Ali A. Baaj ....

- Second Edition
Praveen V. Mummaneni
Juan S. Uribe
Alexander R. Vaccaro
Marl< S. Greenberg

@!)Thieme
Handbook of Spine Surgery
Second Edition
Ali A. Baaj, MD
Assistan t Professor
Depar t m en t of Neurological Surger y
Weill Corn ell Medical College
Adu lt an d Pediat ric Spin e Su rger y
New York Presbyterian Hospit al
New York, New York
Praveen V. Mu m m an en i, MD
Professor an d Vice- Ch airm an
Depar t m en t of Neurosurger y
Un iversit y of Californ ia–San
Fran cisco
Co-Director, UCSF Sp in e Cen ter
San Fran cisco, Californ ia
Ju an S. Ur ib e, MD
Associate Professor
Director, Spin e Sect ion
Depar t m en t of Neurosurger y
Un iversit y of Sou th Florida
Tam p a, Florida
196 illu st rat ion s
Th iem e
New York • St u t tgar t • Delh i • Rio d e Jan eiro
Alexan d er R. Vaccaro, MD, Ph D,
MBA
Rich ard H. Roth m an Professor an d
Ch airm an
Depar t m en t of Or th opaedic Su rger y
Professor of Neu rosurger y
Co- Ch ief of Sp in e Su rger y
Sidn ey Kim m el Medical Cen ter at
Th om as Jefferson Un iversit y
Co-Director, Delaw are Valley Sp in al
Cord Inju r y Cen ter
Presiden t , Roth m an In st it ute
Ph iladelp h ia, Pen n sylvan ia
Mark S. Green b er g, MD
Associate Professor
Depar t m en t of Neurosurger y an d
Brain Repair
Un iversit y of Sou th Florida
Tam pa, Florida
Execu t ive Ed itor: Tim othy Hiscock
Man aging Editor: Sarah Lan dis
Director, Ed itor ial Ser vices: Mar y Jo Casey
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Presiden t: Br ian D. Scan lan
Librar y of Con gress Cat alogin g-in -Pu blicat ion Dat a
Han dbook of spin e su rger y / [edited by] Ali A. Baaj,
Praveen V. Mu m m an en i, Juan S. Ur ibe, Alexan der R.
Vaccaro, Mark S. Greenburg.—2n d edit ion .
p. ; cm .
In clu des bibliograph ical referen ces an d in dex.
ISBN 978-1-62623-163-4 (alk. paper)—ISBN 978-
1-62623-164-1 (eBook)
I. Baaj, Ali A., editor. II. Mum m an eni, Praveen V.,
editor. III. Ur ibe, Juan S., editor. IV. Vaccaro, Alex-
an der R., editor. V. Green bu rg, Mark S., editor.
[DNLM: 1. Spine—surger y—Han dbooks. 2. Neu ro-
su rgical Proced ures—m eth ods—Han dbooks.
3. Or th op edic Procedures—m eth ods—Han dbooks.
4. Spin al Cord—su rger y—Hand books. W E 39]
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 To m y p aren t s, Abd u lw ah ab an d Han a, to m y w ife, Gabriela,
to all m y m en tors of sp in e surger y, especially Juan Uribe an d Ziya Gokaslan ,
an d to th e residen t s an d fellow s w h o give us th e reason to do all th is.
AAB

For Valli, Nikh ita, Nkih il, an d Neel for all th eir love an d su p port .
For th e fellow s an d resid en t s w h om I h ave h ad th e pleasu re to h elp teach .
PVM

I w ould like to dedicate th is book to th e birth of m y ch ild,

Ch rist ian Joh n Vaccaro, an d to m y beau t ifu l w ife, Lauren . Lauren’s
gift of caring an d love h as on ly added to th e joy of ou r fam ily life.
ARV

To m y fam ily.
MSG

To m y w ife, Cat alin a, m y son , Sebast ian , m y daugh ter, Cam ila, m y p aren t s,
Carlos San t iago an d Maria Cecilia, an d m y paren ts-in -law, Ivan an d Maria
Cecilia, for th eir love an d un con dit ion al su pport .
JSU
Contents
Forew ord ................................................................................................................. xi
Forew ord ................................................................................................................ xii
Preface ...................................................................................................................xiii
Ack n ow ledgm en t s ..............................................................................................xiii
Con t r ibu tor s ......................................................................................................... xiv

I Anato m y
1 Em br yology of t h e Sp in e ..................................................................................... 3
Eric Mom in, Jared Fridley, and Andrew Jea
2 Cran iover teb ral Ju n ct ion ..................................................................................... 8
Jonathan Hobbs and Edw in Ram os
3 Cer vical Sp in e ....................................................................................................... 16
W illiam J. Readdy, Eric Sribnick , and Sanjay S. Dhall
4 Th oracic Sp in e ...................................................................................................... 22
W hit ney S. Jam es, Jens R. Chapm an, and Rod J. Oskouian Jr.
5 Lu m b ar Sp in e ........................................................................................................ 28
Horm uzdiyar H. Dasenbrock , Rafael De la Garza-Ram os, and Ali Bydon
6 Sacral–Iliac Sp in e ................................................................................................. 36
Am it R. Patel, Mat thew Chin, Am rit Khalsa, and Ravi K. Ponnappan

II Clinical Spine Surgery

7 Ph ysical Exam in at ion ......................................................................................... 45
Mark S. Greenberg
8 Sp in al Im agin g ...................................................................................................... 53
David Minges and Joon Y. Lee
9 Rad iat ion Exp osu re in Sp in e Su r ger y ............................................................. 60
Alexander Tuchm an and Pat rick C. Hsieh
10 Elect rod iagn ost ic Test in g in Sp in e Su r ger y .................................................. 64
Kam ak shi Patel and Holli A. Horak
11 In t raop erat ive Neu rop h ysiological Mon itor in g in Sp in e Su r ger y .......... 70
Colin R. Bam ford
12 Bed sid e Proced u res ............................................................................................. 76
Daniel C. Lu and Praveen V. Mum m aneni
13 Ph ar m acology ....................................................................................................... 83
Mark S. Greenberg
14 Rad iat ion Th erapy in Sp in e Su r ger y ............................................................... 90
Alexander Tuchm an and Pat rick C. Hsieh
15 Sp in al Rad iosu r ger y Th erapy ........................................................................... 94
Benjam in M. Zussm an, Edw ard A. Monaco III, and Peter Carlos Gerszten

vii
viii Content s

16 Sp in al Navigat ion ...............................................................................................100

Roger Härtl and José A. Corredor
17 Sp in e Biologics ...................................................................................................107
Zorica Buser, Rahul Basho, and Je rey C. W ang

III Spinal Patho log y

18 Con gen it al An om alies ......................................................................................115
Jared Fridley, Eric Mom in, and Andrew Jea
19 Cer vical Trau m a .................................................................................................124
Gregory D. Schroeder and Alexander R. Vaccaro
20 Th oracolu m bar Trau m a ...................................................................................138
W yat t L. Ram ey, Jesse Skoch, and Ali A. Baaj
21 Sacrop elvic Trau m a ...........................................................................................147
Kelley Banagan, Salm an Abbasifard, Ali A. Baaj, and Steven C. Ludw ig
22 In fect ion ...............................................................................................................156
Arya Giri Varthi, W illiam D. Long III, Jason O. Toy, and Peter G. W hang
23 Sp in al Colu m n an d Sp in al Cord Tu m or s ......................................................165
C. Rory Goodw in, Cam ilo Molina, and Daniel M. Sciubba
24 Cer vical an d Th oracic Sp in e Degen erat ive Disease ..................................175
Clinton J. Burkett and Mark S. Greenberg
25 Degen erat ive Lu m b ar Sp in e Disease ............................................................182
Michael Y. W ang
26 Con gen it al an d Neu rom u scu lar Scoliosis ...................................................191
Marie Roguski, Am er F. Sam dani, and Steven W. Hw ang
27 Sch eu er m an n ’s Kyp h osis .................................................................................199
Jahangir Asghar, Paul D. Kiely, and Harry L. Shu ebarger
28 Ad olescen t Id iop at h ic Scoliosis ......................................................................206
Law rence G. Lenke and Todd M. Chapm an Jr.
29 Ad u lt Degen erat ive Defor m it y .......................................................................212
Salm an Abbasifard and Ali A. Baaj
30 Rad iograp h ic Param eter s of Sp in al Defor m it y ..........................................217
Khoi D. Than, Andrei Fernandes Joaquim , and Praveen V. Mum m aneni
31 Vascu lar Pat h ology of t h e Sp in e ....................................................................223
Tim othy D. Uschold and Steven W. Chang
32 Sp on d yloar t h rop at h ies ....................................................................................231
Am ir A. Ahm adian and Fernando L. Vale
33 Sp in al Em er gen cies ...........................................................................................240
Puya Alikhani, Andreas K. Filis, and Frank D. Vrionis

IV Surgical Techniques
34 Occip itocer vical Fu sion ....................................................................................249
Gisela Murray, Edw in Ram os, and Juan S. Uribe
35 Ch iar i I Decom p ression ....................................................................................253
Mark S. Greenberg
 Content s ix

36 Tran soral Od on toid ectom y .............................................................................258

Steven M. Presciut t i, Mart in Quirno, Colin B. Harris, and Frank M. Phillips
37 C1–C2 Tech n iqu es ..............................................................................................265
Jau-Ching W u, Khoi D. Than, and Praveen V. Mum m aneni
38 Direct Fixat ion of Od on toid Fract u res .........................................................272
Rajiv Saigal and Dean Chou
39 Cer vical Ar t h rop last y .......................................................................................277
Jau-Ching W u, Ali A. Baaj, and Praveen V. Mum m aneni
40 An t er ior Cer vical Cor p ectom y .......................................................................283
Colin B. Harris and Frank M. Phillips
41 An t er ior Cer vical Diskectom y ........................................................................290
Daniel C. Lu, Khoi D. Than, Kevin T. Foley, and Praveen V. Mum m aneni
42 Cer vical Lam in ectom y w it h an d w it h ou t Fu sion .....................................295
Shyam M. Shridharani and F. Andrew Row an
43 Cer vical Lam in op last y ......................................................................................302
Glen R. Manzano and Allan D. Levi
44 Poster ior Cer vical Foram in otom y .................................................................308
Andreas K. Filis and Frank D. Vrionis
45 Cer vical Op en Red u ct ion Tech n iqu es: An t er ior an d
Poster ior Ap p roach es .......................................................................................315
Harm inder Singh, George M. Ghobrial, and Jam es S. Harrop
46 An t er ior Cer vical–Th oracic Ju n ct ion Tech n iqu e .......................................321
Muham m ad M. Abd-El-Barr, Viren S. Vasudeva, and Michael W. Gro
47 Freeh an d Th oracic Ped icle Screw Placem en t Tech n iqu e ........................328
Sheri Palejw ala, Jesse Skoch, and Ali A. Baaj
48 Tran sp ed icu lar Ap p roach ................................................................................333
Vinko Zlom islic and Steven R. Garf n
49 Costot ran sver sectom y ......................................................................................338
Hasan A. Zaidi and U. Kum ar Kakarla
50 Lateral Ext racavit ar y Ap p roach .....................................................................343
Marco Ferrone and Christopher M. Bono
51 Ped icle Su bt ract ion Osteotom y/Sm it h -Peter sen Osteotom y .................351
Frank La Marca, Paul Park , and Juan M. Valdivia
52 Th oracoscop ic Ap p roach es to t h e Sp in e ......................................................356
Meic H. Schm idt and Rick y Kalra
53 Lateral Ap p roach es to t h e Th oracolu m b ar Sp in e .....................................363
Jay Rhee, C. Rory Goodw in, and Jean-Paul W olinsk y
54 Op en an d Min im ally In vasive Sp in al Lu m b ar Microd iskectom y ..........370
Ali A. Baaj and Mark S. Greenberg
55 Lu m b ar Foram in otom y ....................................................................................375
Ali A. Baaj and Juan S. Uribe
56 Posterolateral En d oscop ic Diskectom y ........................................................378
Christopher Yeung and Anthony T. Yeung
57 Lu m b ar Lam in ectom y ......................................................................................387
Benjam in D. Elder and Tim othy F. W itham
x Content s

58 Poster ior an d Tran sforam in al Lu m b ar In t erbody Fu sion .......................393

Zachary J. Tem pel, Hazem A. Mashaly, and Adam S. Kanter
59 Min im ally In vasive Tran sforam in al Lu m b ar In t erb od y Fu sion .............399
Michael Y. W ang
60 Percu t an eou s Ped icle Screw Placem en t ......................................................405
Michael Y. W ang
61 Min im ally In vasive Lateral Ret rop er iton eal Tran sp soas
In terb od y Fu sion ................................................................................................411
Gisela Murray, Ali A. Baaj, and Juan S. Uribe
62 An ter ior Lu m bar In terbody Fu sion ...............................................................416
Junyoung Ahn, Krzysztof Siem ionow , Dust in H. Massel, Benjam in C. Mayo,
W illiam D. Long III, Krishna D. Modi, and Kern Singh
63 Facet Screw Fixat ion /Fu sion ...........................................................................421
Just in W . Miller and Rick C. Sasso
64 In ter sp in ou s Process Decom p ression ..........................................................426
Jason O. Toy, Ravi Ram achandran, Arya Giri Varthi, and Peter G. W hang
65 Lu m b ar Ar t h rop last y ........................................................................................432
Keith Jack son and Joon Y. Lee
66 Lu m b osacroiliac Fixat ion ................................................................................439
Phillip Horne, W illiam D. Long III, and Andrew A. Sam a
67 Iliosacral Percu t an eou s Fixat ion (Iliosacral Screw s) ...............................446
Jonathan G. East m an and Eric O. Klineberg
68 Sacroiliac Join t Fu sion ......................................................................................456
Kornelis Poelst ra and Jessica Sosio
69 Sacrectom y ..........................................................................................................468
Thom as Kosztow ski, Moham ad Bydon, C. Rory Goodw in,
and Ziya L. Gokaslan
70 Ver t eb ral Bod y Au gm en t at ion .......................................................................476
Andrey Alex Volkov, Ioannis Papanastassiou , and Frank D. Vrionis
71 Sp in al Cord Tu m or Resect ion .........................................................................483
Mari L. Groves and George I. Jallo
72 Su r gical Resect ion of Sp in al Vascu lar Lesion s ...........................................490
Tim othy D. Uschold, Alim P. Mitha, and Steven W. Chang

Appendices

I Posit ion in g ..........................................................................................................499

Tien V. Le, Juan S. Uribe, and Fernando L. Vale

II Selected Sp in al Or t h oses .................................................................................505

Tien V. Le, Juan S. Uribe, and Fernando L. Vale

III Ou t com e Scales ..................................................................................................516

In d ex .....................................................................................................................521
Forew ord
In this exciting second edition of the Handbook
of Spine Surgery, editors Ali A. Baaj, Praveen V.
Mum m aneni, Juan S. Uribe, Alexander R. Vac-
caro, and Mark S. Greenberg have configured
a virtual step-by-step “cookbook” of all the
com m on and uncom m on surgical spine proce-
dures utilized around the globe, w ith chapters
authored by highly recognized spinal surgeons.
This task has been expertly accom plished by
the overall organization of the chapters into
sections: Anatomy, Clinical Spine Sur gery,
Spinal Pathology, and Surgical Techniques.
Specific topics are thoroughly covered w ithin
and across sections, such as “Thoracolum bar
Traum a” (Chapter 21 in the Spinal Pathology
section), “Freehand Thoracic Pedicle Screw
Placem ent Technique” (Chapter 47 in the Sur-
gical Techniques section), and specific surgical
procedures, such as “Sacrectomy” (Chapter 69
in the Surgical Techniques section). A com m on
tem plate is followed in w hich each chapter lo-
gically proceeds from Key Points to Indications,
Techniques, Complications, Postperative Care,
Outcom es, Surgical Pearls, Com m on Clinical
Questions and Answers (as is seen in current
CME form ats), and Key References. This struc-
ture is very effective and ideal for quick and
easy review the evening before, or even the
m orning of, conferences and surgical procedu-
res. Trainees still trying to m aster these topics,
as well as m ore senior surgeons needing a quick
refresher, w ill benefit. The organizational style
is direct and compact but thorough, approp-
riately illustrated w hen helpful, and perfectly
suited to a busy clinical schedule w here essen-
tial inform ation and details need to be gleaned
in rapid fashion, w hether in print, on a phone,
tablet, or computer. The organizational consis-
tency of the chapters also aids in quick disse-
m ination and retention, w hich is critical to our
training environm ent.
I can envision this text being extrem ely
useful to a w ide range of individuals: from a
third-year m edical student perform ing his or
her initial surgical rotation w hile assigned to
the spine service, to a spine physician assis-
tant helping out during surgery, to a spinal
surgery fellow gaining technical confidence
during the m ost im portant year of fellowship
training. Those residents, fellows, and atten-
dings utilizing this text w ill probably find the
greatest “bang for their buck” in the pearls and
tips, w hich are w ritten to optim ize safet y and
m axim ize efficiency during various specific
spinal surgery procedures. I also found the Q
and A sections a nice refresher for keeping up
on the m yriad of spine surgery techniques that
have rapidly advanced over the past decade, as
spine surgery itself continues dow n a subspe-
cialization pathway distinct from orthopedic
surgery and neurosurgery. In that regard, this
book would also serve as an excellent review
for those studying for board certification or
recertification for the Am erican Board of Or-
thopaedic Surgery or the Am erican Board of
Neurological Surgery exam s.
I congratulate the editors and contributing
authors for this im portant piece of work. Any
“handbook” should, by definition, be able to
concisely provide essential details of a condi-
tion and various rem edies and solutions—as
well as obstacles encountered along the way—
to best educate the intended audience. I am
confident that the Handbook of Spine Surgery
has m ore than accom plished these objecti-
ves and w ill have an enduring and im portant
im pact on those fortunate enough to benefit
from the assem bled inform ation provided.
Law rence G. Lenke, MD
Professor and Chief of Spinal Surgery
Depart m ent of Orthopaedic Surgery
Colum bia Universit y College
of Physicians and Surgeons
Surgeon-in-Chief
The Spine Hospital at
New York-Presbyterian/Allen Hospital
New York , New York
xi
 Forew ord
Th e secon d ed it ion of t h e Handbook of
Spine Surgery, ed ited by Dr. Ali A. Baaj, Dr.
Praveen V. Mu m m an en i, Dr. Ju an S. Ur ibe,
Dr. Alexan d er R. Vaccaro, an d Dr. Mark S.
Green berg, is an ou t st an d in g d ist illat ion
of t h e cu r ren t kn ow ledge of t h e evalu a-
t ion an d su rgical m an agem en t of sp in al
d isord ers. Th e book is d ivid ed in to fou r
w ell-organ ized sect ion s: a d et ailed syn -
op sis of sp in al an atom y, an evalu at ion of
t h e tech n iqu es u sed for clin ical evalu at ion
of sp in al su rger y, a d et ailed d escr ipt ion of
sp in al su rgical p at h ology, an d a step -by-
step d escr ipt ion of su rgical tech n iqu es. In
ad d it ion , t h ere are ap p en d ices on p at ien t
p osit ion in g, selected sp in al or t h oses, an d
com m on ly u sed ou tcom e scales.
Th e Handbook of Spin e Surger y par t icu-
larly excels as a qu ick reference for alm ost
any t yp e of sp in al su rgical con d it ion or su r-
gical procedure, from occipitocer vical fusion
to sp in op elvic xat ion . Each of th e ch apters
is w rit ten by a w orld-ren ow n ed physician .
Th e surgical ch apters are auth ored by ex-
per t s from th e eld of or th op aedic or neu -
rosurgical sp in al surger y; ever y ch apter h as
in t rodu ctor y key p oin t s an d det ailed d e-
script ion s of in dicat ion s for each of th e sur-
gical procedures. A step -by-step descript ion
xii
of in st ru m en t at ion tech n iqu es, frequ en tly
asked quest ion s, an d surgical pearls are pro-
vided by exper t s in th e eld .
This book w ill be an invaluable resource
for orthopaedic and neurosurgical residents
in t raining, spinal surgical fellow s, and prac-
ticing orthopaedic surgeon s and n eurosur-
geon s w h o deal w ith spinal pathology. The
book covers an exh aust ive set of topics in a
succinct m anner, but su cient inform at ion is
provided to serve as a surgical atlas. I feel that
th is w ill becom e the standard resource for
surgeons in training, early in practice, those
preparing for board exam inations, and expe-
rienced spine surgeon s needing a refresh er.
I am positive that in its electronic form this
book w ill be used as a quick reference on a
daily basis by m ost pract icing spine surgeon s.
I congrat ulate th e editors on this outstanding
resource and look forward to having it avail-
able to use in m y ow n practice.
Christopher I. Sha rey, MD, FACS
John A. Jane Professorship of Neurological
Surgery
Division Head Spine Surgery
Professor of Orthopaedic Surgery
Universit y of Virginia Medical Center
Charlot tesville, Virginia
Preface
We are deligh ted to presen t th e secon d
ed it ion of t h e Handbook of Spine Surgery.
As w ith t h e previou s edit ion , ou r goal is to
p rovide a com p reh en sive yet por t able an d
com p act text t h at d ist ills t h e basic p rin cip -
les of con tem p orar y spin e surger y. We h ave
on ce again been for t u n ate to receive con t ri-
but ion s from dozen s of reput able surgeon s
represen t ing acclaim ed ort h opedic an d n eu -
rosurger y program s.
W h ereas th e h igh ly popu lar form at of th e
first ed it ion is on ce again adopted, w e h ave
sign ifican tly en h an ced th e text w ith several
n ew ch apters add ressing top ics like p ediat-
ric scoliosis an d ad u lt deform it y p rin cip les.
We h ave also expan ded th e spin al t raum a
Acknow ledgments
The editors would like to than k all the ch ap -
ter auth ors for contribut ing to th is second
edition . We also than k the team at Th iem e
Publishers for their assistan ce in the prepara-
tion and publicat ion of this text .
sect ion to in clude dedicated ch apters on
cer vical, th oracolu m bar, an d sacrop elvic in -
ju ries. Su rgical p earls an d board-st yle qu es-
t ion s at th e en d of each ch apter em ph asize
th e salien t poin t s of each topic.
We are con fiden t th at th is text w ill con t i-
n u e to be an excellen t resou rce for su rgeon s
an d t rain ees alike as w e all st rive to im p rove
spin e educat ion an d t rain ing and th e clin ical
care of ou r pat ien t s.
Ali A. Baaj, MD
Praveen V. Mum m aneni, MD
Juan S. Uribe, MD
Alexander R. Vaccaro, MD, PhD
Mark S. Greenberg, MD
xiii
 Contributors
Salm an Abbasifard, MD
Su rger y Depart m en t
Neu rosu rger y Division
Un iversit y of Arizon a Medical
Health Cen ter
Tucson , Arizon a
Muham m ad M. Abd-El-Barr, MD, PhD
Depart m en t of Su rger y
Brigh am an d Wom en’s Hospit al
Boston , Massach u set ts
Am ir A. Ahm adian, MD
Neu rosu rgeon
Depart m en t of Neu rosu rger y
Un iversit y of Sou th Florida
Tam pa, Florida
Junyo ung Ahn, BS
Depart m en t s of Su rger y, Or th opedic
Su rger y, an d Biological Psych ology
Un iversit y of Texas Sou th w est
Dallas, Texas
Puya Alikhani, MD
Depart m en t of Neu rosu rger y
Un iversit y of Sou th Florida
Tam pa, Florida
Jahangir Asghar, MD
Pediat ric Or th opedic Spin e Su rgeon
Nicklau s Ch ildren’s Hospit al
Miam i, Florida
Ali A. Baaj, MD
Assistan t Professor
Depart m en t of Neu rological Su rger y
Weill Corn ell Medical College
Adu lt an d Pediat ric Sp in e Su rger y
New York Presbyterian Hosp it al
New York, New York
xiv
Co lin R. Bam ford, MD
Associate Professor
Depart m en t of Neu rology
Un iversit y of Arizon a
Tucson , Arizon a
Kelley Banagan, MD
Assistan t Professor
Depart m en t of Orth op aedics
Un iversit y of Mar ylan d Medical
Cen ter
Balt im ore, Mar ylan d
Rahul Basho, MD
Director of Spin e Su rger y
Han n ibal Region al Hosp it al
Midw est Orth op edic Sp ecialist s
Han n ibal, Missou ri
Christo pher M. Bo no, MD
Ch ief, Or th opaedic Spin e Ser vice
Depart m en t of Orth op aedic Su rger y
Brigh am an d Wom en’s Hospit al
Boston , Massach u set t s
Clinto n J. Burkett, MD
Neu rosu rgeon
Neu rological Su rger y Associates
For t Lau derdale, Florida
Zo rica Buser, PhD
Sen ior Research Associate
Depart m en t of Orth op aedic Su rger y
Keck Sch ool of Medicin e
Un iversit y of South ern Californ ia
Los Angeles, Californ ia
Ali Bydo n, MD
Associate Professor of Neurosurger y
Th e Joh n s Hopkin s Un iversit y
Balt im ore, Mar ylan d

Mo ham ad Bydo n, MD
Assist an t Professor of Neu rologic
Su rger y
Dep ar t m en t of Orth op ed ic Su rger y
an d Health Scien ces Research
Mayo Clin ic
Roch ester, Min n esot a
Steven W. Chang, MD
At ten d ing Physician
Barrow Neu rological In st it u te
Barrow Neu rosu rgical Associates
Ph oen ix, Arizon a
Je ns R. Chapm an, MD
Com plex Spin e Surger y
Sw edish Neuroscien ce In st it ute
Seat tle, Wash ington
To dd M. Chapm an Jr., MD
Dep ar t m en t of Orth op aedic Su rger y
Wash ington Universit y
St . Lou is, Missou ri
Matthew Chin, MD
Dep ar t m en t of Orth op aedic Su rger y
Drexel Un iversit y College of Medicin e
Ph iladelph ia, Pen n sylvan ia
Dean Cho u, MD
Professor
Dep ar t m en t of Neu rosu rger y
Un iversit y of Californ ia–San
Fran cisco Spin e Cen ter
San Fran cisco, Californ ia
Jo sé A. Co rredo r, MD
Weill Corn ell Brain an d Spin e Cen ter
Dep ar t m en t of Neu rological Su rger y
Weill Corn ell Medical College
New York-Presbyterian Hospital
New York, New York
Cirujan o de Colum n ae
Bogot á, Colom bia
Contributors xv
Ho rm uzdiyar H. Dasenbrock, MD
Depart m en t of Neu rosu rger y
Brigh am an d Wom en’s Hospit al
Boston , Massach u set ts
Sanjay S. Dhall, MD
Associate Professor
Depart m en t of Neu rological Su rger y
Universit y of California–San Francisco
Director
Sp in al Neu rot rau m a Program
San Fran cisco Gen eral Hosp ital
San Fran cisco, Californ ia
Jo nathan G. Eastm an, MD
Assistan t Professor
Depart m en t of Orth p aedic Su rger y
Division of Trau m atology
Un iversit y of Californ ia–Davis
Health System
Sacram en to, Californ ia
Be njam in D. Elde r, MD, PhD
Depart m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y
Sch ool of Med icin e
Balt im ore, Mar ylan d
Marco Ferro ne, MD
In st ru ctor of Or th opaedic Su rger y
Depart m en t of Orth op aedic
On cology
Brigh am an d Wom en’s Hospit al/
Dan a Farber Can cer In st it ute
Boston , Massach u set ts
Andreas K. Filis, MD
Depart m en t of Orth op edics an d
On cological Scien ces
Un iversit y of Sou th Florida
College of Medicin e
Tam pa, Florida
xvi Contributors
Kevin T. Fo ley, MD, FACS, FAANS
Professor of Neurological Surger y,
Or th opaedic Su rger y, an d
Biom edical Engin eering
Un iversit y of Ten n essee Health
Scien ce Cen ter
Ch airm an , Sem m es-Mu rp h ey Clin ic
Mem ph is, Ten n essee
Jared Fridley, MD
Depart m en t of Neu rosu rger y
Baylor College of Medicin e
Hou ston , Texas
Steve n R. Garf n, MD
Dist ingu ish ed Professor an d Ch air
Depart m en t of Orth op aedic Su rger y
Un iversit y of Californ ia–San Diego
San Diego, Californ ia
Rafael De la Garza-Ram o s, MD
Depart m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y
Balt im ore, Mar ylan d
Peter Carlos Gerszten, MD, MPH, FACS
Peter E. Sh ept ak Professor an d
Vice- Ch airm an
Depart m en t s of Neu rological Su rger y
an d Rad iat ion On cology
Un iversit y of Pit t sburgh Medical
Cen ter
Pit t sburgh , Pen n sylvan ia
Geo rge M. Gho brial, MD
Depart m en t of Neu rological Su rger y
Th om as Je erson Un iversit y
Ph iladelp h ia, Pen n sylvan ia
Ziya L. Go kaslan, MD, FAANS, FACS
Gus Stoll, MD Professor an d Ch air
Dep ar t m en t of Neu rosu rger y
Th e Warren Alper t Medical Sch ool of
Brow n Un iversit y
Neu rosu rgeon -in - Ch ief
Rh ode Islan d Hosp it al an d
Th e Miriam Hospital
Clin ical Director, Norm an Prin ce
Neu roscien ces In st it u te
Presiden t , Brow n Neurosurger y
Foun dat ion
Rh ode Islan d Hosp it al
Dep ar t m en t of Neu rosu rger y
Norm an Prince Neurosciences Institute
Providen ce, Rh ode Islan d
C. Ro ry Go o dw in, MD, PhD
Dep ar t m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y
Balt im ore, Mar ylan d
Mark S. Greenberg, MD
Associate Professor
Dep ar t m en t of Neu rosu rger y an d
Brain Rep air
Un iversit y of South Florida
Tam pa, Florida
Michael W. Gro , MD
Director of Sp in al Neu rosu rger y
Dep ar t m en t of Neu rosu rger y
Brigh am an d Wom en’s Hospit al
Boston , Massach u set t s
Mari L. Groves, MD
Dep ar t m en t of Neu rosu rger y
Th e Joh n s Hopkin s Hospital
Balt im ore, Mar ylan d
Colin B. Harris, MD
At ten ding Spin e Su rgeon
Syracuse Orth opedic Specialist s
Crou se Hospit al an d St . Joseph’s
Hosp it al Health Care Cen ter
Syracuse, New York

Jam es S. Harro p, MD, FACS
Professor
Dep ar t m en t s of Neu rological an d
Orth op edic Su rger y
Director, Division of Sp in e an d
Periph eral Ner ve Su rger y
Neu rosu rger y Director of Delaw are
Valley SCI Cen ter
Th om as Je erson Un iversit y
Ph iladelph ia, Pen n sylvan ia
Ro ger Härtl, MD
Professor of Neurological Surger y
Director of Sp in al Su rger y
Co-Director, Spin e Cen ter
Weill Corn ell Brain an d Spin e Cen ter
New York, New York
Jo nathan Ho bbs, MD
Dep ar t m en t of Neu rosu rger y
Un iversit y of Ch icago
Ch icago, Illin ois
Holli A. Ho rak, MD
Associate Professor
Dep ar t m en t of Neu rology
Un iversit y of Arizon a
Tucson , Arizon a
Phillip Ho rne, MD, PhD
Assist an t Professor of Surger y
Dep ar t m en t of Orth op aedic Su rger y
Du ke Or th opaedics of Raleigh
Du ke Raleigh Hosp it al
Raleigh , North Carolin a
Patrick C. Hsieh, MD, MSc
Associate Professor
Director of Min im ally Invasive Sp in e
Program an d Spin al On cology
Dep ar t m en t of Neu rosu rger y
USC Sp in e Cen ter
Un iversit y of Sou th ern Californ ia
Keck Sch ool of Med icin e
Los Angeles, Californ ia
Contributors xvii
Steve n W. Hw ang, MD
Ch ief
Division of Pediat ric Neu rosu rger y
Depart m en t of Neu rosu rger y
Tuft s Medical Cen ter an d Float ing
Hosp it al for Ch ildren
Boston , Massach u set ts
Keith Jackson, MD
St a Su rgeon
Depart m en t of Orth op aedics an d
Reh abilitat ion
Wom ack Arm y Medical Cen ter
Fort Bragg, North Carolin a
Ge orge I. Jallo, MD
Professor of Neurosurger y, Pediat rics,
an d On cology
Director
In st it u te Brain Protect ion Ser vices
All Ch ildren’s Hospital–Joh ns
Hopkin s Medicin e
St . Petersburg, Florida
Whitney S. Jam es, MD, MHS
Depart m en t of Neu rosu rger y
Un iversit y of Arizon a Medical Cen ter
Tucson , Arizon a
Andrew Jea, MD
Associate Professor
Depart m en t of Neu rosu rger y
Baylor College of Medicin e
Hou ston , Texas
Andrei Fernandes Joaquim , MD, PhD
Neu rosu rgeon
Depart m en t of Neu rology
St ate Un iversit y of Cam pin as
Cam p in as-SP, Brazil
U. Kum ar Kakarla
At ten ding Physician
Barrow Neu rological In st it u te
Barrow Neu rosu rgical Associates
Ph oen ix, Arizon a
xviii Contributors
Rick y Kalra, MD
Depart m en t of Neu rosu rger y
Un iversit y of Utah
Salt Lake Cit y, Ut ah
Adam S. Kante r, MD
Ch ief
Division of Sp in e Su rger y
Associate Professor
Depart m en t of Neu rological Su rger y
Un iversit y of Pit t t sburgh
Pit t sburgh , Pen n sylvan ia
Am rit Khalsa, RN, IBCLC
Con sultan t
Labor of Love Lact at ion Ser vices
Met a Midw ifer y in th e Bay Area
Oaklan d , Californ ia
Paul D. Kiely, MCh, FRCh
In tegrated Sp in e Research
Dep art m en t
Hosp it al for Sp ecial Su rger y
New York, New York
Eric O. Klineberg, MD, MS
Associate Professor
Depart m en t of Orth op aedic Su rger y
Un iversit y of Californ ia–Davis Health
System
Sp in e Cen ter
Sacram en to, Californ ia
Tho m as Ko sztow ski, MD
Depart m en t of Neu rosu rger y
Th e Joh n s Hopkin s Hospit al
Balt im ore, Mar ylan d
Frank La Marca, MD
Clin ical Associate Professor
Depart m en t of Neu rosu rger y
Un iversit y of Mich igan
An n Arbor, Mich igan
Tie n V. Le, MD
Neu rological Su rgeon
Tam pa Bay Neurosurger y an d Spin e
Sp ecialist s
Tam pa, Florida
Jo o n Y. Le e, MD
Associate Professor
Director of Clin ical Research
Dep ar t m en t of Or th opaedic Su rger y
University of Pittsburgh Medical Center
Pit t sburgh , Pen n sylvan ia
Law rence G. Lenke, MD
Professor an d Ch ief of Spin al Surger y
Dep ar t m en t of Or th opaedic Su rger y
Colu m bia Un iversit y College of
Physician s an d Su rgeon s
Su rgeon -in -Ch ief
Th e Spin e Hospit al at New York-
Presbyterian /Allen Hospit al
New York, New York
Allan D. Levi, MD, PhD, FACS
Professor an d Ch airm an
Dep ar t m en t of Neu rological Su rger y
Un iversit y of Miam i
Miam i, Florida
William D. Lo ng III, MD
Private Pract ice
Prem ier Orth opaedics
Bergen Coun t y, New Jersey
Daniel C. Lu, MD, PhD
Associate Professor
Dep ar t m en t of Neu rosu rger y
Sp in al Cord Reh abilit at ion Cen ter
Ron ald Reagan UCLA Medical Cen ter
UCLA Medical Cen ter
Director, Neu roplast icit y
Com preh en sive Spin e Cen ter
San ta Mon ica, Californ ia

Steven C. Ludw ig, MD
Ch ief of Sp in e Su rger y
Director of Sp in e Fellow sh ip
Head of th e Division of Spin e Su rger y
Un iversit y of Mar ylan d
Dep ar t m en t of Orth op aedics
Balt im ore, Mar ylan d
Glen R. Man zano, MD
Assist an t Professor of Clin ical
Neu rosu rger y
Dep ar t m en t of Neu rological Su rger y
Un iversit y of Miam i Health System
Un iversit y of Miam i Hospital
Miam i, Florida
Hazem A. Mashaly, MD
Dep ar t m en t of Neu rosu rger y
Ain Sh am s Un iversit y
Cairo, Egypt
Dustin H. Massel, BS
Research Coordin ator
Dep ar t m en t of Orth op aedic Su rger y
Rush Un iversit y Medical Cen ter
Ch icago, Illin ois
Benjam in C. Mayo , BA
Research Coordin ator
Dep ar t m en t of Orth op aedic Su rger y
Rush Un iversit y Medical Cen ter
Ch icago, Illin ois
Justin W. Miller, MD
Orth op aed ic Sp in e Su rgeon
In dian a Sp in e Grou p
Carm el, In d ian a
David Minges, MD
Orth op aed ic Sp in e Su rgeon
Advan ced Bon e an d Join t
St . Peters, Missou ri
Contributors xix
Alim P. Mitha, MD
Cerebrovascular/En dovascu lar/Sku ll
Base Neu rosu rgeon
Depart m en t of Clin ical Neu roscien ces
Footh ills Medical Cen t re
Un iversit y of Calgar y
Calgar y, Alber t a, Can ada
Krishna D. Mo di, BS
Research Assist an t
Depart m en t of Orth op aedic Su rger y
Ru sh Un iversit y Medical Cen ter
Midw est Or th op aedics at Ru sh
Ch icago, Illin ois
Cam ilo Mo lina, MD
Depart m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y
Balt im ore, Mar ylan d
Eric Mo m in, MD
Depart m en t of Neu rosu rger y
Baylor College of Medicin e
Hou ston , Texas
Edw ard A. Mo naco III, MD, PhD
Assistan t Professor
Depart m en t of Neu rological Su rger y
University of Pittsburgh Medical Center
Pit t sburgh , Pen n sylvan ia
Pravee n V. Mum m ane ni, MD
Professor an d Vice- Ch airm an
Depart m en t of Neu rosu rger y
Universit y of California–San Francisco
Co-Director, UCSF Spin e Cen ter
San Fran cisco, Californ ia
Gisela Murray, MD
Neu rosu rgeon
San Ju an , Pu erto Rico
Ro d J. Osko uian Jr., MD
Ch ief of Spin e Division
Depart m en t of Neu rological Su rger y
Sw edish Neuroscien ce In st it ute
Seat tle, Wash ington
xx Contributors
She ri Palejw ala, MD
Depart m en t of Neu rosu rger y
Un iversit y of Arizon a
Tucson , Arizon a
Io annis Papanastassio u, MD, PhD
Or th opedic Depart m en t
Gen eral On cological Hospit al Ki sias
‘Agioi An argyroi’
Ath en s, Greece
Paul Park, MD
Associate Professor
Depart m en t of Neu rosu rger y
Un iversit y of Mich igan
An n Arbor, Mich igan
Am it R. Patel, MD
Or th opaedic Sp in e Su rgeon
Or th opaedic an d Sp in e Sp ecialist s
York, Pen n sylvan ia
Kam akshi Patel, MD, MPH
Assistan t Professor of Neurology
Un iversit y of Texas Medical Bran ch
Galveston , Texas
Frank M. Phillips, MD
Professor
Depart m en t of Orth op aedic Su rger y
Sp in e Fellow sh ip Co-Director
Rush Un iversit y Medical Cen ter
Ch icago, Illin ois
Ko rnelis Po elstra, MD, PhD
Ch airm an
Depart m en t of Su rger y
Sacred Hear t Hosp it al on th e
Em erald Coast
Presiden t , Th e Spin e In st it ute on th e
Em erald Coast
Miram ar Beach , Florida
Ravi K. Po nnappan, MD
Clin ical Associate Professor
Dep ar t m en t of Or th opaedic Su rger y
Drexel Un iversit y College of Medicin e
Ph iladelp h ia, Pen n sylvan ia
Steven M. Presciutti, MD
Midw est Orth op aedics at Ru sh
Rush Un iversit y
Ch icago, Illin ois
Martin Quirno , MD
Midw est Orth op aedics at Ru sh
Rush Un iversit y
Ch icago, Illin ois
Ravi Ram achandran, MD
Sp in e Su rgeon
Sacram en to, Californ ia
Wyatt L. Ram ey, MD
Division of Neu rosu rger y
Dep ar t m en t of Su rger y
Un iversit y of Arizon a
Tu cson , Arizon a
Edw in Ram o s, MD
Assist an t Professor
Dep ar t m en t of Neu rosu rger y
Un iversit y of Ch icago
Ch icago, Illin ois
William J. Readdy, BS
Robert Wood Joh n son
Medical Sch ool
New Bru n sw ick, New Jersey
Jay Rhee, MD
Director of Sp in e Su rger y
Dep ar t m en t of Neu rosu rger y
Holy Cross Health System
Silver Spring, Mar ylan d

Marie Ro guski, MD, MPH
Dep ar t m en t of Neu rosu rger y
Tuft s Medical Cen ter
Boston , Massach u set t s
F. Andrew Row an, MD, MS
Dep ar t m en t of Orth op ed ics
Un iversit y of Arizon a
Tucson , Arizon a
Rajiv Saigal, MD, PhD
Dep ar t m en t of Orth op ed ic Su rger y
Scrip ps Health , San Diego Sp in e
Foun dat ion
San Diego, Californ ia
Andrew A. Sam a, MD
Associate Professor
Dep ar t m en t of Orth op aedic Spin e
Su rger y
Hospital for Special Su rger y
Weill Corn ell Sch ool of Medicin e
New York, New York
Am er F. Sam dani, MD
Ch ief of Su rger y
Sh rin ers Hospit als for
Ch ildren –Ph iladelp h ia
Ph iladelph ia, Pen nyslvan ia
Rick C. Sasso, MD
Professor
Ch ief of Sp in e Su rger y
Dep ar t m en t of Orth op aedic Su rger y
In dian a Un iversit y Sch ool of
Medicin e
In dian a Sp in e Grou p
In dian ap olis, In d ian apolis
Contributors xxi
Meic H. Schm idt, MD, MBA, FAANS,
FACS
Professor of Neurosurger y an d
Or th opaedics
Ron ald I. Ap felbaum En dow ed Ch air
for Sp in e Su rger y
Vice Ch air for Clin ical A airs
Depart m en t of Neu rosu rger y
Ch ief Valu e O cer, Un iversit y
Hosp it al, Neu rosu rger y Ser vice
Program Director, Neurosurger y
Sp in e Fellow sh ip
Director, Sp in al On cology Ser vice,
Hu n t sm an Can cer In st it u te
Clin ical Neu roscien ces Cen ter
Un iversit y of Ut ah
Salt Lake Cit y, Ut ah
Gregory D. Schro eder, MD
Depart m en t of Orth op aedic Su rger y
Roth m an In st it u te at Th om as
Je erson Un iversit y
Ph iladelp h ia, Pen n sylvan ia
Daniel M. Sciubba, MD
Associate Professor of Neurosu rger y,
On cology, an d Or th opaedic Su rger y
Depart m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y
Balt im ore, Mar ylan d
Shyam M. Shridharani, MD
Assistan t Professor
Depart m en t of Orth op aedic Su rger y
Th e Un iversit y of Arizona
Tucson , Arizon a
Harry L. Shu ebarger, MD
Ch ief
Division of Spin al Su rger y
Depart m en t of Orth op edic Su rger y
Nicklau s Ch ildren’s Hospit al
Miam i, Florida
xxii Contributors
Krzyszto f Siem io now , MD
Ch ief of Spin e Su rger y
Assistan t Professor of Orth opaedics
an d Neu rosu rger y
Un iversit y of Illin ois–Ch icago
Ch icago, Illin ois
Harm inder Singh, MD, FACS, FAANS
Assistan t Professor
Depart m en t of Neu rosu rger y
Stanford Universit y School of Medicine
St an ford, Californ ia
Kern Singh, MD
Associate Professor
Depart m en t of Orth op aedic Su rger y
Rush Un iversit y Medical Cen ter
Ch icago, Illin ois
Jesse Sko ch, MD
Depart m en t of Su rger y
Division of Neu rosu rger y
Ban n er Un iversit y Medical Cen ter
Tucson , Arizon a
Jessica So sio , BS
Depart m en t of Biology
Florida State Un iversit y
Tallah assee, Florida
Eric Sribnick, MD, PhD
Assistan t Professor
Depart m en t of Neu rosu rger y
Th e Oh io State Un iversit y
Colum bus, Oh io
Zachary J. Tem pel, MD
Depart m en t of Neu rological Su rger y
Un iversit y of Pit t sburgh Medical
Cen ter
Pit t sburgh , Pen n sylvan ia
Kho i D. Than, MD
Assist an t Professor
Dep ar t m en t of Neu rological Su rger y
Oregon Health & Scien ce Un iversit y
Por tlan d, Oregon
Jaso n O. Toy, MD
Dep ar t m en t of Or th opaedics an d
Reh abilit at ion
Yale Un iversit y Sch ool of Medicin e
New Haven , Con n ect icu t
Alexander Tuchm an, MD
Dep ar t m en t of Neu rological Su rger y
Keck Sch ool of Medicin e
Un iversit y of South ern Californ ia
Los Angeles, Californ ia
Juan S. Uribe, MD
Associate Professor
Director, Sp in e Sect ion
Dep ar t m en t of Neu rosu rger y
Un iversit y of South Florida
Tam pa, Florida
Tim othy D. Uschold, MD
Neu rological an d Spin e Su rgeon
Sou th ern Oregon Neu rosu rgical
an d Sp in e Associates
Med ford, Oregon
Alexander R. Vaccaro, MD, PhD,
MBA
Rich ard H. Roth m an Professor an d
Ch airm an
Dep ar t m en t of Or th opaedic Su rger y
Professor of Neurosurger y
Co- Ch ief of Spin e Surger y
Sidn ey Kim m el Medical Cen ter at
Th om as Je erson Un iversit y
Co-Director, Delaw are Valley Spin al
Cord Injur y Cen ter
Presiden t , Roth m an In st it ute
Ph iladelp h ia, Pen n sylvan ia

Juan M. Valdivia, MD, FAANS
Neu rosu rgeon
Bay Care Medical Grou p
Tam pa, Florida
Fe rnando L. Vale, MD
Professor an d Vice- Ch airm an
Dep ar t m en t of Neu rosu rger y an d
Brain Repair
Un iversit y of Sou th Florida
Tam pa, Florida
Arya Giri Varthi, MD
Dep ar t m en t of Orth op aedic Su rger y
an d Reh abilit at ion
Yale New Haven Hosp it al
New Haven , Con n ect icu t
Vire n S. Vasudeva, MD
Dep ar t m en t of Neu rosu rger y
Brigh am an d Wom en’s Hospital
Har vard Medical Sch ool
Boston , Massach u set t s
Andrey Alex Vo lkov, DO
Dep ar t m en t of Neu roon cology
Mo t t Can cer Cen ter
Tam pa, Florida
Frank D. Vrio nis, MD, PhD
Ch ief of Neu rosurger y
H. Lee Mo t t Can cer Cen ter
Professor of Neurosu rger y
Dep ar t m en t of Orth op ed ics an d
On cological Scien ces
Un iversit y of Sou th Florida College of
Medicin e
Tam pa, Florida
Contributors xxiii
Je rey C. Wang, MD
Ch ief, Or th opaedic Spin e Ser vice
Co-Director, Un iversit y of South ern
Californ ia Sp in e Cen ter
Professor of Or th opaedic Surger y an d
Neu rosu rger y
USC Spin e Cen ter
Los Angeles, Californ ia
Michael Y. Wang, MD, FACS
Professor
Dep ar t m en ts of Neu rological Su rger y
an d Reh ab Medicin e
Un iversit y of Miam i Miller Sch ool of
Med icin e
Miam i, Florida
Peter G. Whang, MD, FACS
Associate Professor, Spin e Ser vice
Dep ar t m en t of Or th opaedics an d
Reh abilit at ion
Yale Un iversit y Sch ool of Medicin e
New Haven , Con n ect icu t
Tim othy F. Witham , MD, FACS
Associate Professor of Neurosurger y
an d Or th op aedic Su rger y
Director, Th e Joh n s Hop kin s Bayview
Sp in e Program
Director, Th e Joh n s Hop kin s
Neu rosu rger y Sp in al Fu sion
Laborator y
Co-Program Director, Joh n s Hopkin s
Neu rosu rger y Resid en cy
Balt im ore, Mar ylan d
Jean-Paul Wo linsk y, MD
Associate Professor of Neurosurger y
an d On cology
Dep ar t m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y
Balt im ore, Mar ylan d
xxiv Contributors
Jau-Ching Wu, MD, PhD
Con sultan t , Assist an t Professor
Depart m en t of Neu rosu rger y
Neu rological In st it u te
Taipei Veteran s Gen eral Hospit al
Sch ool of Medicin e
Nat ion al Yang-Ming Un iversit y
Taipei Cit y, Taiw an
Antho ny T. Yeung, MD
Or th op ed ic Sp in e Su rgeon
Desert In st it u te for Spin e Care
Ph oen ix, Arizon a
Christo pher Yeung, MD
Presiden t
Desert In st it u te for Spin e Care
Ph oen ix, Arizon a
Hasan A. Zaidi, MD
Barrow Neurological In st it ute
Barrow Neurosurgical Associates
Ph oen ix, Arizon a
Vinko Zlo m islic, MD
Assist an t Clin ical Professor
Dep ar t m en t of Or th op aedic Su rger y
Un iversit y of Californ ia–San Diego
San Diego, Californ ia
Benjam in M. Zussm an, MD
Dep ar t m en t of Neu rosu rger y
Un iversit y of Pit t sburgh Medical
Cen ter
Pit t sburgh , Pen n sylvan ia
I
Anatomy
1 Embryology of the Spine
Eric Momin, Jared Fridley, and Andrew Jea

1.1 Key Points

• Ver tebral body develop m en t: Gast ru lat ion gives rise to para xial m esod erm ,
w h ich form s som ites, w h ich di eren t iate in to sclerotom es, w h ich
su rrou n d n eu ral t issu e th en resegm en t , an d ossify in to ver tebral bod ies.
• Vertebral body sh ap e is determ in ed by several h om eobox (Hox) gen es.1
• Posterior elem en t develop m en t: Cells adjacen t to th e n eu ral t u be form
ver tebral arch es (or n eu ral arch es).
• Ep iblast cells m igrate to form th e p rim it ive groove, w h ich in t u rn form s
th e n otoch ord.
• Th e an terior n eu ropore closes on day 25 an d th e p osterior n eu rop ore on
day 27.
• Neu roblast s form th e m an tle layer; th e ven t ral p or t ion form s th e basal
plates (m otor), an d th e dorsal port ion form s th e alar plates (sen sor y).
• Th e cau dal port ion of th e t u be u n dergoes ret rogressive di eren t iat ion an d
relat ive ascen sion of th e con us.

1.2 Bony Development

• Vertebral bo dy:
– Som atogen esis: Paraxial m esod erm gives rise to 42 to 44 som ites.
Som ites give rise to ven t rom edial sclerotom es an d d orsolateral
derm om yotom es. In w eek 4, cells of th e sclerotom es m ove to su rroun d
th e spin al cord an d n otoch ord.2
– Resegm en tat ion : Each sclerotom e is at rst sep arated by m esen chym e.
Sclerotom es u n dergo resegm en t at ion , w h ich occu rs w h en th e cau dal
h alf of each sclerotom e separates an d fu ses w ith th e cep h alic h alf of th e
n ext sclerotom e.
• Po sterio r elem ents: Cells adjacen t to th e n eu ral t u be form ver tebral
arch es (or n eu ral arch es) th at give rise to th e posterior elem en t s.
• Disk: Cells from th e cau dal port ion of th e sclerotom e form th e an n u lu s
brosu s. Notoch ord rem n an t s form th e n u cleu s p u lp osu s.
• Ossi catio n: An ossi cat ion cen ter is a car t ilagin ou s “m odel” th at is
ossi ed in to bon e.
– Th ree p rim ar y ossi cat ion cen ters for each ver tebrae: On e for th e
ver tebral body an d on e for each h alf of th e ver tebral arch es. Five

3
4 I Anatom y

secon dar y ossi cat ion cen ters for su baxial ver tebrae: On e for th e
su p erior an d in ferior en dp lates of th e body, on e for th e sp in ou s p rocess,
an d on e at th e t ip of each t ran sverse process.
– C2 develops from ve p rim ar y ossi cat ion cen ters: Tw o for th e body of
th e den s, on e for th e vertebral body, an d on e for each n eural arch .3 Th e
t ip of th e den s represen t s a secon dar y ossi cat ion cen ter.
– Hox gen es: Th e sh ape of vertebral bodies is regu lated by Hox gen es th at
code for t ran script ion factors.1
• Spinal curves: Th oracic an d sacral cu r ves are presen t du ring th e fet al
period. Cer vical lordosis develops w h en th e ch ild learn s to h old up th e
h ead . Lu m bar lordosis d evelop s w ith w alking.

1.3 Neural Development

• Prim itive pit: Th e bilam in ar disk con sist s of epiblast an d hypoblast layers.
Som e epiblast accu m u lates at each side of th e dorsal m idlin e to form th e
prim it ive st reak an d, subsequ en tly, th e prim it ive groove. At th e rost ral
edge of th e p rim it ive groove is a pit , th e p rim it ive n od e.
• Genesis o f noto cho rd: After gast ru lat ion occu rs, ep iblast m igrates
rost rally from th e prim it ive n od e, w h ich is called th e n otoch ordal process.
(Th is ph en om en on can be com p ared to p u sh ing on e’s nger in to an
in ated balloon .) Th e t ube is form ed exactly bet w een th e ectoderm an d
en doderm , an d it divid es th e m esoderm . Th u s, it is bordered laterally by
m esod erm , su p eriorly by ectoderm , an d in feriorly by en doderm .
• Inductio n o f ne ural plate : At 3 w eeks’ gest at ion , th e edges of th e n eu ral
plate begin to elevate to form n eural folds th at begin to fuse in th e cer vical
region , form ing th e n eu ral t ube (Fig. 1.1).2
– An terior n eu ropore closes on th e 25th day.
– Posterior n eu ropore closes on th e 27th day.

Neu ral crest cells det ach from th e n eu ral folds an d m igrate to form glia, arach -
n oid, p ia, m elan ocytes, ch on drocytes, ch rom a n cells, osteocytes, Sch w an n
cells, an d en teric ganglia.

• Mantle layer: Neu roblasts form a m an tle layer arou n d th e n eu roep ith elial
layer th at form s th e gray m at ter of th e spin al cord (Fig. 1.2).2
– Th e ven t ral m an tle layer form s th e basal p lates (m otor h orn ), an d th e
dorsal m an tle layer form s th e alar plates (sen sor y h orn ). Th e boun dar y
bet w een th e plates is called sulcus lim itan s.
– At th e th oracic (T1–T12) an d u p per lu m bar (L1–L2) region , th e
in term ediate h orn con t ain s sym path et ic n eu ron s of th e auton om ic
n er vou s system .
 1 Em bryology of the Spine 5

a b

Fig. 1.1 (a) Dorsal view of the human em bryo during the third week of gestation. Note the
somites on each side of the neural tube as it begins to fuse in the cervical region. (b) The
fused neural tube then continues to close both rostrally and caudally.

a b

Fig. 1.2 (a) Cross-section of the developing spinal cord dem onstrates how the m igrating
neuroblasts from the neuroepithelial layer form dorsal and ventral m antle layers. These ulti-
m ately becom e the gray mat ter of the spinal cord. (b) In addition, note the developm ent of
the dorsal root ganglion, as well as the out ward growth of the m otor axons.
6 I Anatom y

• Marginal laye r: Th e m argin al layer con tain s n er ve bers from n eu roblasts

in th e m an tle layer th at u lt im ately form th e w h ite m at ter of th e spin al
cord.
• Th e cau dal t u be form s du ring can alizat ion (days 28–42).
• From day 43 to day 48, th e ven t ricu lu s term in alis (a cyst ic st ru ct u re at th e
caudal n eural t ube en d) u n dergoes ret rogressive di eren t iat ion , w h ich is
com pleted post n at ally at 2 m on th s.2
– Th is resu lt s in relat ive ascen sion of th e con u s to it s n al level of L1/L2
an d form at ion of th e cau da equ in a an d lu m term in ale (Fig. 1.3).

Fig. 1.3 The relative ascension of the conus and form ation of the lum term inale via retro-
gressive di erentiation.
 1 Em bryology of the Spine 7

1.4 Clinical Correlates

• Th e con u s ascen d s to L1 to L2 by 2 m on th s of age an d m ay be low er in a
n eon ate (keep in m in d for lu m bar pu n ct u res).
• Com p lete fu sion of th e ossi cat ion cen ters of C2 does n ot occu r u n t il
age 12 (syn ch on droses bet w een ossi cat ion cen ters can be m ist aken for
fract u res).
• In com p lete closu re of
– An terior n eu ral t ube (22 days) → occipit al en cep h alocele
– An terior n eu ropore (24 days) → an en cep h aly
– An terior n eu ropore + an terior n eu rot ube → cran iorach isch isis (brain
an d u p p er sp in al cord rem ain op en )
– Posterior n eu ropore (26 days) → sp in a bi da/sp in al dysrap h ism below
L1/L2
– Neu ral t u be (defect of secon dar y n eu ru lat ion , 28 to 35 days) → sp in al
dysraph ism above L1/L2
– Ven t ricu lu s term in alis → term in al m yelocystocele (cyst lin ed w ith
ep en dym al cells, com m u n icates w ith th e cen t ral can al)

Common Clinical Questions

1. W h ich st ruct ures border th e n otoch ordal process?
2. W hy is th e dorsal m idlin e devoid of vascular st ruct ures?
3. W hy do m ost m am m alian species h ave seven cer vical vertebrae?

Answ ers to Common Clinical Questions

1. Mesoderm laterally, ectoderm superiorly, en doderm in feriorly.
2. Mesoderm does n ot cross th e dorsal m idlin e in developm en t , so th e
vascu lar st ru ct u res derived from m esoderm are n ot p resen t on th e dorsal
m idlin e.
3. Th e Hox gen es are h igh ly con ser ved bet w een species.

References
1. Wellik DM. Hox gen es an d vertebrate a xial pat tern . Cu rr Top Dev Biol 2009;88:
257–278
2. Sadler TW. Langm an’s Med ical Em br yology. 8th ed. Ph iladelp h ia, PA: Lipp in -
cot t William s & Wilkin s; 2000
3. Green berg MS. Han dbook of Neu rosu rger y. 6th ed. New York, NY: Th iem e;
2005
 2 Craniovertebral Junction
Jonathan Hobbs and Edwin Ramos

2.1 Key Points

• Th e cran iovertebral ju n ct ion (CVJ) is com p osed of th e occip u t (O), occipit al
con dyles, atlas (C1), an d axis (C2) an d represen t s th e t ran sit ion bet w een
th e cran ium an d m obile cer vical spin e.
• CVJ is com p osed of osseou s st ru ct u res ar t icu lated w ith syn ovial join t s,
m u scles, ligam en t s an d m em bran es.
• Th e prin cipal m ot ion segm en t of th e O–C1 join t is exion exten sion ;
th e C1 to C2 m ot ion segm en t is th e m ost exible of th e cer vical spin e in
respect to axial rot at ion .
• Th e u n iqu e ligam en t an d m em bran e con gu rat ion of th e CVJ p rovide
st abilit y an d p erm it m ovem en t w ith ou t com p rom ising th e t raversing
n eu ral elem en t s (Fig. 2.1).

Fig. 2.1 CVJ ligam entous structures. (From Thiem e Atlas of Anatomy, General Anatomy and
Musculoskeletal System, © Thiem e 2005, illustration by Karl Wesker.)
8
 2 Craniovertebral Junction 9

2.2 Bony Anatomy

• Th e CVJ con sist s of th e base of th e occip u t , th e atlas (C1), an d th e axis (C2).
• Th e bou n daries of th e foram en m agn u m are th e basion an teriorly, th e
opisth ion posteriorly, an d th e occipit al con dyles in ferolaterally.
• Th e atlas (C1) h as n o vertebral body or sp in ou s p rocess. It is com p rised
of an an terior arch , a posterior arch , an d t w o lateral m asses. Th e superior
facet s are con cave an d accom m odate th e convex occip ital con dyles,
allow ing for exion -exten sion m ot ion segm en t s (Fig. 2.2).
• Th e C1 an terior t u bercle (C1 “bu t ton ”) is th e at t ach m en t site of th e
an terior longit u d in al ligam en t (ALL) an d th e longu s colli m u scle.

Fig. 2.2 (a) Superior and (b) lateral view of the atlas. (From Thiem e Atlas of Anatomy, Gen-
eral Anatomy and Musculoskeletal System, © Thieme 2005, illustration by Karl Wesker.)
10 I Anatom y

• Th e vertebral ar ter y an d C1 n er ve ru n along th e su p erior lateral groove

on C1 (sulcu s arteriosu s). In less th an 15% of th e populat ion , th e groove is
roofed, form ing th e arcuate foram en .
• Th e axis (C2) con sist s of th e body, odon toid p rocess, art icu lat ing su rfaces,
pedicles, pars in terart icularis (n ote th at pars an d pedicles are dist in ct
an atom ical lan dm arks), lam in a, an d large, bi d sp in ou s process (Fig. 2.3).1
• Th e C2 od on toid (Gr. “tooth ”) process p roject s su p eriorly an d h as m u lt iple,
overlapp ing ligam en tou s at t ach m en t s to C1 an d th e occip u t .

Superior Groove for

articular vertebral artery
facet
Posterior
tubercle
Anterior
tubercle
Posterior
arch of atlas
Transverse Transverse
foramen process
Inferior
a articular facet

Dens
Anterior articular
facet Posterior
articular facet
Superior
articular
facet
Spinous process
Transverse
foram en
Body

Transverse Inferior Vertebral arch

process articular facet
b Pars

Fig. 2.3 (a) Superior and (b) lateral view of the axis. (From Thiem e Atlas of Anatomy, General
Anatomy and Musculoskeletal System, © Thiem e 2005, illustrations by Karl Wesker.)
 2 Craniovertebral Junction 11

2.3 Neural Anatomy

• Cer vical n er ve roots exit above th eir corresp on ding level (e.g., th e C2 n er ve
root exit s above th e C2 pedicle).
• C1 n er ve root: Th e p osterior division (su boccipit al n er ve) is m ore
prom in en t th an th e an terior division . It in n er vates suboccip it al m uscles
an d occasion ally bran ch es to th e lesser/greater occipit al n er ve.
• C2 n er ve root: Posterior, m edial (greater occip ital n er ve), an d lateral
division s in n er vate su boccipit al m uscles an d scalp from occiput to vertex.
• Th e lesser occip it al n er ve is form ed by dorsal division s of C2 an d C3.

2.4 Vascular Anatomy

• Th e ver tebral arter y (VA) leaves th e C2 t ran sverse foram en (becom ing V3),
t akes a 45° lateral p roject ion , an d ascen ds (vert ical port ion of V3) in to th e
C1 t ran sverse foram en .
• Th e VA th en cou rses m edially (h orizon tal p or t ion of V3) along th e
C1 su lcu s arteriosu s an d th en an teriorly th rough th e atlan tooccip it al
m em bran e, w h ere it becom es in t radu ral (begin n ing of V4 segm en t).
• Blood is su p plied to th e CVJ p rim arily th rough bran ch es of th e vertebral
an d occip it al arteries.
• Th e base of th e den s of C2 receives blood su p p ly from vertebral arter y
bran ch es (posterior circulat ion ); th e top is supplied by th e apical bran ch of
th e hypoglossal ar ter y (an terior circulat ion ).
• Lym p h at ic d rain age of th e CVJ is th rough ret roph ar yngeal an d deep
cer vical n odes (Grisel’s syn drom e: CVJ in st abilit y w ith con com itan t
ret roph ar yngeal in am m at ion /in fect ion ).

2.5 Ligamentous and Muscular Anatomy

(Table 2.1)
• Su boccipit al m u scles an d th e CVJ (Fig. 2.4)
– Su p erior obliqu e: C1 t ran sverse process laterally to occipu t m edially
– In ferior obliqu e: C1 t ran sverse p rocess laterally to sp in ou s p rocess of C2
m edially
– Rect u s cap it is p osterior m ajor: Sp in ou s process of C2 u p to base of
occiput
– Rect u s cap it is p osterior m in or: Posterior t u bercle of C1 u p to base of
occiput
– Sem isp in alis capit is: Tran sverse p rocesses of cer vical vertebrae to
n u ch al ligam en t an d occipit al bon e; su per cial to su boccip it al m u scles
 3 , 4
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