with a
transiliac bular graft, lumbar pedicle screws, bilateral iliac screws, and rod xation. The patient was
m obilized imm ediately, and healing was evident without recurrence at follow-up.

278 23 Spinal Tum ors

b
Fig. 23.6 (a) Axial computed tom ographic im age of a chondrosarcoma in the sacrum . (b) Microscopic im age of chondrosarcom a cells.

23 Spinal Tum ors 279

Fig. 23.7 (a,b) Anteroposterior and lateral radiographs following total spondylectomy for a T11
chordom a with spinal instrumentation and graft in position. (From Dickm an CA, Fehlings MG,
Gokaslan ZL. Spinal Cord and Spinal Colum n Tumors. New York, NY: Thiem e Medical Publishers; 2006:
Fig. 34.14. Reproduced with permission.)

Suggested Reading
Cloyd JM, Acost a FL Jr, Polley MY, Am es CP. En bloc resect ion for prim ar y an d m et ast at ic t u m ors of th e sp in e: a system at ic review of th e literat u re. Neu rosu rger y
2010;67(2):435444, discussion 444445
Gerszten PC, Men del E, Yam ada Y. Radioth erapy an d radiosu rger y for m et ast at ic spin e
disease: w h at are th e opt ion s, in dicat ion s, an d ou tcom es? Spin e 2009;34(22, Suppl):
S78S92
Gh ogaw ala Z, Man s eld FL, Borges LF. Spin al radiat ion before surgical decom pression adversely a ect s ou tcom es of su rger y for sym ptom at ic m et ast at ic sp in al cord com p ression . Spin e 2001;26(7):818824
Klim o P Jr, Th om pson CJ, Kestle JR, Sch m idt MH. A m et a-an alysis of su rger y versu s con ven t ion al radioth erapy for th e t reat m en t of m et ast at ic sp in al ep idu ral disease. Neu ro-on col 2005;7(1):6476
Polly DW Jr, Chou D, Sem brano JN, Ledonio CG, Tom ita K. An analysis of decision m aking and
treatm ent in thoracolum bar m etastases. Spine 2009;34(22, Suppl):S118S127

24 Spinal Infections

24.1 General Considerations


I. Vertebral osteom yelit is.
A. In ciden ce/risk factors.
1. Approxim ately 2 to 7% of all osteom yelit is (12% in ch ildren ).
2. Lu m bar > th oracic > cer vical.
3. Males > fem ales (2:1).
4. More com m on after th e fth decade of life (> 50% of cases).
5. Risk factors include diabetes, m alnutrition, perioperative hyperglycem ia,
obesit y, sm oking, im m unocom prom ise (steroids, HIV/AIDS), previous surger y.
B. Et iology.
1. Hem atogen ous spread is th e m ost com m on route for vertebral osteom yelit is.
a. Urin ar y t ract is th e m ost com m on sou rce (e.g., u rin ar y t ract in fect ion s,
t ran sien t bacterem ia from gen itourin ar y procedures).
b. Soft t issue in fect ion s.
c. Respirator y in fect ion s.
2. Un iden t i ed source.
3. Direct in oculat ion (e.g., pen et rat ing t raum a, invasive spin al procedu re).
4. Causat ive bacteria (in order of frequen cy):
a. Gram -p osit ive aerobic cocci (> 80%).
(1) Staphylococcus aureus (> 50%).
(a) Meth icillin -resist an t S. aureus (7%).
(2) St reptococcus (1020%).
(3) Coagulase-n egat ive Staphylococcus (10%).
(4) Propionibacterium acnes (d elayed in fect ion ).
b. Gram -n egat ive aerobic cocci (1520%).
(1) Most com m on origin is from th e u rin ar y t ract (Escherichia coli,
Pseudom onas aeruginosa, Proteus).
c. Gast roin test in al t ract organ ism s.
(1) Salm onella (rare).
(a) More com m on in pat ien t s w ith sickle cell.
d . Gran u lom atou s in fect ion s (far less com m on ).
(1) Mycobacterium t uberculosis, fu ngi, sp iroch etes.
(2) More com m on in th e th oracic region .
C. Path ology.
1. In oculat ion .
a. Hem atogen ou s sp read to th e vertebral m et ap hysis m ost likely occu rs via
rich arterial an astom osis (n u t rien t arter y) (Fig. 24.1).
(1) Bat sons valveless ven ous plexus is n ot con sidered to play a
sign i can t role in bacterial h em atogen ou s seeding.
280

24 Spinal Infections 281

Fig. 24.1 Sagit tally sectioned human fetal specim en (26 weeks gestation), injected, cleared, and
transillum inated, showing cartilage canals and absence of vessels in nucleus pulposus. (A) Cartilage
canal; (B) nucleus pulposus; (C) hyaline cartilage; (D) ossi ed vertebral body.

(2) Vertebral m et aphysis is a low - ow environ m en t th at m ay allow for


th e direct spread of bacteria in to an d across th e in ter ver tebral disk.
2. Spread to th e in ter vertebral disks.
a. Bon e/disk dest ru ct ion (Fig. 24.2).
(1) Bacteria produce en zym es th at digest disk t issue.
(2) Bon e resorpt ion by osteoclast s is act ivated by various in am m ator y
m ediators.
3. Soft t issue exten sion .
a. Psoas abscess.
b. Paraspin al m uscle abscess.
c. Epidural abscess.
(1) May result in n eurological com prom ise secon dar y to direct
com pression of th e spin al cord an d n er ve roots.
D. Clin ical n dings.
1. Delay in diagn osis is com m on .
2. Back or n eck pain is th e m ost com m on presen t ing com plain t (90%).
a. Sym ptom s are t yp ically presen t for m ore th an 3 m on th s in 50% of
p at ien t s.
b. Acute presen t at ion w ith sept icem ia an d toxem ia is ext rem ely rare.
3. Localized pain an d ten dern ess w ith a decreased range of m ot ion are th e
m ost con sisten t n dings.
4. Histor y of fever > 100F (w ith or w ith ou t ch ills) is presen t in over 50% of
p at ien t s.
5. In ch ildren , a lim p an d refusal to w alk are ch aracterist ically presen t .

282 24 Spinal Infections

d
Fig. 24.2 A 76-year-old woman with rheumatoid arthritis and a T12L1 diskitis/ L1 osteomyelitis.
Result s of three needle biopsies were negative. (a,b) Anteroposterior and lateral radiographs dem onstrated a diskitis at T12L1 with destruction of the L1 vertebral body. (c) T1-weighted sagit tal m agnetic resonance im aging (MRI) sequence shows decreased signal throughout and across the T12L1
disk space. The end plates are blurred and indistinct. (d) T2-weighted sagit tal MRI sequence shows
high signal within the T12L1 disk and the L1 vertebral body.

E. Laborator y n dings (Table 24.1).


F. Rad iograp h ic im aging st u dies (Table 24.2).
G. Treat m en t .
1. Goals.
a. Est ablish a t issu e diagn osis an d iden t ify th e organ ism .
b. Eradicate th e infect ion .
c. Provide long-term pain relief.
d. Preven t or relieve any n eurological de cit s.
e. Restore sp in al st abilit y/align m en t .

24 Spinal Infections 283

h
Fig. 24.2 (Continued) A 76-year-old wom an with rheum atoid arthritis and a T12L1 diskitis/ L1 osteomyelitis. Result s of three needle biopsies were negative. (e) T1-weighted sagit tal MRI sequence with
gadolinium shows enhancement of the T12L1 disk space and L1 vertebral body. There is a slight
am ount of enhancing tissue in the anterior epidural space without compression of the conus m edullaris or cauda equina. (f) T1-weighted axial MRI sequence with gadolinium shows enhancem ent of
the T12L1 disk space. (g,h) Anteroposterior and lateral radiographs taken 6 m onths after surgery
dem onstrating incorporation of the bone graft anteriorly with solid xation posteriorly.

2. Prin ciples.
a. Medically opt im ize th e p at ien t .
(1) Nut rit ion al supplem en tat ion .
(2) Correct any laborator y abn orm alit ies.
b. Treat ext raspin al sources of in fect ion .
(1) Urin ar y t ract .
(2) Cardiovascu lar (in fected th rom bus).
(3) Gast roin test in al.
c. Broad-spect rum an t ibiot ics sh ould be st ar ted, an d th en an t ibiot ic
th erapy sh ould be speci c to th e organ ism iden t i ed.

284 24 Spinal Infections

Table 24.1

Laboratory m arkers in spinal infections

Test

Findings

ESR

Elevated at presentation in m ore than 80% of cases


ESR norm alizes in t wo-thirds of patients adequately treated

WBC

> 10,000/m m 3 in m ore than 50% of cases


WBC count has a low sensitivit y for diagnosis

CRP

More sensitive and speci c than ESR for m onitoring postoperative


spine infections

Blood cultures

Most useful in children with vertebral pyogenic osteomyelitis


Only positive in ~ 35% of patients
Reliable in detecting the o ending organism

Needle biopsy

False-negative examinations are common when patient is on antibiotics

Open biopsy

Indicated if needle biopsy is negative, nondiagnostic, or both despite


high clinical suspicion
Lower false-negative rate than closed biopsy

Abbreviations: CRP, C-reactive protein; ESR, erythrocyte sedim entation rate; WBC, white
blood cell count.

d. Er yth rocyte sedim en t at ion rate (ESR) an d C-react ive protein (CRP) levels
are u sefu l to obtain prior to th erapy.
(1) May be follow ed as an in dicat ion of t reat m en t e cacy.
3. Operat ive t reat m en t .
a. In dicat ion s.
(1) Cases th at h ave failed n on operat ive m an agem en t .
(2) Progressive n eu rological de cit .
(a) Du e to direct com pression from th e in fect ion .
(b) Du e to p rogressive d eform it y or in stabilit y.
(3) Abscess or gran ulom a form at ion .
(a) An t ibiot ics are in e ect ive.
(4) In t ract able pain n ot respon sive to con ser vat ive m easures.
b. Tech n ique (Fig. 24.3).
(1) An terior approach is th e m ost useful for vertebral body debridem en t
(corpectom y).
(a) Lam in ectom y alon e for decom pression is con t rain dicated
because of th e poten t ial for spin al destabilizat ion .

24 Spinal Infections 285

Table 24.2

Diagnostic im aging in spinal infections

Imaging study

Findings

Plain radiographs

Findings lag behind clinical presentation (at least 2 weeks


from the onset of infection)
Disk space narrowing with erosive changes (75%)
Osteolysis, di use osteopenia, focal defect
50% trabecular bone destruction before radiographic
evidence is noted
Osteosclerosis (11%)
Chronic cases may reveal spontaneous bone fusion (50%)

Nuclear im aging

E ective as an initial screening tool


Earlier detection and localization when compared with
plain lms
Com bination of gallium (in amm atory) and technetium
(bone) scans provides > 90% accuracy in diagnosis
Indium -111-labeled leukocyte (white blood cell) scans are
not sensitive in the spine
High false-negative rate m ay be related to leukopenia

Computed tomography

Best modalit y for identifying bone destruction

Magnetic resonance
im aging

Im aging modalit y of choice for spine infections


T1-weighted im agesdecreased signal around adjacent
T2-weighted imageshigh signal intensit y in bodies near
adjacent end plates and disk space end plates and disk space
Loss of end plate de nition
Involved portions of disks and vertebral bodies enhance
with gadolinium
Allows for visualization of soft tissue involvem ent
(paraspinal, psoas abscess)
Best imaging modality to di erentiate infection versus tumor

(2) Autogen ous bon e graft is th e gold st an dard for recon st ruct ion (iliac
crest , rib, or bula).
(a) How ever, au tograft- lled t it an ium cages an d cor t ical st rut
allograft h ave dem on st rated good clin ical resu lt s.
(b) Tit an iu m alloys h ave dem on st rated low er bacterial ad h esion th an
st ain less steel alloys an d are n ow com m on ly u sed in th e set t ing
of an terior corpectom ies.
(c) More recen tly, polyeth ereth erketon e (PEEK) in terbody devices
(expan dable) h ave been su ccessfully used in th e set t ing of a
corpectom y for a spin al in fect ion .
(3) Th oracic an d lum bar ver tebral osteom yelit is m ay be t reated by
a single p osterior ap p roach (debridem en t an d xat ion ) u sing an
in terbody tech n ique.

286 24 Spinal Infections

a
Fig. 24.3

(a) A corpectomy procedure.

II. Ep idu ral abscess.


A. Et iology.
1. Associated w ith ver tebral pyogen ic osteom yelit is in 28% of cases.
2. S. aureus m ost com m on cau sat ive organ ism (~ 60%).
3. Region al or locat ion frequen cies:
a. Th oracic (50%).
(1) Neu rological de cit s are m ore com m on .
b. Lu m bar (35%).
c. Cer vical (14%).
4. Most cases are in adult s (rare in ch ildren ).
a. Postop erat ive (16%).
B. Clin ical p resen tat ion .
1. High ly variable, leading to m isdiagn osis an d delayed t reat m en t in > 50% of
p at ien t s.
2. Localized spin e ten dern ess is m ore com m on .
3. Nuch al rigidit y an d oth er m en ingeal sign s are possible.
4. With or w ith out n eurological de cit .
C. Diagn osis.
1. ESR is elevated in > 98% of cases.
2. W h ite blood cell coun t (W BC) is un reliable.

24 Spinal Infections 287

b
Fig. 24.3 (Continued) (b) Incorporation of an expandable cage.

3. Magnetic resonance im aging (MRI) is the im aging m odalit y of choice (Fig. 24.4
and Fig. 24.5).
a. In ten se focal sign al on T2.
b. Epidural m et ast asis an d subdural abscess sh ou ld be con sidered in th e
di eren t ial.
D. Treat m en t .
1. Epidural abscess requires urgen t surgical at ten t ion .
2. Epidural abscess in th e presen ce of a w orsen ing n eurological de cit is a
su rgical em ergen cy.
a. Except ion s.
(1) Non operat ive t reat m en t con sist ing of an t ibiot ic th erapy w ith close
m on itoring m ay be con sid ered if su rger y w ou ld en danger th e
pat ien ts life.
III. Disk sp ace in fect ion s.
A. Epidem iology/et iology.
1. May occur as a result of direct in oculat ion .
a. Su rgical p roced u res.
(1) Diskogram .
(2) Diskectom y.
(3) In t radiskal elect roth erm al th erapy (IDET).

288 24 Spinal Infections


Fig. 24.4 Sagit tal T2-weighted magnetic resonance image dem onstrating increased signal intensit y of the intervertebral disks and vertebral bodies
bet ween L2L5 suggestive of vertebral osteomyelitis with disk involvem ent. (From Im hof H, ed. Spinal
Im aging (Direct Diagnosis in Radiology). Stut tgart,
Germ any: Georg Thieme Verlag; 2008: Fig. 4.46.
Reproduced with perm ission.)

Fig. 24.5 Sagit tal T2-weighted magnetic resonance im aging


of a subdural abscess versus epidural metastases in the cervical
spine. (From Uhlenbrock D. MR Im aging of the Spine and Spinal Cord. Stut tgart, Germ any: Georg Thiem e Verlag; 2004: Fig.
6.50. Reproduced with perm ission.)

2. Hem atogen ous spread:


a. Th is is th e rou te m ost com m on ly en cou n tered in th e pediat ric
p op u lat ion .
(1) Blood supply from th e disk is from th e surface of th e adjacen t
vertebral bodies.

24 Spinal Infections 289

3. Th e lum bar spin e is m ost com m on ly involved.


B. Clin ical n dings.
1. Th e t ypical pat ien t is bet w een 2 an d 7 years of age.
a. Pat ien t s m ay n ot com p lain of back p ain .
b. Lim ping, refusal to w alk, or h ip pain m ay be presen t ing sym ptom s.
2. ESR an d W BC are elevated.
3. MRI or bon e scan is posit ive early in th e disease (Fig. 24.6).
a. Plain rad iograp h s m ay d em on st rate n arrow ing of th e in ter vertebral
sp ace, sclerosis, or bony erosion .
C. Treat m en t .
1. Surger y is rarely in dicated or n eeded.
2. Im m obilizat ion w ith a brace.
3. An t ibiot ic th erapy.
4. Biopsy is in dicated if an t ibiot ics are n ot e ect ive.
IV. Tu bercu losis of th e sp in e.
A. Epidem iology/et iology.
1. Most com m on gran u lom atous in fect ion in th e w orld.
2. Hem atogen ous spread is th e m ost com m on source (pulm on ar y or
gast roin test in al in fect ion s).

Fig. 24.6 (a,b) Sagit tal T1-weighted magnetic resonance im aging demonstrating decreased signal
intensit y, epidural collection, and irregularit y of the cervical spine suggestive of vertebral osteomyelitis. (From Uhlenbrock D. MR Imaging of the Spine and Spinal Cord. Stut tgart, Germ any: Georg Thieme
Verlag; 2004: Fig. 6.48. Reproduced with perm ission.)

290 24 Spinal Infections

3. Th e spin e is th e m ost com m on sou rce of skelet al involvem en t .


a. Most cases involve th e an terior sp in e.
b. Involvem en t of adjacen t levels from expan sion th rough th e disk space.
c. Fift y percen t of in fect ion s are localized an d can be categorized (Fig. 24.7).
(1) Peridiskal (m ost com m on ): st art s in th e m et aphysis an d spreads
u n der th e an terior longit udin al ligam en t .

d
c
Fig. 24.7 Radiographic features of the three t ypes of tuberculous spondylitis. (a,b) Peridiskal involvem ent is characterized by disk-space narrowing followed by variable bone destruction. The radiograph
on the left is early in the disease. The radiograph on the right is after resolution of the disease with
m inor deform it y. (c) Anterior m ultilevel disease is distinguished by scalloped erosions of the anterior
aspect of several adjacent vertebrae (T11, T12, L1). (d) Central involvem ent resembles a tumor with
central body rarefaction and bone destruction followed by collapse (L1 and L2).

24 Spinal Infections 291

(2) Cen t ral (rare): st art s w ith in a single ver tebral body.
(3) An terior (rare): st art s un der th e an terior longit udin al ligam en t .
B. Clin ical presen t at ion /diagn osis.
1. Pain is presen t w ith eviden ce of system ic illness.
a. Fever, m alaise, an d w eigh t loss.
2. Local ten dern ess, m uscle spasm , an d lim ited range of m ot ion .
3. Tissue biopsy can be di cu lt because of th e long in cubat ion period for
m ycobacterium .
a. Fift y percen t false-n egat ive rate.
4. Di eren t ial diagn osis:
a. Neop lasm s.
b. Sarcoidosis.
c. Ch arcot spin e.
C. Radiological evalu at ion .
1. MRI is th e m odalit y of ch oice.
a. Un iqu e ch aracterist ics of t u bercu losis versu s pyogen ic in fect ion s.
(1) Disk space is often spared.
(2) Involvem en t of an terior bodies over con t iguou s segm en ts.
(3) Paraspin al abscesses an d gran ulom as are dist inguish ed w ith th e use
of gadolin ium .
D. Treat m en t .
1. Conser vat ive m an agem en t .
a. An t it u bercu lou s drugs con st it u te rst-lin e t reat m en t .
b. Nin e to 12 m on th s of th erapy.
c. Su ccessful th erapy is associated w ith a fall in th e serial ESR values, a
decrease in pain , an d w eigh t gain .
2. Surgical m an agem en t .
a. In dicat ion s:
(1) Failure to respon d to an t it uberculosis therapy.
(2) Neurological com prom ise or evidence of progressive spinal instabilit y.
b. Th e Hong Kong procedure (Fig. 24.8):
(1) An terior approach for an terior path ology.
(2) Radical debridem en t an d rem oval of all n ecrot ic t issue.
(3) St rut graft/fusion using autograft or allograft restoring an terior
colu m n su ppor t .
(4) Posteriorly su pplem en ted in st rum en tat ion in m ore th an t w o levels
an teriorly.
c. Lam in ectom y alon e is con t rain dicated.
V. Postoperat ive in fect ion s.
A. Risk factors (Table 24.3).
B. Preven t ion .
1. Optim izat ion of pat ien t risk factors prior to su rger y.
2. St rict sterile tech n ique.
3. Dilute iodin e in irrigat ion solut ion or dilute iodin e w oun d soak prior to
closure.

292 24 Spinal Infections

Fig. 24.8 Tuberculosis of the lum bar spine. A 52-year-old man with dissem inated tuberculosis was
treated with 1 year of therapy with three antituberculous drugs. He presented with progressive low
back pain and neurogenic claudication. (a) Anteroposterior and (b) lateral lumbar spine radiographs
show collapse of L2 and L3 with kyphotic deform it y. (c,d) T1-weighted im age sagit tal m agnetic resonance imaging (MRI) sequence dem onstrates decreased signal in the bodies of L1 to L4, kyphotic
deformit y, and epidural m ass composed of necrotic bone, disk, and purulent debris. (e,f) T2-weighted
sagit tal MRI sequence dem onstrates areas of high signal intensit y within the L2 and L3 vertebral bodies
and in the anterior paraspinal region.

4. Van com ycin m ixed bon e graft or pulse lavage.


a. Most recen t m et a-an alyses dem on st rate favorable ou tcom es.
b. Result s m ay depen d on th e in ciden ce of postoperat ive spin al in fect ion s in
th e local populat ion .
(1) Van com ycin m ixed bon e graft is likely m ore e cacious if th e n um ber
to t reat is greater.

24 Spinal Infections 293

Table 24.3

Risk factors for postoperative infections

Diabetes m ellitus
Chronic corticosteroid use
Chem otherapy
Revision surgery
Prolonged operative tim e (> 4 h)
Morbid obesit y
Preoperative/postoperative infectious condition
Tooth abscess
Urinary tract infection
Pneum onia
Open sores
Prolonged drainage from the surgical wound

C. Presen t at ion .
1. Elevated ESR an d W BC w ith con com it an t fever an d w oun d drain age are
su sp iciou s sign s.
D. Diagn osis.
1. MRI w ith gadolin iu m en h an cem en t is th e best m odalit y to detect an SSI.
2. Ver tebral an d soft t issue ch anges m ust be di eren t iated bet w een n orm al
postoperat ive ch anges an d ver tebral osteom yelit is.
a. Both st ates are associated w ith t yp e 1 en d p late ch anges ch aracterized by
adjacen t m arrow edem a an d hyp oin ten se sign al on T1 im aging.
b. Gadolin ium con t rast dem on st rates areas of en h an cem en t in th e disk
space.
c. In fect ion is associated w ith circum feren t ial disk en h an cem en t , w h ereas
lin ear areas of en h an cem en t are m ore con sisten t w ith n orm al ch anges.
E. Early versus late.
1. Early in fect ion s are t ypically recogn ized by system ic com plain ts.
a. Fevers, ch ills, local w ou n d er yth em a, drain age, in creased back p ain
2. Late in fect ion s:
a. More com m on , p art icu larly in th e p resen ce of in st ru m en t at ion .
(1) Di cu lt clin ical diagn osis th at sh ould be con sidered if sign i can t risk
factors are ap paren t .

294 24 Spinal Infections

F. Su p er cial versu s deep .


1. Di cu lt to di eren t iate by physical exam in at ion .
a. Irrigat ion an d debridem en t sh ou ld in clu de op en ing th e deep fascial layer
to evaluate for th e presen ce of an occult deep w oun d in fect ion .
G. Man agem en t .
1. Th e t ype of postoperat ive in fect ion dictates m an agem en t:
a. Su p er cial SSIs resp on d to a cou rse of in t raven ou s an t ibiot ics an d /or
bedside drain age.
b. Medical th erapy alon e is un successfu l w ith subfascial in fect ion s due to
p oor an t ibiot ic pen et rat ion .
(1) May w arran t m ult iple episodes of exten sive debridem en t of in fected
an d n ecrot ic t issu e.
2. In st rum en tat ion sh ould be ret ain ed to m ain t ain th e st abilit y of th e spin al
colum n ; h ow ever, loosen ed im plan t s sh ou ld be rem oved, an d th e pat ien t
sh ou ld be m on itored closely for p seu darth rosis.
3. Negat ive-pressure w ou n d th erapy:
a. Vacu u m -sealed su ct ion d evice th at en closes th e su rgical w ou n d .
b. En h an ces w ou ld h ealing an d closure due to th e follow ing m ech an ism s:
(1) Rem oval of in terst it ial uid th at redu ces in terst it ial uid pressure
an d en h an ces blood p erfu sion .
(2) Negat ive pressure cau ses m ech an ical st im ulat ion th at facilit ates cell
grow th , in creases blood ow, an d red u ces bacterial load .

Suggested Reading
Borkh uu B, Borow ski A, Sh ah SA, Lit tleton AG, Dabn ey KW, Miller F. An t ibiot ic-loaded allograft decreases th e rate of acute deep w ou n d in fect ion after spin al fu sion in cerebral
palsy. Spin e 2008;33(21):23002304
Canavese F, Gupta S, Krajbich JI, Em ara KM. Vacuum -assisted closure for deep in fection after
spinal instrum entation for scoliosis. J Bone Joint Surg Br 2008;90(3):377381
Ch iang HY, Her w aldt LA, Blevin s AE, Ch o E, Sch w eizer ML. E ect iven ess of local van com ycin pow der to decrease su rgical site in fect ion s: a m et a-an alysis. Sp in e J 2014;14(3):
397407
Olsen MA, Nep ple JJ, Riew KD, et al. Risk factors for su rgical site in fect ion follow ing orth opaedic sp in al op erat ion s. J Bon e Join t Surg Am 2008;90(1):6269
Sasso RC, Garrido BJ. Postop erat ive spin al w oun d in fect ion s. J Am Acad Orth op Surg
2008;16(6):330337

25 Rheumatoid Arthritis

25.1 General Considerations


I. Ep idem iology.
A. Most com m on during th e fth an d sixth decade.
B. Fem ale > m ale (3:1).
C. Tw en t y- ve to 80% of p at ien t s w ith rh eu m atoid arth rit is (RA) w ill h ave cer vical
sp in e involvem en t .
1. Th e th oracic an d lum bar spin e are rarely a ected.
II. Path ogen esis.
A. Com plex in teract ion bet w een gen es an d environ m en t .
1. Gen et ic com pon en t .
a. In creased su scept ibilit y m ediated by HLA-DR an t igen s.
b. Tw elve to 15% con cordan ce rate of RA bet w een iden t ical t w in s.
2. Environ m en tal com pon en t s.
a. Sm oking (st rongest eviden ce).
(1) In creases suscept ibilit y 20 to 40 t im es.
(2) Act ivates in am m ator y cascade result ing in com plem en t at tach m en t
to th e t issues.
b. Oth er environ m en tal com pon en t s.
(1) In fect ion s (n o causal e ect h as been proven ).
(a) Mycoplasm a.
(b) Proteus m irabilis.
(c) Epstein Barr virus (EBV).
(d) Ret rovirus.
(2) Occupat ion exposure.
(a) Silica.
(3) Alcoh ol in take.
B. Cellu lar in teract ion w ith syn ovial t issu e.
1. T lym ph ocytes.
a. Con st it u te > 50% of cells in m ost RA syn oviu m .
b. Act ivate B cells to in crease an t ibody produ ct ion .
c. A defect in program m ed cell death (apoptosis) results in lym phoproliferation.
d. An t igen s th at can in duce a T cellm ediated adapt ive im m un e respon se:
(1) Type II collagen .
(2) Im m un oglobulin G (IgG).
(3) Cit rullin ated protein s.
(4) Glycoprotein s (secreted by syn ovial cells an d ch on drocytes).
2. Angiogen esis an d cell m igrat ion .
a. New syn ovial blood vessels are form ed.
(1) In creases uid t ran sudat ion s.
295

296 25 Rheum atoid Arthritis

(2) Prom otes t ran sm igrat ion of lym ph ocytes in to th e syn ovium an d
polym orph on uclear leukocytes in to th e syn ovial uid.
3. Tum or n ecrosis factor (TNF).
a. Act ivates p rod u ct ion of adh esion cells in n ew ly form ed en doth elial cells.
b. Helps recru it in am m ator y cells in to th e syn ovium .
c. In h ibits apoptosis of in am m ator y cells.
d. In duces th e product ion of cytokin es to propagate th e in am m ator y
cascade.
4. Cellular com pon en ts in syn ovium an d syn ovial u id.
a. Syn oviu m .
(1) T lym ph ocytes (CD4).
(2) Fibroblast-like syn oviocytes.
(a) Mediate in it ial dest ruct ion of car t ilage at th e car t ilagepan n us
ju n ct ion (periph er y of join t s).
b. Syn ovial uid.
(1) T lym ph ocytes (CD8).
(2) Neu t roph ils.
III. Clin ical n dings.
A. In sidious on set .
B. Con st it u t ion al sym ptom s.
C. Sym m et rical p olyar th rit is.
1. Morn ing st i n ess.
2. Joint pain an d sw elling.
3. Wrist an d nger involvem en t (does n ot a ect dist al in terph alangeal [DIP]
join t).
4. Axial spin e is involved in 20 to 50% of th e cases.
D. Ext ra-art icu lar involvem en t .
1. Su bcut an eou s n odules.
2. Pleuropericardit is.
3. Episclerit is.
E. Variable clin ical course.
1. Spon tan eous exacerbat ion s an d decrease in sym ptom s.
2. St ruct ural dam age is cum ulat ive an d irreversible.
IV. Laborator y n dings.
A. Syn ovial uid aspirate (rarely obtain ed in pract ice).
1. In am m ator y e usion .
2. Leukocyte coun t 1,500 to 25,000/m m 3 .
3. Predom in an ce of polym orph on uclear (PMN) cells.
B. Serological test s.
1. Not used for screen ing purposes.
2. Rh eum atoid factor (RF) (7585%).
3. An t icit rullin ated pept ide an t ibodies (ACPA) (> 95%).
4. Posit ive serological n dings can be presen t as early as 10 years prior to any
sym ptom s.
5. Both RF an d ACPA are associated w ith a h igher risk of developing erosive
join t dam age an d fu n ct ion al im p airm en t .

25 Rheum atoid Arthritis 297

C. Oth er h em atologic n dings.


1. An em ia of ch ron ic disease.
2. Elevated ESR an d CRP.
V. Radiograph ic st udies.
A. All RA pat ien t s sh ould h ave cer vical spin e exam in at ion .
1. Plain lm radiograph s.
a. Help s determ in e atlan toaxial in st abilit y.
b. Used to predict risk of paralysis.
2. Magn et ic reson an ce im aging (MRI).
a. Usefu l in visu alizing spin al cord com p ression d u e to odon toid p an n u s
(space available for th e cord [SAC]).
3. Com puted tom ograph ic (CT) scan .
a. Provides excellen t bony d etail.
b. Excellen t abilit y to detect spin al cord com pression from syn ovial pan n us
if p erform ed w ith in t rath ecal con t rast .
c. Reser ved for pat ien t s w ith con t rain dicat ion to MRI (e.g., pacem akers).
VI. Cer vical spin e deform it y.
A. In st abilit y depen ds on th e severit y of th e disease process.
B. Su blu xat ion appears 1 decade after th e disease on set .
C. Radiographic progression of subluxation has been observed in 35 to 80%of patients.
1. Seven to 34% w ill develop a n eurological de cit .
2. Recen t eviden ce h as dem on st rated th at aggressive early m edical t reat m en t
w ith disease-m odifying an t irh eum at ic drugs (DMARDs) can sign i can tly
decrease th e risk of cer vical spin e atlan toaxial disorders.
D. Atlan toaxial in st abilit y (or su blu xat ion ) (Fig. 25.1):
1. Most com m on cer vical spin e abn orm alit y in RA (49%).
2. Result s from erosive syn ovit is in th e follow ing join t s:
a. Atlan toaxial.
b. Atlan to-odon toid.
c. Atlan to-occipital.
3. Radiograph ic n dings.
a. An terior atlan toden s in ter val (AADI):
(1) Dist an ce bet w een th e posterior m argin of C1 to th e an terior surface
of th e odon toid:
(a) Th e n orm al distan ce is 3 m m in adu lts an d 4.5 m m in ch ildren .
(2) AADI is an un reliable predictor of paralysis because of poor
correlat ion bet w een th e AADI an d th e degree of cord com pression as
sh ow n by m agn et ic reson an ce im aging (MRI).
(a) AADI 8 m m h as a posit ive predict ive valu e (PPV) of 61% an d a
n egat ive p redict ive valu e (NPV) of 56%.
b. Th e posterior atlan toden s in ter val (PADI) h as been dem on st rated as a
bet ter predictor of paralysis.
(1) Th e in ter val bet w een th e posterior den s an d th e an terior m argin of
th e lam in a at C1 is m easured in a lateral plain lm radiograph .
(a) An in ter val 14 m m h as a PPV of 69% an d an NPV of 94% w ith
regard to predict ing paralysis.
(b) Preferred screen ing test .

298 25 Rheum atoid Arthritis


Fig. 25.1 Sagit tal T2-weighted magnetic resonance imaging taken of the
patient demonstrating that the spinal
cord is decompressed in extension.

(2) Lim itat ion s:


(a) Ret ro-odon toid syn ovial pan n us m ay occupy as m uch as 3 m m of
sp ace.
(b) May n ot rep resen t th e t ru e SAC.
(c) PADI < 14 m m on lateral plain lm radiograph w arran t s MRI.
i. PADI 13 m m m easured on MRI represen t s spin al cord
com pression.
4. Clinical sym ptom s.
a. Neck pain .
b. Headach e.
c. Vert igo.
d. Myelopathy.
(1) Paresth esias.
(2) Abn orm al gait .
(3) Bow el/bladder di cu lt ies.
(4) Di cu lt y w ith n e m otor con t rol.
E. Atlan toaxial im pact ion or basilar invagin at ion (Fig. 25.2):
1. Secon d m ost com m on cer vical spin e abn orm alit y in RA (38%).
2. Ch aracterist ics:
a. Su p erior m igrat ion of th e odon toid (SMO).
b. Vert ical sublu xat ion of th e axis.
c. Pseudobasilar invagin at ion .
3. Synovit is an d car t ilage dest ru ct ion of th e occipitoatlan tal an d atlan toaxial
join ts.

25 Rheum atoid Arthritis 299

b
Fig. 25.2 (a) Illustration and (b) radiograph dem onstrating the m easurem ents of the skull, including
McRaes line, Cham berlains line, Wackenheims line, and Ranawats line. (Fig. 25.2b from Bohndorf
K, Im hof H, Pope TH Jr. Musculoskeletal Im aging: A Concise Multimodalit y Approach. Stut tgart, Germany: Georg Thiem e Verlag; 2001: Fig. 9.105. Reproduced with permission.)

4. Sym ptom s in clude occipit al h eadach e, m yelopathy, or brain stem


com pression sign s.
5. Radiograph ic m easurem en ts (Table 25.1) (Fig. 25.3):
a. Used to id en t ify th e d egree of odon toid en croach m en t on th e sp in al cord .
b. Most are di cult to reproduce.

300 25 Rheum atoid Arthritis

Table 25.1

Radiographic lines to m easure superior migration of the odontoid

Name

Measurements

Characteristic

Results

McGregor line

Line connecting
posterior margin of
the hard palate to the
m ost caudal point of
the occiput

Most consistent
reference

Vertical set tling is


de ned as m igration
of odontoid > 4.5 mm

RedlundJohnell
line

Distance bet ween


the midpoint of the
inferior m argin of the
body of the axis to the
McGregor line

Measures the
occiput to C2
complex

Increased risk of
neurological injury
with values < 34 m m
for men and < 29 mm
for wom en

Ranawat index

Distance bet ween the


center of the pedicle
of the axis and the
transverse axis of the
atlas

Evaluates the
C1C2 segm ent

< 13 m m is diagnostic
of vertical set tling

McRae line

Connects the anterior


and the posterior
m argins of the
foram en m agnum

The tip of the


odontoid should lie
1 cm below this line

Fig. 25.3 Lateral plain lm radiograph demonstrating the anatom ical landmarks used to draw the
(a) McGregor line (McG), RedlundJohnell line (RJ), McRae line (McR), and (b) the Ranawat index. HP,
hard palate; TA, transverse axis of atlas; CP, center of pedicle of axis.

25 Rheum atoid Arthritis 301

6. MRI m easu rem en t s:


a. Any degree of atlan toaxial im p act ion on plain lm rad iograp h w arran ts
MRI.
b. Cer vicom edullar y angle:
(1) E ect ive in dicator of cord distort ion .
(2) Th e angle form ed by lin es draw n parallel to th e an terior border of th e
m edu lla an d u p p er cer vical sp in al cord .
(3) Angles < 135 h ave been associated w ith m yelopathy.
F. Su baxial su blu xat ion (Fig. 25.4):
1. Least com m on deform it y in RA (1020%).

Fig. 25.4 (a) Illustration and (b,c) lateral radiographs dem onstrating subaxial subluxation of the cervical spine. (Fig. 25.4b,c reprinted from Im hof H, ed. Spinal Im aging [Direct Diagnosis in Radiology].
Stut tgart, Germ any: Georg Thiem e Verlag; 2008: Figs. 4.2, 4.3. Reproduced with perm ission.)

302 25 Rheum atoid Arthritis

2. Syn ovit is of facet join t s, in ter ver tebral disks (spon dylodiskit is), an d
in tersp in ou s ligam en t .
3. Osteophytes are rarely obser ved.
4. Mult ilevel involvem en t:
a. Part icu larly com m on at C2C3 an d C3C4 region .
b. Degen erat ive involvem en t t ypically occurs at C5C6.
5. En d plate erosion s are presen t in 12 to 15% of pat ien t s.
6. On lateral plain lm radiograph s a can al diam eter < 14 m m represen t s a
h igh er risk of n eu rological involvem en t an d w arran t s MRI.
7. RA pat ien t s w ith a previou s u pper cer vical fusion h ave an in creased risk of
developing suba xial sublu xat ion .
VII. Treat m en t con siderat ion s.
A. Avoid th e developm en t of an irreversible n eurological de cit .
B. Preven t su d den death from u n recogn ized n eu ral com pression (~ 10%).
C. Early aggressive m ed ical m an agem en t:
1. DMARDs: m ech an ism s of act ion in RA are un clear.
a. Meth ot rexate (MTX).
(1) In h ibit s th e pu rin e m et abolism s, result ing in accum ulat ion of
aden osin e (st rong an t i-in am m ator y e ect s).
(2) In h ibit s T cell act ivat ion an d expression of adh esion m olecules.
(a) Decreases product ion of T cellm ediated in am m ator y cytokin es.
(3) Also in h ibits folic acid m et abolism .
(a) Pat ien t s sh ould con su m e folic acid supplem en t du ring t reat m en t .
b. Sulfasalazin e.
(1) Associated w ith in creased product ion of aden osin e (sim ilar to MTX).
(2) Free radical scavenger.
(3) In h ibit s TNF by in ducing m acroph age apoptosis.
(4) Appears to suppress B cell fun ct ion , but n ot T cells.
c. Hydroxych loroquin e (HCQ).
(1) Decreases T cell act ivat ion by in terfering w ith an t igen -presen t ing
cells.
(a) As a lipoph ilic w eak base, it t respasses th e cell m em brane an d
accu m u lates in lysosom es, in creasing th e in t racellu lar p H.
i. In m acroph ages an d den drit ic cells, th e in crease of
in t racellular p H in h ibits an t igen coupling w ith an t igen presen t ing pept ides.
(b) HCQ blocks toll-like receptors (TDR) th at are resp on sible for
act ivat ing den drit ic an t igen -presen t ing cells.
2. Soft cer vical collars:
a. Relieve sym ptom s bu t do n ot p reven t disease progression .
D. Predictors of p ostoperat ive n eu rological recover y:
1. Ran aw at classi cat ion (Table 25.2).
a. More severe preoperat ive n eu rological d e cit s are associated w ith a
p oorer n eu rological recover y.
2. Locat ion of disease.
a. Proxim al locat ion of th e p ath ology w orsen s th e progn osis.

25 Rheum atoid Arthritis 303

Table 25.2

Ranawat classi cation of rheum atoid myelopathy

Class

Clinical characteristics

No neural de cit

II

Subjective weakness with hyperre exia and dysesthesia

IIIA

Objective weakness and long-tract signs; am bulatory patient

IIIB

Objective weakness and long-tract signs; nonam bulatory patient

3. PADI.
a. Preop erat ive.
(1) A PADI < 10 m m is associated w ith poor progn osis.
(2) In pat ien t s w ith isolated atlan toaxial su blu xat ion w ith PADI > 10 m m
p redicted im provem en t w as at least on e Ran aw at class.
(3) In com bin ed atlan toaxial sublu xat ion an d im pact ion recover y w as
associated w ith a PADI 13 m m .
(4) All patients w ith a PADI 14 m m dem onstrate signi cant m otor recovery.
4. Factors th at do n ot predict n eurological recover y.
a. Age.
b. Gen der.
c. Du rat ion of paralysis.
d. Preoperat ive AADI.
VIII. Indicat ion s for surgical stabilizat ion .
A. Spin al in st abilit y w ith accom panying:
1. In t ract able pain .
2. Neurological defect .
B. Radiograp h ic p aram eters (regardless of n eu rological involvem en t).
1. Atlan toaxial sublu xat ion w ith PADI 14 m m .
2. Su perior odon toid m igrat ion 5 m m .
3. Su baxial su blu xat ion w ith sagit t al can al diam eter 14 m m .
4. Cer vicom edullar y angle < 135.
IX. Su rgical st abilizat ion .
A. Gen eral con siderat ion s.
1. Preoperat ive h alo t ract ion can provide pain relief, correct deform it y, an d
arrest or reverse n eu rological d eteriorat ion .
2. Aw ake beropt ic in t ubat ion w ith out n eck exten sion is in dicated.
B. Speci c con dit ion s.
1. Atlan toaxial sublu xat ion (Fig. 25.5).
a. Posterior atlan toaxial fu sion .
b. C1C2 t ran sart icular screw xat ion (Magerl).
(1) May n ot be tech n ically possible depen ding on th e deform it y an d
course of th e vertebral ar ter y.
c. C1C2 lateral m ass/pedicle screw xat ion (Harm s con st ruct).

304 25 Rheum atoid Arthritis

Fig. 25.5 Techniques for posterior cervical screw xation, including the Magerl, Sonntag, and Harms
techniques.

2. Superior m igrat ion of th e odon toid (Fig. 25.6a).


a. Posterior occip itocer vical fu sion .
b. An terior decom pression via t ran soral resect ion of th e odon toid is
in d icated w h en th ere is evid en ce of sign i can t an terior pan n us or
m arked ver t ical t ran slocat ion of th e odon toid (> 5 m m ).
3. Subaxial sublu xat ion .
a. Posterior cer vical fu sion w ith lateral in st ru m en tat ion .
(1) Rarely, w h en n otable su blu xat ion is presen t an d can n ot be reduced,
an terior decom pression w ith corpectom y an d recon st ru ct ion w ith
st ru t bon e graft ing m ay be in dicated (Fig. 25.6b,c).
X. Postoperat ive ou tcom es.
A. Recen t im provem en t in outcom es.
1. Earlier diagn osis.
2. Decrease in use of cort icosteroids.
3. Im provem en t w ith com bin at ion DMARDs t reat m en t .
4. Bet ter in st rum en t at ion .
B. Occip itocer vical fu sion for atlan toaxial im p act ion (Casey et al).
1. Bet ter outcom es com pared w ith th ose w ith out occipit al fusion .
2. Fort y- ve percen t dem on st rated n eu rological im provem en t .

25 Rheum atoid Arthritis 305


Fig. 25.6 (a) Preoperative sagit tal magnetic
resonance im aging of a 76-year-old m an with
rheum atoid arthritis who presented to the
em ergency room with the inabilit y to swallow
and speak. A large rheum atoid pannus is noted
to cause upper cervical cord compression
and destruction of the dens. (b,c) Postoperative anteroposterior and lateral radiographs
dem onstrating occipital cervical xation (C2
pedicle screws and C3C6 lateral mass screws).
The patient was decompressed with C2C4
lam inectomies and traction, allowing restoration of norm al cervical lordosis.

3. Nin et y-seven percen t dem on st rated pain relief.


4. Progression of subaxial in st abilit y below th e level of fusion w as th e m ain
cau se of failu re (reoperat ion ).
5. Perioperat ive m ort alit y w as 10%.
C. An terior an d/or p osterior decom p ression an d fu sion for su baxial su blu xat ion
(Olerud et al).
1. Neck pain w as t ypically relieved.
2. Myelopathy w as associated w ith w orsen ed outcom es.
3. Surger y is recom m en ded before pat ien t s develop m yelopathy.

306 25 Rheum atoid Arthritis

D. Gen eral com p licat ion s.


1. High in fect ion rate (25%).
2. Pseu darth rosis (poor bon e qualit y).
3. Adjacen t-level in st abilit y.

Suggested Reading
Boren stein D. In am m ator y arth rit ides of th e spin e: su rgical versu s n on su rgical t reatm en t . Clin Orth op Relat Res 2006;443(443):208221
Ciprian i P, Ruscit t i P, Caru bbi F, Liakou li V, Giacom elli R. Meth ot rexate in rh eu m atoid arthrit is: opt im izing th erapy am ong di eren t form u lat ion s. Cu rren t an d em erging paradigm s. Clin Th er 2014;36(3):427435
Kauppi MJ, Neva MH, Laih o K, et al; FIN-RACo Trial Group. Rh eum atoid atlan toaxial sub lu xat ion can be preven ted by in ten sive u se of t radit ion al disease m odifying ant irh eu m at ic drugs. J Rh eum atol 2009;36(2):273278
Kim DH, Hilibran d AS. Rh eu m atoid ar th rit is in th e cer vical spin e. J Am Acad Orth op Su rg
2005;13(7):463474
Zikou AK, Alam an os Y, Argyrop ou lou MI, et al. Rad iological cer vical sp in e involvem en t
in pat ien t s w ith rh eum atoid arth rit is: a cross sect ion al st u dy. J Rh eu m atol 2005;
32(5):801806

26 Seronegative Spondyloarthropathies

26.1 General Considerations


I. In t rodu ct ion .
A. Group of in am m atory disorders a ecting various joints and periarticular structures.
B. Ext raskeletal m an ifest at ion s:
1. Gast roin test in al (GI).
2. Skin .
3. Ocular.
4. Cardiac.
5. Respirator y.
C. Th e m ajorit y of cases are HLA-B27 (+) an d rh eu m atoid factor (RF) ().
D. Most laborator y n dings are n on sp eci c.
II. An kylosing sp on dylit is (Fig. 26.1).
A. Epidem iology.
1. Main ly predom in an t during secon d an d th ird decades of life.

Fig. 26.1 (a) Lateral radiograph of a patient with ankylosing spondylitis with severe sagit tal plane
im balance. (b) Anteroposterior radiograph following an L2 pedicle subtraction osteotomy. (c) Lateral
radiograph shows the osteotomy site at L2 with correction of the positive sagit tal balance. (Fig. 26.1a
from Im hof H, ed. Spinal Imaging (Direct Diagnosis in Radiology). Stut tgart, Germany: Georg Thieme
Verlag; 2008: Fig. 4.18. Reproduced with perm ission.)

307

308 26 Seronegative Spondyloarthropathies

2. Males > fem ales.


a. Men t ypically p resen t a m ore severe d isease exp ression .
b. Prevalen ce is 1 in 1,000.
c. Mostly Caucasian (HLA-B27).
B. Path ogen esis.
1. HLA-B27 posit ive in 88 to 96% of pat ien t s (n on speci c).
a. Eigh t p ercen t of gen eral pop u lat ion .
2. Syn ovit is from lym ph ocyte an d plasm a cell in lt rate.
3. Ch ron ic in am m ator y ch anges (cart ilage dest ruct ion an d bony erosion ) to
th e axial skeleton .
a. Bilateral sacroiliit is is th e m ost com m on an d earliest sign of disease
(p ath ogn om on ic).
b. En th esit is at ten don bony in sert ion s.
C. Clin ical n dings.
1. In sidious on set:
a. Sym ptom s are gen erally p resen t for 3 m on th s.
2. Sym ptom s in clu de low back pain an d st i n ess.
a. Worsen ed in th e m orn ing an d im p rove w ith act ivit y.
3. Fifteen to 25% h ave periph eral join t arth rit is.
4. For w ard- exed post ure:
a. Decreased lu m bar lordosis.
b. In creased th oracic kyph osis.
5. Physical n dings:
a. Lim ited range of m ot ion of th e lu m bar sp in e (Sch obers test).
b. Decreased ch est expan sion (< 78 cm ).
c. Posit ive sacroiliac st ress m an euver (Pat ricks test).
d. Rigid kyph ot ic spin e.
(1) Most e ect ive m easure of spin al deform it y is th e ch in brow to
vert ical angle.
(2) Occiput to w all test (cer vical spin e involvem en t).
e. Com p en sator y h ip exion con t ract u res.
f. Ten dern ess over th e isch ial t u berosit y, greater t roch an ter, an teriorsu perior iliac sp in e (ASIS), an d iliac crest (en th esit is).
6. Ext raskeletal m an ifest at ion s:
a. Gen eral com p lain t s
(1) Fat igue.
(2) Weigh t loss.
(3) Low -grade fever.
b. Gast roin test in al.
(1) In am m ator y bow el disease.
c. Cardiac.
(1) Cardiac con duct ion defect s.
(2) Aort it is.
d. Acute irit is (m ost com m on ext raskeletal com plain t).
(1) Pain .
(2) Ph otoph obia.

26 Seronegative Spondyloarthropathies 309

(3) Blurred vision .


e. Pu lm on ar y brosis (cau se of death in 10% of p at ien t s).
(1) Dyspn ea an d cough .
f. Am yloid osis.
D. Laborator y n d ings.
1. HLA-B27 (~ 90%): often n ot ordered due to h igh cost .
2. Elevated er yth rocyte sedim en tat ion rate (ESR) an d C-react ive protein (CRP).
3. An em ia of ch ron ic disease (n orm och rom ic/n orm ocyt ic).
4. RF ().
5. An tin uclear an t ibody (ANA) ().
E. Radiograph ic n dings (Fig. 26.2 an d Fig. 26.3) (Table 26.1).

c
Fig. 26.2 (a,b) Radiograph dem onstrating sclerosis and erosion at the sacroiliac joint. (c) Axial com puted tomographic im age dem onstrating erosions at the sacroiliac joint. (From Bohndorf K, Im hof H,
Pope TH Jr. Musculoskeletal Im aging: A Concise Multim odalit y Approach. Stut tgart, Germ any: Georg
Thiem e Verlag; 2001: Figs. 9.112, 9.113. Reproduced with permission.)

310 26 Seronegative Spondyloarthropathies


Fig. 26.3 Anteroposterior radiograph dem onstrating
bamboo spine in a patient with ankylosing spondylitis.
(From Im hof H, ed. Spinal Im aging [Direct Diagnosis in
Radiology]. Stut tgart, Germany: Georg Thiem e Verlag;
2008: Fig. 4.27. Reproduced with perm ission.)

F. Treat m en t .
1. Non operat ive.
a. Physical th erapy.
(1) Exten sion exercises.
(2) Sw im m ing.
b. Respirator y th erapy.
(1) Breath ing exercises.
(2) Cessat ion of sm oking.
c. Medicat ion s.
(1) Non steroidal an t i-in am m ator y drugs (NSAIDs).
(a) Sym ptom at ic pain relief.

26 Seronegative Spondyloarthropathies 311

Table 26.1

Radiographic ndings

Type

Notes

Sacroiliitis erosion
(Fig. 26.2)

Reactive bone and fusion of the joint (on the lower portion
of iliac side rst)
Bilateral and sym metric
Magnetic resonance im aging is m ore sensitive than plain
lm radiographs to detect in am m atory changes in the
sacroiliac joint

Spine

Syndesm ophyte form ation from the m argins of the


vertebral bodies (bam boo spine) (Fig. 26.3)
Vertical paravertebral ossi cation
Erosion of the vertebrae (squaring of the vertebral body)
Osteoporosis, disk and apophyseal joint narrowing

Occult fractures

Occur with m inim al traum a


Lum bar spine and lower cervical spine are the m ost
com m on sites of fracture
Plain radiographs can be di cult to interpret
Computed tom ography can be hard to interpret because
of the di cult y in obtaining true axial cuts
Magnetic resonance im aging is the m ost reliable test for
occult fractures and hem atom a evaluation

(2) Cor t icosteroids (sh ort courses w ith t apering dose).


(a) System ic.
(b) Topical drop s (uveit is).
(3) Disease-m odifying m edicat ion s.
(a) Sulfasalazin e (m ost ben e cial).
(b) Meth ot rexate.
(4) Tum or n ecrosis factor alph a (TNF- ) in h ibitors.
(a) Adalim um ab an d et an ercept .
(b) Never rst-lin e t reat m en t .
(5) Bisph osph on ates.
2. Surgical m an agem en t .
a. In dicat ion s.
(1) Flexion deform it y associated w ith pain an d n eurological com prom ise.
(2) Loss of h orizon t al gaze (e.g., ch in on ch est deform it y).
(3) Un st able spin e fract ures.
b. Spin al deform it y in an kylosing spon dylit is.
(1) Loss of lum bar lordosis an d th oracic kyph osis.
(2) Prim ar y locat ion of disabling deform it y sh ould be assessed.

312 26 Seronegative Spondyloarthropathies

(3) Osteotom ies:


(a) Cer vical.
i. Osteotom y at C7T1 ju n ct ion w ith lam in ectom y from C6 to T2
is con sidered for prim ar y cer vical kyph osis.
(b) Th oracic.
i. In severe kyp h ot ic th oracic deform it y, m u lt iple posterior
th oracic resect ion osteotom ies can be don e after an terior
osteotom ies.
ii. Costot ran sverse osteotom ies.
iii. Th oracic kyp h osis can often be addressed via a lum bar
osteotom y.
(c) Lum bar.
i. Osteotom ies are p erform ed t ypically bet w een L2 an d L4.
Pedicle su bt ract ion (closing w edge) osteotom y (CWO).
Modi ed Sm ith Petersen (op en ing w edge) osteotom y
(OWO) (Fig. 26.4).
ii. OWO versus CWO:
No d i eren ce in p ostop erat ive p ain scores.
Sim ilar rad iograp h ic ou tcom es.
Sagit t al vert ical axis.
Lu m bar lordosis.
Global kyph osis.
Com p licat ion s.
Greater blood loss w ith CWO.
No sign i can t di eren ces in oth er com p licat ion s (e.g.,
du rotom ies, ileu s, in fect ion s, n eu rological injuries).
III. React ive arth rit is.
A. Epidem iology.
1. Males > fem ales.
2. More com m on in Caucasian s.
3. Associated organ ism s.
a. Chlam ydia.
b. Cam pylobacter.
c. Yersinia.
d . Shigella.
e. Salm onella.
B. Clin ical p resen t at ion .
1. Classic clin ical t riad.
a. Ureth rit is.
(1) Balan it is circin at a (pain less ulcer in th e glan s pen is).
b. Conjun ct ivit is.
(1) Irit is.
(2) Uveit is.
(3) Episclerit is.
(4) Corn eal ulcerat ion .

26 Seronegative Spondyloarthropathies 313

b
Fig. 26.4 (a) The closing wedge pedicle subtraction and (b) the opening wedge Sm ithPetersen
osteotomy procedures.

314 26 Seronegative Spondyloarthropathies

c. Polyarth rit is.


(1) Asym m et ric.
(2) Appears 2 to 4 w eeks after in fect iou s even t .
(3) Low er ext rem it ies > upper ext rem it ies.
(a) Rare h ip involvem en t .
(4) En th esit is (in am m at ion of th e con n ect ive t issue bet w een a ten don
or ligam en t an d bon e).
(a) Ach illes ten don .
(5) Low er back pain .
(a) Sacroiliit is (310% progress to an kylosing spon dylit is).
C. Laborator y n d ings.
1. Elevated ESR.
2. RF () an d ANA ().
3. Ch ron ic an em ia.
4. HLA-B27 (+) (> 90%).
D. Radiograp h ic n dings.
1. Periost it is in th e h eel an d toes.
2. Sacroiliit is (un ilateral).
3. Non m argin al asym m et ric syn desm ophytes (large an d bulky).
IV. Psoriatic ar th rit is.
A. Epidem iology.
1. A ect s 5 to 7% of pat ien t s w ith psoriasis.
2. A ect s 0.1% of th e gen eral populat ion .
3. Male = fem ale.
4. On set ranges bet w een th e th ird an d sixth decade.
5. More com m on in Caucasian s.
B. Clin ical n dings.
1. Ar th rit is (precedes skin lesion s in 15% of cases).
a. Sp in e st i n ess > 30 m in u tes.
b. Oligoar t icular an d m on oar t icular.
(1) Asym m et ric.
(2) Dist al in terph alangeal (DIP) involvem en t .
c. En th esit is.
d. Sacroiliit is.
2. Skin lesion s.
a. Balan it is circin at a.
b. Oral ulcers.
c. Keratoderm a blen n orrh agica.
3. Key feat ures.
a. Nail p it t ing.
b. Sausage-sh aped digit s.
C. Laborator y n d ings.
1. Elevated ESR an d CRP.
2. HLA-B27 (+) (20%).

26 Seronegative Spondyloarthropathies 315

D. Rad iograp h ic n dings.


1. Asym m et ric sacroiliit is (autofusion ).
2. Bony erosion .
3. Syn desm ophyte form at ion (bam boo spin e).
E. Treat m en t .
1. Physical th erapy.
a. Range of m ot ion exercises.
2. Medicat ion s.
a. NSAIDs.
(1) Aspirin , in dom eth acin , or n aproxen .
b. Secon d-lin e.
(1) TNF- in h ibitors (in ixim ab).
(2) Meth ot rexate.
V. En teropath ic arth rit is (in am m ator y bow el disease).
A. Epidem iology.
1. Males > fem ales.
2. Associated w ith pat ients w ith Crohns disease and ulcerative colitis (1020%).
B. Clin ical n dings.
1. Arth rit is.
a. Asym m et ric.
b. Mon oart icu lar or polyart icular.
(1) Large join t s.
(a) Periph eral ar th rit is im proves w ith gast roin test in al im provem en t .
(2) Spin e (sacroiliit is).
(a) Bilateral (sim ilar to AS).
(b) In dep en d en t of bow el disease.
2. Ext ra-ar t icular sym ptom s.
a. Er yth em a n odosa (Croh ns).
b. Pyoderm a gangren osu m (UC).
c. Oral ulcers.
d. Uveit is.
C. Laborator y n dings.
1. Ch ron ic anem ia.
2. Elevated ESR an d CRP.
3. RF () an d ANA ().
4. An t in eut roph il cytoplasm ic an t ibodies (ANCA) (+) (60%).
5. Five percen t HLA-B27 (+).

316 26 Seronegative Spondyloarthropathies

Suggested Reading
Ravin sky RA, Ouellet JA, Brodt ED, Det tori JR. Vertebral osteotom ies in an kylosing spon dylit iscom p arison of ou tcom es follow ing closing w edge osteotom y versu s op en ing w edge osteotom y: a system at ic review. Evid Based Spin e Care J 2013;4(1):
1829
Steim an AJ, Pope JE, Th iessen -Ph ilbrook H, et al. Non -biologic disease-m odifying an t irh eum at ic drugs (DMARDs) im p rove p ain in in am m ator y arth rit is (IA): a system at ic literat u re review of ran d om ized con t rolled t rials. Rh eu m atol In t 2013;33(5):
11051120
Viap ian a O, Gat t i D, Idolazzi L, et al. Bisp h osph on ates vs in ixim ab in an kylosing sp on dylit is t reat m en t . Rh eu m atology (Oxford) 2014;53(1):9094

Index
Note: Page n um bers follow ed by f and t in dicate gures and tables, respect ively.

A
abscess
epidural, 286287, 288f
subdural, 288f
achon droplasia, 253, 259
adalim um ab, 311
Adam s for w ard ben d test , 231
Adsons test , 54, 56f
adult scoliosis. See scoliosis, adult
Allen -Ferguson m ech anist ic
classi cat ion, 132t
allografts, 107, 111112
vs autograft s, 112f
Am erican Medical Associat ion ,
145146
Am erican Spin e Injur y Associat ion
(ASIA), 117, 119f, 120t , 134
An lateral m ass screw orien t at ion ,
90f
anatom y
cer vical spin e, 1319
coccyx, 2124
disk, 148149
radiograph ic, 5766
sacrum , 2124
spinal, 13
th oracolu m bar, 1921
An derson an d DAlon zo
classi cat ion of odontoid
fract ures, 127f
An derson lateral m ass screw
orien tat ion , 90f
anesth esia, e ects
on in t raoperat ive
n eurom on itoring, 82
aneur ysm al bon e cyst , 268t
angiography, 67, 266t
ankylosing spon dylit is
(in am m ator y kyph osis),
249250, 253, 307312
clin ical n dings, 308309
epidem iology, 307308
im aging, 307f, 309, 309f, 310f, 311t
laborator y n dings, 309
path ogen esis, 308
surgical m an agem ent , 311312
t reat m en t, 310312
ann ular tears, 177
ann ulus brosus, 99
anterior cer vical corpectom y and
fusion , 162

an terior cer vical diskectom y an d


fusion (ACDF), 160162
an terior cord syn drom e, 8f
an terior fusion , 95
an terior horn cell disease (spinal
m uscular at rophy), 246
an terior lum bar in terbody fusion
(ALIF), 189t , 191, 193f
an terior odon toid screw s, 85, 88f
arth rit is, en teropath ic
(in am m ator y bow el disease),
315
arth rit is, psoriat ic, 314315
arth rit is, react ive, 312, 314
arth roplast y, tot al disk, 194195
art i cial disks, 162
ast rocytom a, 271t
atlan toaxial im pact ion , 298301
atlan toaxial in stabilit ies, 259260,
297298
atlan toaxial join t , 83, 84f
atlan toaxial sublu xat ion , 303304f
atlan toden s in ter val (ADI), 86t ,
125, 252, 253f, 297298, 301f,
303
atlas (C1) fract ure, 126127
autogen ous bon e graft , 285
autografts, 107, 111
vs allografts, 112f
axial lum bar in terbody fusion
(AxiaLIF), 194

B
Babinskis sign, 50f, 51t , 156
balance, sagit tal, 83
basilar invagin at ion, 252256,
298301
Beevors sign , 55t
biom echan ical m easurem ent s, 86t
biom echan ics, 8589
bisph osph onates, 311
bone cells, 104105
bone form at ion, 105, 106f
bone graft s, 107109. See also
speci c graft t ypes
bone m arrow aspirate an d stem
cells, 111, 114115
bone m orph ogen et ic proteins
(BMP-2, BMP-7), 111, 113114
con t roversies, 114
In fuse (BMP-2), 113

OP-1 (BMP-7), 114


Yale Open Dat a Access (YODA)
project , 114
bon e repair an d rem odeling,
106107
bon e scin t igraphy, 67, 69t
lum bar degenerat ive disease,
178
spin al in fect ion s, 285t
t um ors, 266t
bony arch com pon en ts, posterior,
2t
Brow n -Sequard syndrom e, 8f
Br yan Disc art i cal disk, 162
bu lbocavernous re ex, 54f, 55
bu rst fract ures, 94, 138f, 140

C
C1 (atlas) fract ure, 126127
C1 lateral m ass screw /C2 pedicle
screw, 85, 87f, 88f
C1C2 sublu xat ion, 125
C2 t ran slam in ar screw, 85
cen t ral cord syndrom e, 8f
cen t ral sacral vert ical lin e (CSVL),
230
ceram ics, 111, 112113
cerebral palsy, 239, 241, 246
cer vical degenerat ive disease,
154165
cer vical disk ar th roplast y (CDA),
162
com plicat ion s, 165
di eren t ial diagn osis, 158, 160t
im aging, 156157, 158f, 159f
postop m an agem en t , 165
su rgical tech n iques, 159165
an terior cer vical corpectom y
an d fusion, 162
an terior cer vical diskectom y
an d fusion (ACDF), 160162
lam inectom y an d fu sion w ith
inst rum en t at ion , 164165
lam inoforam in otom y, 162163f
lam inoplast y, 163164f
t reat m en t , 158159
cer vical disk arthroplast y (CDA),
162
cer vical fusion , 89, 90f
cer vical kyph osis, 263f
cer vical orth osis, 89, 91f, 91t

317

318 Index
cer vical spine
surgical approaches
anterior, 2538
an terom edial approach (de
An drade an d Macnab), 29
ret roph ar yngeal exposure
(McAfee), 2930
t ransoral approach to C1C2,
2829
anterolateral ret roph ar yngeal
approach (W h iteside and
Kelley), 30
lateral approach (Verbiest), 30
posterior, 2425
cer vical spine t raum a, 122133
atlas (C1) fract ure, 126127
C1C2 sublu xat ion , 125
clay-shovelers fract ure, 130
h angm ans fract ure, 128, 129f,
130t
in ciden ce, 122
occipit al con dyle fract u res, 124
occiputC1 dislocat ion , 124
odontoid fract ures, 127128
pat ient evaluat ion , 122, 123f
soft tissue injur y, 133
subaxial cer vical t raum a, 128
teardrop fract ures, 130
t ract ion, 122124f
u pper cer vical injuries, 124129
w edge com pression fract ures,
130
cer vical spine, an atom y, 1319
cer vicoth oracic jun ction
surgical approaches, 3038
low cer vical approach to
C6T2, 30
stern um -split t ing approach to
C4T4, 3738
supraclavicular approach to
C6T2, 30
th oracotom y to T1T4, 36, 37f,
38f, 39f, 40f
cer vicoth oracic-st yle orth osis, 91t
Ch am berlain lin e, 299f
Ch arcot-Marie-Tooth disease, 246
ch em on ucleolysis, 153
ch on drosarcom a, 269t , 278f
ch ordom a, 269t , 279f
ch ronic pain , psych ological e ect s
of, 143144
claudicat ion , 208
clay-sh ovelers fract ure, 130
clon us re ex, 51t
Cobb angle m easurem en t , 221f,
231232
coccyx, anatom y, 2124
com pression fract u res, 9394
com pression - exion injuries, 138

com puted tom ography (CT), 58,


59f, 67, 68t , 75f
an kylosing spon dylit is, 309f
cer vical degen erat ive disease,
156157
ch ondrosarcom a, 278f
fract ure-dislocat ion of the
th oracolu m bar spin e, 139f
gian t cell t um or, 276f
h ern iated disk, 167, 169f
Je erson fract ure, 261f
lum bar degen erat ive disease,
178, 184, 185, 186f, 187f
n euro brom a, 275f
osteoid osteom a, 274f
rh eum atoid arth rit is, 297
spin al cord inju r y, 119
spin al in fect ions, 285t
spin al stenosis, 124f
spondylosis, 124f
t um ors, 266t
congen it al atlan to-occipital fusion ,
258
congen it al scoliosis. See scoliosis,
congen it al
cord syn drom es, 8f
cort ical can cellous ch ips, 107
costot ran sversectom y, 170
CT. See com puted tom ography (CT)

D
de An drade an d Macnab
an terom edial approach to th e
u pper cer vical spin e, 29
decom pression , 204, 205f
degen erat ive disease, cer vical. See
cer vical degen erat ive disease
degen erat ive disease, th oracic. See
th oracic degen erat ive disease
degen erat ive spon dylolisthesis,
215, 217219
dem in eralized bon e m at rix (DBM),
107, 111112
Den is th ree-colum n classi cation ,
93, 94f, 94t , 134135
derm atom es, 10, 11f, 12t , 53t ,
54f, 155f
developm en t al/paralyt ic kyphosis,
249
diast roph ic dysplasia, 259
direct pars repair, 215
disabilit y, 145
disabilit y an d im pairm en t
evaluat ion, 145146
disease-m odifying an t irh eum at ic
drugs (DMARDs), 297
disk an atom y, 148149
disk degen erat ion , 70f, 73, 99,
151f

disk h ern iat ion , 154t , 167, 167f,


175f
thoracic, 167, 167f, 169f
disk regen erat ion, biologic, 153
disk replacem en t , total (TDR), 195
disk space collapse, 70f
disk space infect ions, 287289
diskectom y
m icroscopically assisted, 180t
open , 180t
percut an eous, 180t
diskography, 67, 69t , 75f
lum bar degen erat ive disease,
178, 185188
disks, art i cial, 162
dislocat ion s
facet , 1
occiputC1, 124
dist ract ion exion injuries (seat
belt inju r y), 138140
Dow ns syn drom e, 259
Duch en n es m uscular dyst rophy,
241
dysdiadoch okin esia, 156
dysplasia, 259

E
elect rodiagn ost ic tests, 7778
elect rom yography (EMG), 7778,
80, 81
elect rom yography, t riggered
(tEMG), 81
en teropath ic arth rit is
(in am m ator y bow el disease),
315
eosin ophilic gran ulom a, 268t
ependym om a, 271t
epidural abscess, 286287, 288f
et an ercept , 311
Ew ings sarcom a, 269t
ext racellular m at rix (ECM), 105

F
facet dislocat ion, 131f
facet inject ion , 187
facet syn drom e, 177
Fielding classi cat ion , 260
nger escape sign, 50f, 51t
at-back syn drom e, 225, 251
exion injuries, 138140
four-poster-t ype orth osis, 91t
fract ure xat ion , percut aneous, 95
fract ures
atlas (C1), 126127
burst , 94, 140
clay-sh ovelers, 130
com pression, 9394
h angm ans, 85, 87f, 128, 129f,
130t , 262, 262f

Index 319
Je erson, 261, 261f
occipit al con dyle, 124
odontoid, 127128, 261262
Salter I, 257, 258f
teardrop, 130
th oracolu m bar, 134141
w edge com pression , 130
fract ure/dislocat ion, 95
Fran kel scale, 134
Friedreichs ataxia, 246
fun ct ional restorat ion program s,
144
fusion . See speci c fusions

G
Gaen slens test , 54
GCS. See Glasgow Com a Scale (GCS)
gian t cell t um or, 268t , 276f
Glasgow Com a Scale (GCS), 116,
117f
grafts. See speci c graft s
Grisels syn drom e, 259
grow ing rod inst rum en t at ion ,
236, 237f
Guillain -Barre syndrom e, 160t

H
h alo devices, 91t , 92f
h angm ans fract ure, 85, 87f, 128,
129f, 130t , 262
Harm s con st ruct , 303304f
h ealing period, 145
h ealing plateau , 145
h em angiom a, 268t
h ern iated nu cleus pulposu s (HNP),
177
h ern iated disk. See disk h erniat ion
h istor y, m edical, 4749
Ho m ans sign , 50f, 51t , 156
Hong Kong procedure, 291, 292f
Horn ers syn drom e, 13
How ships lacun ae, 105, 105f
hydroxych loroquin e, 302
hypokyphosis, 96, 96f

I
idiop athic adolescen t scoliosis
(IAS). See scoliosis, idiopath ic
adolescen t
idiop athic infant ile an d juven ile
scoliosis. See scoliosis,
idiopathic infant ile an d
juven ile
iliac crest bon e graft (ICBG), 107
im aging, 5766, 6777. See also
speci c im aging m odalit ies
im pairm en t , 145
im pairm en t an d disabilit y
evaluat ion , 145146

in fect ion s, postoperat ive, 291294


in fect ious kyph osis, 249, 250f
in am m ator y bow el disease
(en teropath ic arth rit is), 315
in am m ator y kyphosis
(an kylosing spon dylit is),
249250
in ixim ab, 315
inject ions, for pain , 144145
in st rum ent at ion
grow ing rod, 236, 237f
posterior rod, 97f
t ran spedicu lar, 95, 95f, 100101
in terbody cage devices, 161162
in terspinous spacers, 207
in ter vertebral disk, 12
in ter vertebral disk (IVD)
degen erat ion , 171174
biom ech an ical aspects of,
148153
repair or regen erat ion , 150153
in t radiskal elect roth erm al therapy,
180t
in t radiskal pressure, 99
in t raoperat ive n eurom onitoring
(IONM), 8082
an esth et ic e ects on , 82
inverted radial re ex, 51t
isth m ic spon dylolisth esis,
212214

J
jaw -jerk re ex, 50f, 51t
Je erson fract u re, 261, 261f
juven ile kyph osis (Sch euerm anns
disease), 242246
juven ile rh eum atoid arth rit is, 259
juven ile scoliosis. See scoliosis,
idiopath ic in fan t ile and
juven ile

K
Kadish an d Sim m ons n er ve root
an om alies, 11, 12f
kin em at ics of th e spin e, 8385
King classi cat ion of scoliosis,
227, 229t
Klippel-Feil syn drom e, 256257
kyph osis, 97, 97f
kyph ot ic deform ities, 242251
biom ech an ics, 242
classi cat ion , 242, 243t
congen ital kyph osis, 242244
developm en tal/paralyt ic
kyph osis, 249
infect iou s kyph osis, 249, 250f
in am m ator y kyph osis
(an kylosing spon dylit is),
249250

m yelom en ingocele, 247


neurom uscular kyph osis,
246247
postsurgical kyph osis, 249
post t raum at ic kyph osis, 249
post u ral kyph osis, 242
Sch euerm an ns disease (juven ile
kyph osis), 244246

L
lam inectom y, 170
lam inectom y an d fusion w ith
inst rum en t at ion , 164165
lam inoforam in otom y, 162163f
lam inoplast y, 163164f
Larsens syn drom e, 259
lateral lum bar interbody fusion
(LLIF), 189t , 191, 194
lateral m ass screw orien tat ion , 90f
Lenke classi cat ion of scoliosis,
227, 228f, 229, 236
Levin e an d Edw ards classi cat ion
of atlas fract ures, 126f
Levin e classi cat ion of h angm ans
fract ure, 130t
Lh erm it tes grip release, 51t , 156
ligam en tous an atom y, 17, 18f
low back pain. See lum bar
degen erat ive disease
low cer vical approach to C6T2, 30
lu m bar degen erat ive disease,
171195
an n ular tears, 177
bioch em ical path ology, 175
clin ical evaluat ion, 176181
di eren t ial diagn osis, 176, 177t
n eurological exam in at ion , 176
physical exam , 176
conser vat ive t reat m ent , 179
et iologies, 183, 184t
facet syn drom e, 177
hern iated nucleu s pulposus
(HNP), 177
hern iat ion, 172174
im aging, 178179, 183188
in ciden ce, 171, 183
in ter vertebral disk (IVD)
degen erat ion, 171174
m yofascial syndrom es, 177
path ogen esis, 171175
risk factors, 183
spon dylolysis, 177
sten osis, 177
su rgical m an agem en t, 179, 180f,
180t , 181f, 187195
an terior lum bar in terbody
fusion (ALIF), 189t , 191, 193f
axial lum bar interbody fusion
(AxiaLIF), 194

320 Index
lum bar degen erat ive disease
surgical m an agem ent
(cont inued)
in t radiskal elect rotherm al
th erapy, 180t
lateral lu m bar interbody fusion
(LLIF), 189t , 191, 194
m icroscopically assisted
diskectom y, 180t
open diskectom y, 180t
percut an eous diskectom y, 180t
posterior lum bar in terbody
fusion (PLIF), 189t , 190191f
posterolateral (in tert ransverse
process) fusion (PLF), 188190
total disk ar th roplast y,
194195
t ran sforam inal lum bar
in terbody fu sion (TLIF), 189t ,
191, 192f
Wiltse paraspinal approach ,
181f
total disk replacem ent (TDR), 195
lum bar fusion , 205207
lum bar in dex, 214
lum bar in terbody fu sion. See
anterior lu m bar interbody
fusion (ALIF); axial lum bar
in terbody fu sion (AxiaLIF);
lateral lu m bar interbody
fusion (LLIF); posterior
lum bar in terbody fu sion
(PLIF); t ran sforam inal lum bar
in terbody fu sion (TLIF)
lum bar plexus, ner ve st ruct ures
of, 3f
lum bar spin al sten osis, 197209
classi cat ion , 197198
acqu ired, 198
congenital, 197198
clin ical n dings, 202204
di erent ial diagn osis, 204
dim en sion s, 201, 202f
path ogen esis, 198202
surgical tech n iques
decom pression, 204, 205f
lum bar fusion , 205207
t reat m en t, 204209
lum bar spin e pain. See lum bar
degen erat ive disease
lum bar spin e st abilit y, 98100
lum bar spon dylolisth esis, 210220
biom echan ics, 210
classi cat ion s, 210
degen erat ive, 215, 217219
clinical n dings, 215, 217
epidem iology, 215
radiographic n dings, 217

surgical opt ion s, 219f


t reat m en t , 217219
epidem iology, 210
h eredit ar y factors, 210
isth m ic, 212214
radiograph ic m easurem en ts,
213214
roen tgen ograph ic n dings, 213
surgical tech n iques
direct pars repair, 215
in terbody fusion , 215, 216f
posterolateral fusion w ith or
w ith out decom pression , 215
t reat m en t , 214215
path ological, 220
t rau m at ic, 219
lum bosacral spin e stabilit y,
98100
lym phom a, 269t

M
Magerl lateral m ass screw
orien tat ion, 90f, 303
m agn et ic reson ance im aging
(MRI), 58, 59f, 67, 68t , 7074,
76f, 77f
bu rst fract ure, 138f
cer vical degen erat ive disease,
156157, 159f
cer vical kyph osis, 263f
disk degen erat ion , 73, 151f
facet dislocat ion, 131f
fract ure-dislocat ion of the
th oracolu m bar spin e, 139f
gian t cell t um or, 276f
h ern iated disk, 167, 167f, 175f
Klippel-Feil syn drom e, 256f
lu m bar degen erat ive disease,
178, 184
n eoplast ic disease, 267t
osteogenesis im perfecta, 255f
osteoporot ic com pression
fract ure, 267t
rh eu m atoid arth rit is, 297, 298,
301, 305f
spin al cord inju r y, 7273, 119
spin al in fect ions, 285t
spin al stenosis, 64f, 65f, 164f
spondylolisth esis, 66f, 218f
spondylosis, 61f, 62f
subdural abscess, 288f
t ubercu losis of th e spin e, 292f
t um ors, 266t
vertebral body collapse, 63f
vertebral osteom yelit is, 267t ,
288f, 289f
March et t i-Bar tolozzi classi cat ion
of spondylolisth esis, 210, 212

McAfee an terior ret rophar yngeal


exposu re of th e upper cer vical,
2930
McGregors lin e, 86t , 300f, 300t
McRaes lin e, 299f, 300f, 300t
m edical histor y, 4749
m easurem ent s
atlan toden s inter val (ADI), 86t ,
125, 252, 253f, 297298, 301f,
303
biom ech anical, 86t
cen t ral sacral vert ical lin e
(CSVL), 230
Ch am berlain lin e, 299f
Cobb angle, 221f, 231232
McGregors line, 86t , 300f, 300t
McRaes line, 299f, 300f, 300t
Pow ers rat io, 84f, 86t , 260
radiograph ic, 299301
Ranaw ats index, 86t , 299f, 300f,
300t , 302, 303t
Redlun dJoh nell index, 86t ,
300f, 300t
slip angle, 214, 214f
space available for cord (SAC),
86t , 252, 253f, 254f
Wacken heim line, 299f
m en ingiom a, 270t
m esenchym al stem cells (MSCs),
114115
m ethot rexate, 302, 311, 315
m ethylpredn isolon e, 120121
Meyerding classi cat ion of
spondylolisth esis, 213
Modic end plate ch anges, 73,
76f, 77f
Morquios syn drom e, 259
m otor evoked poten t ials (MEPs),
78
m otor evoked poten t ials, m yogen ic
(m MEPs), 81
m otor evoked poten t ials,
t ranscran ial (tcMEPs), 80, 81
m otor st rength test ing, 55t
MRI. See m agn et ic reson an ce
im aging (MRI)
m uscle st rength , 5354
m uscular anatom y, 14f15f, 18
m uscular dyst rophy, 246
m yelography, 67, 266t
n eu ro brom a, 275f
m yelom eningocele, 241, 247
m yelopathic sign s, 51t , 156
m yelopathy, 47, 155
m yofascial syn drom es, 177
m yogen ic m otor evoked poten t ials
(m MEPs), 81
m yotom e dist ribut ion , 12t

Index 321

N
Nat ional Acute Spin al Cord Injur y
St udy (NASCIS) guidelin es,
120121
n egat ive-pressu re w oun d th erapy,
294
n er ve con duct ion st udies (NSCs),
7778
n er ve root an om alies, 11, 12f
n er ve root s, 174175
n er ve ten sion signs, 49t
n er ves, spin al, 1013
n eural com pression , 199202
n euroan atom y, spin al, 413
n euro brom a, 270t , 275f
n euro brom atosis, 253
n eurom on itoring, in t raoperat ive.
See in t raoperat ive
n eurom on itoring (IONM)
n eurom u scular kyph osis, 246247
n eurom u scular scoliosis. See
scoliosis, n eurom uscular
n ucleus p ulposus, 99
h ern iated, 177

O
occipital con dyle fract ures, 124
occipitoatlan tal in stabilit y, 260
occipitoatlan tal join t , 83
occiputC1 dislocat ion , 124
odon toid
an om alies, 257258
fract u res, 127128, 261262
m igrat ion , superior, 304, 305f
screw s, an terior, 85, 88f
orth osis, 89, 91f, 91t , 234
osteoblast ic lesion s, 266f
osteoblastom a, 268t
osteoblast s, 104, 104f
osteoch on drom a, 268t
osteoclasts, 104f, 105
osteocytes, 104, 104f
osteogen esis im perfecta, 220,
253, 255f
osteoid osteom a, 268t
osteom alacia, 220, 253
osteom yelit is, vertebral. See
vertebral osteom yelit is
osteoporosis, 220
osteosarcom a, 269t
osteotom ies, 312

P
Pagets disease, 220, 253
pain cen ters, 144
pain
a xial vs radicular, 47
m ech an ical vs n on m ech anical,
47

palpat ion, 5051


paralyt ic/developm ent al kyphosis,
249
Parson age-Tu rner syn drom e, 160t
pat ient edu cat ion, 142
Pat ricks test , 54, 308
PCM disc ar t i cial disk, 162
pediat ric cer vical spin e disorders,
252263
atlan toaxial in st abilites,
259260
basilar invagin at ion , 252256
clin ical n dings, 254255
congenital atlan to-occipit al
fusion , 258
diagn ost ic evalu at ion , 252, 253f,
254f
Klippel-Feil syndrom e, 256257
odon toid an om alies, 257258
tort icollis (w r y n eck), 259
t raum at ic, 260263
h angm ans fract ure, 262, 262f
Je erson fract u re, 261, 261f
occipitoatlant al in st abilit y, 260
odontoid fract ures, 261262
pediat ric spin al deform it y,
227251
pedicle diam eter, 101
pedicle screw failure, 102
pedicle subt ract ion osteotom y,
250
percutan eous fract ure xat ion , 95
P rrm an n classi cat ion of disk
degen erat ion , 99, 100f
Ph iladelphia (Miam i J) collars, 91t
physical exam in at ion of th e spine,
4956
plasm acytom a, solitar y, 269t
poliom yelit is, 246
polyeth ereth erketon e (PEEK)
cages, 161162, 285
posterior cord syn drom e, 8f
posterior lum bar in terbody fusion
(PLIF), 189t , 190191f
p osterior rod in st r u m en t at ion ,
97f
posterolateral (in tert ran sverse
process) fusion (PLF), 188190
posterolateral fusion w ith or
w ith ou t decom pression , 215
postoperative in fect ion s, 291294
postsurgical kyphosis, 249
post t raum at ic kyph osis, 249
Pow ers rat io, 84f, 86t , 260
Prest ige Disc art i cial disk, 162
ProDisc-C art i cial disk, 162
proteoglycan s (PGs), 149
proxim al jun ct ional kyph osis
(PJK), 225226

pseudarth rosis, 215


psoriat ic arth rit is, 314315
psych iat ric disease, 143144

R
radiat ion therapy, 272273
radiograph ic an atom y, 5766
radiograph ic m easurem ent s,
299301
radiograph s, 5758, 67, 68t , 70f
adult scoliosis, 224
an kylosing spon dylit is, 307f,
309f, 310f
cer vical degen erat ive disease,
156157, 158f
cer vical kyph osis, 263f
chordom a, 279f
disk degen erat ion , 70f
disk space collapse, 70f
facet dislocat ion , 131f
fract ure-dislocat ion of th e
thoracolum bar spine, 139f
gian t cell t u m or, 276f
hangm ans fract ure, 262f
idiopathic adolescen t scoliosis
(IAS), 235f
Klippel-Feil syn drom e, 256f
lum bar degenerat ive disease,
178, 183
neurom uscular scoliosis, 240f
osteogen esis im perfecta, 255f
osteoid osteom a, 274f
rheum atoid arth rit is, 297, 305f
Sch euerm an ns kyph osis, 248f
of spinal cord injur y, 117, 119
spin al in fect ion s, 285t
spon dylolisthesis, 66f, 218f
spon dylosis, 60f
t uberculosis of th e spine, 290f,
292f
t um ors, 266t
vacuu m disk sign , 70f
vertebral body collapse, 63f
Ran aw ats in dex, 86t , 299f, 300f,
300t , 302, 303t
range of m ot ion test ing, 5152
react ive arth rit is, 312, 314
recom binan t h um an gen e
m orph ogen etic protein -2
(rh BMP-2), 160
Redlun dJoh nell in dex, 86t , 300f,
300t
reh abilit at ion , 142145
ren al osteodyst rophy, 253
rh eu m atoid arth rit is, 253,
295306
cer vical spine deform it y,
297302
clin ical ndings, 296

322 Index
rheum atoid arthrit is (cont inued)
disease-m odifying
ant irheum at ic drugs
(DMARDs), 297
epidem iology, 295
im aging, 297, 298, 301, 305f
laborator y n dings, 296297
path ogen esis, 295296
postoperat ive outcom es,
304306
subaxial sublu xat ion, 301302
surgical st abilizat ion , 303304
treat m en ts, 302303
ricket s, 253
rigid cer vicoth oracic brace (Yale
t ype), 91t
Risser sign , 232, 233f
roentgen ograph ic n dings, 213

S
sacral/pelvic xat ion , 102
sacroiliit is erosion , 309f, 311t
sacropelvic radiograph ic
param eters, 222, 222t , 223f
sacrum , an atom y, 2124
sagit tal balan ce, 83
sagit tal cur ves, 1
Salter I fract ure, 257, 258f
Sch euerm anns disease (juven ile
kyph osis), 242246, 248f
Sch obers test , 55, 308
schw an n om a, 270t
SCI. See spin al cord injur y (SCI)
sciat ica, 222
scoliosis, 9697
Scoliosis Research Societ y (SRS)
Sch w ab Adult Spinal Deform it y
Classi cat ion , 222, 223f, 224
scoliosis, adu lt , 221226
com plicat ions, 225226
at-back syndrom e, 225
proxim al jun ct ion al kyph osis
(PJK), 225226
evaluat ion, 224
tech n iques, 224225
t reat m en t, 224
scoliosis, congen it al, 239
scoliosis, idiopath ic adolescen t
(IAS), 227238
an atom ical ch aracterist ics,
227230
classi cat ion
King, 227, 229t
Len ke, 227, 228f, 229, 236
diagn osis, 230234
physical exam , 230231
screen ing, 230
ScoliScore, 230
et iology, 227

inst rum en t at ion , 236, 237f


m an agem en t , 234237
or th osis, 234
n at ural histor y an d progn osis,
230, 231t
operat ive t reat m ent , 235237
X-ray exam , 231232
Cobb angle, 231232
Risser sign , 232, 233f
scoliosis, idiopath ic infan tile an d
juven ile, 239
scoliosis, n eu rom uscu lar, 239241
cerebral palsy, 239, 241
Duch en n es m uscular dyst rophy,
241
m yelom eningocele, 241
spin al m uscular at rophy, 241
Secure C disc art i cial disk, 162
seron egat ive
spon dyloarth ropath ies,
307315
Sh im izu re ex, 51t
slip angle, 214, 214f
Sm ith -Petersen /Pon te open ing
w edge exten sion osteotom y,
250
soft collar, 91t
soft t issue injur y, of th e cer vical
spine, 133
solitar y plasm acytom a, 269t
som atosen sor y evoked poten t ials
(SSEPs), 78, 8081
Sorensons criteria, 245
space available for cord (SAC), 86t ,
252, 253f, 254f
SPECT. See com puted tom ograp hy
(CT)
spinal can als, 198
spinal cord fu nct ion , 7t
spinal cord injur y (SCI)
evaluat ion an d m an agem en t of,
116121
im aging, 7273
inciden ce, 116
Nat ion al Acute Spin al Cord
Inju r y St udy (NASCIS)
guidelin es, 120121
Surgical Tim ing in Acute Spin al
Cord Injur y St udy (STASCIS)
trials, 121
t reat m en t , 119121
ph arm acological in ter ven t ion ,
120121
spinal cord injur y w ith out
radiograph ic abn orm alit y
(SCIWORA), 260
spinal cord m en inges, 7, 9f
spinal cord syn drom es, 8f
spinal deform it y, 4849

spin al deform it y group L5S1


classi cat ion , 210, 211f
spin al deform it y, pediat ric,
227251
spin al im pairm en t rat ing, 146
spin al in fect ion s, 280294
spin al m uscular at rophy (an terior
h orn cell disease), 241, 246
spin al n er ves, 1013
spin al st abilit y, 83, 98100
spin e an atom y, 13, 413, 252
spin e inst rum en t at ion , th oracic,
9297
spin e n euroan atom y, 413
spin e pat ien t outcom es research
t rials (SPORT), 179180,
208209, 217218
spin e t raum a, cer vical. See cer vical
spin e t raum a
spondylectom y, tot al en bloc, 274,
278f, 279f
spondyloarthropath ies,
seron egat ive, 307315
spondyloepiphyseal dysplasia, 259
spondylolisth esis, 99
degen erat ive, 215, 217219
lum bar. See lum bar
spondylolisth esis
radiograph ic n dings, 6566f
vs spon dylolysis, 210
spondylolysis, 177
spondylosis, 124f, 154t
radiograph ic n dings, 6062
Sprengels deform ities, 257
Spurlings sign , 154
stabilit y, spin al, 83, 98100
Stagn ara w ake-up test , 80
stem cells, m esen chym al (MSCs),
114115
stem cells an d bon e m arrow
aspirate, 111, 114115
stenosis, 124f, 177
lum bar spin al. See lum bar spin al
stenosis
radiograph ic n dings, 6465f
thoracic, 167, 170
stereot act ic radiosurger y (SRS),
275
stern o-occipit al-m andibular
im m obilized (SOMI) brace, 91t
stern um -split t ing approach to
C4T4, 3738
subaxial cer vical spin e injur y
classi cat ion (SLIC) system ,
129, 132t
subaxial cer vical t raum a, 128
subaxial su blu xat ion , 301302,
304, 305f
subdural abscess, 288f

Index 323
sublu xat ion
atlan toaxial, 303304f
C1C2, 125
subaxial, 301302, 304, 305f
sulfasalazin e, 302, 311
superior odon toid m igrat ion, 304,
305f
supraclavicular approach to
C6T2, 30
surgical anatom y, spinal, 1324
surgical approach es, gen erally
cer vical spin e, 2438
anterior approach es, 2538
an terom edial approach
(de An drade and Macn ab), 29
ret roph ar yngeal exposure
(McAfee), 2930
t ran soral approach to C1C2,
2829
anterolateral ret roph ar yngeal
approach (W h iteside and
Kelley), 30
lateral approach (Verbiest), 30
posterior approach es, 2425
cer vicoth oracic jun ct ion , 3038
low cer vical approach to
C6T2, 30
stern um -split t ing approach to
C4T4, 3738
supraclavicular approach to
C6T2, 30
th oracotom y to T1T4, 36, 37f,
38f, 39f, 40f
th oracolum bar spin e, 3845
anterior approach es, 3945
posterior approach es, 3839
Surgical Tim ing in Acute Spinal
Cord Injur y St udy (STASCIS)
t rials, 121

T
teardrop fract ures, 130
Th om pson grading scale of disk
degen erat ion , 151f
th oracic degen erat ive disease,
167170
disk hern iat ion, 167, 167f, 169f
et iologies, 167, 168t169t
sten osis, 167, 170
surgical tech n iques, 170
costot ransversectom y, 170
lam in ectom y, 170
th oracoscopic diskectom y, 170
t reat m en t, 170
th oracic spin e in strum en tat ion,
9297
th oracic sten osis, 167, 170
th oracolum bar injur y classi cat ion
and severit y (TLICS) score, 93,
93t , 135136

th oracolum bar spin e


an atom y, 1921
inst rum en t at ion , 9297
surgical approach es, 3845
an terior, 3945
posterior, 3839
th oracolum bar spin e fract ures,
134141
Am erican Spin al Injur y
Associat ion (ASIA) m otor in dex,
134
Fran kel scale, 134
inciden ce, 134
stabilit y (Denis), 134135
thoracolum bar injur y
classi cat ion an d severit y
(TLICS) score, 135136
t reat m en t , 137141
com pression - exion injuries,
138
dist ract ion exion injuries (seat
belt injur y), 138140
torsion al exion inju ries
(fract ure-dislocat ion s), 140,
141f
vert ical com pression inju ries
(burst fract ures), 140
th oracoscopic diskectom y, 170
th oracotom y to T1T4, 36, 37f, 38f,
39f, 40f
th ree-colum n classi cat ion of
Den is, 93, 94f, 94t , 134135
torsion al exion inju ries (fract uredislocat ion s), 140, 141f
tort icollis (w r y n eck), 259
tot al disk arth roplast y, 194195
tot al disk replacem ent (TDR), 195
t ract ion, for cer vical spine t raum a,
122124f
t ranscran ial m otor evoked
poten t ials (tcMEPs), 80, 81
t ransforam in al lum bar in terbody
fusion (TLIF), 189t , 191, 192f
t ransoral approach to C1C2,
2829
t ranspedicular in st rum en tat ion,
95, 95f, 100101
t riggered elect rom yography
(tEMG), 81
t uberculosis of th e spin e, 289291,
292f
t um ors, 264279
diagn ost ic st udies, 265, 266f,
266t , 267t
int radural int ram edu llar y
t um ors, 271t
int raspinal n eoplasm s or cysts,
270t
prim ar y ben ign bone, 268t

prim ar y m align ant bone, 269t


radiat ion vs surger y, 272273
risk factors, 264
stereotact ic radiosurger y (SRS),
275
su rger y, 273279
su rger y plu s postop radiat ion vs
radiat ion alon e, 273
Tw in Spin e St udy, 171

V
vacuum disk sign , 70f
vancom ycin m ixed bone graft , 292
Verbiest lateral approach to th e
cer vical spin e, 30
vertebrae, anatom y of, 1
vertebral body collapse, 63
vertebral osteom yelit is, 280286
clin ical ndings, 281
et iology, 280
im aging, 282, 285t , 288f, 289f
in ciden ce, 280
laborator y n dings, 282, 284t
path ology, 280281
t reat m en t , 282286
surgical tech niques, 284286
vertebral pyogen ic osteom yelit is,
286
vert ical com pression injuries
(burst fract u res), 140
Vert ical Expan dable Prosthet ic
Titan ium Rib (VEPTR), 236,
237f

W
Wacken h eim lin e, 299f
Waddells sign s, 55
w edge com pression fract ures, 130
Weinstein -Borian i-Biagin i system
for staging, 267, 272f, 272t
Werdn ig-Ho m an disease, 241
w h iplash injuries, 123f
W hite and Panjabi checklist for
clin ical instabilit y, 85, 88t , 98f
W hiteside an d Kelley anterolateral
ret rophar yngeal approach, 30
w h ole person , de n it ion, 145
Wiltse paraspin al approach , 181f
Wiltse spon dylolisth esis
classi cat ion , 210, 211t
w r y n eck (tort icollis), 259

X
X-rays. See radiograph s

Y
Yale Open Data Access (YODA)
project , 114