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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 Alexan d er R. Vaccaro, MD, Ph D,


Assistan t Professor MBA
Depar t m en t of Neurological Surger y Rich ard H. Roth m an Professor an d
Weill Corn ell Medical College Ch airm an
Adu lt an d Pediat ric Spin e Su rger y Depar t m en t of Or th opaedic Su rger y
New York Presbyterian Hospit al Professor of Neu rosurger y
New York, New York Co- Ch ief of Sp in e Su rger y
Sidn ey Kim m el Medical Cen ter at
Praveen V. Mu m m an en i, MD Th om as Jefferson Un iversit y
Professor an d Vice- Ch airm an Co-Director, Delaw are Valley Sp in al
Depar t m en t of Neurosurger y Cord Inju r y Cen ter
Un iversit y of Californ ia–San Presiden t , Roth m an In st it ute
Fran cisco Ph iladelp h ia, Pen n sylvan ia
Co-Director, UCSF Sp in e Cen ter
San Fran cisco, Californ ia Mark S. Green b er g, MD
Associate Professor
Ju an S. Ur ib e, MD Depar t m en t of Neurosurger y an d
Associate Professor Brain Repair
Director, Spin e Sect ion Un iversit y of Sou th Florida
Depar t m en t of Neurosurger y Tam pa, Florida
Un iversit y of Sou th Florida
Tam p a, Florida

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[DNLM: 1. Spine—surger y—Han dbooks. 2. Neu ro- to th e publishers any discrep ancies or inaccu racies
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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 her initial surgical rotation w hile assigned to
of Spine Surgery, editors Ali A. Baaj, Praveen V. the spine service, to a spine physician assis-
Mum m aneni, Juan S. Uribe, Alexander R. Vac- tant helping out during surgery, to a spinal
caro, and Mark S. Greenberg have configured surgery fellow gaining technical confidence
a virtual step-by-step “cookbook” of all the during the m ost im portant year of fellowship
com m on and uncom m on surgical spine proce- training. Those residents, fellows, and atten-
dures utilized around the globe, w ith chapters dings utilizing this text w ill probably find the
authored by highly recognized spinal surgeons. greatest “bang for their buck” in the pearls and
This task has been expertly accom plished by tips, w hich are w ritten to optim ize safet y and
the overall organization of the chapters into m axim ize efficiency during various specific
sections: Anatomy, Clinical Spine Sur gery, spinal surgery procedures. I also found the Q
Spinal Pathology, and Surgical Techniques. and A sections a nice refresher for keeping up
Specific topics are thoroughly covered w ithin on the m yriad of spine surgery techniques that
and across sections, such as “Thoracolum bar have rapidly advanced over the past decade, as
Traum a” (Chapter 21 in the Spinal Pathology spine surgery itself continues dow n a subspe-
section), “Freehand Thoracic Pedicle Screw cialization pathway distinct from orthopedic
Placem ent Technique” (Chapter 47 in the Sur- surgery and neurosurgery. In that regard, this
gical Techniques section), and specific surgical book would also serve as an excellent review
procedures, such as “Sacrectomy” (Chapter 69 for those studying for board certification or
in the Surgical Techniques section). A com m on recertification for the Am erican Board of Or-
tem plate is followed in w hich each chapter lo- thopaedic Surgery or the Am erican Board of
gically proceeds from Key Points to Indications, Neurological Surgery exam s.
Techniques, Complications, Postperative Care, I congratulate the editors and contributing
Outcom es, Surgical Pearls, Com m on Clinical authors for this im portant piece of work. Any
Questions and Answers (as is seen in current “handbook” should, by definition, be able to
CME form ats), and Key References. This struc- concisely provide essential details of a condi-
ture is very effective and ideal for quick and tion and various rem edies and solutions—as
easy review the evening before, or even the well as obstacles encountered along the way—
m orning of, conferences and surgical procedu- to best educate the intended audience. I am
res. Trainees still trying to m aster these topics, confident that the Handbook of Spine Surgery
as well as m ore senior surgeons needing a quick has m ore than accom plished these objecti-
refresher, w ill benefit. The organizational style ves and w ill have an enduring and im portant
is direct and compact but thorough, approp- im pact on those fortunate enough to benefit
riately illustrated w hen helpful, and perfectly from the assem bled inform ation provided.
suited to a busy clinical schedule w here essen-
tial inform ation and details need to be gleaned Law rence G. Lenke, MD
in rapid fashion, w hether in print, on a phone, Professor and Chief of Spinal Surgery
tablet, or computer. The organizational consis- Depart m ent of Orthopaedic Surgery
tency of the chapters also aids in quick disse- Colum bia Universit y College
m ination and retention, w hich is critical to our of Physicians and Surgeons
training environm ent. Surgeon-in-Chief
I can envision this text being extrem ely The Spine Hospital at
useful to a w ide range of individuals: from a New York-Presbyterian/Allen Hospital
third-year m edical student perform ing his or New York , New York

xi
Forew ord
Th e secon d ed it ion of t h e Handbook of of in st ru m en t at ion tech n iqu es, frequ en tly
Spine Surgery, ed ited by Dr. Ali A. Baaj, Dr. asked quest ion s, an d surgical pearls are pro-
Praveen V. Mu m m an en i, Dr. Ju an S. Ur ibe, vided by exper t s in th e eld .
Dr. Alexan d er R. Vaccaro, an d Dr. Mark S. This book w ill be an invaluable resource
Green berg, is an ou t st an d in g d ist illat ion for orthopaedic and neurosurgical residents
of t h e cu r ren t kn ow ledge of t h e evalu a- in t raining, spinal surgical fellow s, and prac-
t ion an d su rgical m an agem en t of sp in al ticing orthopaedic surgeon s and n eurosur-
d isord ers. Th e book is d ivid ed in to fou r geon s w h o deal w ith spinal pathology. The
w ell-organ ized sect ion s: a d et ailed syn - book covers an exh aust ive set of topics in a
op sis of sp in al an atom y, an evalu at ion of succinct m anner, but su cient inform at ion is
t h e tech n iqu es u sed for clin ical evalu at ion provided to serve as a surgical atlas. I feel that
of sp in al su rger y, a d et ailed d escr ipt ion of th is w ill becom e the standard resource for
sp in al su rgical p at h ology, an d a step -by- surgeons in training, early in practice, those
step d escr ipt ion of su rgical tech n iqu es. In preparing for board exam inations, and expe-
ad d it ion , t h ere are ap p en d ices on p at ien t rienced spine surgeon s needing a refresh er.
p osit ion in g, selected sp in al or t h oses, an d I am positive that in its electronic form this
com m on ly u sed ou tcom e scales. book w ill be used as a quick reference on a
Th e Handbook of Spin e Surger y par t icu- daily basis by m ost pract icing spine surgeon s.
larly excels as a qu ick reference for alm ost I congrat ulate th e editors on this outstanding
any t yp e of sp in al su rgical con d it ion or su r- resource and look forward to having it avail-
gical procedure, from occipitocer vical fusion able to use in m y ow n practice.
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 . Christopher I. Sha rey, MD, FACS
Th e surgical ch apters are auth ored by ex- John A. Jane Professorship of Neurological
per t s from th e eld of or th op aedic or neu - Surgery
rosurgical sp in al surger y; ever y ch apter h as Division Head Spine Surgery
in t rodu ctor y key p oin t s an d det ailed d e- Professor of Orthopaedic Surgery
script ion s of in dicat ion s for each of th e sur- Universit y of Virginia Medical Center
gical procedures. A step -by-step descript ion Charlot tesville, Virginia

xii
Preface
We are deligh ted to presen t th e secon d sect ion to in clude dedicated ch apters on
ed it ion of t h e Handbook of Spine Surgery. cer vical, th oracolu m bar, an d sacrop elvic in -
As w ith t h e previou s edit ion , ou r goal is to ju ries. Su rgical p earls an d board-st yle qu es-
p rovide a com p reh en sive yet por t able an d t ion s at th e en d of each ch apter em ph asize
com p act text t h at d ist ills t h e basic p rin cip - th e salien t poin t s of each topic.
les of con tem p orar y spin e surger y. We h ave We are con fiden t th at th is text w ill con t i-
on ce again been for t u n ate to receive con t ri- n u e to be an excellen t resou rce for su rgeon s
but ion s from dozen s of reput able surgeon s an d t rain ees alike as w e all st rive to im p rove
represen t ing acclaim ed ort h opedic an d n eu - spin e educat ion an d t rain ing and th e clin ical
rosurger y program s. care of ou r pat ien t 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 Ali A. Baaj, MD
sign ifican tly en h an ced th e text w ith several Praveen V. Mum m aneni, MD
n ew ch apters add ressing top ics like p ediat- Juan S. Uribe, MD
ric scoliosis an d ad u lt deform it y p rin cip les. Alexander R. Vaccaro, MD, PhD
We h ave also expan ded th e spin al t raum a Mark S. Greenberg, MD

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 .

xiii
Contributors
Salm an Abbasifard, MD Co lin R. Bam ford, MD
Su rger y Depart m en t Associate Professor
Neu rosu rger y Division Depart m en t of Neu rology
Un iversit y of Arizon a Medical Un iversit y of Arizon a
Health Cen ter Tucson , Arizon a
Tucson , Arizon a
Kelley Banagan, MD
Muham m ad M. Abd-El-Barr, MD, PhD Assistan t Professor
Depart m en t of Su rger y Depart m en t of Orth op aedics
Brigh am an d Wom en’s Hospit al Un iversit y of Mar ylan d Medical
Boston , Massach u set ts Cen ter
Balt im ore, Mar ylan d
Am ir A. Ahm adian, MD
Neu rosu rgeon Rahul Basho, MD
Depart m en t of Neu rosu rger y Director of Spin e Su rger y
Un iversit y of Sou th Florida Han n ibal Region al Hosp it al
Tam pa, Florida Midw est Orth op edic Sp ecialist s
Han n ibal, Missou ri
Junyo ung Ahn, BS
Depart m en t s of Su rger y, Or th opedic Christo pher M. Bo no, MD
Su rger y, an d Biological Psych ology Ch ief, Or th opaedic Spin e Ser vice
Un iversit y of Texas Sou th w est Depart m en t of Orth op aedic Su rger y
Dallas, Texas Brigh am an d Wom en’s Hospit al
Boston , Massach u set t s
Puya Alikhani, MD
Depart m en t of Neu rosu rger y Clinto n J. Burkett, MD
Un iversit y of Sou th Florida Neu rosu rgeon
Tam pa, Florida Neu rological Su rger y Associates
For t Lau derdale, Florida
Jahangir Asghar, MD
Pediat ric Or th opedic Spin e Su rgeon Zo rica Buser, PhD
Nicklau s Ch ildren’s Hospit al Sen ior Research Associate
Miam i, Florida Depart m en t of Orth op aedic Su rger y
Keck Sch ool of Medicin e
Ali A. Baaj, MD Un iversit y of South ern Californ ia
Assistan t Professor Los Angeles, Californ ia
Depart m en t of Neu rological Su rger y
Weill Corn ell Medical College Ali Bydo n, MD
Adu lt an d Pediat ric Sp in e Su rger y Associate Professor of Neurosurger y
New York Presbyterian Hosp it al Th e Joh n s Hopkin s Un iversit y
New York, New York Balt im ore, Mar ylan d

xiv
Contributors xv

Mo ham ad Bydo n, MD Ho rm uzdiyar H. Dasenbrock, MD


Assist an t Professor of Neu rologic Depart m en t of Neu rosu rger y
Su rger y Brigh am an d Wom en’s Hospit al
Dep ar t m en t of Orth op ed ic Su rger y Boston , Massach u set ts
an d Health Scien ces Research
Mayo Clin ic Sanjay S. Dhall, MD
Roch ester, Min n esot a Associate Professor
Depart m en t of Neu rological Su rger y
Steven W. Chang, MD Universit y of California–San Francisco
At ten d ing Physician Director
Barrow Neu rological In st it u te Sp in al Neu rot rau m a Program
Barrow Neu rosu rgical Associates San Fran cisco Gen eral Hosp ital
Ph oen ix, Arizon a San Fran cisco, Californ ia

Je ns R. Chapm an, MD Jo nathan G. Eastm an, MD


Com plex Spin e Surger y Assistan t Professor
Sw edish Neuroscien ce In st it ute Depart m en t of Orth p aedic Su rger y
Seat tle, Wash ington Division of Trau m atology
Un iversit y of Californ ia–Davis
To dd M. Chapm an Jr., MD Health System
Dep ar t m en t of Orth op aedic Su rger y Sacram en to, Californ ia
Wash ington Universit y
St . Lou is, Missou ri Be njam in D. Elde r, MD, PhD
Depart m en t of Neu rosu rger y
Matthew Chin, MD Th e Joh n s Hopkin s Un iversit y
Dep ar t m en t of Orth op aedic Su rger y Sch ool of Med icin e
Drexel Un iversit y College of Medicin e Balt im ore, Mar ylan d
Ph iladelph ia, Pen n sylvan ia
Marco Ferro ne, MD
Dean Cho u, MD In st ru ctor of Or th opaedic Su rger y
Professor Depart m en t of Orth op aedic
Dep ar t m en t of Neu rosu rger y On cology
Un iversit y of Californ ia–San Brigh am an d Wom en’s Hospit al/
Fran cisco Spin e Cen ter Dan a Farber Can cer In st it ute
San Fran cisco, Californ ia Boston , Massach u set ts

Jo sé A. Co rredo r, MD Andreas K. Filis, MD


Weill Corn ell Brain an d Spin e Cen ter Depart m en t of Orth op edics an d
Dep ar t m en t of Neu rological Su rger y On cological Scien ces
Weill Corn ell Medical College Un iversit y of Sou th Florida
New York-Presbyterian Hospital College of Medicin e
New York, New York Tam pa, Florida
Cirujan o de Colum n ae
Bogot á, Colom bia
xvi Contributors

Kevin T. Fo ley, MD, FACS, FAANS Ziya L. Go kaslan, MD, FAANS, FACS
Professor of Neurological Surger y, Gus Stoll, MD Professor an d Ch air
Or th opaedic Su rger y, an d Dep ar t m en t of Neu rosu rger y
Biom edical Engin eering Th e Warren Alper t Medical Sch ool of
Un iversit y of Ten n essee Health Brow n Un iversit y
Scien ce Cen ter Neu rosu rgeon -in - Ch ief
Ch airm an , Sem m es-Mu rp h ey Clin ic Rh ode Islan d Hosp it al an d
Mem ph is, Ten n essee Th e Miriam Hospital
Clin ical Director, Norm an Prin ce
Jared Fridley, MD Neu roscien ces In st it u te
Depart m en t of Neu rosu rger y Presiden t , Brow n Neurosurger y
Baylor College of Medicin e Foun dat ion
Hou ston , Texas Rh ode Islan d Hosp it al
Dep ar t m en t of Neu rosu rger y
Steve n R. Garf n, MD Norm an Prince Neurosciences Institute
Dist ingu ish ed Professor an d Ch air Providen ce, Rh ode Islan d
Depart m en t of Orth op aedic Su rger y
Un iversit y of Californ ia–San Diego C. Ro ry Go o dw in, MD, PhD
San Diego, Californ ia Dep ar t m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y
Rafael De la Garza-Ram o s, MD Balt im ore, Mar ylan d
Depart m en t of Neu rosu rger y
Th e Joh n s Hopkin s Un iversit y Mark S. Greenberg, MD
Balt im ore, Mar ylan d Associate Professor
Dep ar t m en t of Neu rosu rger y an d
Peter Carlos Gerszten, MD, MPH, FACS Brain Rep air
Peter E. Sh ept ak Professor an d Un iversit y of South Florida
Vice- Ch airm an Tam pa, Florida
Depart m en t s of Neu rological Su rger y
an d Rad iat ion On cology Michael W. Gro , MD
Un iversit y of Pit t sburgh Medical Director of Sp in al Neu rosu rger y
Cen ter Dep ar t m en t of Neu rosu rger y
Pit t sburgh , Pen n sylvan ia Brigh am an d Wom en’s Hospit al
Boston , Massach u set t s
Geo rge M. Gho brial, MD
Depart m en t of Neu rological Su rger y Mari L. Groves, MD
Th om as Je erson Un iversit y Dep ar t m en t of Neu rosu rger y
Ph iladelp h ia, Pen n sylvan ia 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
Contributors xvii

Jam es S. Harro p, MD, FACS Steve n W. Hw ang, MD


Professor Ch ief
Dep ar t m en t s of Neu rological an d Division of Pediat ric Neu rosu rger y
Orth op edic Su rger y Depart m en t of Neu rosu rger y
Director, Division of Sp in e an d Tuft s Medical Cen ter an d Float ing
Periph eral Ner ve Su rger y Hosp it al for Ch ildren
Neu rosu rger y Director of Delaw are Boston , Massach u set ts
Valley SCI Cen ter
Th om as Je erson Un iversit y Keith Jackson, MD
Ph iladelph ia, Pen n sylvan ia St a Su rgeon
Depart m en t of Orth op aedics an d
Ro ger Härtl, MD Reh abilitat ion
Professor of Neurological Surger y Wom ack Arm y Medical Cen ter
Director of Sp in al Su rger y Fort Bragg, North Carolin a
Co-Director, Spin e Cen ter
Weill Corn ell Brain an d Spin e Cen ter Ge orge I. Jallo, MD
New York, New York Professor of Neurosurger y, Pediat rics,
an d On cology
Jo nathan Ho bbs, MD Director
Dep ar t m en t of Neu rosu rger y In st it u te Brain Protect ion Ser vices
Un iversit y of Ch icago All Ch ildren’s Hospital–Joh ns
Ch icago, Illin ois Hopkin s Medicin e
St . Petersburg, Florida
Holli A. Ho rak, MD
Associate Professor Whitney S. Jam es, MD, MHS
Dep ar t m en t of Neu rology Depart m en t of Neu rosu rger y
Un iversit y of Arizon a Un iversit y of Arizon a Medical Cen ter
Tucson , Arizon a Tucson , Arizon a

Phillip Ho rne, MD, PhD Andrew Jea, MD


Assist an t Professor of Surger y Associate Professor
Dep ar t m en t of Orth op aedic Su rger y Depart m en t of Neu rosu rger y
Du ke Or th opaedics of Raleigh Baylor College of Medicin e
Du ke Raleigh Hosp it al Hou ston , Texas
Raleigh , North Carolin a
Andrei Fernandes Joaquim , MD, PhD
Patrick C. Hsieh, MD, MSc Neu rosu rgeon
Associate Professor Depart m en t of Neu rology
Director of Min im ally Invasive Sp in e St ate Un iversit y of Cam pin as
Program an d Spin al On cology Cam p in as-SP, Brazil
Dep ar t m en t of Neu rosu rger y
USC Sp in e Cen ter U. Kum ar Kakarla
Un iversit y of Sou th ern Californ ia At ten ding Physician
Keck Sch ool of Med icin e Barrow Neu rological In st it u te
Los Angeles, Californ ia Barrow Neu rosu rgical Associates
Ph oen ix, Arizon a
xviii Contributors

Rick y Kalra, MD Tie n V. Le, MD


Depart m en t of Neu rosu rger y Neu rological Su rgeon
Un iversit y of Utah Tam pa Bay Neurosurger y an d Spin e
Salt Lake Cit y, Ut ah Sp ecialist s
Tam pa, Florida
Adam S. Kante r, MD
Ch ief Jo o n Y. Le e, MD
Division of Sp in e Su rger y Associate Professor
Associate Professor Director of Clin ical Research
Depart m en t of Neu rological Su rger y Dep ar t m en t of Or th opaedic Su rger y
Un iversit y of Pit t t sburgh University of Pittsburgh Medical Center
Pit t sburgh , Pen n sylvan ia Pit t sburgh , Pen n sylvan ia

Am rit Khalsa, RN, IBCLC Law rence G. Lenke, MD


Con sultan t Professor an d Ch ief of Spin al Surger y
Labor of Love Lact at ion Ser vices Dep ar t m en t of Or th opaedic Su rger y
Met a Midw ifer y in th e Bay Area Colu m bia Un iversit y College of
Oaklan d , Californ ia Physician s an d Su rgeon s
Su rgeon -in -Ch ief
Paul D. Kiely, MCh, FRCh Th e Spin e Hospit al at New York-
In tegrated Sp in e Research Presbyterian /Allen Hospit al
Dep art m en t New York, New York
Hosp it al for Sp ecial Su rger y
New York, New York Allan D. Levi, MD, PhD, FACS
Professor an d Ch airm an
Eric O. Klineberg, MD, MS Dep ar t m en t of Neu rological Su rger y
Associate Professor Un iversit y of Miam i
Depart m en t of Orth op aedic Su rger y Miam i, Florida
Un iversit y of Californ ia–Davis Health
System William D. Lo ng III, MD
Sp in e Cen ter Private Pract ice
Sacram en to, Californ ia Prem ier Orth opaedics
Bergen Coun t y, New Jersey
Tho m as Ko sztow ski, MD
Depart m en t of Neu rosu rger y Daniel C. Lu, MD, PhD
Th e Joh n s Hopkin s Hospit al Associate Professor
Balt im ore, Mar ylan d Dep ar t m en t of Neu rosu rger y
Sp in al Cord Reh abilit at ion Cen ter
Frank La Marca, MD Ron ald Reagan UCLA Medical Cen ter
Clin ical Associate Professor UCLA Medical Cen ter
Depart m en t of Neu rosu rger y Director, Neu roplast icit y
Un iversit y of Mich igan Com preh en sive Spin e Cen ter
An n Arbor, Mich igan San ta Mon ica, Californ ia
Contributors xix

Steven C. Ludw ig, MD Alim P. Mitha, MD


Ch ief of Sp in e Su rger y Cerebrovascular/En dovascu lar/Sku ll
Director of Sp in e Fellow sh ip Base Neu rosu rgeon
Head of th e Division of Spin e Su rger y Depart m en t of Clin ical Neu roscien ces
Un iversit y of Mar ylan d Footh ills Medical Cen t re
Dep ar t m en t of Orth op aedics Un iversit y of Calgar y
Balt im ore, Mar ylan d Calgar y, Alber t a, Can ada

Glen R. Man zano, MD Krishna D. Mo di, BS


Assist an t Professor of Clin ical Research Assist an t
Neu rosu rger y Depart m en t of Orth op aedic Su rger y
Dep ar t m en t of Neu rological Su rger y Ru sh Un iversit y Medical Cen ter
Un iversit y of Miam i Health System Midw est Or th op aedics at Ru sh
Un iversit y of Miam i Hospital Ch icago, Illin ois
Miam i, Florida
Cam ilo Mo lina, MD
Hazem A. Mashaly, MD Depart m en t of Neu rosu rger y
Dep ar t m en t of Neu rosu rger y Th e Joh n s Hopkin s Un iversit y
Ain Sh am s Un iversit y Balt im ore, Mar ylan d
Cairo, Egypt
Eric Mo m in, MD
Dustin H. Massel, BS Depart m en t of Neu rosu rger y
Research Coordin ator Baylor College of Medicin e
Dep ar t m en t of Orth op aedic Su rger y Hou ston , Texas
Rush Un iversit y Medical Cen ter
Ch icago, Illin ois Edw ard A. Mo naco III, MD, PhD
Assistan t Professor
Benjam in C. Mayo , BA Depart m en t of Neu rological Su rger y
Research Coordin ator University of Pittsburgh Medical Center
Dep ar t m en t of Orth op aedic Su rger y Pit t sburgh , Pen n sylvan ia
Rush Un iversit y Medical Cen ter
Ch icago, Illin ois Pravee n V. Mum m ane ni, MD
Professor an d Vice- Ch airm an
Justin W. Miller, MD Depart m en t of Neu rosu rger y
Orth op aed ic Sp in e Su rgeon Universit y of California–San Francisco
In dian a Sp in e Grou p Co-Director, UCSF Spin e Cen ter
Carm el, In d ian a San Fran cisco, Californ ia

David Minges, MD Gisela Murray, MD


Orth op aed ic Sp in e Su rgeon Neu rosu rgeon
Advan ced Bon e an d Join t San Ju an , Pu erto Rico
St . Peters, Missou ri
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 Ravi K. Po nnappan, MD


Depart m en t of Neu rosu rger y Clin ical Associate Professor
Un iversit y of Arizon a Dep ar t m en t of Or th opaedic Su rger y
Tucson , Arizon a Drexel Un iversit y College of Medicin e
Ph iladelp h ia, Pen n sylvan ia
Io annis Papanastassio u, MD, PhD
Or th opedic Depart m en t Steven M. Presciutti, MD
Gen eral On cological Hospit al Ki sias Midw est Orth op aedics at Ru sh
‘Agioi An argyroi’ Rush Un iversit y
Ath en s, Greece Ch icago, Illin ois

Paul Park, MD Martin Quirno , MD


Associate Professor Midw est Orth op aedics at Ru sh
Depart m en t of Neu rosu rger y Rush Un iversit y
Un iversit y of Mich igan Ch icago, Illin ois
An n Arbor, Mich igan
Ravi Ram achandran, MD
Am it R. Patel, MD Sp in e Su rgeon
Or th opaedic Sp in e Su rgeon Sacram en to, Californ ia
Or th opaedic an d Sp in e Sp ecialist s
York, Pen n sylvan ia Wyatt L. Ram ey, MD
Division of Neu rosu rger y
Kam akshi Patel, MD, MPH Dep ar t m en t of Su rger y
Assistan t Professor of Neurology Un iversit y of Arizon a
Un iversit y of Texas Medical Bran ch Tu cson , Arizon a
Galveston , Texas
Edw in Ram o s, MD
Frank M. Phillips, MD Assist an t Professor
Professor Dep ar t m en t of Neu rosu rger y
Depart m en t of Orth op aedic Su rger y Un iversit y of Ch icago
Sp in e Fellow sh ip Co-Director Ch icago, Illin ois
Rush Un iversit y Medical Cen ter
Ch icago, Illin ois William J. Readdy, BS
Robert Wood Joh n son
Ko rnelis Po elstra, MD, PhD Medical Sch ool
Ch airm an New Bru n sw ick, New Jersey
Depart m en t of Su rger y
Sacred Hear t Hosp it al on th e Jay Rhee, MD
Em erald Coast Director of Sp in e Su rger y
Presiden t , Th e Spin e In st it ute on th e Dep ar t m en t of Neu rosu rger y
Em erald Coast Holy Cross Health System
Miram ar Beach , Florida Silver Spring, Mar ylan d
Contributors xxi

Marie Ro guski, MD, MPH Meic H. Schm idt, MD, MBA, FAANS,
Dep ar t m en t of Neu rosu rger y FACS
Tuft s Medical Cen ter Professor of Neurosurger y an d
Boston , Massach u set t s Or th opaedics
Ron ald I. Ap felbaum En dow ed Ch air
F. Andrew Row an, MD, MS for Sp in e Su rger y
Dep ar t m en t of Orth op ed ics Vice Ch air for Clin ical A airs
Un iversit y of Arizon a Depart m en t of Neu rosu rger y
Tucson , Arizon a Ch ief Valu e O cer, Un iversit y
Hosp it al, Neu rosu rger y Ser vice
Rajiv Saigal, MD, PhD Program Director, Neurosurger y
Dep ar t m en t of Orth op ed ic Su rger y Sp in e Fellow sh ip
Scrip ps Health , San Diego Sp in e Director, Sp in al On cology Ser vice,
Foun dat ion Hu n t sm an Can cer In st it u te
San Diego, Californ ia Clin ical Neu roscien ces Cen ter
Un iversit y of Ut ah
Andrew A. Sam a, MD Salt Lake Cit y, Ut ah
Associate Professor
Dep ar t m en t of Orth op aedic Spin e Gregory D. Schro eder, MD
Su rger y Depart m en t of Orth op aedic Su rger y
Hospital for Special Su rger y Roth m an In st it u te at Th om as
Weill Corn ell Sch ool of Medicin e Je erson Un iversit y
New York, New York Ph iladelp h ia, Pen n sylvan ia

Am er F. Sam dani, MD Daniel M. Sciubba, MD


Ch ief of Su rger y Associate Professor of Neurosu rger y,
Sh rin ers Hospit als for On cology, an d Or th opaedic Su rger y
Ch ildren –Ph iladelp h ia Depart m en t of Neu rosu rger y
Ph iladelph ia, Pen nyslvan ia Th e Joh n s Hopkin s Un iversit y
Balt im ore, Mar ylan d
Rick C. Sasso, MD
Professor Shyam M. Shridharani, MD
Ch ief of Sp in e Su rger y Assistan t Professor
Dep ar t m en t of Orth op aedic Su rger y Depart m en t of Orth op aedic Su rger y
In dian a Un iversit y Sch ool of Th e Un iversit y of Arizona
Medicin e Tucson , Arizon a
In dian a Sp in e Grou p
In dian ap olis, In d ian apolis 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 Kho i D. Than, MD


Ch ief of Spin e Su rger y Assist an t Professor
Assistan t Professor of Orth opaedics Dep ar t m en t of Neu rological Su rger y
an d Neu rosu rger y Oregon Health & Scien ce Un iversit y
Un iversit y of Illin ois–Ch icago Por tlan d, Oregon
Ch icago, Illin ois
Jaso n O. Toy, MD
Harm inder Singh, MD, FACS, FAANS Dep ar t m en t of Or th opaedics an d
Assistan t Professor Reh abilit at ion
Depart m en t of Neu rosu rger y Yale Un iversit y Sch ool of Medicin e
Stanford Universit y School of Medicine New Haven , Con n ect icu t
St an ford, Californ ia
Alexander Tuchm an, MD
Kern Singh, MD Dep ar t m en t of Neu rological Su rger y
Associate Professor Keck Sch ool of Medicin e
Depart m en t of Orth op aedic Su rger y Un iversit y of South ern Californ ia
Rush Un iversit y Medical Cen ter Los Angeles, Californ ia
Ch icago, Illin ois
Juan S. Uribe, MD
Jesse Sko ch, MD Associate Professor
Depart m en t of Su rger y Director, Sp in e Sect ion
Division of Neu rosu rger y Dep ar t m en t of Neu rosu rger y
Ban n er Un iversit y Medical Cen ter Un iversit y of South Florida
Tucson , Arizon a Tam pa, Florida

Jessica So sio , BS Tim othy D. Uschold, MD


Depart m en t of Biology Neu rological an d Spin e Su rgeon
Florida State Un iversit y Sou th ern Oregon Neu rosu rgical
Tallah assee, Florida an d Sp in e Associates
Med ford, Oregon
Eric Sribnick, MD, PhD
Assistan t Professor Alexander R. Vaccaro, MD, PhD,
Depart m en t of Neu rosu rger y MBA
Th e Oh io State Un iversit y Rich ard H. Roth m an Professor an d
Colum bus, Oh io Ch airm an
Dep ar t m en t of Or th opaedic Su rger y
Zachary J. Tem pel, MD Professor of Neurosurger y
Depart m en t of Neu rological Su rger y Co- Ch ief of Spin e Surger y
Un iversit y of Pit t sburgh Medical Sidn ey Kim m el Medical Cen ter at
Cen ter Th om as Je erson Un iversit y
Pit t sburgh , Pen n sylvan ia 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
Contributors xxiii

Juan M. Valdivia, MD, FAANS Je rey C. Wang, MD


Neu rosu rgeon Ch ief, Or th opaedic Spin e Ser vice
Bay Care Medical Grou p Co-Director, Un iversit y of South ern
Tam pa, Florida Californ ia Sp in e Cen ter
Professor of Or th opaedic Surger y an d
Fe rnando L. Vale, MD Neu rosu rger y
Professor an d Vice- Ch airm an USC Spin e Cen ter
Dep ar t m en t of Neu rosu rger y an d Los Angeles, Californ ia
Brain Repair
Un iversit y of Sou th Florida Michael Y. Wang, MD, FACS
Tam pa, Florida Professor
Dep ar t m en ts of Neu rological Su rger y
Arya Giri Varthi, MD an d Reh ab Medicin e
Dep ar t m en t of Orth op aedic Su rger y Un iversit y of Miam i Miller Sch ool of
an d Reh abilit at ion Med icin e
Yale New Haven Hosp it al Miam i, Florida
New Haven , Con n ect icu t
Peter G. Whang, MD, FACS
Vire n S. Vasudeva, MD Associate Professor, Spin e Ser vice
Dep ar t m en t of Neu rosu rger y Dep ar t m en t of Or th opaedics an d
Brigh am an d Wom en’s Hospital Reh abilit at ion
Har vard Medical Sch ool Yale Un iversit y Sch ool of Medicin e
Boston , Massach u set t s New Haven , Con n ect icu t

Andrey Alex Vo lkov, DO Tim othy F. Witham , MD, FACS


Dep ar t m en t of Neu roon cology Associate Professor of Neurosurger y
Mo t t Can cer Cen ter an d Or th op aedic Su rger y
Tam pa, Florida Director, Th e Joh n s Hop kin s Bayview
Sp in e Program
Frank D. Vrio nis, MD, PhD Director, Th e Joh n s Hop kin s
Ch ief of Neu rosurger y Neu rosu rger y Sp in al Fu sion
H. Lee Mo t t Can cer Cen ter Laborator y
Professor of Neurosu rger y Co-Program Director, Joh n s Hopkin s
Dep ar t m en t of Orth op ed ics an d Neu rosu rger y Resid en cy
On cological Scien ces Balt im ore, Mar ylan d
Un iversit y of Sou th Florida College of
Medicin e Jean-Paul Wo linsk y, MD
Tam pa, Florida 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 Hasan A. Zaidi, MD


Con sultan t , Assist an t Professor Barrow Neurological In st it ute
Depart m en t of Neu rosu rger y Barrow Neurosurgical Associates
Neu rological In st it u te Ph oen ix, Arizon a
Taipei Veteran s Gen eral Hospit al
Sch ool of Medicin e Vinko Zlo m islic, MD
Nat ion al Yang-Ming Un iversit y Assist an t Clin ical Professor
Taipei Cit y, Taiw an Dep ar t m en t of Or th op aedic Su rger y
Un iversit y of Californ ia–San Diego
Antho ny T. Yeung, MD San Diego, Californ ia
Or th op ed ic Sp in e Su rgeon
Desert In st it u te for Spin e Care Benjam in M. Zussm an, MD
Ph oen ix, Arizon a Dep ar t m en t of Neu rosu rger y
Un iversit y of Pit t sburgh Medical
Christo pher Yeung, MD Cen ter
Presiden t Pit t sburgh , Pen n sylvan ia
Desert In st it u te for Spin e Care
Ph oen ix, Arizon a
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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