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Library of Congress Cataloging-in-Publication Data


Spine : core knowledge in orthopaedics / [edited by] Alexander R.Vaccaro. 1st ed.
p. ; cm.
ISBN 0-323-02731-8
1. SpineDiseasesTreatment. 2. SpinePathophysiology. 3. SpineSurgery. 4. Orthopedics. I.Vaccaro,
Alexander R.
[DNLM: 1. Spinal DiseasesHandbooks. 2. SpinesurgeryHandbooks, 3. Back PaintherapyHandbooks. 4.
Orthopedic ProceduresHandbooks.WE 39 S757 2005]
RD768.S674 2005
616.7306dc22
2004059217

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1


Contributors

TODD J. ALBERT,
M.D., Professor and Vice Chairman, Department of Orthopaedics,Thomas Jefferson University Medical College and the
Rothman Institute, Philadelphia, PA
HOWARD S. AN,
M.D.,The Morton International Professor of Orthopaedic Surgery, Director of Spine Fellowship Program, Rush Medical
College, Director of Spine Surgery, Rush University Medical Center, Chicago, IL
LUKE S. AUSTIN,
Medical Student,Thomas Jefferson University, Philadelphia, PA
ROBERT J. BANCO,
M.D., Boston Spine Group, New England Baptist Hospital, Boston, MA
JOHN M. BEINER,
M.D., B.S., Attending Surgeon, Connecticut Orthopaedic Specialists, Hospital of Saint Raphael; Clinical Instructor,
Department of Orthopaedics,Yale University School of Medicine, New Haven, CT.
CHRISTOPHER M. BONO,
M.D., Attending Orthopaedic Surgeon, Boston University Medical Center; Assistant Professor of Orthopaedic Surgery, Boston
University School of Medicine, Boston, MA
EUGENE J. CARRAGEE,
M.D., Director, Orthopaedic Spine Center; Professor, Department of Orthopaedic Surgery, Stanford University School of
Medicine, Stanford, CA
MATTHEW D. EICHENBAUM,
M.D., Spine Research Fellow, Department of Orthopaedic Surgery,Thomas Jefferson University, Philadelphia, PA
JEFFREY S. FISCHGRUND,
M.D., Spine Surgeon,William Beaumont Hospital, Royal Oak, MI
MARC D. FISICARO,
B.A., Medical Student, Jefferson Medical College,Thomas Jefferson University, Philadelphia, PA
MITCHELL K. FREEDMAN,
D.O., Director of Physical Rehabilitation and Pain Management,The Rothman Institute; Clinical Instructor,Thomas Jefferson
University Hospital, Philadelphia, PA.
GUY W. FRIED,
M.D., Medical Director of Outpatient Services, Incontinence Program, and Respiratory Care Program, Magee Rehabilitation
Hospital; Clinical Assistant Professor,Thomas Jefferson University Hospital, Philadelphia, PA
STEVEN R. GARFIN,
M.D., Professor and Chair, Department of Orthopaedics, University of California San Diego, San Diego, CA

v
vi Contributors

JONATHAN N. GRAUER,
M.D., Assistant Professor, Co-Director Orthopaedic Spine Surgery,Yale-New Haven Hospital; Assistant Professor, Department
of Orthopaedics,Yale University School of Medicine, New Haven, CT
JAMES S. HARROP,
M.D., Assistant Professor of Neurosurgery, Department of Neurosurgery,Thomas Jefferson University, Philadelphia, PA
VICTOR M. HAYES,
M.D., Chief Resident, Long Island Jewish Medical Center, Long Island, NY
HARRY N. HERKOWITZ,
M.D., Chairman, Department of Orthopaedic Surgery,William Beaumont Hospital, Royal Oak, MI
ALAN S. HILIBRAND,
M.D., Associate Professor of Orthopaedic Surgery, Director of Education, Thomas Jefferson University, the Rothman Institute,
Philadelphia, PA
LOUIS G. JENIS,
M.D., Boston Spine Group, New England Baptist Hospital, Boston, MA
DAVID H. KIM,
M.D., Orthopaedic Spine Surgeon,The Boston Spine Group, Boston, MA
DMITRIY KONDRACHOV,
M.D., Chief Resident, Long Island Jewish Medical Center, Long Island, NY
BRIAN K. KWON,
M.D., Orthopaedic Spine Fellow, Department of Orthopaedic Surgery,Thomas Jefferson University and the Rothman Institute,
Philadelphia, PA; Clinical Instructor, Combine Neurosurgical and Orthopaedic Spine Program, University of British Columbia;
and Gowan and Michele Guest Neuroscience Canada Foundation/CIHR Research Fellow, International Collaboration on
Repair Discoveries, University of British Columbia,Vancouver, Canada
ERIC LEVICOFF,
M.D., Orthopaedic Surgery Resident, University of Pittsburgh Medical Center, Pittsburgh, PA
RAFAEL LEVIN,
M.D., M.Sc. Comprehensive Spine Care, Emerson, NJ
ROBERTO LUGO,
M.D., Medical Student,Yale University School of Medicine, New Haven, CT
JENNIFER MALONE,
R.N., Department of Neurosurgery,Thomas Jefferson University, Philadelphia, PA
REBECCA S. OVSIOWITZ,
M.D.,Thomas Jefferson University, Philadelphia, PA
KEVIN F. RAND,
M.D., Boston Spine Group, New England Baptist Hospital, Boston, MA
MATTHEW ROSEN,
B.A.,Thomas Jefferson University College of Medicine, Philadelphia, PA
ARJUN SAXENA,
B.S.,Thomas Jefferson Medical College, Philadelphia, PA
DILIP K. SENGUPTA,
M.D., Dr. Med; Assistant Professor, Department of Orthopaedics, Staff Spine Surgeon, Spine Center, Dartmouth-Hitchcock
Medical Center, Lebanon, NH
BILAL SHAFI,
M.D., M.S., Surgical Resident, Hospital of University of Pennsylvania, Philadelphia, PA
ASHWINI D. SHARAN,
M.D., Assistant Professor of Neurosurgery, Department of Neurosurgery,Thomas Jefferson University, Philadelphia, PA
Contributors vii

FARHAN N. SIDDIQI,
M.D., Chief Resident, Long Island Jewish Medical Center, Long Island, NY
JEFF S. SILBER,
M.D., Assistant Professor, Department of Orthopaedic Surgery, Long Island Jewish Medical Center, North Shore University
Hospital Center, Long Island, NY; Albert Einstein University Hospital, Bronx, NY
MARCO T. SILVA,
M.D., Department of Neurosurgery, Jefferson Medical College,Thomas Jefferson University, Philadelphia, PA
KERN SINGH,
M.D., Assistant Professor, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
DANIEL J. SUCATO,
M.D., M.S., Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center;
Staff Orthopaedic Surgeon,Texas Scottish Rite Hospital for Children, Dallas,TX
KEVIN P. SULLIVAN,
M.D., MetroWest Medical Center, Framingham, MA; Nashoba Valley Medical Center, Ayer, MA;The Boston Spine Group,
Southboro, MA
PRIYA SWAMY,
M.D.,Thomas Jefferson University, Philadelphia, PA
SCOTT G. TROMANHAUSER,
M.D., Boston Spine Group, New England Baptist Hospital, Boston, MA
EERIC TRUUMEES,
M.D., Attending Spine Surgeon,William Beaumont Hospital, Royal Oak, MI; Adjunct Faculty, Bioengineering Center,Wayne
State University, Detroit, MI
ALEXANDER R.VACCARO,
M.D., Professor of Orthopaedic Surgery,Thomas Jefferson University and the Rothman Institute, Philadelphia, PA
BRADY T.VIBERT,
M.D., Resident, Orthopaedic Surgery,William Beaumont Hospital, Royal Oak, MI
Preface

The great aim of education is not knowledge but action


Herbert Spencer
Our understanding of spinal disease is increasing at an expediential rate, in part due to the progress of
imaging technology (MRI, CT imaging), diagnostic injections and advances in implant technology.The
most learned spinal surgeon is challenged just to keep up with the myriad of published contemporary
spine journals and books.
Common to all medical disciplines is a core foundation of knowledge i.e. anatomy, physiology and
the nature history of the disorder, which must be understood in order to embark on new frontiers in
research and medical treatment. A Resident and Fellows Guide to the Fundamentals of Spine Surgery was
written to provide a resident, fellow, or even an established spinal surgeon with a simple and general, but
complete overview of the basics of spinal surgery.This book is a wonderful asset for a medical student
on a spinal surgery rotation or spine fellow at the commencement of their fellowship.The bulleted for-
mat of the text and accompanying text boxes and illustrations allow for a rapid review of information
in a short period of time providing a foundation for learning that would normally take hours to accom-
plish with a standard text format. Established spinal surgeons will enjoy an easy to digest and timely
review of the basics of spinal surgery which is often necessary on a periodic basis as one moves further
from their formal training. Lastly, nurses, physician assistants, spinal care physicians (chiropractors, anes-
thesiologists, physiatrists) and hospital administrators may also use this book to become familiar with a
review of commonly used terminologies and frequently performed spinal procedures.
The overall structure of the book is designed to be a high yield, efficient source of clinical informa-
tion. The book is organized by medical relevance and conceptual difficulty. Within each chapter are
numerous algorithms, pictures, grafts and drawings that highlight the most important clinical pearls of
each subject matter and organize the information in a logical way to facilitate learning and recall. The
annotated references at the end of each chapter serve as a source for those who would like to expand
on the topics found in each chapter.
We hope that you enjoy reading this book as much as we enjoyed editing it and we hope that it serves
as a useful tool until the next edited version is available.
Alexander R.Vaccaro, M.D.
Marc Fisicaro

ix
Introduction

This book is designed to function as a pocket aid or reference for medical and graduate students, resi-
dents, and those in the beginning of their fellowship training interested in spinal medicine.A general but
complete overview of topics commonly encountered in clinical spinal medicine is presented, intended
to focus and supplement daily readings and round discussions. Students will find this text useful initially
in building a foundation of the core principles of spinal care. Spine fellows and even attending physi-
cians will find this book useful as a quick, on-the-spot review of contemporary treatment principles of
commonly encountered spinal disorders.
The design of this text allows you to quickly scan a topic of interest to acquire useful information
while on rounds or before entering the operating arena. The book is written in an informal bulleted
format with a plethora of outlines, pictures, charts, and graphs.The student or fellow on rounds can refer
to any pertinent topic being discussed that day and assimilate the most important facts regarding a par-
ticular topic while actively participating in clinical rounds.
The book begins with a basic overview of spinal anatomy, surgical approaches, and physical exami-
nation of the spine. As you progress through the book, the topics become more focused on specific but
common spinal disorders, such as primary and metastatic tumors of the spine, spinal trauma, and spondy-
lolisthesis. For the seasoned spinal care physician, the book is a wonderful review of specific pathologies
that can be read in a short period and can be used for teaching students, residents, ancillary personnel,
and spine fellows.
This book is a must for any physician or physician in training who wishes to review on a yearly basis
the basics and, if necessary, the details of a particular spinal pathology to maintain a well-rounded under-
standing of the principles of spinal care.

xv
1

CHAPTER
Basic Anatomy of the Cervical,
Thoracic, Lumbar, and Sacral
Spine
Marc D. Fisicaro*, Jonathan N. Grauer , John M. Beiner , Brian K. Kwon , and
Alexander R.Vaccaro ||

*B.A., Medical Student, Jefferson Medical College,Thomas Jefferson University,


Philadelphia, PA
M.D., Assistant Professor, Co-Director Orthopaedic Spine Surgery, Yale-New Haven
Hospital; Assistant Professor, Yale School of Medicine, New Haven, CT
M.D., B.S., Attending Surgeon, Connecticut Orthopaedic Specialists, Hospital of
Saint Raphael; Clinical Instructor, Department of Orthopaedics, Yale University School
of Medicine, New Haven, CT.
M.D., Professor of Orthopaedic Surgery, Jefferson Medical College,Thomas Jefferson
University, Philadelphia, PA
||M.D., Orthopaedic Spine Fellow, Department of Orthopaedic Surgery,Thomas Jefferson
University and the Rothman Institute, Philadelphia, PA; Clinical Instructor, Combine
Neurosurgical and Orthopaedic Spine Program, University of British Columbia; and Gown
and Michele Guest Neuroscience Canada Foundation/CIHR Research Fellow, International
Collaboration on Repair Discoveries, University of British Columbia,Vancouver, Canada

(Fig. 11).The 24 cervical through lumbar vertebrae are


Introduction mobile.
A thorough understanding of spinal anatomy is crucial for The vertebral column has four distinct curvescervical
a comprehensive evaluation of a patient with spinal lordosis, lumbar lordosis, thoracic kyphosis, and sacral
disorders (Moore 1999, An 1998, Frymoyer et al. 2001, kyphosis. In stance, the sagittal vertical axis passes through
Rothman et al. 1999, Hoppenfeld et al. 1994). the odontoid, posterior to the cervical vertebrae, through
The primary roles of the spine are maintaining stability, the C7-T1 intervertebral disk, anterior to the thoracic
protecting the neural elements, and allowing range of vertebrae, through the T12-L1 intervertebral disk,
motion. Specifically adapted anatomic features facilitate posterior to the lumbar vertebrae, through the L5-S1
these functions. intervertebral disk, and anterior to the sacrum.
The vertebra is the structural building block of the spine, The primary curves are those of the kyphotic thoracic
with specific morphologic and functional roles based on the and sacral regions. These form during the fetal period.
vertebras position in the spinal column.The intervertebral The secondary curves are those of the lordotic cervical
disks, ligaments, and muscles add stability and control. and lumbar regions. These are initiated during the late
The spinal cord travels within, and is protected by, the fetal period but do not become significant until after
spine. Paired nerve roots exit at each spinal level. birth when the spinal column begins to bear the
weight of the body and head. Primary curves are
caused by the wedge-shaped nature of involved
Bony Vertebral Column vertebrae, whereas secondary curves are caused by
The vertebral column consists of 33 vertebrae7 differences in the anterior and posterior dimensions of
cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal the intervertebral disks.
1
2 Spine Core Knowledge in Orthopaedics

C2
Vertebral
Cervical spine canal or foramen
lordosis
C7 Posterior
T1 bony arch

Anterior
Thoracic spine
vertebral body
kyphosis

Figure 12: Anatomic configuration of a lumbar vertebra.


T12
L1
Lumbar spine processes changes when one moves down the vertebral
lordosis column.The bony region between the two articular
L5 processes of an individual vertebra is termed the pars
S1 interarticularis.
Sacrum The vertebral bodies of the lumbar spine support an
kyphosis average of 80% of the axial load experienced by the
spinal column; the facet joints support the other 20%.
Coccyx
Figure 11: Lateral view of the spine demonstrating the
normal spinal curvatures. Specific Vertebral Anatomy
Each vertebra consists of an anterior body and a posterior Atlas (C1)
bony arch (Fig. 12).Together these surround the The atlas is the first cervical vertebra (Fig. 14).This is a
vertebral canal or foramen. Lateral spaces between the
ring-like structure that does not have an anterior body or
posterior arches of adjacent vertebrae form the foramen
a posterior spinous process.There is an anterior and a
through which the spinal nerve roots pass (Fig. 13).
much longer posterior arch.
The posterior vertebral arch consists of the pedicles, The posterior arch has a groove along its superior border
laminae, spinous processes, facet joints, and transverse
where the vertebral artery passes in its tortuous path
processes.The pedicles and laminae form the borders of
toward the foramen magnum of the skull.
the vertebral canal with the posterior border of the The superior articular facets are saucer-like and form the
vertebral body.The spinous and transverse processes are
atlanto-occipital articulation with the occipital condyles.
sites of attachment of supporting ligaments and muscles.
Because of the orientation of these facets, the majority of
Of note, the posterior arches include the thickest cortex
cervical flexion and extension of the upper cervical spine
of the vertebra (Doherty et al. 1994).
is possible in this region.
The superior articular process is the portion of the The inferior articular facets are flatter, more circular, and
posterior elements that articulates with the supra-adjacent
contribute to the atlantoaxial articulation with the second
vertebra.The inferior articular process articulates with the
cervical vertebra, or axis.The remainder of this
subadjacent vertebra.The orientation of the articular
articulation is through the unique relationship of the

Figure 13: Borders of the intervertebral Intervertebral foramen


foramen through which the spinal nerve roots Pedicle above
pass.
Vertebral body
Lamina

Intervertebral disk

Superior articular
process of facet joint
Pedicle below
CHAPTER 1 Basic Anatomy of the Cervical, Thoracic, Lumbar, and Sacral Spine 3

Superior articular facet of C1 which Transverse


articulates with the occipital condyles foreamen C2 Body C2
Anterior arch C1
Anterior tubercle C2
Dens C2
Transverse Posterior tubercle C2
process C1

Pedicle C2
Lamina C2 Inferior articular
Lamina C1 Groove for
facet C2
vertebral artery
Posterior arch C1 Spinous process C2 Spinous process C2

View from above View from below

Transverse
Atlas C1
process C1

Lateral Atlano-axial
masses articulation
Axis C2

Dens C2 Spinous process C2


View from anterior View from posterior
Figure 14: C1 and C2 vertebrae.

posterior border of the anterior arch of the atlas and the against the posterior surface of the anterior C1 arch
dens. (Fig. 15). Extensions of this ligament superiorly and
The transverse processes of the atlas are longer and larger inferiorly create the cruciform ligament.
than those of the other cervical vertebrae.Within the The dens is further stabilized by the alar ligaments that
transverse processes is the transverse foramina through connect the odontoid tip to the occipital condyles.The
which the vertebral artery passes. apical ligament, at the tip of the dens, is a remnant of the
notochord.
Axis (C2) The C2-C3 articulation is anatomically similar to the rest
The axis is the second cervical vertebra (Fig. 14).This of the subaxial cervical levels.
includes the dens, or odontoid, which projects superiorly The C2 pedicle is relatively large and projects 30 degrees
from the anterior vertebral body to articulate with the atlas. medially and 20 degrees superiorly (Xu et al. 1995).
The atlas contacts the axis through the posterior facet The C2 spinous process is large, bifid, and often
joints and the anterior atlantodens articulation. A synovial palpable.This serves as the site of attachment for several
joint is present between the anterior arch of C1 and the muscles.
dens and transverse ligament that bonds the odontoid to The transverse processes of this vertebra are similar in
the anterior C1 arch.The majority of upper cervical morphology, but smaller, than those of the other
rotation occurs at the atlantoaxial joint. cervical vertebrae. The vertebral artery passes
The transverse ligament is a stout ligament that runs from through the transverse processes in the transverse
one side of the atlas to the other and holds the dens foramen.

Alar ligament Figure 15: Ligaments specific to the


Dens atlantoaxial articulation.
Transverse
ligament

C1
Cruciform
C2 ligament
4 Spine Core Knowledge in Orthopaedics

Subaxial Cervical Spine (C3-C7) Thoracic Spine


The C3-C6 vertebral bodies are small in relationship The thoracic vertebrae are intermediate in size between
to their vertebral canals (Fig. 16).The canal, the cervical and lumbar vertebrae (Fig. 17).Their size
triangular in shape, has the greatest cross-sectional increases as one moves down the spinal column.
area at C2. The defining characteristic of thoracic vertebrae is their
The superior surfaces, or endplates, of the cervical intimate relationship with the ribs (Vollmer et al. 1997).
vertebrae are concave.The inferior endplates are convex. A rib articulates at the junction of the vertebral body and
As such, the lateral aspects of the superior endplates curve pedicle (superior costal facet) of its named vertebra and
superiorly to approach the supra-adjacent vertebrae to the vertebra above (inferior costal facet).The rib also
form what is known as the uncovertebral joints, or the articulates with the transverse costal facet of the
joints of Luschka. transverse process of its named vertebra.These relations of
The facets gradually become steeper and more sagittally the rib and the vertebrae are supported by accessory
oriented as one descends the cervical levels.The bony ligaments that make the thoracic spine mechanically
regions between the cervical facets, called the lateral stiffer than the cervical and lumbar spine.
masses, are just lateral to the laminae. Anteriorly, the thoracic vertebral bodies are relatively
The spinous processes are short and bifid. heart shaped. Sometimes, the left side of the vertebrae has
Similar to the atlas and axis, the vertebral artery travels a depression secondary to the descending aorta.
within the transverse foramina of the transverse processes. The pedicles of the thoracic vertebrae are oval in cross
This divides the transverse processes into the anterior and section.These have been reported to be 10 mm in height
posterior tubercles. and 4.5 mm in width at T4 and 14 mm height and 7.8 mm
Between the two tubercles of the transverse processes is in width at T12 (Vaccaro et al. 1995).As with the pedicles of
the groove on which the exiting nerve roots pass after the lumbar spine, the walls are thicker medially than laterally.
exiting the intervertebral foramen. The spinal canal has less free space for the spinal cord
The seventh cervical vertebra (vertebra prominens) is than the cervical and lumbar regions.
a transitional vertebra and has several unique Posteriorly, the thoracic vertebrae have long, slender
characteristics. spinous processes that point downward and overlap the
The inferior surface of C7 is larger than its superior vertebral arches of the inferior vertebra.
surface.The lateral masses of C7 are taller and shallower The transverse processes are posteriorly angulated, leaving
than those of the other subaxial cervical vertebrae.The room for the ribs to pass anterior to them.
pedicles also begin to enlarge as one goes caudally from
this level. Lumbar Spine
The C7 spinous process is long, nonbifid, and almost The lumbar vertebrae are stouter than those of the other
horizontal.This serves as a site of attachment for the spinal regions because they bear the greatest weight
ligamentum nuchae. (Fig. 18).
The transverse processes of C7 do have transverse Anteriorly, the lumbar vertebral bodies are kidney shaped.
foramina, but the vertebral arteries rarely (5% of cases) Their bodies are wider transversely than they are deep
pass through this vertebra. Rather, the vertebral artery anteroposteriorly, and both of these dimensions exceed
usually joins the spinal column at C6. their height.

Bifid spinous Inferior articular


Superior process facet Superior
articular facet Lamina articular facet
Pedicle Spinous
Pedicle
process
Spinal
Posterior canal
tubercle
Body
Anterior Inferior
tubercle articular facet
Vertebral Groove for Uncovertebral
foramen spinal nerve joint Lateral mass

C4 view from above View from below Lateral view


Figure 16: C4 as a representative subaxial vertebra.
CHAPTER 1 Basic Anatomy of the Cervical, Thoracic, Lumbar, and Sacral Spine 5

Superior articular Spinous Inferior articular Superior


facet process facet articular facet
Lamina Transverse Pedicle
Transverse
process Superior
process
costal facet
Transverse
costal facet Spinous
Pedicle
process
Inferior
Superior Inferior
costal facet
costal facet costal facet
Spinal canal Inferior Vertebral
articular facet foramen

T6 view from above View from below Lateral view


Figure 17: T6 as a representative thoracic vertebra.

The pedicles are short and large and arise from the upper The nerve roots pass under the lateral recess of the
part of the vertebral body. Based on posterior landmarks, pedicles/articular facets and through the intervertebral
a pedicle is located behind the facet of the named foramina.These foramina are bordered by the pedicles
vertebra and the supra-adjacent vertebra. In the above and below, the vertebral body and intervertebral
cephaladcaudad direction, it is in the midline of the disk anteriorly, and the lamina and facets posteriorly
associated transverse process. In the mediallateral (Fig. 13).
direction, the medial aspect of the pedicle is in line with The spinous processes are broad and tall within the
the lateral aspect of the pars interarticularis. lumbar spine.
At L1, the transverse pedicular diameter is The transverse process of L5 is often much smaller than
approximately 9 mm with a medial angle of 12 degrees the transverse processes of the other lumbar vertebrae.
(Zindrick et al. 1987). The height-to-width ratio at The L5 transverse process is the site of attachment of
L1-L4 is approximately1:8, but this decreases to 1:1 at the iliolumbar ligament. As with the other lumbar
L5 (Panjabi et al. 1992). L1 and L2 are transitional transverse processes, L5 often has an irregular accessory
vertebrae similar to the thoracic vertebrae (Panjabi process on the medial aspect of the transverse process
et al. 1992). near where it joins the rest of the posterior bony arch
The lumbar facets are in a relative sagittal orientation. As and a mammillary process at the prominence of the
such, axial rotation is limited.The exception is the L5-S1 facet joint.
facet, which is more coronal and resists anteroposterior
translation (An 1998).The pars interarticularis is more Sacrum
defined in this region of the spine than in the cervical or The sacrum is composed of five fused vertebrae and is a
thoracic region. large, wedge-shaped bone (Fig. 19).

Superior articular Superior


facet Spinous process Inferior articular articular facet
facet
Lamina Pars inter- Transverse
Transverse Mammilary articularis process
process process

Body
Accessory
process Pedicle
Spinous Pedicle
Spinal canal process
Inferior Vertebral
articular facet foramen

L2 view from above View from below Lateral view


Figure 18: L2 as a representative lumbar vertebra.
6 Spine Core Knowledge in Orthopaedics

Body Sacral Superior


Ala canal articular facet
Median
Articular
crest
surface with ilium
Promontory Posterior sacral
Sacrum
foramen
Transverse
Sacral hiatus
Anterior process of
sacral foramen coccyx
Coccyx Base of coccyx Curnua of
sacrum and coccyx
Tip of coccyx
Anterior view Posterior view
Figure 19: Sacrum and coccyx.

The functions of the sacrum are to provide strength Coccyx


and stability to the pelvis and to transmit the weight of
the body from the vertebral column to the pelvic
The coccyx, colloquially called the tail bone, is the
girdle through articulation with the ilea (the sacroiliac terminal portion of the spinal column. It consists of four
joints). fused rudimentary vertebrae.
The spine has an acute angle at L5-S1, which is called
The primary role of the coccyx in the human is to
the sacrovertebral angle. serve as a site of attachment for muscles of the pelvic
The promontory is the superior flare of the sacrum floor.
that articulates with L5. The transverse lines are the
The coccygeal cornua are proximal extensions of
residual of the divisions of the sacral vertebrae. The the coccyx. The tip of the coccyx is usually flexed
alae are the two lateral wings that extend laterally to forward.
the sacroiliac joints. These are derived from fused
transverse processes of the sacral vertebrae. The median
sacral crest is formed by the fused sacral spinous
Intervertebral Disks
processes. Intervertebral disks are located between the
The sacrum has four pairs of anterior and posterior vertebral bodies of C2-C3 through L5-S1. The
foramina through which the ventral and dorsal primary disks are located between the vertebral endplates
rami exit.The anterior sacral foramina are larger than the covered with hyaline cartilage and supported by
posterior foramina (Esses et al. 1991). subchondral bone.
The sacral hiatus is formed by the absence of the Analogous to the menisci of the knee, the
laminae and spinous process of S5.The sacral hiatus intervertebral disk is a relatively avascular structure with
is the termination of the sacral canal.This contains only the outermost layers receiving nutrients from
the fatty connective tissue, the filum terminale, the peripheral vascularization. The central portions of the
S5 nerves, and the coccygeal nerves. disk receive nutrients through diffusion from the
The sacral cornu is formed by the pedicles of the fifth vertebral endplates.
sacral vertebra.They project inferiorly on each side of the The nucleus pulposus is the inner portion of the disk
hiatus. (Fig. 110).This mucoid portion of the disk is

Anulus
Endplates
fibrosus

Nucleus Anulus fibrosus


pulposus

Nucleus pulposus
Figure 110: Transverse and sagittal images of an intervertebral disk.
CHAPTER 1 Basic Anatomy of the Cervical, Thoracic, Lumbar, and Sacral Spine 7

predominantly made of type II collagen and is a remnant ligament are found at only one level.The intermediate
of the primitive notochord.The nucleus acts at a cushion fibers span two or three levels.The most superficial fibers
to axial loads. span four or five levels.
The anulus fibrosus is the outer portion of the disk.This The functions of the anterior longitudinal ligament are to
multilayered, fibrocartilaginous structure is prevent hyperextension and to support the anulus fibrosus
predominantly made of type I collagen. A lattice is made anteriorly.
with overlapping sheets running in opposite directions to
give the anulus increased strength, especially in rotation. Posterior Longitudinal Ligament
The anulus is thickest anteriorly and thinnest The posterior longitudinal ligament runs along the
posterolaterally. posterior aspect of the vertebral column (Fig. 111).
The anulus absorbs the radially directed forces from the It begins along the posterior border of the basion
nucleus and converts these to hoop stresses at the as the tectorial membrane, continues within the
periphery of the disk, where they are firmly attached to spinal canal, and ends on the posterior surface of
the vertebral endplates. the sacrum.
The outermost portions of the anulus are continuous The posterior longitudinal ligament is narrow over the
with the anterior and posterior longitudinal ligaments. middle of the vertebral bodies and expands over the
The intervertebral disks contribute {1/4} of the disks and vertebral endplates (Fig. 112). The lateral
length to the spinal column, but this is a dynamic expansions are thin, and the central portion of the
measure. When in the horizontal position, nutrients ligament is thick.
and fluid enter the disk, increasing height. With The posterior longitudinal ligament is double layeredits
prolonged stance, nutrients and fluids exit the disk, superficial layer is adjacent to the dura and contributes to
decreasing height. the enveloping connective tissue underlying neural
elements.The deep layers connect to the anulus fibrosus
centrally and blend into the intervertebral foramen laterally.
Ligaments of the Vertebral The functions of the posterior longitudinal ligament are to
prevent hyperflexion and to support the posterior aspects of
Column the anterior vertebral column.
Anterior Longitudinal Ligament Ligamentum Flavum
The anterior longitudinal ligament runs along the anterior The ligamentum flavum, or the yellow ligament, is a thick,
aspect of the vertebral column (Fig. 111). It begins at the segmental ligament that runs between the lamina of
anterior border of the anterior margin of the foramen adjacent vertebrae (Fig. 111). It begins on the undersurface
magnum (basion) as the anterior occipital membrane and of the inferior border of the lamina and courses down to
ends on the anterior surface of the sacrum. the leading superior edge of the lamina (Fig. 112).
As the ligament descends, it widens, and it is thickest There are gaps at the midline of the ligamentum flavum
opposite the disk spaces.The deepest fibers of this to allow the veins to exit.

Anterior Posterior
atlanooccipital atlanooccipital
membrane Intervertebral
membrane foramen
C2 spinous process
Spinous
Ligamentum nuchae
process
Vertebral
body Ligamentum
flavum
Ligamentum Intervertebral
flavum disk Interspinous
ligament
C7 spinous process
Anterior
Supraspinous
longitudinal Posterior ligament
ligament longitudinal
ligament
Figure 111: Ligaments of the spinal column.
8 Spine Core Knowledge in Orthopaedics

Figure 112: Posterior longitudinal


Thin lateral Begins on ligament and ligamentum flavum.
expansions under surface
Ligamentum of superior
flavum lamina
Thicker
central
region
Goes to
superior aspect
Posterior of inferior lamina
longitudinal
ligament

The function of the ligamentum flavum is to posterior superior, and the serratus posterior
maintain upright posture. It helps to preserve the inferior.
normal curvature of the spine and to straighten the The intrinsic posterior spinal muscles are located under
column after it has been flexed. However, the elasticity of the more superficial extrinsic musculature.The intrinsic
the ligamentum flavum decreases with age, and this may spinal muscles extend, rotate, and laterally bend the
be associated with hypertrophy and buckling. vertebral column. As a rule, superficial spinal muscles are
longer than deeper spinal muscles. Many of these muscles
Supraspinous Ligament are named in subdivisions based on the site of insertion
The supraspinous ligament is a midline structure that of portions of the muscle.
runs over the posterior aspect of the spinous processes The intrinsic posterior muscles are divided into
(Fig. 111).The cervical expansion of this ligament is superficial, intermediate, and deep layers (Fig. 113,
called the ligamentum nuchae. Table 11).These are innervated by the dorsal ramus of
The nuchal portion of this ligament extends from the the spinal nerves.
seventh cervical spinous process to the external occipital The superficial layer consists of the splenius capitis
protuberance. It is attached to the posterior tubercle of the and the splenius cervicis muscles.
atlas and to the spinous processes of the other cervical The muscles of the intermediate layer are also known
vertebrae. as the erector spinae muscles. This layer is composed of:
The primary purpose of this ligament is to act as a (1) the iliocostalis, subdivided into the cervicis, thoracis,
tension band in preventing hyperflexion. It also acts as a and lumborum portions; (2) the longissimus,
site of attachment for the fascial coverings of the medial subdivided into the capitis, cervicis, and thoracic
spinal muscles. portions; and (3) the smaller spinalis muscle group,
subdivided into the capitis, cervicis, and thoracis
portions.
Additional Spinal Ligaments The muscles of the deep layer are also known as the
The interspinous ligaments connect adjacent spinous transversospinalis muscles.This layer is composed of: (1)
processes. As with the supraspinous ligament, this contri- the semispinalis, subdivided into the capitis, cervicis, and
butes to the posterior tension band preventing hyperflexion. thoracis portions; (2) the multifidus; (3) the rotators; and
Intertransverse ligaments connect adjacent transverse (4) the short rotators (the interspinales and
processes.These help to limit lateral bending and act as a intertransversarii muscles).
border between anterior and posterior structures, The muscles of the upper cervical spine make up
particularly in the lumbar spine. the suboccipital triangle (Fig. 113,Table 11).The
Denticulate ligaments are fine intradural ligaments that suboccipital triangle is bound medially by the rectus
attach neural elements to overlying covering capitis posterior, laterally by the obliquus capitis
membranes. superior, and inferiorly by the obliquus capitis
inferior.The roof is formed by the semispinalis capitis
and longissimus capitis.The posterior arch of the atlas
Muscles of the Vertebral Column and posterior atlanto-occipital membrane form the
floor of the triangle.Within the triangle are the
Posterior Muscles vertebral artery and suboccipital nerve and vessels.
The extrinsic posterior muscles of the back include All of the muscles are innervated by the suboccipital
the trapezius and latissimus dorsi, the serratus nerve.
CHAPTER 1 Basic Anatomy of the Cervical, Thoracic, Lumbar, and Sacral Spine 9

Figure 113: Posterior intrinsic spinal


Superficial layer Suboccipital triangle muscles.
Splenius cervicis Rectus capitis posterior minor
Superior obliquus capitus
Splenius capitus
Rectus capitus posterior major
Inferior obliquus capitus
C2

Intermediate layer
(erector spinae)
Iliocostalis
Longissimus
Spinalis

Superficial layer
Semispinalis (5 levels)
Multifidus (1-3 levels)
Rotatores (0-1 level)

Segmental vessels have dorsal branches that divide into


Anterior Spinal Muscles anterior and posterior radicular arteries when they enter
Anterior muscles that flex, laterally bend, and rotate the the intervertebral foramen.These form a single anterior
spine generally act a greater distance from the vertebral spinal artery and a pair of posterior spinal arteries,
column than the posterior muscles. respectively.
The sternocleidomastoid, scalene muscles, longus colli, The artery of Adamkiewicz is a particularly large
and longus capitis act on the cervical spine. radicular vessel that generally arises in the left
The abdominal, psoas, and quadratus lumorum muscles thoracolumbar region and is considered to
act on the thoracolumbar spine. contribute significantly to the anterior vascular supply
of the spinal cord at this level.
The vertebral artery deserves specific mention. This
Blood Supply and Venous is a branch off the subclavian artery that, as
discussed in preceding sections, usually enters
Drainage the transverse foramen of the cervical vertebra at
The arterial blood supply of the spine is predominantly C6, gives off segmental branches when it ascends
from segmental vessels that originate from the vertebral the cervical spine, and then curves medially,
arteries, aorta, and iliac vessels (Fig. 114). Not only are after passing through C1, to within 1.5 cm of
these important for the bony spine, but they also are midline in the adult before entering the foramen
crucial for the functioning of the spinal cord. magnum.
10 Spine Core Knowledge in Orthopaedics

Table 11: Posterior Spine Muscles

MUSCLE ORIGIN INSERTION PRIMARY FUNCTIONS


Superficial Splenius capitis Ligamentum nuchae, Mastoid process, Extension, lateral bending, rotation
spinous processes occipital nuchal line
Splenius cervicis Same Posterior tubercles C1-C3 Same
Intermediate Iliocostalis Iliac crests, sacrum, Ribs, cervical transverse Extension, lateral bending
spinous processes processes
(erector spinae) Longissimus Same Ribs, transverse processes, Same
mastoid process
Spinalis Same Spinous processes, skull Same
Deep layer Semispinalis Transverse processes Spinous processes of vertebrae Extension, rotation
(transversospinalis and 5-6 levels above
short rotators) Multifidus Sacrum, ilium, transverse Spinous processes of vertebrae Stabilizing effect
processes 1-3 levels above
Rotators Transverse processes Spinous processes of vertebrae Extension, rotation
1-2 levels above
Interspinales Spinous processes Spinous process of adjacent Extension
vertebra
Intertransversarii Transverse process Transverse process of adjacent Lateral bending
vertebrae
Suboccipital muscles Rectus capitis posterior C2 spinous process Lateral portion of nuchal Extension, rotation of head
major line of skull
Rectus capitis posterior Posterior tubercle of atlas Medial portion of nuchal Same
minor line of skull
Superior obliquus capitis Transverse process of C1 Lateral portion of nuchal Same
line of skull
Inferior obliquus capitis Spinous process of C2 Transverse process of C1 Same

Posterior
cerebellar artery

Spinal cord
Posterior Vertebral artery
spinal arteries

Posterior
radicular artery Subclavian
Anterior
spinal artery

Anterior
Dorsal branch spinal artery
of posterior
intercostal artery

Posterior intercostal Artery of


artery Adamkiewicz
Anterior Aorta
radicular artery

Figure 114: Arterial blood supply to the spine.


CHAPTER 1 Basic Anatomy of the Cervical, Thoracic, Lumbar, and Sacral Spine 11

The spinal veins form plexuses within the


C1
vertebral bodies and around the epidural space C1
C2
(Fig. 115). C3
C4
C5
C6
Neuroanatomy C7 C7
C8
There are 31 pairs of spinal nerves8 cervical, 12 T1
T1
thoracic, 5 lumbar, 5 sacral, and 1 coccygeal (Fig. 116). T2
The first seven cervical nerves leave the vertebral canal T3
T4
above their named vertebrae.The eighth cervical and T5
the remainder of the spinal nerves exit the vertebral T6
canal below their named vertebrae. T7
T8
The dorsal and ventral rootlets coalesce to form the T9
dorsal and ventral roots, respectively (Fig. 117).The T10
dorsal root has the cell bodies of the entering sensory T11
T12
neurons (dorsal root ganglion) medial to its union with T12
L1
the motor neurons of the ventral root.The dorsal and L1
ventral roots form the spinal nerve that divides into the L2
dorsal and ventral primary rami after developing
sympathetic branches. L3
The dorsal primary ramus innervates the skin and deep
L4
muscles of the back.The ventral primary ramus forms the L5
plexi, intercostals, and subcostal nerves. L5
Sacrum
The spinal cord is shorter than the vertebral column; it
usually ends at L1 or L2. The spinal cord has cervical S1
S2
and lumbar enlargements because the nerves branch S3
out to the upper and lower extremities, and it S4
S5
terminates in the conus medullaris. Nerve roots
continue more distally in the cauda equine until the Figure 116: Diagram of the spinal nerves when they exit the
thecal sac terminates in the filum terminale (Fig. 116). vertebral column.
The spinal cord is covered by three layers of meninges
the dura, the arachnoid, and the pia mater, from
peripheral to central (Figs. 117 and 118).Together
these form the thecal sac.
The pia is closely related to the spinal cord and thick and gives rise to a longitudinal projection on each
therefore cannot be dissected from it. It is relatively side called the denticulate ligament. These ligaments
anchor the spinal cord to the arachnoid and, through it,
to the dura.
The arachnoid is a transparent layer that connects to the
pia by web-like trabeculations. Under it is the
subarachnoid space, which is filled with cerebrospinal
Vertebral body fluid.This space extends down to S2.There is a large
subarachnoid space between L1 and S2 called the lumbar
cistern.
Epidural veins The dura is the tough, fibrous, outer covering of the
spinal cord. Between the dura and the arachnoid is a
potential space, called the subdural space, that also
extends to S2. The epidural space is outside the
dura and contains the internal venous plexus and
epidural fat.
The internal morphology of the spinal cord consists
of central gray matter, which is predominantly cell
bodies, surrounded by peripheral white matter, which is
predominantly axons that make up specific neural tracts
Figure 115: Venous drainage of the spine. (Fig. 117 and Table 12).
12 Spine Core Knowledge in Orthopaedics

Dura Figure 117: Spinal root and nerve


Dorsal rootlets anatomy.
Arachnoid
Pia
Denticulate ligament

Dorsal root
Dorsal primary ramus
Spinal ganglion

Spinal nerve
Ventral primary ramus Ventral root

Dorsal gray horn Figure 118: Spinal supra-adjacent cord


Posterior columns anatomy.
Ventral gray horn
Spinocerebellar tract
Dura
Corticospinal tract Arachnoid

Spinothalamic tract Denticulate ligament

Arachnoid trabeculae
Subarachnoid space
Pia

Table 12: Spinal Tracts

NAME OF INFORMATION
TRACT TRANSMITTED DECUSSATION
Posterior columns Light touch, vibration, Caudal medulla
proprioception
Spinocerebellar Unconscious proprioception No decussation
Corticospinal Voluntary movement Caudal medulla
Spinothalamic Pain, temperature At level of spinal
cord entry

Frymoyer JW, Ducker TB, Hadler NM et al., eds. (1991) The Adult
References Spine: Principles and Practice, 2nd edition. New York: Raven Press.
An HS, ed. (1998) Principles and Techniques of Spine Surgery, A reference spine textbook with well-prepared sections on
Baltimore:Williams and Wilkins. spinal anatomy.
A reference textbook with well-prepared illustrations.
Hoppenfeld S, deBoer P. (1994) Surgical Exposures in
Doherty BJ, Heggeness MH. (1994) Quantitative anatomy of the Orthopaedics:The Anatomic Approach. Philadelphia: Lippincott-
atlas. Spine 19(22): 2497-2500. Raven.
The authors establish the range and variability of external Unlike anatomy texts, this book highlights the anatomy seen
dimensions of the atlas using cadaveric specimens. during specific surgical approaches.

Esses SI, Botsford DJ, Huler RJ et al. (1991) Surgical anatomy of Moore K. (1999) Clinically Oriented Anatomy, 4th edition.
the sacrum: A guide for rational screw fixation. Spine 16(6 Suppl.): Philadelphia: Lippincott Williams & Wilkins.
S283-S288. A complete, well-illustrated basic anatomy textbook presented
The authors studied prepared cadaveric specimens to allow safe with clinical correlations.This book is a popular medical school
screw placement. textbook.
CHAPTER 1 Basic Anatomy of the Cervical, Thoracic, Lumbar, and Sacral Spine 13

Panjabi MM, Goel V, Oxland T et al. (1992) Human lumbar Vollmer DG, Banister WM. (1997) Thoracolumbar spinal anatomy.
vertebrae: A three-dimensional anatomy. Spine 17(3): 299-306. Neurosurg Clin N Am 8(4): 443-453.
The authors used prepared cadaveric specimens to study various The authors reviewed the anatomy of the thoracolumbar spine
surface dimensions of the lumbar vertebrae. relevant to disorders of the region.
Rothman R, Simeone FE, eds. (1999) The Spine, 4th edition. Xu R, Naudaud MC, Ebraheim NA et al. (1995) Morphology of
Philadelphia:W.B. Saunders. the second cervical vertebra and the posterior projection of the
A comprehensive spine textbook that covers spinal anatomy, C2 pedicle axis. Spine 20: 259-263.
physical examination, myriad spinal disorders, and their nonop- The authors studied 50 dried C2 vertebrae to assess their struc-
erative and operative treatment. tural features.
Vaccaro AR, Rizzolo SJ, Allerdyce TJ et al. (1995) Placement of Zindrick MR,Wiltse LL, Doornick A et al. (1987) Analysis of the
pedicle screws in the thoracic spine. J Bone Joint Surg 77A: morphometric characteristics of the thoracic and lumbar pedicles.
1193-1199. Spine 12: 160-166.
The authors studied the morphology of thoracic vertebrae using The authors measured pedicles of T1-L5 using CT scan and
17 prepared cadaveric specimens. roentgenograms.
2

CHAPTER
Physical Examination of the Spine
Jennifer Malone*, James S. Harrop , Ashwini D. Sharan , Matthew D. Eichenbaum ,
and Alexander R.Vaccaro

* R.N., Department of Neurosurgery,Thomas Jefferson University, Philadelphia, PA


M.D., Assistant Professor of Neurosurgery, Department of Neurosurgery,Thomas Jefferson
University, Philadelphia, PA
M.D., Spine Research Fellow, Department of Orthopaedic Surgery,Thomas Jefferson
University, Philadelphia, PA
M.D., Professor of Orthopaedic Surgery,Thomas Jefferson University and the Rothman
Institute, Philadelphia, PA

5 lumbar vertebrae
Introduction 5 sacral vertebrae
The spine is a complex biomechanical structure that does 3 to 4 coccygeal vertebrae
the following: Spinal ligaments include the following:
Protects the neural structures The anterior longitudinal ligament
Allows an upright posture The posterior longitudinal ligament
Aids in respiration and ambulation The ligamentum flavum
Unfortunately, these requirements place a great strain on Interspinous ligaments
the spine and may promote accelerated aging or Numerous smaller ligaments
symptomatic degeneration.
Muscles of the Back
Anatomy of the Spinal Column Superficial Extrinsic Back Muscles
The vertebral spinal column does the following: The following muscles connect the upper limbs to the
Supports the cranium and trunk trunk and control limb movements:
Allows movement Trapezius
Protects the spinal cord Latissimus dorsi
Absorbs stresses produced by walking, running, and Levator scapulae
lifting Rhomboid major
The vertebral spinal column consists of 33 vertebrae with Rhomboid minor
23 intervening fibrocartilage intervertebral disks
supported by numerous ligaments and paraspinal muscles.
Intermediate Extrinsic Back Muscles
The spinal column is divided into five regions consisting The following superficial respiratory muscles are deep to
of the following: the rhomboids and latissimus:
7 cervical vertebrae Serratus posterior superior
12 thoracic vertebrae Serratus posterior inferior

14
CHAPTER 2 Physical Examination of the Spine 15

SemispinalisSuperficial layer
Superficial Intrinsic Back Muscles MultifidusIntermediate layer
(Fig. 21) RotatorsDeepest layer
Splenius capitis
Splenius cervicis
Minor Deep Intrinsic Back Muscles
Interspinales
Intertransversarii
Intermediate Intrinsic Back Muscles Levatores costarum
The Erector Spinae (Fig. 21)
The following muscles are massive and strong and Prevertebral (Deep) Muscles of the
function as the chief extensors of the vertebral column: Neck (Fig. 22)
IliocostalisLateral column
LongissimusIntermediate column Anterior Vertebral Muscles
SpinalisMedial column The following muscles are deep to the anterior
cervical triangle and are anterior flexors of the head
and neck:
Deep Intrinsic Back MusclesThe Longus colli
Transversospinal Muscle Group (Fig. 21) Longus capitis
The following muscles are deep to the erector spinae and Rectus capitis anterior
obliquely disposed: Rectus capitis lateralis

Figure 21: Superficial, intermediate,


Superficial layer Suboccipital triangle and deep back musculature.
Splenius cervicis Rectus capitis posterior minor
Superior obliquus capitus
Splenius capitus
Rectus capitus posterior major
Inferior obliquus capitus
C2

Intermediate layer
(erector spinae)
Iliocostalis
Longissimus
Spinalis

Superficial layer
Semispinalis (5 levels)
Multifidus (1-3 levels)
Rotatores (0-1 level)
16 Spine Core Knowledge in Orthopaedics

Occipital bone
(basilar part) Longus capitis muscle (cut)
Occipital condyle

Mastoid process Rectus capitis


lateralis muscle
Styloid process Transverse process of C1
Longus capitis muscle Transverse process of C3
Transverse process of C2 Anterior scalene
Longus colli muscle muscle (slips of origin)
Phrenic nerve Posterior scalene
Middle scalene muscle muscle (slips of origin)
Posterior scalene muscle
Brachial plexus Anterior scalene
Anterior scalene muscle muscle (cut)

Subclavian artery
First rib
Subclavian vein
Transverse process
Internal jugular vein of C7
Common carotid artery
Figure 22: Prevertebral musculature of the neck.

Lateral Vertebral Group Table 21: Curvature of the Spine


The muscles of this group are deep to the posterior cervical CURVATURE NORMAL CURVATURE
triangle and are rotators and lateral flexors of the neck: Cervical lordosis 20 to 40 degrees
Splenius capitis Thoracic kyphosis 20 to 45 degrees
Posterior scalene Lumbar lordosis 40 to 60 degrees
Middle scalene Sacral kyphosis Sacrum fused in a kyphotic curve
Anterior scalene

Overall, the spine should support the head over the


Coronal and Sagittal Spinal pelvis, a state referred to as being in coronal and sagittal
balance or alignment.
Alignment The length of the cervical spinal canal measured in the
The vertebral column has four major curves (Fig. 23): sagittal plane during flexion (kyphotic posture) is greater
Cervical than the length during extension (lordotic posture).
Thoracic The normal cervical lordosis allows the neural elements
Lumbar to traverse the spinal canal through a shorter course
Sacrococcygeal or pelvic without ventral compression.
The thoracic and sacrococcygeal curves are referred to as The lordotic cervical curvature might also protect
primary curves because they retain the kyphotic curvature against neural injury because axial loads
from embryogenesis, as seen in the fetus. are dispersed dorsally onto the facet joints and
The cervical and lumbar spines are secondary curves. large articular pillars rather than onto the
They develop or adapt a lordotic structure as a result of vertebral body.
postural changes to accommodate sitting and ambulation. The flexibility of the cervical spine allows it to compensate
There is a large degree of variability in what is for misalignment of the thoracic and lumbar spine.
considered the normal sagittal curvature of the cervical, An increased lordotic cervical posture is observed in the
thoracic, and lumbar spine. (Table 21) setting of exaggerated thoracic kyphosis.
CHAPTER 2 Physical Examination of the Spine 17

Figure 23: Spinal cord (lateral view).


C1
Cervical lordosis

C7
T1

Thoracic kyphosis

T12
Anterior Posterior
L1

Cauda equina
Lumbar lordosis

L5

Sacral and coccygeal

A plumb line dropped from C7 should fall and cross the distraction instrumentation placed in the posterior
posterior vertebra line or body walls at the L5-S1 lumbar spine.
interspace. Younger patients may assume a flattened lumbar posture
Variability in sagittal alignment is influenced by age in the setting of an acute muscle spasm or a symptomatic
and gender; females have a greater degree of acute herniated disk.
thoracic kyphosis than males, and older people have
a greater degree of thoracic kyphosis than younger
Exaggerated Lumbar Lordosis
people. An exaggeration of the normal lumbar lordotic curve
There is also a significant degree of variability in spinal can develop to compensate for the protuberant abdomen
alignment on a segmental basis, particularly at the of pregnancy or marked obesity.
transitional regions of the lordotic cervical and lumbar It may also develop as a compensation for exaggerated
spine. thoracic kyphosis or contractures of the hips.
Normal thoracic kyphosis has been reported to be Superficially, a deep midline furrow may be seen
between 20 and 45 degrees. between the lumbar paravertebral muscles on a
posterior examination of a patient with increased
Spinal Curvatures lumbar lordosis.
Flattening of the Lumbar Curve Thoracic Kyphosis (Fig. 25)
(Fig. 24) An increase in thoracic kyphosis is seen with aging and
The most common cause of loss of lumbar lordosis is in the setting of multiple thoracic vertebral compression
degenerative disk disease. fractures.
Secondary causes include lumbar compression In adolescent patients, thoracic kyphosis may be
fractures or iatrogenic flatback posture from secondary to Scheuermanns disease.
18 Spine Core Knowledge in Orthopaedics

Figure 24: Spinal curvatures. Normal spinal


curvature (A), flattening of the lumbar curve
(B), and lumbar lordosis (C).

A B C

Gibbus (Fig. 25) Structural Scoliosis


A gibbus is a prominent thoracic bony ridge caused by a Structural scoliosis typically is associated with a rotation
severe kyphotic angle. of the vertebrae upon each other, and the rib cage is
It most often occurs as a result of an angular deformity accordingly deformed.
caused by a collapsed vertebra. This deformity is best seen when the patient flexes forward.
On the side of the thoracic convexity, the ribs bulge
Scoliosis posteriorly and are widely separated.
Scoliosis is a lateral curvature of the spine (Fig. 26). On the opposite side (concavity), they are displaced
The body normally attempts to compensate for coronal anteriorly and are close together.
plane curves by developing secondary coronal curves.
A plumb line dropped from C7 or T1 should pass Functional Scoliosis
through the gluteal cleft. Functional scoliosis compensates for other abnormalities
Scoliosis may be structural or functional. such as unequal leg lengths.
It involves neither fixed vertebral rotation nor fixed
thoracic deformity.
The scoliosis resolves with correction of the primary
A B process.
List (Fig. 26)
List is a lateral tilt of the spine.
A plumb line dropped from the spinous process of T1
falls to one side of the gluteal cleft.
Causes include a symptomatic herniated disk and painful
spasms of the paravertebral muscles.

Surface Landmarks
Surface landmarks help orient the examiner to certain
vertebral levels.
The spinous processes of C7 and T1 are typically large
and prominent, making them readily palpable at the base
of the neck.
The interspace between T7 and T8 is typically at the level
Figure 25: Thoracic kyphosis (A) and gibbus deformity (B). of the inferior angle of the scapula.
CHAPTER 2 Physical Examination of the Spine 19

Figure 26: Scoliosis (A) and list (B).

A B

An imaginary line connecting the highest point on each Patients are asked to walk at their usual pace across the
iliac crest crosses the L4 body. room or down the hall, turn, and return to the starting
An imaginary line connecting the two dimples found position.
over the posterior superior iliac spine indicates the level The examiner should observe posture, balance,
of S1. swinging of the arms, and movements of the legs.
1. Balance should be easily maintained.
2. The arms should freely swing at the patients sides.
Techniques of Examination 3. Turns should be accomplished smoothly and without
difficulty.
Inspection
A gait that lacks coordination, with reeling and
Examination of the spine begins with inspecting and instability, is referred to as ataxic and may be caused by
observing the patients static and dynamic posture and cerebellar disease or loss of proprioception.
gait when they enter the room. Patients are asked to walk heel-to-toe in a straight line
Drape or gown patients to expose the entire neck and (also called tandem walking).
back for complete inspection.
Patients should be observed in their natural standing Range of Motion of the Spine (Figs.
position with the feet together and the arms hanging
at the sides.The head should be midline in the same 27 and 28)
plane as the sacrum, and the shoulders and pelvis Range of motion consists of the following:
should be level. Flexion
Neck stiffness, the splinting of an extremity, or an Extension
uncomfortable writhing in the sitting position all may Lateral bending to the right and left
reveal underlying spinal pathology. Rotation to the right and left
Examination of the skin should be performed to observe Approximately 50% of cervical flexion and extension occurs
any pigmented or raised lesions.The presence of cafe-au-lait between the occiput and C1, and 50% of rotation
spots or neurofibromas may suggest a neurocutaneous occurs between C1 and C2.
syndrome such as neurofibromatosis.
The posterior midline should be examined to evaluate Atrophy
cutaneous midline rosy spots, tufts of hair, or dimples. Atrophy is the loss of the muscle bulk or mass and
These observations may indicate a failure of midline definition.
skeletal fusion during embryogenesis and possibly may It has multiple etiologies.
suggest an occult spinal dysraphism. It is most commonly caused by a loss of anterior horn
Gait is a complex process relying on the input and output of cells from neural compression.
information from all aspects of the neuraxis; it is also Myopathies are typically present with proximal muscle
dependent on the structural properties of the spinal column. wasting.
Examination of gait involves observation of Fasciculations are spontaneous discharges of
cadence, ease of movement, arm swing, and overall individual muscles fibers and are seen as twitches under
steadiness. the skin.
20 Spine Core Knowledge in Orthopaedics

Figure 27: Range of motion of


the spine. Extension and lateral
bending.

vertebral translocation or spondylolisthesis. Working


Techniques of Examination caudally, palpation over the sacroiliac jointoften
identified by the dimple overlying the posterior
Palpation superior iliac spinemay reveal tenderness resulting
Palpation of each spinal vertebra and muscle follows from sacroiliac joint pathology, a common cause of low
inspection. back pain.
Tenderness may suggest a bruise, a fracture, or a Palpation of the paravertebral musculature is essential.
dislocation if preceded by trauma; the presence of an Muscles in spasm may feel firm and knotted. Spasms may
underlying infection; or arthritis. be the result of bony, ligamentous, or muscle sprain or
In the cervical spine, palpation may elicit discomfort injury and are not necessarily helpful in the localization
from the posterior facet joints, located about one inch of a causative process.
lateral to the spinous processes of C2-C7. These joints
lie deep to the trapezius muscle and may not be
palpable unless the neck muscles are relaxed.
Motor Examination
In the lumbar spine, the examiner may palpate for any The motor examination begins proximally and proceeds
vertebral step-offs to determine the presence of distally.

Figure 28: Rotation.


CHAPTER 2 Physical Examination of the Spine 21

Motor Examination of the Upper Muscle Tests


Extremities (Fig. 29) The motor examination is designed to detect muscle
The deltoid muscles should be examined with the arms weakness in a pattern that localizes the level of pathology
held at a 90-degree angle to the torso. or dysfunction (central nervous system, spinal cord,
The biceps muscles are tested by flexion at the elbows peripheral nerve, or muscle) and provides a reproducible
with the hands fully supinated. means of assessing strength (Tables 22 and 23).
The wrist extensors are tested by applying tension to the The tone of the muscle is defined as the degree of
wrist while the patient attempts to extend the wrist. tension of the muscle at rest.
The triceps muscles are tested with the arms held against Spasticity is increased muscle tone or a resistance to
the body with the elbows flexed.The patient then motion.
attempts to extend at the elbows against resistance. Muscles should be noted for stiffness, elasticity, rigidity,
The intrinsic hand muscles are tested with finger flexion cogwheeling, and the presence of postural tremor.
or by spreading of the fingers.
Sensory Examination
Motor Examination of the Lower The sensory examination is the most subjective portion
Extremities (Fig. 210) of the neurologic or spinal evaluation (Table 24).There
The iliopsoas muscle is tested by applying downward are four distinct sensations with defined anatomic
force against hip flexion. pathways in the spinal cord.
The quadriceps muscles are tested by applying force Pain perception may be tested with the sharp portion

against knee extension. of a safety pin.


The anterior tibialis muscles are tested by applying force Light touch may be tested with a cotton swab.

against active ankle dorsiflexion. Temperature may be tested with two test tubes

The extensor hallucis longus muscles are tested by containing either a hot or a cold solution.
applying force against active toe dorsiflexion. Proprioception examination begins distally at the distal

The gastrocnemii muscles are tested by applying force phalanx or great toe and proceeds proximally to each
against active ankle plantar flexion. larger joint.Testing is specifically conducted to assess

A B
Figure 29: Muscle tests of the upper extremities. A, Shoulder abduction, deltoidC5. B, BicepsC5, C6.
22 Spine Core Knowledge in Orthopaedics

E
C

D F

Figure 29: Contd C, Wrist extensionC6. D, TricepsC7. E, Wrist flexionC7, C8. F, Finger extensionC7.
CHAPTER 2 Physical Examination of the Spine 23

G H
Figure 29: Contd G, Finger flexionC8. H, Finger abductionadduction, T1.

whether the patient can reliably detect excursion of the


joint and position sense. Localizing Dermatomes (Fig. 211)
The aim of sensory testing is to identify whether C6Thumb
there is a dermatomal pattern of sensory dysfunction, C7Middle digit
which would suggest spinal root pathology; a C8Fifth digit
peripheral nerve disorder; or possibly a glove or T4Nipple
stocking distribution deficit, which would suggest a T10Umbilicus
neuropathy. L1Inguinal ligament

A B
Figure 210: Muscle tests of the lower extremities. A, IliopsoasL2, L3. B, QuadricepsL3, L4.
24 Spine Core Knowledge in Orthopaedics

C
E

G
Figure 210: Contd C, Hip adductorsL2, L3. D, Hip abductorsL4, L5, S1. E, Tibialis anteriorL4. F, Extensor hallucis
longusL5. G, Gastrocnemius or soleusL5, S1.
CHAPTER 2 Physical Examination of the Spine 25

Table 22: Motor Function Grading Table 23: Spinal Nerve Innervation

MOTOR FUNCTION DESCRIPTION GRADE SPINAL


Absent Total paralysis 0
SEGMENT MUSCLE FUNCTION
Trace Palpable or visible contraction 1 C3-C5 Diaphragm Inspiration
Poor Active movement through the range C5, C6 Biceps brachii brachialis Elbow flexors
of motion with gravity eliminated 2 C6, C7 Extensor carpi radialis longus Wrist extensors
Fair Active movement through the range and brevis
of motion against gravity 3 C7, C8 Triceps brachii Elbow extensors
Good Active movement through the range C8, T1 Interossei thenar group Hand intrinsics
of motion against resistance 4 L2, L3 Iliopsoas Hip flexion
Normal Normal strength 5 L2, L3 Adductor longus and brevis Hip adductors
L3, L4 Quadriceps Knee extensors
L4, L5 Tibialis anterior Ankle dorsiflexors
L4-S1 Gluteus medius Hip abductors
L5-S1 Extensor hallucis longus Great toe extensor
S1, S2 Gastrocnemius soleus Ankle plantarflexors
S2-S4 Sphincter ani externus Anal sphincter

Table 24: Spinal Nerve Innervation

ROOT MUSCLES REFLEX SENSATION


C5 Deltoid, biceps Biceps Lateral arm
Axillary nerve
C6 Biceps, wrist extensors Brachioradialis Lateral forearm
Musculocutaneous nerve
C7 Triceps, wrist extensors, finger extensors Triceps Middle finger
Median nerve
C8 Hand intrinsics, finger flexors Medial forearm
Median antebrachial cutaneous nerve
T1, T2 Hand intrinsics Medial arm
Median brachial cutaneous nerve
T2-T12 Intercostals, rectus abdominus Beevors signAbnormal T2Clavicle, axilla
T3Axilla
T4-T6Nipple line to inferior xiphoid process
T7-T9Xiphoid process to inferior umbilicus
Ventral and lateral cutaneous branches of intercostal
nerves
Upper lateral cutaneous nerve of arms
T10, T11Umbilicus
T12Groin
Lateral cutaneous branches of subcostal and
iliohypogastric nerves
Femoral branch of the genitofemoral nerve
Ilioinguinal nerve
T12, L1-L3 Iliopsoas (hip flexion) Patellar tendon reflex T12Groin
(supplied by L2-L4) L1-L3Anterior thigh between the inguinal ligament
and the knee
Ilioinguinal nerve
Lateral, anterior, medial femoral cutaneous nerves
of the thigh
Obturator nerve
L4 Tibialis anterior Patellar tendon Medial leg
Saphenous nerve
L5 Extensor hallucis longus Lateral leg and dorsum of the foot
Lateral cutaneous nerve of the calf
Medial plantar nerve
S1 Peroneus longus and brevis Achilles tendon Lateral foot
Lateral plantar nerve
26 Spine Core Knowledge in Orthopaedics

Figure 211: Sensory examination points. (Leventhal 2003.)

Reflexes are graded from 0 to 4. Hyperactive reflexes are


Reflexes graded 3 or 4 and suggest the presence of spinal cord
Reflex testing is an essential part of the examination and pathology or upper motor nerve dysfunction.
provides a means of differentiating between spinal cord Reflex grading is as follows:

and peripheral pathology. 0Absence


A simple monosynaptic reflex consists of an afferent input 1Diminished
that synapses in the spinal cord and returns to the extremity 2Normal reflex
through an efferent output (Fig. 212). Upper motor 3Hyperactive reflex
neurons inhibit the output of the efferent signal; therefore, 4Clonus present
if reflexes are increased, the examiner should suspect a Distracting patients may help elicit reflexes through
decrease in upper motor influence. techniques such as the Jendrassik maneuver (having
Decreased reflexes may imply the loss either of sensory patients pull their hands apart while the stimulus is being
input or of motor neuron or muscle integration. applied).
CHAPTER 2 Physical Examination of the Spine 27

Stretch
Upper Extremity Long Tract Reflexes
receptor
Musc Hoffmans reflexTriggered by taking the middle finger,
flicking the distal phalanx from the palm, and observing a
pincer movement between the thumb and the index
finger (Fig. 213).
Trmner signElicited by elevating the middle
Musc finger from the rest of the hand and flicking the
Motor spind distal phalanx toward the palm, again looking for the
pincher movement between the thumb and the index
neuron
finger.
Figure 212: A simple monosynaptic reflex. These two reflexes may not necessarily be signs of
pathology; rather, they may be indications of brisk muscle
stretch reflexes. Asymmetry may be significant and may
herald the presence of a central nervous dysfunction or a
significant cervical cord compression, especially in an
elderly patient.
The examination of the upper extremity deep tendon
reflexes includes tests of the biceps tendon, the
brachioradialis, and the triceps tendon reflexes. Reflexes Nerve Root Tension Signs
in the lower extremities include the quadriceps reflex Spurlings signThis extends the neck with concurrent
(knee jerk) and the gastrocnemius reflex (ankle jerk). In lateral bending and an axial load on the head.This is a
addition, reflexes of the hamstring muscles (biceps positive sign if the maneuver reproduces the patients pain
femoris) can be tested. in a radicular nature; this is suggestive of a cervical
radiculopathy (Fig. 214).
Upper Extremity Lasgues sign (straight leg raise)Flexing the leg at the
Triceps reflexForearm extension hip reproduces the patients radicular pain in the leg and
Biceps reflexElbow flexion not the back. Pain should be reproduced with less than
Brachioradialis reflex 60 degrees of flexion to be positive.This is highly
Tap distal radius Lateral wrist flexion and partial suggestive of nerve root irritation, typically by a
supination of the forearm herniated lumbar disk (Fig. 215).
Bowstring signAfter reproducing the patients pain and
Lower Extremity obtaining a positive Lasgues sign, the knee is flexed.This
Patellar reflexContraction of quadriceps (strongest is positive if the patients pain resolves with flexion at the
muscles in body) and extension of the leg knee. If the pain persists, this is suggestive of hip pathology.
Suprapatellar reflexAbove the knee; same response Cram testThe cram test is similar to the Lasgues sign.
Achilles reflexCauses plantar-flexion of foot The patient is supine; the leg is flexed at the hip and then

Figure 213: Hoffmanns reflex.


28 Spine Core Knowledge in Orthopaedics

Pathologic Long Tract Signs


Babinskis sign (extensor plantar reflex)This is
elicited by applying a gentle stimulus to the lateral
aspect of the sole starting over the heel and extending
toward the base of the little toe. A positive Babinskis
sign refers to the initial dorsiflexion of the great toe
upward and the spreading of the other toes; it is
indicative of corticospinal tract dysfunction
(Fig. 217).
Crossed adductors signThis stimulates the patellar
reflex and causes the contralateral thigh adductors to
contract.This is suggestive of an upper motor lesion.
Chaddocks signThis is tested by laterally abducting the
little toe briskly and allowing it to slap back against the
other toes, looking for dorsiflexion of the great toe, or
flicking the third or fourth toe down rapidly, again
looking for great toe dorsiflexion.
ClonusThis is a rhythmic, nonvoluntary movement of
Figure 214: Spurlings sign. muscle with stimulation.
Lhermittes signFlexion of the neck causes an electric
shock-like sensation to shoot down the spine.This
originally was described with multiple sclerosis and
believed to be the result of posterior column
dysfunction. It may be seen in patients with severe
extended at the knee. It is positive if it reproduces the cervical cord compression from stenosis or a disk
patients pain. herniation (Fig. 218).
Frajersztajns sign (contralateral straight leg raise)flexing
the leg at the hip with an extended knee of the
asymptomatic leg reproduces the pain in the contralateral
Superficial Reflexes
leg (Fig. 216). The following are cutaneous abdominal reflexes:
Femoral stretch signThe patient is placed prone Superficial abdominal reflexThis reflex is elicited by
and the leg is straightened and extended at the hip.This scratching from the abdominal margins toward the
places tension on the femoral nerve (L2-L4) and may umbilicus and observing a quivering motion of the
suggest an upper lumbar radiculopathy. abdominal muscles.

Figure 215: Lasgues sign.


CHAPTER 2 Physical Examination of the Spine 29

Figure 216: Frajersztajns sign.

Deep abdominal reflexThis is elicited by tapping


over the anterior rectus abdominal muscle sheath
and observing a contraction of the abdominal
muscles.
Beevors signPatients perform a quarter sit-up with
Figure 218: Lhermittes sign.
the arms crossed behind the head.The examiner should
be watching the navel. Beevors sign is considered
positive if the navel moves up, down, or to either side. Cremasteric reflex (in males)This is elicited by stroking
A positive Beevors sign occurs if the lower abdominal
the thigh (the genitofemoral nerve) and observing the
musculature (controlled by the spinal cord below T9) is
ascent of the ipsilateral testicle (Fig. 220).
weaker than the upper abdominal musculature Anal wink reflexContraction of the external anal
(Fig. 219).
sphincter follows application of a sharp stimulus.This test
is used to determine the end of spinal shock in the
context of spinal cord injury (Fig. 221).

Figure 217: Babinskis sign. Figure 219: Beevors sign.


30 Spine Core Knowledge in Orthopaedics

Figure 220: Cremasteric reflex.

Bulbocavernosus reflexThe anal sphincter is contracted


by compressing the glans penis.This test is used in the
Figure 222: Bulbocavernosus reflex.
setting of spinal cord injury to identify the end of spinal
shock (Fig. 222).

Spinal Syndromes
Syndromes are collections of signs and symptoms that anatomic region. Spinal cord syndromes therefore
occur consistently when a lesion is present in a particular indicate the location of a lesion but do not indicate a
specific cause.The syndromes described in this section
usually occur as a result of trauma.
Central Cord Syndrome
Central cord syndrome (Fig. 223) occurs in the
cervical level and usually results from hyperextension

Figure 223: Spinal cord injury pattern in central cord


Figure 221: Anal wink reflex. syndrome.
CHAPTER 2 Physical Examination of the Spine 31

injuries of the spinal cord. It typically occurs in an


elderly stenotic, spondylotic cervical canal without
Anterior Cord Syndrome
associated fractures. Anterior cord syndrome (Fig. 225) occurs from damage
The hands are usually more severely compromised than to the ventral portion of the spinal cord with
the legs. interruption of the ascending spinothalamic tracts and
If the lesion or injury is minimal, the patient may only descending motor tracts.
have loss of pain and temperature because of an There is a loss of pain and temperature sensation along
interruption of the spinothalamic fibers crossing the with a loss of motor control.
midline. The tracts conveying proprioception and discriminative
More significant injuries impair upper motor function touch information are located in the posterior cord; these
because of the medial location of upper limb fibers in the functions are spared.
lateral corticospinal tracts. These lesions may be caused by thrombosis of the
anterior spinal artery and resultant spinal infarction.
Brown-Squards Syndrome
Brown-Squards syndrome (Fig. 224) results from a
Foix-Alajouanine Syndrome
hemisection injury of the spinal cord. This rapid loss of spinal cord function is caused by
It is manifested as ipsilateral loss or diminished venous engorgement and ischemic infarction of the
appreciation or function of voluntary motor control, spinal cord.
conscious proprioception, and discriminative touch The results are caused by obstructed venous outflow,
below the level of the lesion. typically as a result of an arteriovenous malformation.
Contralateral loss or diminished appreciation or function This typically affects the lower thoracic level, the
of the sensations of pain and temperature may occur lumbosacral level, or both.
below the level of the lesion. Gray matter (as compared with white matter)
structures are more severely involved.
Dissociated Sensory Loss Masses of enlarged, tortuous, and thick-walled
This is a band of sensory loss with normal sensation subarachnoid veins are observed overlying the surface
below the area. of the cord (primarily on the posterior aspect).
Decussating fibers located along the central canal (pain Smaller blood vessels with thickened fibrotic walls also
and temperature) are impaired, resulting in a decrease or are present within the affected spinal cord segments.
a loss of pain or temperature sensation. The enlarged, abnormal veins are associated with a
Position, touch, and vibratory sensations are not dural arteriovenous shunt, which is associated with the
impaired. reflux of arterial blood into the venous drainage of the
Dissociated sensory loss is typically caused by cord.
intramedullary lesions such as primary neoplasms or This increases venous pressure in the affected regions
syringomyelia. of the spinal cord, possibly leading to ischemic injury.

Figure 224: Spinal cord injury pattern in Brown-Squards Figure 225: Spinal cord injury pattern in anterior cord
syndrome. syndrome.
32 Spine Core Knowledge in Orthopaedics

Patients show increasing unilateral and/or bilateral Orthopaedics (Canale ST, ed.), 10th edition. Philadelphia:
extremity weakness and numbness or tingling in the Mosby.
lower extremities, which may be symmetric. Lucas JT, Ducker TB. (1979) Motor classification of spinal cord
Symptoms begin as a heavy feeling in the legs after brief injuries with mobility, morbidity, and recovery indices. Am Surgeon
exertion.The feeling improves with rest. 45: 151.
Symptoms gradually worsen over months, and the patient This article presents a new motor classification for patients with
may have difficulty standing for long periods. spinal cord injuries that provides statistically discrete subdivi-
Urinary and fecal incontinence eventually appear. sions, which can be mathematically summarized and more
Complaints of nonradiating lower back pain in the accurately analyzed.
lumbosacral or coccygeal regions are common. Marino RJ, ed. (2000) International Standards for Neurological
Weakness or numbness eventually can progress to the Classification of Spinal Cord Injury. Chicago: American Spinal
upper extremities. Injury Association.
This booklet summarizes and standardizes evaluation and
References recording of spinal cord injuries.
Moore KL, Dalley AF. (1999) Clinically Oriented Anatomy, 4th
Bickley, LS. (1999) Bates Guide to Physical Examination and History
edition. Philadelphia: Lippincott Williams & Wilkins.
Taking, 7th edition. Philadelphia: Lippincott Williams & Wilkins.
An updated version of a popular medical student anatomy
This textbook provides a solid foundation for learning physical
textbook. Organized by organ systems within anatomic regions,
examination and history taking.With numerous illustrations
this text includes numerous clinical correlates and surface
and photographs, this edition highlights procedures, interpreta-
anatomy pearls.
tions, and common abnormalities throughout the physical
examination. Netter FH. (1997) Atlas of Clinically Oriented Anatomy, 2nd
edition. East Hanover, NJ: Novartis.
Bondurant FJ, Cotler HB et al. (1990) Acute spinal cord injury:
One-volume collection of normal anatomic renditions covering
A study using physical examination and magnetic resonance
the entire human body.
imaging. Spine 15: 161-168.
A preliminary report from a study conducted at the University Rengachary SS. (1996) Examination of the motor and sensory
of Texas Medical School in Houston shows a clear relationship systems and reflexes. In: Neurosurgery (Wilkins RH et al., eds.),
between the appearance of spinal cord injuries, as identifiable 2nd edition. New York: McGraw-Hill.
on an MRI, and the postinjury neurologic recovery. Chapter in a textbook that explains, in detail, a systematic
examination of the motor system; muscle contour and abnormal
Cailliet R. (1988) Low Back Pain Syndrome, 4th edition.
movements; motor tone, strength and coordination; and assess-
Philadelphia: FA Davis.
ment of reflex activity.
This book explains low back pain syndrome; it focuses on
functional anatomy, lumbar spine diseases, clinical diagnosis, Rengachary SS. (1996) Gait and station: Examination of
and comprehensive therapeutic approaches in treatment. coordination. In: Neurosurgery (Wilkins RH et al., eds.), 2nd
edition. New York: McGraw-Hill.
Chadwick PR. (1984) Examination, assessment, and treatment of
Chapter in a textbook that describes the examination and
the lumbar spine. Physiotherapy 70: 2-10.
assessment of gait with common gait disturbances seen in
One in a series of articles elucidating a standard approach to
clinical practice.
evaluation and management of lumbar spine pathology.
Singer KP, Jones TJ, Breidahl PD. (1990) A comparison of
Cipriano JJ. (1991) Photographic Manual of Regional
radiolographic and computer-assisted measurements of thoracic
Orthopaedic and Neurological Tests, 2nd edition. Baltimore:
and thoracolumbar sagittal curvature. Skeletal Radiol 19: 21-26.
Williams & Wilkins.
Report from a study of 286 radiographs comparing the Cobb
Extensively photographed atlas with definitions illustrating the
technique with a computer-aided digitizer to measure sagittal
key points of a thorough neurologic and musculoskeletal
plane curve characteristics of the thoracolumbar spine.
examination.
Snider RK, ed. (1997) Essentials of musculoskeletal care.
Hoppenfeld S. (1976) Physical Examination of the Spine and
Rosemont, IL: American Academy of Orthopedic Surgeons,
Extremities. Norwalk, CT: Appleton-Century-Crofts.
American Academy of Pediatrics.
This functional guidebook allows the rapid assimilation of the
The spine section includes a concise review of the vertebral
basic knowledge essential to physical examination of the spine
levels associated with specific neurologic symptoms or findings
and extremities.
and illustrations that may help clinicians to distinguish psy-
Hoppenfeld S. (1977) Orthopaedic Neurology: A Diagnostic Guide chogenic from mechanical symptoms.
to Neurologic Levels. Philadelphia: JB Lippincott and Co.
Williams PL, Bannister LH et al., eds. (1995) Grays Anatomy, 38th
A concise, well-diagrammed text that systematically explains the
edition. Churchill-Livingstone.
characteristics and clinical correlates of a complete spine and
The first revision of the British version of the classic anatomy
extremity neurological examination.
reference since 1989; it shows the effects advances in molecular
Leventhal MR. (2003) Fractures, dislocations, and biology and imaging have had on medicine in its illustrations
fracture-dislocations of spine. In: Campbells Operative and commentaries.
3

CHAPTER
Surgical Approaches to the Spine
Kern Singh*, Howard S. An , and Alexander R.Vaccaro

* M.D., Assistant Professor, Department of Orthopedic Surgery, Rush University Medical


Center, Chicago, IL
M.D.,The Morton International Professor of Orthopedic Surgery, Director of Spine
Fellowship Program, Rush Medical College, Director of Spine Surgery, Rush University
Medical Center, Chicago, IL
M.D., Professor of Orthopaedic Surgery,Thomas Jefferson University and the Rothman
Institute, Philadelphia, PA

Introduction Technique
A thorough knowledge of human anatomy is paramount The patient is placed in the supine position.
in performing any surgical procedure (Box 31). The key surgical landmark is the anterior tubercle of the
The intimate association of muscular, osteoligamentous, atlas to which the anterior longitudinal ligament and
and neurovascular structures in the cervical spine requires longus coli muscles are attached.
a precise understanding of their relationships to safely and The vertebral arteries are at least 20 mm from the
efficiently navigate these structures during any surgical midline bilaterally.
procedure. A transoral tongue retractor is inserted, exposing the
The cervical spine can be approached surgically from the posterior oropharynx.
anterior or posterior depending on the location of The palatal retractors are inserted to elevate the soft
pathology. palate and expose the anterior rim of the foramen
magnum, the atlas, and the axis.
The area of incision is infiltrated with 1:200,000
Anterior Cervical Spine epinephrine.
Procedures A midline 3-cm vertical incision centered on the anterior
tubercle of the atlas is made through the pharyngeal
Transoral Approach mucosa and muscle (Fig. 31).
The transoral approach to the spine allows midline A pharyngeal retractor is inserted, converting the vertical
surgical exposure of the arch of the atlas to the C2-C3 incision into a hexagon to expose the tubercle of the
intervertebral disk. atlas, the anterior longitudinal ligament, and the longus
The exposure may be increased in a cephalad direction colli muscles.
by dividing the soft and hard palate to allow access to the The origins of the anterior longitudinal ligament and the
foramen magnum and the lower half of the clivus and longus colli muscles are divided with a Bovie and
sphenoid sinus. elevated in a subperiosteal fashion to expose the arch of
The transoral approach allows excellent midline access the atlas (Fig. 32).
but is limited laterally by the vertebral arteries within the To achieve good wound healing, the pharyngeal mucosa
spine (Box 32). and muscle should be closed carefully in two layers using

33
34 Spine Core Knowledge in Orthopaedics

Anatomic Landmarks of the Cervical


Box 31:
Spine
Arch of the atlasHard palate
C2-C3Lower border of the mandible
C3Hyoid bone
C4-C5Thyroid cartilage
C6Cricoid cartilage
C6Carotid tubercle

Box 32: Indications for the Transoral Approach


Irreducible atlantoaxial subluxation
Midline anterior extradural or intradural spinal cord compression
Midbasilar artery aneurysms

Figure 32: The arch of the atlas has been exposed. The
interrupted 3-0 absorbable sutures, one layer for muscle anterior longitudinal ligament and longus colli muscles have
and one for mucosa. been divided and retracted.
Anterior Retropharyngeal Approach The mandibular branch of the facial nerve is identified
The anterior retropharyngeal approach to the upper (Fig. 34).
cervical spine allows visualization from the clivus to C3. It is important to use bipolar cautery on the
This approach may be extended inferiorly to expose the retromandibular and facial veins to avoid inadvertent
middle and lower cervical spine (Box 33). injury to the mandibular branch of the facial nerve.
If the mandibular branch of the facial nerve is injured,
Technique the patient will have a noticeable droop of the ipsilateral
A modified transverse submandibular incision is made
(Fig. 33).
An incision is made through the skin, the subcutaneous Indications for the Anterior
Box 33:
tissue, and the platysma. Retropharyngeal Approach
Decompression and stabilization of fixed atlantoaxial subluxation
Anterior upper cervical vertebral debridement or decompression

Figure 33: The retropharyngeal approach to the upper


Figure 31: A midline vertical pharyngeal incision made cervical spine. A submandibular incision is illustrated with an
during a transoral approach. optional vertical extension to the subaxial cervical spine.
CHAPTER 3 Surgical Approaches to the Spine 35

After the superficial layer of the deep cervical fascia is


incised along the anterior border of the
sternocleidomastoid, the superior thyroid artery and vein
are ligated.
The hypoglossal and superior laryngeal nerves are
mobilized.
Branches of the carotid artery and internal jugular vein are
ligated to allow retraction of the carotid sheath posteriorly
and laterally when the pharynx is mobilized medially.
The submandibular gland may be resected if necessary
(its duct being sutured to prevent salivary fistula
formation).
The posterior belly of the digastric and stylohyoid
muscles is tagged with suture for later repair.
Care must be taken not to retract near the origin of the
Figure 34: The superficial neurovascular structures in the posterior belly of the digastric and stylohyoid muscles to
anterolateral neck. avoid neuropraxic injury to the facial nerve.
Division of the posterior belly of the digastric and
aspect of the mouth secondary to denervation of the stylohyoid muscles allows mobilization of the hyoid bone
orbicularis oris muscle. anteriorly and medially, thus allowing mobilization of the
The common facial vein is usually continuous with the pharynx.
retromandibular vein.The mandibular branch of the facial The hypoglossal nerve is mobilized from the base of the
nerve usually crosses the retromandibular vein skull to the posterior border of the mylohyoid bone,
superficially and superiorly and is superficial to the where it is then retracted superiorly for the remainder of
anterior facial vein. the case.
The submandibular gland is displaced and the digastric The dissection continues within the retropharyngeal
muscle is divided (Fig. 35). space between the carotid sheath laterally and the
The facial, lingual, and superior thyroid vessels, with the pharynx, larynx, and esophagus medially.
exception of the superior thyroid artery, are isolated, The alar and prevertebral fascia are split longitudinally
ligated, and divided. to expose the longus colli muscles that run
The superior laryngeal nerve may run close to the longitudinally on the anterior lateral aspects of the
superior thyroid artery. spine (Fig. 36).

Figure 36: The prevertebral fascia is split longitudinally


Figure 35: The neck after the submandibular gland has been between the longus colli muscles, exposing the anterior atlas
resected and the digastric muscle has been divided. and the C2 body.
36 Spine Core Knowledge in Orthopaedics

Smith-Robinson Approach to the


Subaxial Spine
The most common anterior approach to the subaxial
(middle, lower) cervical spine is the Smith-Robinson
approach (Box 34).
Technique
The patient is positioned supine with a bump placed in
the interscapular region.
Extending the neck and slightly rotating the head toward
the contralateral shoulder helps to provide greater ease of
exposure to the spinal elements.
A transverse incision is used in most cases, but an
oblique incision may be used for exposure of multiple
levels.
A right- or left-sided approach may be selected. Figure 37: The Smith-Robinson approach to the subaxial
If the surgeon extends the approach below the level of cervical spine. A transverse and oblique incision is illustrated.
C5, a left-sided approach is theoretically safer in
avoiding inadvertent injury to the recurrent laryngeal The bony spinous processes are palpable posteriorly with
nerve. noted large, spinous processes at C2, C7, and T1.
A transverse incision in line with the skin crease is made The C2 and C7 spinous processes are large and the
from the midline to the anterior aspect of the C3-C6 spinous processes are usually bifid.
sternocleidomastoid muscle (Fig. 37). A direct midline interfascial, internervous approach is
The skin and subcutaneous tissues are undermined used to expose the posterior vertebrae (Fig. 311,
slightly and the platysma is divided (Fig. 38). Box 37).
Retraction of the platysma exposes the The ligamentum nuchae, a fibroelastic septum with few
sternocleidomastoid muscle laterally and the strap elastic fibers, originates from the occiput and inserts onto
muscles medially. the C7 spinous process.
The sternocleidomastoid muscle is retracted laterally with The supraspinous ligaments are in continuity with the
the carotid sheath (enclosing the common carotid artery, ligamentum nuchae and spinous processes posteriorly, and
internal jugular vein, and vagus nerve) (Fig. 39). they blend with the interspinous ligaments anterior to
Carefully palpate the carotid sheath retracted laterally them.
with the sternocleidomastoid. The course of the vertebral artery (Fig. 312) along the
The sternohyoid and sternothyroid strap muscles (with posterior superior arch of C1 makes it prone to injury if
the trachea and esophagus) are retracted medially,
allowing blunt dissection through the pretracheal
fascia.
The prevertebral fascia and longus colli muscles are
exposed (Box 35).
The prevertebral fascia is divided longitudinally to expose
the disk and vertebral body (Fig. 310).
Posterior Cervical Approach
The posterior cervical approach is commonly used to
perform a laminectomy, foraminotomy, or laminaplasty
with or without a fusion (Box 36).

Indications for the Smith-Robinson


Box 34: Approach to the Subaxial Cervical
Spine
Figure 38: An oblique incision is made through the skin,
Anterior cervical discectomy and fusion followed by a horizontal incision through the underlying
Anterior cervical corpectomy and fusion platysma.
CHAPTER 3 Surgical Approaches to the Spine 37

Indications for the Posterior Cervical


Box 36:
Approach
Decompress spinal cord or nerve root
Excision of herniated disks
Fusion of cervical vertebrae

dissection in the adult is performed more than 1.5 cm


from the midline of the C1 posterior tubercle. (The
distance is only 1 cm in the child).
The artery enters the operative field when it passes
from the transverse foramen of the atlas, immediately
behind the atlanto-occipital joint, and pierces the lateral
angle of the posterior atlanto-occipital membrane. It is
vulnerable in this region during surgical exposures
(Fig. 313).
The C1 nerve is also referred to as the suboccipital
Figure 39: Blunt finger dissection is used to divide the nerve, and the C2 nerve is referred to as the greater
pretracheal fascia while palpating and retracting the carotid occipital nerve.
sheath laterally. The posterior cervical musculature is elevated in a
subperiosteal manner with care taken not to disturb the
surrounding facet capsules.

Box 35: Smith-Robinson Approach


Anterior Exposures of the
The superior thyroid artery is encountered above C4 and the infe-
rior thyroid artery is encountered below C6. These vessels should Cervicothoracic Junction
be identified and ligated as necessary. Anterior exposure of the cervicothoracic junction
The thoracic duct may be exposed in surgical approaches below
(C7-T2) is a challenging surgical exercise because of the
the C7 level during a left-sided approach.
overlying clavicle and sternum and the proximity of the
great vessels.
Three methods with various modifications of anterior
approaches to the cervicothoracic junction have been
described:
1. High transthoracic
2. Manubrium or sternal splitting partial resection
3. Low cervical and high transthoracic

High Transthoracic
A periscapular J-shaped incision is made approximately
2.5 cm medial to the superior angle of the scapula
and continued down around its inferior angle
(Fig. 314).
Dissection continues in the line of the incision through
the subcutaneous fat to the level of the superficial
muscles of the back.
The trapezius is divided close to the spinous processes
and parallel to the direction of the skin incision to avoid
injuring the spinal accessory nerve (CN XI).
The latissimus dorsi is divided as medially as possible to
allow adequate retraction of the scapula and to avoid
injuring the thoracodorsal nerve.
Figure 310: The longus colli muscles are mobilized laterally The rhomboid major muscle is divided near its insertion
with the aid of a curette. onto the scapula.
38 Spine Core Knowledge in Orthopaedics

Figure 311: The posterior aspect of the


Greater cervical spine. Depicted are the superficial
Occipital nerve nerves and musculature.
Lesser
Occipital nerve

Occipital artery
Semispinalis
capitis muscle Sternocleidomastoid
Third muscle
occipital nerve
Medial branch of Greater auricular nerve
posterior primary
ramus of C5 External jugular vein
Splenius
capitis muscle
Splenius Levator scapulae muscle
cervicis muscle

Lying inferiorly and laterally, the serratus anterior muscle


Sternal Splitting Approach to the
is divided as caudally as possible to avoid injuring its
nerve supply, the long thoracic nerve (Fig. 315). Cervicothoracic Junction
The scapula can be retracted superolaterally after An oblique incision is made along the anterior border of
protecting its medial surface with a saline-soaked the sternocleidomastoid muscle and courses inferiorly
sponge. over the midline of the manubrium and sternum
The periosteum of the third rib is incised along its (Fig. 318).
longitudinal axis and sharply dissected with the use of an Dissection continues through the subcutaneous tissue and
elevator. platysma in line with the skin incision.
The rib can be divided posteriorly 1-2 cm from its The deep cervical fascia (which invests the anterior
attachment to the transverse process and anteriorly at its border of the sternocleidomastoid) is divided sharply,
junction with the costal cartilage (Fig. 316). allowing the sternocleidomastoid muscle to be retracted
Exposure through the pleural cavity involves making an laterally.
incision through the parietal pleura and retracting the While protecting the carotid sheath laterally, the
dome of the lung inferiorly to expose the anterior pretracheal fascia is divided sharply by spreading it with
surface of the spine. the blunt tips of a forceps, allowing the carotid sheath to
The parietal pleura overlying the upper thoracic be taken laterally and the strap muscles of the neck and
vertebrae are carefully incised to avoid injuring the the underlying trachea or esophagus to be retracted
superior intercostal vein, artery, and the sympathetic medially.
trunk and ganglion (Fig. 317). This allows exposure of the prevertebral fascia, which
invests the longus colli muscles on both sides of the
cervical spine.
The soft tissue aponeurosis investing the superior border
of the sternal notch is released, and blunt finger
Box 37: Posterior Paracervical Muscular Layers dissection is used to clear the underlying retrosternal
adipose tissue from the undersurface of the manubrium.
Superficial layerTrapezius The muscular aponeurotic soft tissue attachments to the
Intermediate layerSplenius capitis inferior xiphoid process are released sharply and the
Deep layerSemispinalis capitis (superficial), semispinalis cervicis retrosternal fatty tissue is separated from its undersurface.
(intermediate), and multifidus (deep) A sternotomy is performed (Fig. 319).
CHAPTER 3 Surgical Approaches to the Spine 39

Figure 312: The coursing of the


vertebral artery and greater occipital Posterior midline
nerve in relation to the posterior midline. Rectus capitis
posterior minor

Obliquus capitis
superior
Rectus capitis
posterior major

Vertebral artery Greater occipital nerve

Obliquus capitis
inferior

Figure 313: The various muscular layers of the


posterior cervical spine.
Semispinalis
capitis muscle

Splenius
capitis muscle

Longissimus
capitis muscle
40 Spine Core Knowledge in Orthopaedics

Figure 314: The incision for the transthoracic approach to the upper
thoracic spine. The trapezius muscle is divided close to the spinous
processes and parallel to the skin.

Figure 315: The rhomboid major is divided near its


insertion and the serratus anterior muscle is divided as
caudally as possible.

Teres major
muscle
Infraspinatus
muscle

Rhomboideus
major muscle

Figure 316: The scapula can then be retracted superolaterally,


and the periosteum can be incised.

Third rib
CHAPTER 3 Surgical Approaches to the Spine 41

Figure 317: Retractors are


positioned and the upper thoracic
spine is exposed.

Figure 318: The incision for the sternal splitting approach. Figure 319: The omohyoid is divided along with the
traversing inferior thyroid artery. The sternotomy is performed
exposing the cervical spine.

Dissection is continued from the exposed subaxial Variations of this approach are now more popular in
cervical spine in a caudal direction through the which only the manubrium or the proximal portion of
pretracheal fascia exposing the left innominate or the sternum is divided and separated.
brachiocephalic vein. In these modified approaches, a T-shaped incision may be
The vein can be ligated with the inferior thyroid artery made with the vertical limb overlying the manubrium
if necessary. and upper portion of the sternum and the horizontal
To complete exposure of the prevertebral fascia, the limb of the incision overlying the base of the neck
esophagus, the trachea, and the brachiocephalic truck are approximately 1 cm above the clavicle.
retracted gently to the right using flexible spatulas; the The medial third of the clavicle may be resected and later
thoracic duct, the cupola of the pleura, and the left replaced for further exposure.
common carotid artery are retracted to the left. The sternal and clavicular heads of the
The prevertebral fascia is then divided in the midline to sternocleidomastoid muscle on the side of the approach
allow sub-periosteal dissection of the vertebral body are detached at the level of the manubrium, and the
(Fig. 320). clavicle is retracted.
42 Spine Core Knowledge in Orthopaedics

The strap muscles on the ipsilateral side of the approach


are detached from the clavicle and retracted medially.
The sternal origin of the pectoralis major is stripped
laterally off the clavicle (Fig. 321).
The medial half of the clavicle is stripped subperiosteally
and its medial third is removed with a Gigli saw.
The sternoclavicular joint is disarticulated sharply and
curetted.
A rectangular piece of manubrium with its posterior
periosteum may be removed using power drill holes and
heavy scissors.
The remainder of the approach is similar to the sternal
splitting approach.

Combined Cervical and Thoracic


Approach
Figure 320: To complete the exposure, the esophagus, An oblique cervical incision is made parallel to the
trachea, and brachiocephalic trunk are gently retracted to the
clavicle with division of the platysma in line with the
right; the thoracic duct is retracted to the left.
incision, and a high thoracic incision is made around the
inferior and medial border of the scapula (Fig. 322).
For the cervical incision, the deep cervical fascia along
the anterior medial border of the sternocleidomastoid
muscle is incised, allowing rotation and retraction of this
muscle laterally to expose its deep surface.

Strap muscle

Sternocleidomastoid
muscle

Figure 321: The sternal and clavicular heads of the sternocleidomastoid are detached at the level of the
manubrium.
CHAPTER 3 Surgical Approaches to the Spine 43

Trapezius
muscle

Latissimus
dorsi muscle

Rib to be
resected Scapula
Figure 323: Following the skin incision, the trapezius is
divided.

Figure 322: The combined cervical and thoracic approach to The trapezius is cut parallel with its fibers close to the
the cervicothoracic junction. transverse processes. Deep to it are the paraspinal muscles.
All muscle attachments are separated from the rib of
The carotid sheath is retracted anteriorly following gentle interest in a subperiosteal manner.
blunt exposure of its posterior border. Dissection is performed laterally along the superior
The inferior thyroid artery is ligated when it courses border of the rib and medially along the inferior border.
posterior to the carotid sheath to obtain better exposure. The rib is cut 6-8 cm from the midline (Fig. 324).
The cervical vertebrae covered by the longus colli The retropleural space is carefully entered with digital
muscles can be palpated. palpation and dissection removing the parietal pleura
The cervical wound is packed, and the transthoracic from the vertebral body.
approach is continued as described previously. Blunt dissection is used to avoid entering the pleural
cavity while exposing the vertebral body and disk space.

Posterolateral Anterior (Transthoracic) Approach to


(Costotransversectomy) the Thoracic Spine (Box 39)
Approach to the Thoracic Spine The patient is placed in the lateral decubitus position and
stabilized with a kidney rest or sandbags.
The classic posterolateral approach to the thoracic spine Although the thoracic vertebrae can be approached from
was developed for drainage of tuberculous abscesses. either side, approaching it from the right side is easier
The major advantage of the posterolateral approach is that because the aortic arch and heart can be avoided.
it does not involve entering the thoracic cavity (Box 38).
The patient is placed prone on an operating table.
A linear incision is made over the midline or curvilinear
incision about 8 cm lateral to the desired spinous process;
the linear incision is 10-13 cm (Fig. 323).
There is no true internervous plane in this approach.
The approach involves splitting the trapezius muscle and
dividing the paraspinal muscles.

Indications for the Posterolateral


Box 38:
Approach to the Thoracic Spine
Abscess drainage
Vertebral body biopsy
Partial vertebral body resection
Thoracic disk excision Figure 324: The periosteum is incised and elevated off the
Anterolateral decompression of the spinal cord rib using a periosteal elevator.
44 Spine Core Knowledge in Orthopaedics

Indications for the Transthoracic


Box 39:
Approach
Debridement or decompression of the anterior vertebral body and
or disk space
Correction of scoliosis
Correction of kyphosis
Osteotomy of the spine
Biopsy of the spine

The incision is often started two rib spaces above the


vertebral body of interest and curved forward toward the Figure 326: The anterior aspect of the latissimus is divided,
inframammary crease (Fig. 325). exposing the underlying rib. The underlying rib is dissected
The latissimus dorsi muscle is divided posteriorly in line free of the periosteum.
with the skin incision.
The serratus anterior muscle is divided in line with the
skin incision down to the level of the ribs. Anterior (Transperitoneal)
The thoracic cavity can be entered either through an
intercostal space or by resection of one or more ribs Approach to the Lumbar Spine
(Fig. 326). The anterior transperitoneal approach to the lumbar
Rib resection creates better exposure, and the cut ribs spine is primarily used for accessing the L5-S1 junction.
can be used for bone grafting (Fig. 327). The umbilicus typically lies opposite the L3-L4 disk space,
but it may vary depending on the patients body habitus.
A longitudinal midline incision is made from just above
the umbilicus (2-3 cm), curving gently to the left of the
umbilicus and continuing to just above the pubic
symphysis (Fig. 328).
Dissection is continued down to the level of the fibrous
rectus sheath.
The rectus sheath is incised longitudinally, beginning in
the lower half of the incision, to reveal the two rectus
abdominis muscles.
The muscles are bluntly separated with the surgeons
Figure 325: The incision used for the transthoracic approach fingers to expose the underlying peritoneum
to the spine. (Fig. 329).
The peritoneum is carefully incised after making sure no
viscera lie beneath it.

Figure 327: The overlying rib is resected near


its articulation with the costovertebral junction.
The parietal pleura are incised and the
overlying prevertebral fascia is identified. Shown
are the ligated segmental vessels overlying the
thoracic vertebrae.
CHAPTER 3 Surgical Approaches to the Spine 45

Figure 328: The transperitoneal approach incision to the


lumbar spine.

Using a self-retaining Balfour retractor, the rectus


abdominis muscles are retracted laterally and the bladder
is retracted distally.
Figure 330: The sacral artery is ligated, allowing greater
The tissue over the anterior surface of the sacral
mobilization of the great vessels.
promontory is often infiltrated with a few milliliters of
saline solution to make dissection easier and to allow
identification of the presacral parasympathetic nerves.
The L5-S1 disk space lies below the bifurcation of the It provides access to all the vertebrae from L1 to the
aorta; it should be possible to expose it fully without sacrum and minimizes the potential for a postoperative
mobilizing any of the great vessels (Fig. 330). ileus (Box 310).
Because of the nature of the vascular anatomy of the
retroperitoneal space, it is slightly more difficult to reach
Anterolateral (Retroperitoneal) the L5-S1 space using this approach.
The patient is placed in a semilateral decubitus position.
Approach to the Lumbar Spine An oblique flank incision is made, extending toward the
The retroperitoneal approach has several advantages over rectus abdominis muscle and stopping at its lateral border
the transperitoneal approach. about midway between the umbilicus and the pubic
symphysis (Fig. 331).
The three muscles of the abdominal wall (external
oblique, internal oblique, transverses abdominis) are
divided in line with the skin incision (Fig. 332).
With blunt finger dissection, a plane is developed
between the retroperitoneal fat and the fascia that
overlies the psoas muscle.
The peritoneal cavity is gently mobilized and its contents
are retracted medially.
The psoas fascia can now be identified.
The medial surface of the psoas is followed to the reach the
anterior lateral surface of the vertebral bodies (Fig. 333).

Indications for the Retroperitoneal


Box 310:
Approach to the Lumbar Spine
Figure 329: The overlying peritoneum is incised with care
being taken to avoid damaging the underlying peritoneum.
Debridement or decompression and fusion of the anterior verte-
The abdominal viscera are retracted and the underlying bral body and or disk space
vertebral bodies are exposed.
Biopsy of the anterior vertebral body and disk space
46 Spine Core Knowledge in Orthopaedics

The aorta and vena cava are bound to the anterior


surfaces of the vertebral bodies by the lumbar arteries
and veins.
Segmental vessels may be identified and ligated as
necessary so that the aorta and vena cava can be
mobilized and the anterior surface of the vertebral bodies
can be exposed.

Posterior Approach to the


Figure 331: Various incisions for the retroperitoneal approach Thoracic and Lumbar Spine
to the lumbar spine. The patient is placed in a prone position with the
abdomen free of pressure.
The spinous processes are easily palpable in the midline.
The iliac crest is approximately at the level of the L4-L5
interspace.
A midline longitudinal incision is made over the spinous
External oblique muscle processes.
The internervous plane lies between the two paraspinal
Internal oblique muscle
muscles (erector spinae), each of which receives a
Transverse abdominus segmental nerve supply from the posterior primary rami
muscle of the lumbar nerves.
The paraspinal muscles are elevated in a subperiosteal
manner to expose the bony elements.
Close to the facet joints, in the area between the
transverse processes, are the vessels supplying the
paraspinal muscles on a segmental basis.These branches
of the lumbar vessels often bleed when the dissection is
carried out laterally (Fig. 334).
Figure 332: The external oblique, the internal oblique, and
the transverse abdominus are incised in line with skin.

Figure 334: A transverse diagram depicting the path of the


Figure 333: Malleable retractors are passed around the dissection during a posterior lumbar or thoracic approach to
vertebral body, exposing the prevertebral fascia. the spine.
CHAPTER 3 Surgical Approaches to the Spine 47

dures.The textbook covers a broad spectrum of topics including


References the indications for operation, the potential complications, and
An HS. (1998) Approaches to the cervical spine. In: An Atlas of the various instrumentation systems employed in the cervical
Surgery of the Spine (An HS et al., eds.). London: Martin-Dunitz. spine.
An illustrative atlas detailing a step-by-step approach to surgical
Hoppenfeld S, DeBoer P. (1994) Surgical Exposures in
dissection of the human spine with full color photos and cross-
Orthopaedics:The Anatomic Approach, 2nd edition. Philadelphia:
sectional illustrations.
Lippincott Williams & Wilkins.
An HS. (1999) Surgical exposure and fusion techniques of the The most commonly referenced anatomic textbook to orthopedic
spine. In: Spinal Instrumentation (HS An et al., eds.), 2nd edition. surgical procedures.The book highlights the various approaches to
Baltimore:Williams and Wilkins. the cervical spine.
A thorough description of various exposure and instrumenta-
Robinson RA, Southwick WO. (1960) Surgical approaches of the
tion techniques commonly employed in the cervical spine with
cervical spine. In:The American Academy of Orthopaedic
detailed explanations regarding commonly made errors and
Surgeons, Instructional Course Lectures,Vol. XVII. New York:
technical pearls.
Mosby.
An HS. (1998) Surgical exposures and fusion techniques of the The authors original description of the anterior approach to
spine. In: Principles and Techniques of Spine Surgery (An HS, ed.). the cervical spine with a detailed account of the anatomic dis-
Philadelphia:Williams & Wilkins, pp. 31-62. section and potential complications associated with the
A comprehensive textbook devoted to various instrumentation approach.
systems used in the spine. Also a detailed overview of com-
Verbiest H. (1969) Anterolateral operations for fractures and
monly used surgical approaches in the cervical spine.
dislocations in the middle and lower parts of the cervical spine.
An HS, Simpson JM. (1994) Surgery of the Cervical Spine. JBJS 51A: 1489-1530.
Philadelphia: Martin Dunitz and Williams and Wilkins. An account of the anterolateral approach to the lower cervical
A detailed description of the surgical approach, the operative spine in the setting of acute cervical trauma.
management, and the indications for various cervical proce-
4

CHAPTER
Lumbar Degenerative Disk
Disease
Understanding the Pain Generator

Eugene J. Carragee

M.D., Director, Orthopaedic Spine Center, Professor, Department of Orthopaedic Surgery,


Stanford University School of Medicine, Stanford, CA

degenerative or age-related changes found in the


Introduction spine.
Specific definitive anatomic diagnoses for low back pain
(LBP) are the exception more than the rule in LBP Definition of a Pain Generator
syndromes. For a definitive diagnosis to be clinically relevant, the
Symptoms resolve in most patients within one week identified pain generator not only must be capable of
and few have serious persistent symptoms after 6-8 causing some discomfort but also should be reasonably
weeks. Because the natural history of nonspecific LBP felt to be the primary cause of the patients apparent
in most patients is spontaneous resolution, most do not severe illness.
require a formal anatomic diagnosis. The practical clinic issue is not whether pain may at

In a few patients, certain so-called red flag clinical some time originate from a certain disk or other
features may suggest serious underlying conditions such structure but whether the pathology of that structure
as tumors, infections, or fractures. In those patients, an can adequately explain the clinical symptoms that
early and aggressive evaluation to rule out serious caused the patient to seek medical attention.
underlying pathology should be performed.
However, even in patients with such red-flag clinical
Two Schools of Thought
variables, serious underlying disease is still uncommon. It is not clear that this taskfinding the discrete local
A thorough diagnostic evaluation is usually pain generator that may cause the serious LBP illness in
recommended when a patient with nonspecific LBP is even a minority of patientscan be accomplished.
unimproved after 6-8 weeks.This evaluation may find
either of the following: Multifactorial School
If clear pathology accounts for symptoms (e.g., tumor, LBP illness is often multifactorialincluding mechanical,
infection, or fracture), proceed to treatment. psychological, and neurophysiological contributors. It is
If a thorough investigation does not disclose such clear therefore unreasonable to expect a specific anatomic
pathologic diagnoses (and it usually will not), some study to confirm a diagnosis for every patients LBP
clinicians may try to identify what is commonly called illness. Even if a pain generator is suspected, it is not clear
the pain generator among the otherwise common how can this be reliably confirmed to be the cause of the

48
CHAPTER 4 Lumbar Degenerative Disk Disease 49

patients perceived pain, impairment, and disability in the back discomfort but would not normally be considered
face of complex social, emotional, and neurophysiological the pain generator causing this patients serious illness.
confounders (Allan et al. 1989, Nachemson 1989, Burton Similarly, the same mild facet arthrosis in a patient
et al. 1995). gravely disabled by the psychiatric illness of a
somatization disorder, with a long history of severe
Single Disabling Pathology School diffuse pain attributed to minimal or no local pathology,
The precise identification of the pain generator is would not have the facet arthrosis diagnosed as the
central to the spinal evaluation. It is a reasonable primary cause of this patients severe illness.
expectation of patients, and it determines the choice of
Pain Generator Theory and
treatments aimed at the suspected disk or facet. In this
model, the social issues of disability or litigation, Associations with Comorbidities
psychological distress, and apparent pain intolerance are Chronic LBP illness associated with only degenerative
secondary to the crippling effect of a painful but changes is rarely one dimensional. It is distinctly unusual
unrecognized spinal structure.These clinicians believe for a patient to have one site of severe degenerative
the pain generator in spinal disorders will usually need disease and no changes at other segments or psychosocial
to be determined by specialized testing such as comorbidities.
provocative discography or differential anesthetic 1. Psychological and social comorbidities are more com-
blockage (Aprill et al. 1992; Schwarzer, Aprill et al. mon in subjects with chronic LBP illness based on
1995; Schwarzer, Bogduk 1996). degenerative changes than in patients with chronic
LBP from other causes.
Scientific Basis Work on zygapophyseal pain, sacroiliac pain, and
It is self-evident that an agreed-upon scientific basis for a discogenic pain syndromes shows that 70%-80% of
pain generator that can explain the morbidity of chronic patients coming to evaluation have personal injury or
LBP illness is elusive. litigation claims (Schwarzer, Aprill et al. 1995;
Carragee 2001).
2. Furthermore, the pain signals from various structures
Pain Generator are not simple direct circuits from the injured part to
General Usage the patients perception.There are common sites associ-
ated with back and buttock pain and a neuraxis capable
This term describes the pathoanatomic site from which
of modulating pain transmission and perception.
the primary cause of a patients LBP is thought to
originate and implies certain premises that make the Modulation of Pain Perception in LBP
term clinically meaningful. Many common factors are known to have potential
Pathologic Structure dampening or amplifying effects on the perception of
LBP from any specific site.These factors are important in
A supposed pain generator is usually considered a determining the clinical expression of LBP syndromes
pathologic structure and not a physiologic or as well as in interpreting common diagnostic tests such as
psychological response. provocative discography, diagnostic facet, or sacroiliac
Example joint anesthetic blockade.
The muscle pain from momentarily holding an awkward Adjacent Tissue Injury
posture (transient ischemia) is not commonly considered Significant injury to nearby structures may increase the
a pain generator, nor is primary psychogenic pain perception of pain through a local hyperalgesic effect.
without anatomic cause. This is a well-known phenomenon, occurring with any
tissue damage. Pain perception is amplified by increasing
Primary Cause of LBP Illness
local inflammatory processes or neurologic sensitization
A supposed pain generator is usually considered the in areas not directly injured, such as the area surrounding
primary or sole cause of a patients illness. a burn or a fracture that is sensitive although without any
thermal or mechanical injury (Birrell et al. 1991, Siddall
Examples et al. 1997).
When an evaluation turns up a discitis or myeloma, the
clinician is reasonably certain that the pain generator Local Anesthetic
causing the severe disabling LBP illness has been Local anesthetic injections, the application of cold packs,
identified definitively.The presence of mild arthritic and so on, may decrease the perception of pain at local
changes at an adjacent segment may also cause some low sites and sometimes at distal or proximal sites through
50 Spine Core Knowledge in Orthopaedics

uncertain mechanisms (Kibler et al. 1960, North et al. likely caused by both central neurochemical changes and
1996, Siddall et al. 1997). systemic effects (Burton 1997, Pincus et al. 2002).
Tissue Injury in Adjacent or Same Social Imperatives
Sclerotome Overriding social imperatives may decrease pain
Tissue injury with the same or adjacent sclerotomal perception or disassociate pain perception and functional
afferents as those of the lower spinal elements may loss. A decreased pain perception or even an absence of
increase LBP sensitivity at a site.This effect is thought to pain perception despite injury can be seen during some
be caused by physiologic and anatomic changes at the short-term stressful events such a motor vehicle accident,
level of the dorsal root ganglion or spinal cord ascending combat, or certain training environments (Allan et al.
tracts. In animal models, single afferent neurons from a 1989, Burton et al. 1995, Burton 1997, Carragee 2001,
diagnosis-related group may innervate three adjacent Pincus et al. 2002).
disks.This effect is important in considering the
specificity of discography at sites adjacent to a known Social Disincentive
pathologic structure (e.g., nonunion, spondylolisthesis, or Secondary gain issues may exaggerate pain responses of
painful iliac crest bone graft site) (Kawakami et al. 1997, all types.When the intensity of pain behavior and report
Carragee et al. 1999). is correlated with a real or perceived social benefit or
monetary compensation, the measurable pain perception
Chronic Pain Syndrome
may be increased (Allan et al. 1989, Burton et al. 1995,
Chronic pain syndromes may complicate the evaluation Burton 1997, Carragee 2001, Pincus et al. 2002).
of LBP syndromes. Chronic pain from regional sites near When considering the certainty of diagnosis of a possible
the LBP (chronic pelvic pain, irritable bowel syndrome, pain generator implicated in chronic LBP illness, it is
or failed hip arthroplasty) or far from the LBP (chronic necessary to view the preceding confounding factors for
neck pain, chronic headache, or temporalmandibular contribution to the illness observed.
joint syndrome) may increase pain sensitivity at lower
spinal elements.This effect may be regional or global and Examples
may be related to neurophysiological changes at multiple Major acute upper extremity trauma, narcotic
levels along the neuraxis. Preexisting chronic pain administration, and social imperatives at the site of an
syndromes are also associated with depression, narcotic accident may mask the perception of a significant LBP
use, and habituation, which have independent pain injury that, absent of these confounders, may manifest as
perception effects (Burton et al. 1995; Carragee et al. clearly symptomatic and disabling.
1999; Carragee, Chen et al. 2000; Carragee, Paragioudakis Minor nociceptive input from a disk can be amplified in
et al. 2000; Carragee et al. 2002). a patient with multiple chronic pain syndromes, narcotic
Narcotic Analgesia habituation, depression, and compensation issues (social
disincentives). In this case, a common, mild backache pain
Narcotic medications act at multiple levels to decrease generator becomes a catastrophic illness by amplification
pain thresholds, intensity, and affective response (Gracely at multiple levels.
et al. 1979).
Narcotic Habituation
Pain Generator and Diagnostic
Chronic narcotic habituation may decrease pain
tolerances in the absence of increased narcotic intake. Anaesthetic Injections
This effect will decrease endogenous abilities to modulate Diagnostic anesthetic blockade of a suspected pain
peripheral nociceptive input.This effect is multifactorial. generator site is a frequently used method recommended
Chronic narcotic habituation is also associated with for establishing a diagnosis in persistent LBP syndromes.
depression and sleep disturbances (Gracely et al. 1979). A critical evaluation of the scientific basis of this
diagnostic method points out the inherent difficulty in
Depression, Anxiety, and Somatic
evaluating the pain generator in degenerative spinal
Distress conditions.
Clinical depression and anxiety disorders may be seen as CriteriaThis method is used primarily for suspected

predisposing factors to chronic LBP syndromes, as facet joint, spondylolysis, and sacroiliac joint pain.The
reactions to the pain and disability of chronic LBP illness, blocked structure is assumed to be the primary pain
or both. In these situations, emotional distress will usually generator if the anesthetic blockage of a structure
decrease the pain threshold and increase the perceived results in some arbitrary degree of pain relief: 50%,
pain intensity and affective response.Theses effects are 75%, 100%, etc. (Saal 2002).
CHAPTER 4 Lumbar Degenerative Disk Disease 51

IncidenceThe incidence of facet joint pain as a block demonstrates the problem of having no gold
cause of serious LBP when derived from these standard in these studies to confirm the diagnostic test.
diagnostic blocks is between 15% and 40% in select These results may indicate that the painful lesion being
groups (Schwarzer et al. 1994; Schwarzer,Wang et al. locally anaesthetized is simply not detectable by imaging
1995; Saal 2002). However, these estimates are studies and is protean in symptom manifestation.
conjectural because none of these studies used a gold On the other hand, it may indicate that the test does
standard test to establish the validity of these injection not identify a true clinical entity.The response in many
blocks in making a diagnosis. One problem is the patients may instead be related to the anesthetic effects
placebo effect seen with pain interventions. on collateral or central pain pathways or perception.
Neurophysiological basisHowever,
neurophysiological studies also indicate that anesthetic Methods to Limit False-Positive
blockade at one site may affect distal or proximal pain Injections
sites and pain perception from distant or regional To address the possibility of placebo or collateral effects
pathology not in the infiltration site.That is even and thereby perhaps increase the reliability of results,
without a placebo effect.The injection does not have some authors have advocated additional controls on these
to block the painful site itself to result in bona fide blocks (Saal 2002).
subjective relief. Placebo injectionsThe use of sham injections
limits the placebo response.
Facet Joint Pain Differential blockThe use of short-acting versus
Facet Joint Stimulation long-acting anesthetic agents differentiates true
or Experimental Pain responders from false-positive results.
Small injection quantityThe careful placement of
The facet joint, capsule, and surrounding structures can be tiny anesthetic doses on the posterior primary ramus
painful. Stimulation by injection of the facet joint with (median branch) innervating the facet joint may
synovial and capsular distension results in LBP discomfort decrease the diffusion effects of larger volumes.
in asymptomatic volunteers and in patients undergoing Gold standardStill, without a gold standard to
diagnostic injections (McCall et al. 1979).There is modest validate the method, the isolation of a clinically
predictability in the location and character of referred significant pain generator by neuroblock remains
pain with saline injections into the facet joints in controversial.
asymptomatic volunteers but no predictable pattern of
referral in LBP patients (Marks et al. 1992, Fukui et al. Therapeutic Trial as a Confirmation of
1997). Pain wiring and perception is altered in the Test Result
symptomatic people in ways poorly understood but likely
related to local and central modulation.
It may be possible to indirectly support a diagnostic
method such as anesthetic facet injections if a certain
Anesthetic Blockade of Experimental treatment method was reliably effective.
Pain There have been numerous trials using steroid
injections and a smaller series of local nerve ablations
The experimental pain associated with facet capsule in subjects diagnosed by these injection techniques.
distension appears usually to be blocked by local Most of these trials have had equivocal results at best.
anesthetic at the medial branches of the primary dorsal The best evidence supporting the differential block
rami above and below a facet (Kaplan et al. 1998). But it technique was reported by Dreyfuss et al. (2000).This
is unclear whether this applies in the clinical situation. trial of median branch ablation made the diagnosis of
When the clinical features of patients responding to chronic zygapophyseal joint pain by differential
facet blocks were examined, there did not appear to be blocks of short- and long-acting anesthetics. In this
a clear clinical presentation that correlated with pain study, more than 80% pain relief for more than one
relief (Schwarzer,Wang et al. 1995). hour after a lidocaine injection and more than two
In addition, a positive response of pain relief to hours after bupivacaine injection was used to
anesthetic facet injections does not appear to correlate determine a positive response to median branch block.
with radiographic evidence of facet arthrosis (Revel For patients meeting these criteria, the results were
et al. 1998). reported as highly successful in pain relief and
improved function.
Mechanism of Pain Relief in Clinical The Dreyfuss et al. study still raised serious questions
Pain regarding the mechanism of action and the logic of
The failure to identify any reliable clinical pattern or differential blocks of the facet joint as a diagnostic tool
radiological finding associated with pain relief by facet to identify the pain generator. For instance, contrary to
52 Spine Core Knowledge in Orthopaedics

pharmacologic expectations and the premise of disease being tested for. In the case of provocative
differential short-acting versus long-acting anesthetics, discography, this would be the likelihood that a patient
both lidocaine (short-acting) and bupivacaine (long- with chronic LBP illness who has a concordant and
acting) anesthetic injections produced the same painful response to an injection is suffering from a pain
duration of relief (4-5 hours). syndrome because of the disk itself.
Apparent false-positive tests have appeared in clinical
Conclusion practice. Block et al. (1996) and Ohnmeiss et al. (1995)
Although increasingly elaborate methods are being independently reported that psychological comorbidities
developed to accurately identify the pain generator, no appeared to correlate with the report of severe pain after
method exists to confirm that this diagnosis is truly the the injection of morphologically normal disks. Carragee
primary source of a patients illness rather than other et al. (1997) reported apparent false-positive injections in
spinal processes or the central effects of LBP patients ultimately found to have nondiscogenic
neurophysiological or psychosocial factors. causes of LBP, including sacroiliac joint pathology and
spinal tumor.

Pain Generator and Provocative Best Case Scenario


Discography Walsh et al. in 1990 found the rate of painful injections
in healthy young men, paid as asymptomatic volunteers,
The lumbar disk may be the structure most commonly was very low. Only 1 in 10 described the pain with
implicated as the primary cause of disabling chronic LBP injection as bad, or 3 of 5 on a 5-point scale.This
illness.This diagnosis is purported to be confirmed by clearly is the best case scenario.These subjects had little
provocative discography alone. or no degenerative changes in their disks.They also had
Clinical history and physical signs do not correlate no known risk factors as described in the preceding
with the positive concordant response to disk injection sections for pain amplification: adjacent tissue injury,
(Schwarzer, Aprill et al. 1995). regional or generalized pain syndrome, narcotic
No finding (e.g., high-intensity zone, or HIZ, lesion; habituation, depression, anxiety disorder, or social
disk desiccation; or Modic changes) or set of findings disincentives to health pain modulation (e.g., litigation,
on magnetic resonance imaging (MRI) are found only sick role support, or financial counterincentives). Despite
in the injection-positive disk (Boden et al. 1990, Jensen these study limitations, these data have been cited as
et al. 1994, Carragee, Paragioudakis et al. 2000). having proven a zero or negligible false-positive rate for
Technique provocative discography.
The technique of provocative discography points out the
need for a careful understanding of the pain generator False-Positive Discography in
concept in the evaluation of chronic LBP illness. Subgroups at Risk
Discography uses the percutaneous pressurization of a disk Because it is unusual for chronic LBP illness patients to
with a contract dye to determine whether this disk is the have no or few comorbidities, as was the case with the
source of pain in an individual with chronic LBP illness. healthy volunteers in the Walsh et al. (1990) study, it is
The examiner relies on the patient to report the difficult to estimate the risk of a false-positive disk
intensity of pain and the similarity of the pain to their injection. A follow-up study on asymptomatic patients in
usual LBP. Both of these reports are obviously regards to LBP at the Stanford University School of
subjective. Furthermore, the stimulation of nociceptive Medicine looked at patient subgroups with different pain
fibers at the disk and the transmission of those signals modulation characteristics:
to form a perception of pain are subject to 1. Asymptomatic LBP subjects with degenerative disk
amplification and down-regulation at multiple levels changes and without chronic pain processes
between the disk and the cortical processing. 2. Asymptomatic LBP subjects with degenerative disk
changes but with a nonlumbar chronic pain process
Criticism
3. Asymptomatic LBP subjects with serious psycho-
The primary criticism of this technique is that many logical somatization issues and chronic nonlumbar
people without significant LBP troubles may report pain
painful disk injectionsrisking false-positive results. By the Walsh et al. (1990) criteria of positive
experiment injections, 10% of group 1, 40% of group
Specificity 2 (chronic pain), and 75% of group 3 (somatization
The specificity of a test refers to the likelihood that a and chronic pain) were false-positive injections
positive result will occur only in a subject with the (Carragee,Tanner et al. 2000).
CHAPTER 4 Lumbar Degenerative Disk Disease 53

Increased Risk of False-Positive and location is elicited on injection.The reliability of the


Injections test would be substantially supported only if patients
could identify the quality of pain coming from a
Psychological distress particular disk and differentially compare that sensation
Chronic pain syndrome and behavior to their usual pain.
Increased somatic awareness Data from the evaluation of other provocative tests
Anular disruption would indicate that caution should be used in
Litigation or workers compensation dispute interpreting the concordant pain response. In
Low Risk for Painful Reporting of the presence of chronic pain, there is a general,
known increased responsiveness to normally
Injections
innocuous stimuli. Furthermore, there may be
In a recent study of unblinded medical professionals hyperalgesia of uninjured tissue in the area
without LBP who underwent experimental surrounding an injury. It is also known that the
discography, few subjects reported significant pain with stimulation of structures near a lesion may mimic
injection. This data suggest that social incentive can the quality and affective component of the patients
work both ways, either to magnify or to minimize usual pain. Even primarily psychogenic pain may be
reported pain depending on circumstances. In this simulated by provocative testing at a specific
cohort, many of whom had a professional interest in anatomic stimulation.
reporting low pain intensity with injections, the pain
intensity reports were skewed below the arbitrary 6/10 Concordancy in Experimental Subjects
cutoff of a positive test result. Still, most injected Volunteer subjects were tested who had no history of
disks were painful (55%). back pain but who were scheduled to undergo posterior
iliac crest bone graft harvesting for nonspinal problems,
Discography in Subjects with
mainly fracture nonunions or bone tumors. Most
Common Backache patients experience low back and buttock pain for some
The difficulty in deciding what is a clinically significant months after a posterior iliac crest bone graft harvest.
pain generator is further demonstrated in subjects with This pain has a similar distribution to what is normally
backache perceived to be below the clinical threshold considered discogenic lumbar pain.The areas have
that usually results in functional loss or a search for similar sclerotomal origins and referred pain
medical treatment. distributions. Discography was then performed some
In volunteer subjects without clinically irrelevant months after the bone graft harvesting; the subjects were
common backache undergoing experimental asked to compare the quality and location of disk-
discography, concordant and back pain rated bad or injection pain to their usual iliac crest pain (Carragee
worse was reproduced in 9 of 25 subjects (36%). Pain et al. 1999).
intensity with injection was predicted by preexisting
Results
chronic pain conditions (nonlumbar) and
psychological distress (Carragee et al. 2002). Twenty-four disks were injected in eight volunteer
subjects. The same protocol as the Walsh et al. (1990)
Implications study was employed. Of the 14 disk injections causing
The disturbing aspect of this data lies in the potential for some pain response, 5 were felt to be different
patients with a bona fide, serious pain generator from a (nonconcordant) pains (35.7%), 7 were similar
spondylolisthesis or other pathology and a mild (50.0%), and 2 were exact pain reproductions
backache-only disk. A discographic injection of the mild (14.3%).
backache-only disk had a high risk of being positive even
Risk Factors for Reporting False-
though this is not the source of the patients pain
syndrome.That is, the discogram is identifying a clinically Positive Concordant Pain with
irrelevant pain generatorand it should not be Discography
considered a pain generator in the usual sense used and The presence of anular disruption predicted concordant
defined previously. pain reproduction (p < 0.05). Of 10 disks with anular
Concordancy and the Discographic tears, the injection of 7 elicited similar or exact pain
reproduction to the iliac crest pain at bone graft harvest
Pain Generator sites. All positive disk injections had anular fissures. Half
Provocative discography is only considered positive of the positive disk injections occurred at low pressures
when pain similar to the patients usual pain in quality (< 20 psi).
54 Spine Core Knowledge in Orthopaedics

Practical Guideline for Discography


Use References
Allan DB,Waddell G. (1989) An historical perspective on low back
Best Utility pain and disability. Acta Orthop Scand Suppl 234: 1-23.
Negative discogram useful in determining the end An excellent review of the concepts that have shaped our think-
of the fusion in deformity or other potentially long ing of LBP through history to the present.The epidemiological
fusion evidence of increasing LBP disability throughout the twentieth
Positive, single-level disk in a subject without risk century, particularly after World War II, is described, as well as
factors for false-positive injection (e.g., normal social and medical reasons that have contributed to this epi-
demic of LBP disability.
psychological profile, no chronic pain behavior or history,
and no compensation issues) Aprill C, Bogduk N. (1992) High-intensity zone: A diagnostic sign
of painful lumbar disc on magnetic resonance imaging. Br J Radiol
Unclear Utility 65(773): 361-369.
Positive two-level disks but no risk factors This report demonstrated that HIZ findings on MRI are fre-
Postoperative disk but otherwise no risk factors quently seen in subjects with LBP and that on discography
these appear to be painful.This is the original description of the
Intermediate (at-risk) psychological profile, single-
HIZ in LBP patients undergoing discography; it was done in
level disk pathology
the absence of knowledge of how frequently this finding occurs
Poor Utility in asymptomatic or minimally symptomatic people.

Spine with multilevel pathology Birrell G, McQueen D, Iggo A et al. (1991) PGI2-induced activation
Abnormal or chronic pain behavior and sensitization of articular mechanonociceptors. Neurosci Lett
124: 5-8.
Abnormal psychometric findings
Prostaglandin (PGI2) appears to induce a local pain sensitization
Disputed compensation cases
effect in a rat laboratory model.This report suggests that the effect
Discography Conclusion of PGI2 is specific for the sensory afferent nerves and appears to
lower the threshold for nociceptive responses in inflamed joints.
It is not clear what should be inferred from a report of
concordant pain on discography.Test reliability depends Block A,Vanharanta H, Olhmeiss DD et al. (1996) Discographic
pain report: Influence of psychological factors. Spine 21(3): 334-338.
on patient risk factors of false-positive testing
A strong correlation was found between abnormal MMPI
psychological factors, social factors, chronic pain
scores for hypochondriasis and hysteria scales and reports of sig-
behavior, and other modulators of pain perception that nificant pain with the injection of morphologically normal
act along the neuraxis. disks.The risk of these false-positive discographic injections in
subjects with abnormal scores ranged from 40%-60%.
Conclusion Boden S, Davis D, Dina TS et al. (1990) Abnormal magnetic
The concept of a single, stand-alone pain generator, resonance scans of the lumbar spine in asymptomatic subjects: A
prospective investigation. JBJS [Am] 72-A(3): 403-408.
existing independently of the larger clinical picture and
This report found an increasing incidence of abnormal lumbar
diagnosable by simple provocative or anesthetic
MRI scans with increasing age in asymptomatic individuals. For
maneuvers, is outdated given our current understanding asymptomatic subjects over 60, 36% had disk herniation, 21%
of chronic pain syndromes. Although some patients had spinal stenosis, and approximately 60% had an abnormal
may have such a lesion, it is an unlikely assumption. MRI finding of some type.
The pain reported clinically, as well as the pain
Burton A. (1997) Spine update: Back injury and work loss
reported with provocative testing or anesthetic block,
biomechanical and psychosocial influences. Spine 22(21): 2575-2580.
occurs within the context of the whole patient. This
This is a review article on the biomechanical and psychosocial
includes the presence of other pain processes, coping influences of back injury.The evidence to date showed that bio-
styles, emotional and psychological reserve, drug use, mechanical and ergonomic factors may be related to the occur-
dependence, abuse, and the balance of social rence of a LBP injury but that chronic disability and chronic
imperatives and disincentives to pain reporting and pain LBP illness appear to be more clearly related to psychosocial
behavior. influences.
Although the neurophysiological literature may be new
Burton AK,Tillotson KM, Main CJ et al. (1995) Psychosocial
and interesting, the basic point is quite old. Sir William predictors of outcome in acute and subchronic low back trouble.
Oslers dictum that a physician had better know the Spine 20(24): 2738-2745.
patient better than the disease has not changed.With This study found that psychosocial factors had moderately good
respect to the pain generator concept in spinal disorders, predictability of progression to longstanding back pain when
it remains imperative. patients were seen early in an LBP episode.
CHAPTER 4 Lumbar Degenerative Disk Disease 55

Carragee E. (2001) Psychological and functional profiles in select This paper showed how subjects with iliac crest pain from bone
subjects with low back pain. Spine J 1: 198-204. graft harvesting were unable to reliably distinguish between the
This study of patients with 6 to 18 months of severe back pain sensation from the bone graft site and the pain with disk injec-
found that psychological distress was much more common tion.This study calls into question the reliability of the concor-
when the ultimate diagnosis was discogenic pain than when it dancy rating made during clinical discography.
was unstable spondylolisthesis or spinal infection.This study
Dreyfuss P, Halbrook B, Pauza K et al. (2000) Efficacy and validity
further points out that most patients with severe spinal illness
of radiofrequency neurotomy for chronic lumbar zygapophyseal
reported in concrete diagnoses do not develop serious psycho-
joint pain. Spine 25: 1270-1277.
logical distress.
This paper reported that approximately 60% of patients had
Carragee E, McCormack M, Schilling P et al. (2001) Resilience in 90% pain relief 12 months after a medial branch neurotomy for
occupational low back disability: Back pain, disability, and stress in suspected facet joint pain. For diagnosis, this group used differ-
soldiers undergoing heavy physical training. Proc Int Soc Study ential blocks with long- and short-acting agents. Interestingly,
Lumbar Spine, Edinburgh, UK. the duration of pain relief with long- and short-acting agents in
This study of soldiers undergoing special operations forces the study was the same.This finding points out that the mecha-
training in the U.S. Army demonstrated that factors including nisms of pain perception emanating from the lumbar spine are
unit leadership and cohesion qualities were more important poorly understood.
than physical factors in determining soldiers ability to complete
Fukui S, Osheto K, Shiotani M et al. (1997) Distribution of
strenuous training associated with reports of significant LBP.The
referred pain from the lumbar zygapophyseal joints and dorsal rami.
most common reason to fail to complete training on a medical
Clin J Pain 13: 303-307.
basis was an LBP complaint.
This study mapped the perceived location of pain with stimula-
Carragee EJ, Alamin TF, Miller J et al. (2002) Provocative tion of the facet joints in the lumbar spine.
discography in volunteer subjects with mild persistent low back
pain (2001 Outstanding Paper Award). Spine J 2: 25-34. Gracely R, Dubner R, McGrath P et al. (1979) Narcotic analgesia:
A study of experimental discography in subjects with mild per- Fentanyl reduces the intensity but not the unpleasantness of painful
sistent LBP found that these subjects frequently reported tooth pulp stimulation. Science 203: 1261-1263.
significant pain with disk injection and that pain with disk This study demonstrated the effect of narcotics on both the pain
injection in this subgroup was associated with anular disruption intensity and the perceived unpleasantness of experimental pain
and other nonlumbar chronic pain states. stimulation.

Carragee EJ, Chen Y,Tanner CM et al. (2000) Provocative Jensen M, Brant-Zawadzki M, Obuchowski N et al. (1994)
discography in patients after limited lumbar discectomy: A Magnetic resonance imaging of the lumbar spine in people without
controlled, randomized study of pain response in symptomatic and back pain. N Engl J Med 331(2): 69-73.
asymptomatic subjects. Spine 25(23): 3065-3071. This classic study of asymptomatic subjects graded MRI findings
Of asymptomatic volunteers who had had a previous limited of the lumbar spine.The authors showed only 36% of subjects had
discectomy for herniated disk, 40% had significant pain on normal disks at all levels.Although many degenerative changes
experimental disk injection. Psychological features and pervious were commonly found (including anular defects, disk degenera-
discectomy correlated with the risk of false-positive injection. tion, and arthrosis), extruded disk herniations were rare (1%).

Carragee EJ, Paragioudakis SJ, Khurana S et al. (2000) Lumbar Kaplan M, Dreyfuss P, Halbrook B et al. (1998) The ability of
high-intensity zone and discography in subjects without low lumbar medial branch blocks to anesthetize the zygapophyseal
back problems (2000 Volvo Award winner in clinical studies). joint: A physiologic challenge. Spine 23: 1847-1852.
Spine 25(23): 2987-2992. This study demonstrated that lidocaine anesthetic applied to the
A HIZ lesion was found in approximately 25% of asymptomatic medial branch effectively eliminated experimental facet joint
subjects, closely matched by age and risk of lumbar disk degen- pain in eight of nine volunteer asymptomatic subjects.
eration to chronic LBP illness patients. Disks with HIZ lesions Kawakami M,Tamaki T, Hashizume H et al. (1997) The role of
were more likely than not painful on disk injection even in phospholipase A2 and nitric oxide in pain-related behavior
asymptomatic subjects. produced by an allograft of intervertebral disc material to the sciatic
Carragee EJ,Tanner CM, Khurana S et al. (2000) The rates of nerve of the rat. Spine 22: 1074-1079.
false-positive lumbar discography in select patients without low This study showed the possible role of chemical mediators in
back symptoms. Spine 25(11): 1373-1380; discussion 1381. the pathomechanism of radicular pain. Physical compression and
This study of experimental discography in subjects asympto- chemical irritation may both cause radicular symptoms.
matic for LBP found that psychological factors, chronic pain Whether this finding is important in LBP symptoms (as
factors, and a history of disputed compensation claims predicted opposed to radicular symptoms) was not tested.
the degree of pain reported on injection of usually asympto- Kibler R, Nathan P. (1960) Relief of pain and paraesthesiae by
matic degenerative disks. nerve block distal to a lesion. J Neurol Neurosurg Psychiatry 23:
Carragee EJ,Tanner CM,Yang B et al.(1999) False-positive findings 91-98.
on lumbar discography: Reliability of subjective concordance This classic paper from 1960 studied subjects with severe pain
assessment during provocative disc injection. Spine 24(23): from a variety of lesions.The authors found that it was possible
2542-2547. to obtain pain relief by the infiltration of anesthetic far from or
56 Spine Core Knowledge in Orthopaedics

in tissues unrelated to the lesion. Even central pain from a which patients in the study had facet joint pain and confirm
spinothalamic track lesion could be relieved with distal injec- either the clinical or the diagnostic injection diagnosis.
tions such as at the sacral roots. Furthermore, even skin or
Saal JSM. (2002) General principles of diagnostic testing as related
peripheral nerve injections in subjects with herniated disk pain
to painful lumbar spine disorders: A critical appraisal of current
appear to have their radicular pain from their central lesion
diagnostic techniques. Spine 27(22): 2538-2545.
relieved.
This paper gives a good general review of diagnostic injection
Marks R, Houston T, Thulbourne T. (1992) Facet joint injection techniques in patients with LBP.
and facet nerve block: A randomized comparison in 86 patients
Schwarzer A, Aprill C, Fortin J et al. (1994) The relative
with chronic low back pain. Pain 49: 325-328.
contribution of the zygapophyseal joint in chronic low back pain.
The facet joint and nerve injections were found to have approx-
Spine 19(7): 801-806.
imately equal diagnostic potential. However, treatment with
This study found that of eight patients with positive pain relief
therapeutic injections appeared to be unsatisfactory.
responses to facet joint blocks, three (32%) also had positive disk
McCall I, Park W, OBrien J et al. (1979) Induced pain referral from injection studies. Once again, whether these patients had disco-
posterior lumbar elements in normal subjects. Spine 4: 441-446. genic pain, facet pain, both, or some other source for their pain
The facet joint discomfort in normal subjects was tested by is unknown.
stimulating the capsule and surrounding tissue. Maps were
Schwarzer A, Aprill C, Derby R et al. (1995) The prevalence and
made, which suggest that gluteal pain is common with stimula-
clinical features of internal disc disruption in patients with chronic
tion from the L4-L5 level; however, there is wide variation
LBP. Spine 20(17): 1878-1883.
among subjects.
These authors found no correlation between the historical clin-
Nachemson A. (1989) Lumbar discography:Where are we today? ical findings in physical examination and the results of lumbar
Spine 14: 555-557. discography.This has been interpreted as demonstrating either
A theoretical critique of discography. that internal disk disruption has no clear clinical picture and can
only be diagnosed on discography or that discography may be
North R, Kidd D, Zahurak M et al. (1996) Specificity of diagnostic
positive in patients with both discogenic and nondiscogenic
nerve blocks: A prospective, randomized study of sciatica due to
causes of chronic LBP.
lumbosacral spine disease. Pain 65: 77-85.
These authors found that the radicular pain from root compres- Schwarzer A, Bogduk N. (1996) The prevalence and clinical features
sion may be relieved with medial branch blocks, distal sciatic of internal disk disruption in patients with low back pain (Letter to
nerve blocks, or a selective block at or near the lesion.These the editor). Spine 21: 776.
findings point out the low specificity of this type of anesthetic This study found that sham injections of saline relieved greater
blockade and the risk of false-positive results. than 50% of LBP in chronic LBP patients receiving placebo
facet injections.
Ohnmeiss DD,Vanharanta H, Guyer RD. (1995) The association
between pain drawings and computed tomographic/discographic Schwarzer A,Wang S, Bog duk N et al. (1995) Prevalence and
pain responses. Spine 20(6): 729-733. clinical features of lumbar zygapophyseal joint pain: A study in an
These authors found a strong correlation between subjects with Australian population with chronic low back pain. Ann Rheum Dis
abnormal pain drawings (thought to be associated with 54(2): 100-106.
increased emotional distress) and reports of pain on discography Here, 63 patients with chronic LBP illness were studied with
with anatomically normal disks. In those patients with abnormal facet joint injections of bupivacaine and paraspinal muscle
pain drawing, 50% reported false-positive pain; 12% of those injections of saline. Of all subjects 32% had more than 50% pain
with normal pain drawings had false-positive injections. relief with saline injections. Of the subjects not showing the
placebo response, 40% had relief with the anesthetic agent.
Pincus T, Burton AK,Vogel S et al. (2002) A systematic review of
psychological factors as predictors of chronicity/disability in Siddall P, Cousins M. (1997) Spinal pain mechanisms. Spine 22(1):
prospective cohorts of low back pain. Spine 27(5): E109-E120. 98-104.
This is a comprehensive and thoughtful review of the psycho- This paper describes neuromodulators of chronic pain at multi-
logical factors predicting chronicity of pain in patients with ple levels along the neuraxis.These authors make a compelling
LBP. An extensive bibliography is provided. argument to shift the conceptualization of spinal pain from a
simple hard wired system of stimulusresponse.
Revel M, Poiraudeau S, Auleley G et al. (1998) Capacity of the
clinical picture to characterize low back pain relieved by facet joint Walsh T,Weinstein J, Spratt K et al. (1990) Lumbar discography in
anesthesia: Proposed criteria to identify patients with painful facet normal subjects: A controlled prospective study. JBJS 72-A(7):
joints. Spine 23: 1972-1976. 1081-1088.
This study demonstrates the poor correlation between clinical In performing experimental discography on 10 asymptomatic
signs and symptoms of LBP and the response to anesthetic facet young men with minimal lumbar disk degeneration, these authors
joint blockade in patients suspected of having facet joint pain. found that 1 subject in 10 had pain rated as bad with disk
As in other studies, there is no gold standard to determine injection and that 2 subjects had pain they rated as moderate.
5

CHAPTER
Low Back Pain
Nonoperative Treatment Strategies

Rebecca S. Ovsiowitz*, Priya Swamy*, Mitchell K. Freedman , Guy W. Fried ,


and Alexander R.Vaccaro

* M.D.,Thomas Jefferson University, Philadelphia, PA


D.O., Director of Physical Rehabilitation and Pain Management,The Rothman Institute;
Clinical Instructor,Thomas Jefferson University Hospital, Philadelphia, PA
M.D., Medical Director of Outpatient Services, Incontinence Program, and Respiratory
Care Program, Magee Rehabilitation Hospital; Clinical Assistant Professor,Thomas Jefferson
University Hospital, Philadelphia, PA
M.D., Professor of Orthopaedic Surgery,Thomas Jefferson University and the Rothman
Institute, Philadelphia, PA

The International Association for the Study of Pain cascade and liberates arachidonic acid from cell
defines pain as follows: membranes at the site of inflammation.
Pain is an unpleasant sensory and emotional Phospholipase A2 generates membrane-destabilizing
experience associated with actual or potential tissue products (unsaturated fatty acids), causing membrane
damage and described in terms of such damage. injury and edema.
Chronic pain lasts beyond three months and is
associated with significant impairment of activities of
Bone
daily living, work, or both. Pain can result from a traumatic fracture in the setting of
normal bone.
A pathologic fracture can be caused by the following:
Low Back Pain Epidemiology Osteoporosis
Lifetime incidence: 60%-90% Multiple myeloma
Leading cause of disability in those 45 and younger Pagets disease
Third leading cause of disability in those older than 45 Primary spine tumor
Metastatic spine tumor
Osteomyeltis
Low Back Pain Generators Nerve Roots
Disk Secondary to disk compression and inflammation
The outer one third of the anulus fibrosus is innervated Lateral recess stenosis with nerve root compression
by afferent pain nerve fibers. Radiculitis
Chondrocytes within the nucleus pulposus produce Radiculitis may manifest as peripheral nerve root
phospholipase A2, which regulates the arachidonic acid motor and sensory abnormalities.

57
58 Spine Core Knowledge in Orthopaedics

A straight leg raise causes pain in a radicular pattern


the posterior aspect of the leg for lower lumbar root Spinal Ligaments
pathology. Chronic lifting may stress the spinal ligamentous complex
A reverse straight leg raise causes pain to radiate (supraspinous, interspinous, posterior longitudinal ligament,
down the front of the thigh in the setting of lumbar anterior longitudinal ligament, and ligamentum flavum).
root compression and inflammation (Fig. 51, Ligamentum flavum contains nerve endings.
Box 51). The posterior longitudinal ligament has large numbers of
free nerve endings and is innervated by the sinuvertebral
Facet Joints nerves (a branch of the somatic ventral rami and
Responsible for 15%-40% of chronic low back pain autonomic grey ramus communicans).
symptoms (i.e., facet syndrome). The anterior longitudinal ligament receives innervation
The anatomy consists of paired synovial joints lined with from the grey ramus communicantes and ventral rami.
a synovial membrane, an articular surface covered with
hyaline cartilage, a fibrous capsule, and mechanosensitive
Visceral or Nonspinal Sources of Low
nociceptive fibers.
Facet joints connect the inferior articular process of the Back Pain
vertebra above and the superior articular process of the Retroperitoneal inflammation
vertebra below. Gallbladder, pancreas, kidney, and stomach dysfunction
They contain high-threshold mechanosensitive Intrapelvic pathology
afferent nerve fibers serving as nociceptors and low-
threshold afferent fibers that modulate proprioceptive
feedback. Nonoperative Treatment
They are innervated by the medial branches of the dorsal
rami of the vertebrae above and at the same level.
Strategies for Low Back Pain
Facet joints are compressed with extension and lateral Lifestyle Changes
bending.
Pain is often provoked with extension. Tobacco Cessation
Microfractures can result in post-traumatic Smoking is a risk factor for low back pain in those with
lumbozygapophyseal pain. a 50 pack per year history, especially if younger than 45.
No unique physical exam findings were diagnostic of Chronic coughing can lead to increased intradiscal
facet joint pathology (Fig. 52). pressure.
Smoking impairs the spinal vertebral arterial supply
Spinal Muscles through functional vasoconstriction, arterial atheromatous
Pain can be induced by mechanical pressure or stretch changes, or both.
and can be relieved by rest. Cigarette smoke inhalation reduces solute exchange
Anaerobic exercise leads to the accumulation of capacity and oxygenation, leading to impaired nutrition
potentially toxic metabolites. to the disk.
Ischemia results in intermittent claudication. Smoke inhalation reduces the cellular uptake rate of
nutritional substances.
Sacroiliac Joint Smoke inhalation has been shown to reduce metabolite
The sacroiliac joint represents the cause of low back pain production within the intervertebral disk in pigs.
in 5%-10% of patients. A greater rate of disk degeneration is noted in smokers.
Pain in the sacroiliac joint can be elicited with palpation
of the posterior inferior iliac spine, buttock, thigh, or Limited Alcohol Intake
groin region. Abuse of alcohol is related to deterioration of muscle
No specific physical exam finding is considered sensitive strength and histologic injury to muscle; falls may lead to
or specific for the diagnosis of sacroiliac joint further tissue damage.
dysfunction. Patients have less ability to perceive tissue damage.
Sacroiliac joint dysfunction may result in axial and
referred lower limb pain arising from the sacroiliac joint Weight Management
(Fig. 53). Patients who are overweight place greater stress on the
Examples of sacroiliac joint pathology include musculoskeletal system and spine.
spondyloarthropathy, crystal and pyogen arthropathy, Patients with spinal injuries may gain weight because of
arthrosis secondary to sacral or pelvis fracture, and less caloric expenditure from inactivity. Medications used
diastasis secondary to pregnancy or childbirth. for spinal pain may have the side effect of weight gain.
CHAPTER 5

Figure 51: Dermatomal chart of lower extremities. Standard neurological classification of spinal cord injury. (American Spinal Injury Association 2002).
Low Back Pain
59
60 Spine Core Knowledge in Orthopaedics

Box 51: Test Key Muscles for Motor Strength Exercise


L2, L3Hip flexors Exercise is the keystone to treatment of lower back pain.
L3, L4Knee extensors Adequate flexibility is believed to prevent excessive stress
L4, L5Ankle dorsiflexors to the lower lumbar spine.
L5Great toe dorsiflexor Patients who are not physically fit may be more likely to
S1Ankle plantar flexor have lower back pain.
Goals
Attempt to centralize pain in the setting of radiculopathy.
Strengthen lumbar extensors and abdominal flexor
musculature.
Strengthen weak muscles.
Stretch tight muscles.
Provide an aerobic program.
Review and educate the patient on proper body
mechanics.
Evaluate ergonomics for home, work, and play.
Address specific functional activities (e.g., ambulation,
activities of daily living, homemaking).
Precautions
Avoid the philosophy no pain, no gain.
Spinal stenosis and spondylolisthesisAvoid excessive
trunk extension.
OsteoporosisAvoid trunk flexion or rotation.
Normal Abnormal
Figure 52: Pain referral patterns. Produced by intra-articular Pilates
injections of hypertonic saline in asymptomatic (normal) and Developed by Joseph Pilates in the 1920s; incorporates
symptomatic (abnormal) patients. (Mooney V, Robertson J.
(1976) Facet joint syndrome. Clin Orthop 115:149-156.)
Zen meditation and yoga
Uses specialized resistive equipment to provide open and
closed kinetic chain exercises
Includes home-based program that uses a mat and gravity
to strengthen and elongate muscles
Increases joint proprioception, strengthens muscles, and
increases flexibility
Includes exercises for abdominal and trunk muscle
strengthening, bridging, and spinal stabilization
Reported to cause less muscle soreness than other forms
of exercise

Transcutaneous Electric Nerve


Stimulation (TENS)
TENS is pulsed electric stimulation to the skin
through electrodes attached to a small battery-powered
device.
The conventional mode uses 10-30 mA of current at a
50-100 Hz current. Amplitude can be varied.
There are several theories of the mechanism of pain
Figure 53: Primary referral pattern after provocative injection control.
The gate control theory states that the stimulation of
of the sacroiliac joint. (Fortin JD, Dwyer AP, West S, Pier J.
(1994) Sacroiliac joint: pain referral maps upon applying a large fibers (A) activates the dorsal horn of the spinal
new injection/arthrography technique. Part I: asymptomatic cord to inhibit pain generated by small diameter,
volunteers. Spine 19:1475-1482.) afferent nociceptive fibers (A and C fibers).
CHAPTER 5 Low Back Pain 61

Electric stimulation may provoke the release of Electromagnetic therapy has been used to promote bone
endogenous opiates. healing, wound healing, and sleep.
TENS is useful as an adjuvant method of pain control Theories of action
for back pain. 1. Magnets create an electromagnetic field that induces a
mild current to stimulate nerve endings.
Acupuncture 2. Magnets decrease sensitivity of nociceptive fibers and
The technique of acupuncture was used for pain relief increase localized blood flow.
for centuries in Eastern cultures. Magnets are available in unipolar and bipolar styles,
The disruption of energy flow, or Qi, is thought to cause arranged in various configurations, and made of different
pain. materials.
Acupuncture involves the placement of solid needles at Only one randomized, controlled study evaluating the
various points. effectiveness of magnets in the treatment of back pain has
The number of needle placements and treatments vary been done. It did not find magnets more effective than a
greatly among patients. Early responders have better placebo.
success rates. Intradiscal Electrothermal Anuloplasty
The technique is effective in some patients.
(IDET)
Osteopathic Manipulation A flexible electrode is fluoroscopically guided
Osteopathic manipulation is performed by osteopathic percutaneously into the disk to coagulate the anulus
physicians, specially trained physical therapists, and fibrosus.
allopathic physicians. IDET results in thermal destruction of nociceptive fibers.
Manipulation is used as an adjuvant to conventional pain This procedure is not universally accepted. At least one
treatment. study reports that patients have more than 50% pain
Nonthrusting manipulation techniques are presented in reduction with this nonoperative technique.
Table 51.
High velocity, low amplitude techniques of spinal
manipulation require experienced practioners and are Medications
contraindicated in certain conditions, including fracture Nonsteroidal Anti-Inflammatory
and malignancy.
Manipulation techniques may reduce the amount of Drugs (NSAIDs)
medication required to treat back pain. NSAIDs block prostaglandin synthesis by reversible
Osteopathic manipulation has been shown to be effective inhibition of cyclooxygenase.
in subacute injury. Prostaglandin E2 sensitizes nerve endings to bradykinin,
histamine, and other inflammatory mediators.
Magnets NSAIDs are effective in relieving mild to moderate
There are two types of magnetic therapystatic and pain.
electromagnetic. They can be used continuously short term to calm
Static magnets vary in strength from 300-5000 gauss. inflammation or on an as-needed basis for pain relief.
NSAIDs are metabolized by the liver and excreted via
the kidney.
Table 51: Nonthrusting Manipulation Techniques Patients who do not respond to one NSAID may
respond to another.
TECHNIQUE MECHANISM METHOD
There is no additive effect with aspirin.
Soft tissue Addresses soft tissue Force is applied by kneading Class side effects include gastrointestinal (GI) ulcers and
restrictions tissue, stretching,
oscillating compression,
renal failure (Table 52).
and release.
Muscle energy Approaches restrictive The joint is held directly
Tramadol
tissue directly; also against the restrictive Centrally acting synthetic opioid for moderate to severe pain
known as contract- tissue and the patient Works through -receptor binding and weak inhibition
relax moves from the barrier.
Myofascial release Applies pressure to The affected part is held in a
of reuptake of serotonin and epinephrine
muscle, tendons, and position of ease; this is Low risk of dependence
fascia repeated until better Liver and renal excretion
range of motion or the Dose: 50-400 mg daily
restriction of motion is Available as Ultracet with 37.5-mg tramadol and 325-mg
relieved.
acetaminophen
62 Spine Core Knowledge in Orthopaedics

Table 52: Examples of NSAIDS

NAME DOSE ADVANTAGES SIDE EFFECTS


Ibuprofen 400-3600 mg per os (PO) daily Over the counter GI side effects, renal insufficiency, liver
toxicity
Diclofenac Delayed or immediate Available in slow and immediate Hepatotoxicity, GI side effects, renal
release50-150 mg PO daily release formulations insufficiency
Extended release100 mg daily
Celecoxib cyclooxygenase-2 200-800 mg PO daily COX-2 selective inhibitor; lower Fluid retention, renal toxicity, hepatic
(COX-2) inhibitor risk of GI complications, no toxicity
antiplatelet activity

Table 53: Examples of Membrane Stabilizers

NAME DOSE ADVANTAGES SIDE EFFECTS


Carbamazepine 100-1200 mg PO daily History of use with other pain Dizziness, nausea, drowsiness
disorders RareAplastic anemia
Gabapentin 100-3600 mg PO daily Minimal end-organ damage, Dizziness, fatigue, peripheral edema, weight gain
can easily titrate
Topiramate 12.5-400 mg PO daily Fatigue, dizziness, somnolence, urinary calculi,
weight loss
RareMyopia, narrow angle glaucoma

Use with caution with concurrent selective serotonin They are thought to act as sodium channel blockers of
reuptake inhibitor (SSRI) or in patients with a history of neuropathic pain.
seizures Doses for pain are lower and time of onset is faster
than for depression.
Membrane Stabilizers Side effects are anticholinergic symptoms and sedation.
Class of medications that are anticonvulsants
Most useful for lancinating or burning pain associated Topical Medications
with radiculopathy or neuropathy Examples of topical medications are presented in
Unknown mechanism of action for pain relief Table 55.
Requires continuous use for effectiveness, and must be
withdrawn slowly to prevent possible seizures Opiates (Table 56)
(Table 53) Interact with receptors in the central nervous system and
GI tract
Antidepressants Most potent analgesic agents available
Tricyclic antidepressants are most effective for pain Act at the receptors located in the substantia gelatinosa
modulation (Table 54). in the spinal cord
Selective serotonin reuptake inhibitors have not been Decrease the release of substance P, a potent modulator of
shown to be effective for back pain modulation. pain perception
They block the uptake of norepinephrine and Useful short-term relief to break the pain cycle and
serotonin into presynaptic nerve terminals. enable the patient to start physical therapy

Table 55: Examples of Topical Medications


Table 54: Examples of Antidepressants
NAME DOSE ADVANTAGES SIDE EFFECTS
NAME DOSE SIDE EFFECTS
Lidoderm Apply to Can be applied Increased absorption
Nortriptyline 10-375 PO Sedation, hypotension, arrhythmias, patch affected to desired area with heat
mg daily confusion, anticholinergic side effects area for a
such as urinary retention and maximum of
constipation 12 hrs/day
Amitriptyline[AU2] 25-250 Sedation, nausea, arrhythmias, Capsaicin Apply cream to Available over the Burning sensation
mg daily anticholinergic effects cream affected area counter
CHAPTER 5 Low Back Pain 63

Injection is repeated a second time with a different


Table 56: Examples of Opiates
duration anesthetic to decrease the false-positive rate.
NAME DOSE ADVANTAGES SIDE EFFECTS
Medial Branch Blocks
Morphine 15-30 mg Short- and long-acting Sedation, dizziness,
sulfate PO every formulations constipation,
These blocks include the medial branches of the L1-L4
4 hours, available tolerance, dorsal rami and the L5 dorsal rami proper.
titrate up respiratory The goal is to anesthetize the nociceptive fibers that
as needed depression innervate the facet joints.
Oxycodone 5-10 mg Short- and long-acting One must anesthetize two levels of the medial branch of
PO every formulations
12 hours, available the dorsal ramus for each facet joint evaluated; for
titrate up example, the L3-L4 facet joint needs to have medial
as needed branch blocks at L3 and L4 (Fig. 54).
Fentanyl 25-150 mg 3-day dosing
patch every 72 regimen, nonoral Facet Joint Injections
hours formulation, not
for acute pain
This combination of steroids and anesthetic is injected at
the most likely level based on pain patterns.
The average time for relief is 3-4 months.
Side effects of injections include hyperglycemia, dizziness,
and localized hematoma.
Can be safely used in chronic conditions
Available in short- and long-acting formulations such as Sacroiliac Injections (Fig. 55)
pills, patches, and lollipops Diagnostic injections are performed fluoroscopically with
Can be titrated up slowly as necessary anesthetics of two different durations on separate
occasions.
Muscle Relaxants (Table 57) A steroid and anesthetic combination may be therapeutic
This nonhomogenous class of medications can be helpful in some patients.
for painful muscle spasms that may exist in the presence
of muscle or nerve injury. Epidural Injections
All have sedative side effects and can be used to promote Most effective in those with a radicular
sleep. Must be performed under fluoroscopy for accurate
All have short half-lives and a dosage may need to be placement
administered several times a day. Transforaminal approach (Fig. 56)
AdvantageAnesthetic and steroid are placed at the
ventral aspect of the nerve root and can reach the
Injections ventral pain generators
Useful as diagnostic tool for facet or sacroiliac joint Useful for disk herniations and foraminal stenosis with
pain radiculopathy
Anesthetic agents may be injected into the joint cavity Less risk of dural puncture
(intra-articular) on the affected side. Translaminar approach
The patient performs pain provocative maneuvers after Requires less injectate than the caudal approach
injection. Injection site close to pathology
Relief of 50%-75% of pain is considered diagnostic. Caudal approach
The length of pain relief must correspond to the Reliable only up to the L5-S1 disk level
duration of anesthetic injected. Requires large amounts of injectate

Table 57: Examples of Muscle Relaxants

NAME DOSE ACTION SIDE EFFECTS


Cyclobenzaprine 10-60 mg PO daily Chemically related to tricyclic antidepressants; Dizziness, drowsiness, central nervous system
primarily exerts effect centrally in the brain stem depression, anticholinergic effects, diarrhea
Diazepam 2-40 mg PO daily True skeletal muscle relaxant Sedation, fatigue, respiratory depression, hypotension
Tizanidine[AU3] 2-36 mg daily Selective blocker Drowsiness, dizziness, dry mouth, hypotension
64 Spine Core Knowledge in Orthopaedics

Medial
branches

Figure 54: Posterior view of the lumbar spine, showing the


location of the z-joints and their innervation by the medial
branches of the dorsal rami. Figure 55: Left sacroiliac joint injection.
On the left, needle positions for the L3 and L4 medial branch
blocks used to anesthetize the L4/L5 z-joint are shown. On
the right, needle positions for L3/L4, L4/L5, and L5/S1 intra-
articular z-joint injections are shown. (Bogduk N. (1989) Back
pain: zygaphysial blocks and epidural steroids. In: Neural
Blockade in Clinical Anaesthesia and Management of Pain
(Cousins MJ, Bridenbaugh PO, eds.), 2nd edition. Philadelphia:
Lippincott, pp. 935-954.)

Trigger Points
Trigger points are hyperirritable foci in muscles and
fascia in areas of muscle tightness.
Palpation produces referred pain.
Trigger points can respond to a stretching program and
the correction of dysfunctional postural mechanics.
Injections with saline or a local anesthetic can be
performed at the site of irritation. Figure 56: Left L5 transforaminal epidural steroid injection.

References This prospective study evaluated 12 sacroiliac joint tests for their
Bogduk N, Karasek M. (2002) Two-year follow-up of a controlled diagnostic usefulness. In the study, 85 patients were evaluated by
trial of intradiscal electrothermal anuloplasty for chronic low back 12 manual examinations and diagnostics blocks (68 unilateral
pain resulting from internal disc disruption. Spine J 2: 343-350. blocks and 17 bilateral blocks). No exam or combination of
This was a prospective cohort study that compared a conven- tests increased the likelihood of a correct diagnosis with the
tional rehabilitation program with IDET for the treatment of exception of the diagnostic block.
low back pain.This study demonstrated approximately 50% pain
Feldman DE, Rossignol M, Shrier I et al. (1999) Smoking: a risk
reduction maintained over two years in more than half of the
factor for development of low back pain in adolescents. Spine 24:
IDET treatment group.
2492-2496.
Brosseau L, Milne S, Robinson V et al. (2002) Efficacy of the This was a prospective study that evaluated 810 high school
transcutaneous electrical nerve stimulation for the treatment of students from Montreal, Canada.The association with low back
chronic low back pain: A meta-analysis. Spine. 27(6): 596-603. pain increases with the amount of cigarettes smoked.
Five studies with 419 patients enrolled found TENS did not
Leboeuf-Yde C. (2000) Body weight and low back pain. Spine 25:
statistically decrease low back pain. However, patients who used
226-237.
TENS reported that they felt better, had less pain, and were
This was a systematic literature review of 56 journal articles
more satisfied with the care.
reporting on 65 epidemiologic studies. Overall, this review
Dreyfuss P, Michaelson M, Pauza K et al. (1996) The value of reported a positive association between body weight and low
medical history and physical examination in diagnosing sacroiliac back pain in 32% of the studies. Bias may be related to the
joint pain. Spine 21: 2594-2602. healthy worker effect, because obese people with low back
CHAPTER 5 Low Back Pain 65

pain are more likely to seek health care than nonobese people This is a literature review article on lumbar disk herniation with
with similar pain. an emphasis on nonoperative care. It highlights the prognostic
factors of positive outcomes, describing favorable, unfavorable,
Leboeuf-Yde C, Kyvik KO, Bruun NH. (1998) Low back pain and
and neutral factors in deciding which candidates are appropriate
lifestyle; Part I: SmokingInformation from a population-based
for nonoperative care.
sample of 29,424 twins. Spine 23: 2207-2214.
This was a twin control method using a Danish register of Saal JS, Franson RC, Dobrow R et al. (1990) High levels of
29,424 twins.The 3,751 monozygotic pairs demonstrated that inflammatory phospholipase A2 activity in lumbar disc herniations.
the smoking monozygotic twin did not have more low back Spine 15: 674-678.
pain than the nonsmoking twin.This study did not show a This study demonstrated high levels of phospholipase A2 in
causal link between low back pain and smoking. human intervertebral disk material obtained from five patients.
Phospholipase A2 is an enzyme responsible for liberating
Longworth W, McCarthy PW. (1997) A review of research on
inflammatory mediators causing tissue and membrane injury.
acupuncture for the treatment of lumbar disk protrusions and
The histopathologic findings in this study focus on the bio-
associated neurological symptomatology. J Alt Comp Med 3: 55-76.
chemical basis of pain mediation in lumbar disk herniation.
A review article with information from many worldwide studies
on the use of acupuncture. Acupuncture can be helpful for Vad VB, Bhat AL, Lutz GE et al. (2002) Transforaminal epidural
those who have had unsuccessful results with other conservative steroid injections in lumbosacral radiculopathy: A prospective
treatment. It is useful as an adjuvant therapy for sciatica and disk randomized study. Spine 27(1): 11-16.
prolapse. Comparative study of transforaminal epidural steroid injections
versus trigger point injections in 48 patients with radiculopathy
Malanga GA, Nadler SF. (1999) Nonoperative treatment of low
because of a herniated disk. Of the patients in the steroid injec-
back pain. Mayo Clin Proc 74: 1135-1148.
tion group, 84% had pain decreased by 50% and satisfaction for
Summary article on conservative treatment of low back pain
more than one year. Of the saline injection group, 48% had
that covers patient history, physical, diagnostic studies, medica-
improvement.
tions, modalities, therapeutic injections, and acupuncture.
Weinstein S, Herring S. (1993) Rehabilitation of the patient with
McPartland J, Miller B. (1999) Bodywork therapy systems. Phys
low back pain. In: Rehabilitation Medicine: Principles and Practice
Med Rehab Clin N Am 10(3): 583-602.
(Delisa JA, ed.), 2nd edition. Philadelphia: JB Lippincott Co.,
A good review of various manual medicine techniques including
pp. 996-1013.
osteopathic manipulation, movement therapies, and muscle energy.
This is a detailed chapter on low back pain rehabilitation pre-
Saal JA. (1996) Natural history and nonoperative treatment of senting epidemiology, anatomy, biochemistry, diagnosis, and
lumbar disc herniation. Spine 21: 2S-9S. treatment options.
6

CHAPTER
Herniation of the Nucleus
Pulposus in the Cervical, Thoracic,
and Lumbar Spine
Matthew Rosen*, John M. Beiner , Brian K. Kwon , Jonathan N. Grauer , and
Alexander R.Vaccaro ||

* B.A.,Thomas Jefferson University College of Medicine, Philadelphia, PA


M.D., B.S., Attending Surgeon, Connecticut Orthopaedic Specialists, Hospital of Saint
Raphael; Clinical Instructor, Department of Orthopaedics, Yale University School of
Medicine, New Haven, CT.
M.D., Orthopaedic Spine Fellow, Department of Orthopaedic Surgery,Thomas Jefferson
University and the Rothman Institute, Philadelphia, PA; Clinical Instructor, Combined
Neurosurgical and Orthopaedic Spine Program, University of British Columbia; and
Gowan and Michele Guest Neuroscience Canada Foundation/CIHR Research Fellow,
International Collaboration on Repair Discoveries, University of British Columbia,
Vancouver, Canada
M.D., Assistant Professor, Co-Director Orthopaedic Spine Surgery,Yale-New Haven
Hospital; Assistant Professor, Department of Orthopaedics,Yale University School of
Medicine, New Haven, CT
|| M.D., Professor of Orthopaedic Surgery,Thomas Jefferson University and the Rothman
Institute, Philadelphia, PA

Anatomy and Physiology of the column (either from sudden movement or chronic stress
such as prolonged obesity).
Intervertebral Disk (Fig. 61) Structural deterioration begins in early adult life with
Each disk consists of a nucleus pulposus dehydration, intradiscal fissuring, and fragmentation
and a surrounding anulus fibrosus (Table 61). progressing to anular disruption and tearing with possible
The centrally located nucleus pulposus consists of herniation.
collagenous and reticular fibers enmeshed in mucoid
material.
The anulus fibrosus, composed of concentric layers of
Terminology
fibrous connective tissue and fibrocartilage, retains the The nomenclature of disk pathology has evolved over the
mucoid nucleus. last five decades from early reports because of newer
The nucleus pulposus functions as a dynamic shock imaging modalities (chiefly magnetic resonance imaging,
absorber, moving posterior with flexion of the vertebral or MRI) (Fig. 62).

66
CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 67

Figure 61: Anatomy of the Spinal cord


intervertebral disk.

Nucleus pulposus
Nerve
root Anulus fibrosus

Disk

Vertebra

Terminology concerning herniation often differs across Proven factors associated with cervical disk herniation
institutions (Table 62, Boxes 61 and 62). include the following (Kelsey et al. 1984):
Lifting heavy objects
Herniation of the Nucleus Smoking cigarettes

Pulposus in the Cervical Spine Diving

Possible, but unlikely, factors associated with cervical disk


Epidemiology herniation include the following (Kelsey et al. 1984):
Operating or driving vibrating equipment (specific
Although all levels of the subaxial cervical spine (Box 63)
may be affected, disk herniation (Fig. 63) most often frequency is important)
Spending significant time driving automobiles
involves the C5-C6 disk followed by the C6-C7 disk and
the C4-C5 disk.
People in the fourth decade of life are affected most

often (Kelsey et al. 1984).


Clinical Presentation
Men outnumber women by a ratio of 1.4 to 1 (Kelsey AcuteA history of trauma or specific episodes such as
et al. 1984). motor vehicle accidents, lifting, or pulling something
(generally younger patients)
Subacute or chronicNo such history (generally older
patients)
Table 61: Anatomy and Physiology of the Symptoms (Table 63)
Intervertebral Disk Neck pain
Stiffness
NUCLEUS PULPOSUS ANULUS FIBROSIS Shoulder, arm, or hand pain or paresthesia
Collagen content Type II Type I Muscle weakness
Water content High Low Symptoms can be generalized and diffuse in a mesodermal
Proteoglycan content High Low
distribution or can be localized and specific with nerve root
Pain fibers No Yes
Healing potential No Yes radiculopathy (sclerotomal distribution)(Figs. 63 and 64).
Function Load bearing Structural containment of Patients can also present the following with myelopathy
Load distribution to end nucleus and long tract findings:
plates and anulus Transfer of load from Clumsiness
Shock absorption compression to Clonus
tension
Comments Inflammatogenic properties Fibers perpendicular
Positive Hoffmans and Babinskis reflex
(when exposed to the to each other to Hyperreflexia in lower and possibly upper extremities
extracellular increase tensile depending on the level of lesion
environment) strength Gait or balance disturbance
Leukotactic Other signs include the following:
Increases vascular
permeability
Muscle atrophy
Weakness
68 Spine Core Knowledge in Orthopaedics

Medial zone
Disk degeneration
Middle zone

Prolapse
A Lateral zone

Extrusion
D

Sequestration

A
Figure 62: Herniated and cervical disks. A, Herniated disks may take the form of protrusion, extrusion, or sequestration. See the
text for details. B, A cervical disk may impinge upon the nerve root at several zones.

Table 62: Terminology of Disk Pathology*

TERM DEFINITION SYNONYMS COMMENTS


Normal Disk does not protrude beyond vertebral end plates Nonbulging Incidence of abnormal findings in
normal patients
Bulge Circumferential, symmetric disk extension around Prolapse Usually <3 mm beyond end plates
the vertebral border Can be a normal variant
NOT a herniation
Protrusion Focal or asymmetric extension of the disk beyond Anulus involvement is generalized or
the vertebral border broad based versus localized or
Disk origin broader than any dimension of the focal based
protrusion
Extrusion More extreme extension of the disk beyond the Ruptured, though the term is
vertebral border ill-defined
Base of disk extrusion at the site of disk origin is
narrower than the diameter of the extruding
material
Connection exists between the extruded material
and the disk of origin
Sequestration No connection between disk fragment and parent disk Free fragment May be difficult to determine presence or
Intermediate signal on T1, increased signal on T2 absence of connection between disk
and fragment
Migration Displacement of disk material from the site of extrusion May or may not be sequestered
Contained Displaced disk is covered by outer anulus Subligamentous refers to posterior Distinction may be hard even with modern
longitudinal ligament (PLL) covering MRI
Uncontained Anulus covering is absent over displaced disk May still be subligamentous, meaning
under intact PLL

* See Fig. 62, A.


CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 69

Definitions of Common Descriptive Box 63: Unique Anatomy of the Cervical Spine
Box 61:
Terms* The cervical spine can be distinguished from the rest of the verte-
Internal disk derangement bral column:
Cervical vertebrae contain foramina transversarium in each
Anular injury in an otherwise normal-appearing disk

Anular tear transverse process to allow passage of the vertebral arteries


Anular disruption to the outer edge of the anulus (except in C7, which 95% of the time contains smaller trans-
Thought to be related to low back pain that does not improve versaria that only permit accessory vertebral veins) (Fig. 6-2, B).
Each nerve root exits the spinal canal above the pedicle of its
After a pop, a patient may feel relief of pain when the pres-

sure in the disk is relieved named vertebra.


The nerve roots exit at an angle of approximately 90 degrees
A.k.a. anular fissure; the term does not imply traumatic origin

Anular rupture from the spinal cord.


A herniated disk compresses the exiting nerve root in the cervi-
Clearly defined traumatic origin (e.g., distraction injury)

High intensity zone cal spine (e.g., a disk herniation at C5-C6 compresses the C6
High signal area on T2 MRI image usually involving the pos- nerve root) (Fig. 63)
teroinferior disk The first, second, and seventh thoracic vertebrae are atypical.
Relation to anular tears and pain is controversial
C1
* (Fardon et al. 2001.) The atlas is a circular, ring-shaped bone.
The superior facets articulate with the occipital condyles of the
skull.
The atlas has no spinous process or body, but it does have ante-
rior and posterior arches (each with a tubercle and a lateral
mass).
Nerve Root Terminology Associated C2
Box 62:
with Disk Herniations The second cervical vertebra, the axis, is the strongest cervical
No contact vertebra.
Normal fat signal surrounds the root on T1 images
The atlas rotates on two flat bearing surfaces of the axis, the
Contact without deviation superior articular facets.
Nerve is not displaced but disk material abuts it
The dens is held in position by the transverse ligament of the
Contact with deviation atlas, thereby preventing horizontal displacement of C1.
Nerve root is displaced but not compressed
C7
Compression
Disk material compresses the nerve root against adjacent
The seventh cervical vertebra is called the vertebra prominens
because of its long, nonbifid spinous process.
structures C7 also has large transverse processes.

Positive Lhermittes signCervical flexionextension


produces electric-like pain down the arm in a
dermatomal pattern
Positive Spurlings testRotation toward the side with
the pain with extension of the neck, reproducing the
radicular pain down the arm (Fig. 65)
Often, a complete physical examination will allow
relatively accurate diagnosis of the level affected (Fig. 64).
Imaging
Radiography may show antero- or retrolisthesis,
narrowed disk spaces, or osteophytes.
Computed tomography (CT) gives the best detail of the
bony overgrowth of joints of Luschka.
MRI is the method of choice for diagnosing cervical disk
herniations (Takhtani et al. 2002) (Fig. 66).
Sagittal T2 weighted gradient-recalled echo imaging
allows excellent visualization of an acute herniation
Figure 63: A herniated disk in cervical spine compressing the (Takhtani et al. 2002, Scherping 2002)
exiting nerve root. If the use of MRI is contraindicated (such as in pacemaker
patients), myelography with postcontrast computed
70 Spine Core Knowledge in Orthopaedics

Table 63: Cervical Disk Herniation Findings

NERVE ROOT
LEVEL COMPRESSED SENSORY OR PAIN FINDINGS (FIG. 65) MOTOR REFLEX
C2-C3 C3 Mastoid process and dorsal surface of neck None None
C3-C4 C4 Dorsum of neck, levator scapulae, and along anterior chest Diaphragm None
C4-C5 C5 Lateral neck pain extending to the top of the shoulder Deltoid, biceps Biceps
Axial nerve involvement manifested as numbness in the
medial deltoid
C5-C6 C6 Pain along the side of the arm and forearm extending into thumb Wrist extension None
and index fingers
Numbness over the tip of thumb and first interosseous muscle on
the dorsum of the hand
C6-C7 C7 Pain along the middle of the forearm extending into the middle, Triceps Triceps
index, and ring fingers
C7-C8 C8 Pain radiating along the medial forearm extending to the ring Interossei None
and small fingers

tomography scanning (Fig. 67) is recommended if


cervical disk disease is suspected (Scherping 2002).
Abnormality or herniation of a disk is not necessarily a
symptomatic event (Table 64).

Treatment
Nonsurgical Methods
Many patients with cervical disk herniations, with or
without radiculopathy, can be treated without surgical
intervention.
Both traction and soft collars prevent extreme movement
of the neck, thereby reducing nerve root compression.
Nonsteroidal anti-inflammatory drugs and occasionally a
short course of oral steroids (in older patients) may
reduce the severity of symptoms.
Physical therapy may alleviate patient discomfort, but
it has not been shown to affect the long-term outcome.

Figure 65: Spurlings test. Rotation toward the side of pain,


with extension of the neck and sight downward pressure on the
Figure 64: Anterior and posterior dermatomes corresponding
skull, reproduces the patients radicular pain.
to the cervical nerve root innervation. (Borenstein et al. 2004.)
CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 71

Figure 66: T2-weighted axial MRI. A right paracentral Figure 67: Myelography with postcontrast axial CT. Reveals
herniated cervical disk is impinging on the exiting nerve root a right paracentral herniated disk effacing the contrast in the
and spinal cord. cerebrospinal fluid but not compressing the spinal cord.

Surgical Methods Approximately 37% of patients report a history of trauma


(Stillerman et al. 1998).
If nonsurgical techniques fail, the patient with cervical Scheuermanns disease predisposes to thoracic disk
disk herniation may be a candidate for surgical herniations.
decompression of the affected nerve root. Most common levels are T9-T12.
Historically, posterior foraminotomy or Many thoracic disk herniations are asymptomatic
laminoforaminotomy was used to treat isolated radicular (Box 66).
symptoms.These techniques allow indirect posterolateral
decompression of the nerve root with little morbidity. Clinical Presentation
Modern techniques of anterior discectomy have Patients with thoracic disk herniations present a variety
improved and are now the standard of care for herniated of symptoms and signs, from pain, burning, numbness,
disks in the cervical spine (Table 65, Box 64). and paresthesia to frank myelopathy and spinal cord
dysfunction.
The clinician must be aware that many potentially life-
Thoracic Spine (Box 65) threatening medical causes of these symptoms exist
Epidemiology (Table 66).
Patients with symptomatic thoracic disk herniations seem
Symptomatic thoracic disk herniations are relatively to present three overlapping forms (Vanichkachorn et al.
rare1 person in 1 million people per year 2000).
(0.25%-0.75% of the total disk herniations). Predominantly axial painMost (75%) patients
Thoracic disk herniations peak in the fourth through will experience pain localized to the middle or lower
sixth decades. thoracic region, which may radiate up or down in a
There is slight male predominance. nondermatomal pattern.
Radicular painDiscomfort radiates to the front of
the chest in a band-like dermatomal pattern (the T10
region is the most common) (Fig. 68).
Table 64: Abnormal Cervical Disk MRI Findings in MyelopathyMotor impairment is found in 61% of
Asymptomatic Subjects* patients, hyperreflexia and spasticity in 58%, sensory
impairment in 61%, and bladder dysfunction in 24%
AGE ANY MAJOR HERNIATED BULGING DEGENERATED (Stillerman et al. 1998).
ABNORMALITY DISK DISK DISK High thoracic disk herniations can produce symptoms or
<40 14% 10% 0% 25% signs including the following:
>40 28% 5% 3% 60%
Upper arm pain or radiculopathy
Horners syndrome
* (Boden et al. 1990a.) Often, the only truly objective finding is change in the
pinwheel sensation along the back.
72 Spine Core Knowledge in Orthopaedics

Table 65: Surgical Approaches in the Treatment of Cervical Disk Disorders*

APPROACH TECHNIQUE VARIATIONS INDICATIONS ADVANTAGES DISADVANTAGES


Anterior Anterior cervical discectomy Disk herniation with symptomatic Avoids morbidity of posterior Risk of injury to esophagus,
Anterior cervical discectomy, fusion myelopathy or radiculopathy exposure trachea, recurrent and
at one, two, or three levels Direct decompression superior laryngeal
of spinal nerve root nerves
Minimized intrusion into spinal Transient sore throat,
canal difficulty swallowing
are common
Vertebral arteries are at risk,
though uncommonly
injured
Posterior Posterior foraminotomy, Posterolateral disk herniation Causes less instability than Only indirectly decompresses
laminoforaminotomy Failed anterior spinal surgery anterior discectomy without nerve roots
Laminaplasty with radicular symptoms fusion Postlaminectomy kyphosis is
Laminectomy, fusion Multilevel cervical spondylosis Allows multilevel decompression common with resection
Posterior cervical with lordotic sagittal Avoids potential for injury of >50% of facets
discectomy (abandoned) alignment to anterior structures without fusion
(especially nerves to larynx) Significant paraspinal muscle
pain is common (because
of extensive dissection of
paraspinal muscles)
Multilevel decompressions
must be lordotic to allow
the cord to float back

* (Rushton et al. 1998, Narayan 2001.)

Natural History pain, myelopathic symptoms, or both, prompting surgical


intervention.
Similar to the case in the cervical and lumbar spine, Older patients with a longer duration of symptoms
many patients will get better with nonoperative representing degenerative disk bulges or herniations
treatment. will more often than not get better without
Stillerman et al. (1998) reported that 0.2%-1.8% of all surgery.
symptomatic herniations are treated surgically each year.
Younger patients presenting an acute soft disk herniation
related to an acute traumatic event will often experience

Box 65: Unique Anatomy of the Thoracic Spine


Anterior Cervical Discectomy: Is
Box 64: The thoracic spine has several features that distinguish it from the
Fusion Necessary?

cervical and lumbar regions:


Most surgeons now routinely include an interbody fusion with Rigid zone secondary to the rib cage

structural bone graft when doing an anterior cervical discectomy. Vertically oriented facets (permit lateral bending and rotation

Reasons for this include the following: but little flexion or extension)
Restoring sagittal lordosis A spinal cord/canal ratio of only 40% (smaller than cervical

Increasing height of intervertebral foramen by distraction and lumbar)


Stabilization of the motion segment to decrease inflammation Dentate ligaments that connect spinal cord and nerve roots

and nerve irritation tether cord to anterior structures, more sensitive to ventral
Faster relief of radiculopathy compression
Some neurosurgeons, however, advocate disk excision without Kyphosis that drape cord over anterior elements

arthrodesis (Sonntag et al. 1996, Dowd et al. 1999). Arguments The blood supply to the thoracic spinal cord is less redundant
include the following: than in the cervical or lumbar regions (Dommisse 1974):
No graft-related and fewer overall complications One anterior and two posterior longitudinal arteries

Faster operative times with less blood loss Segmental vessels

Faster recovery time and return to work Artery of Adamkiewiczusually T9-T11, left-sided

No clinical or psychological issues with graft healing or A particularly tenuous cervicothoracic junction blood supply;

pseudarthrosis the spinal cord from T4-T9 is very sensitive to injury


CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 73

Abnormal Thoracic Disk MRI Findings


Box 66:
in Asymptomatic Subjects*
90 asymptomatic subjects
73% had one or more abnormal disks on MRI scans
37% had disk herniations
T4
20 patients followed for 26 months; no patient became sympto-
matic
T8
Large herniations were resorbed

Small herniations were unchanged or increased in size

* (Wood et al. 1995.) T10

T12
Location of Thoracic Disk Herniations
Disk herniations in the thoracic spine may be central,
centrolateral, and lateral (Stillerman et al. 1998).
94% were centrolateralmore likely to produce
myelopathy. Figure 68: Sensory dermatomes thoracic spine. (Williams
et al. 2003.)
6% were lateralmore commonly present with
radicular symptoms.
65% of patients showed evidence of calcification. CT myelographyUsed less in the thoracic spine but an
7% intradural extension was noted at surgery. important modality for determining the extent of canal
14% were found to have multiple herniations. compromise in those patients with equivocal MRI scans
or those in whom MRI scanning is not possible (e.g.,
Diagnostic Imaging
pacemakers) (Fig. 610)
Plain radiographsIntradiscal calcification (Fig. 69)
MRIA combination of T1- and T2-weighted images Nonsurgical Treatment
in the sagittal and axial planes revealing disk material Initial managementNonsteroidal anti-inflammatory
bulging posteriorly or laterally into the spinal canal medication, activity modification, and a short course of
hyperextension bracing may be beneficial (severe cases in
older patients may warrant a short taper of oral steroids).
Once symptoms have partially subsidedUse
physiotherapy with modalities; a range of motion,
Table 66: Differential Diagnosis of Thoracic Pain* flexibility, and strengthening of erector spinae; then
aerobic conditioning.
NONSPINAL CAUSES SPINAL CAUSES Steroid injectionsEpidurals not routinely used, but
Cardiovascular Infection selective nerve root injections offer good symptomatic
Pulmonary Neoplastic
relief.
Neoplastic Primary
Hepatobiliary Metastatic Surgical Indications
Gastrointestinal Degenerative
Retroperitoneal Spondylosis Myelopathic symptoms or signs
Polymyalgia rheumatica Spinal stenosis Persistent radicular pain unresponsive to conservative
Fibromyalgia Facet syndrome
therapy (for at least 4-6 weeks) with imaging consistent
Rib fractures Disk disease
Intercostal neuralgia Costochondritis with clinical findings
Metabolic Axial painControversial; surgical treatment is less likely
Osteoporosis to relieve back pain than radicular symptoms or
Osteomalacia myelopathy
Deformity
Kyphosis Surgical Treatment
Scoliosis
Trauma The sensitivity of the thoracic spinal cord to injury (see
Neurogenic Box 65) limits the ability of the surgeon to gain access
Herniation to the disk space from the traditional posterior
Spinal cord neoplasm
approaches used in the lumbar spine.
Arteriovenous malformation
Inflammatory (herpes zoster)
Anterior and lateral approaches have been developed that
limit dissection of the cord from the herniated disk
* (Adapted from Vanichkachorn et al. 2000.) (Table 67, Box 67).
74 Spine Core Knowledge in Orthopaedics

Results of thoracic discectomy are generally good, in


terms of both pain relief and recovery of motor function
in those patients with myelopathy (Bohlman et al. 1988,
Simpson et al. 1993).
The overall complication rate for thoracic discectomy is
15% (Stillerman et al. 1998).
MajorDeath, permanent neurological deterioration,
medical complications, need for reoperation
MinorNeuralgia, pneumothorax, continued pain,
wound infection

Lumbar Spine
A symptomatic lumbar disk herniation occurs during the
lifetime of 2% of the general population.
Risk factors for sustaining a lumbar herniated disk
include the following:
Male gender
Age 30-50
Heavy lifting, especially in a twisting motion
Poor job satisfaction or low income
Cigarette smoking
Prolonged vibration exposure
Of lumbar disk protrusions, 90%-95% are observed at the
L4-L5 or L5-S1 level.
Not all disk pathology has clinical importance
(Table 68).
Clinical Presentation
Usually, in mild or moderate disk herniations, patients
Figure 69: Radiograph showing thoracic disk calcification. first notice lower back pain corresponding to anular
pressure and fissuring.
This can progress to frank tears in the anulus and
herniation of inflammatogenic material; the severity of
the lower back pain may lessen, but a radiculopathy in
the form of pain, paresthesia, or weakness can appear
because of pressure on the nerve root.
With severe herniations, the patient may experience
immediate lower extremity pain with little or no lower
back involvement.
Lower back pain will be intermittent and is often
brought on by physical activity and made worse by
prolonged sitting, moving from a seated to a standing
position, or bending and twisting (each of these
movements increases lumbar disk pressure).
In patients experiencing herniation of lumbar disks with
radiculopathy,Valsalva maneuvers may exacerbate pain in
the lower extremity (Box 68).

DiagnosisClinical Exam
PostureStanding (sitting hurts); a possible spasm causes
Figure 610: CT myelogram revealing a herniated thoracic a pseudoscoliotic list to one side or a straightening of the
disk. lumbar lordosis.
CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 75

Table 67: Surgical Approaches for Thoracic Disk Herniations

SURGICAL APPROACH VARIATIONS INDICATIONS ADVANTAGES DISADVANTAGES


Anterior Transsternal Central or centrolateral disks Excellent midline exposure Violates pleura
Thoracotomy or Transsternal T1-T4 Multiple levels accessible Significant perioperations
transthoracic T4-T12 rib resection or Facilitates instrumentation Morbidity
Detachment of diaphragm rib-splitting Diaphragm takedown
for access to lower levels significantly slows recovery
Posterior Laminectomy (abandoned) Lateral, some centrolateral Avoids morbidity of Limited visualization of disk
Pediculofacetectomy disks thoracotomy Access not possible to
Transfacet pedicle-sparing Upper thoracic spine midline or intradural disks
Higher incidence of segmental
instability, pain
Lateral Extracavitary Lateral or centrolateral disks Pleura is not violatedless Technically difficult
Costotransversectomy morbidity, etc. Relatively large posterior
Diaphragm remains intact dissection
Complete anterior decompression
is difficult
Video-assisted Conversion to open Lateral or centrolateral disks Avoids morbidity of Increased operative time
thoracoscopic surgery always possible thoracotomy Steep learning curve
Avoids posterior muscle, Limited decompression, no
bone dissection ability to instrument
Shorter ICU stays, High incidence of intercostal
rapid recovery neuralgia or visceral injury

Role of Arthrodesis in Thoracic Disk


Box 67:
Herniations Heel and toe gait should be observed to detect weakness
of L5 or S1 (see Figs. 611 and 612).
Anatomy
Rib cage stability may make fusion unnecessary
Tension signs are useful in diagnosing a lumbar disk
Relative indications herniation; a straight leg raise (SLR) in patients under 35
Scheuermanns kyphosis patients (prone to further kyphosis) is specific and sensitive to a symptomatic disk herniation.
Lower levels (rib cage stability not present) Maximal tension is created in the sciatic nerve and
Partial corpectomy performed to access disk transmitted to the nerve roots between 35 and 70 degrees
Multiple levels removed
of leg elevation.
Advantages For a true, positive SLR, patients should experience
Low morbidity, easy to perform
radicular pain or paresthesia below the knee within the
Increases stability to prevent collapse (controversial)
leg elevation range above (Fig. 611).
Disadvantages
Requires bone graft (autograft or allograft) unless rib can be

used
Slightly longer operative time

Instrumentation (used almost exclusively for lower levels)


Increases cost and operative time
Lumbar Disk Herniation and Cauda
Box 68:
Provides stability at a high-stress junctional zone Equina Syndrome*
Typically large midline herniations in older patients with spinal
stenosis
Table 68: Abnormal Lumbar Disk MRI Findings in 1-2.4% of symptomatic lumbar disk herniations
Asymptomatic Subjects* Symptoms or signs
Bowel or bladder difficulties

AGE HERNIATED DISK BULGING DISK DEGENERATED DISK Saddle anesthesia

Diminished rectal tone


20-39 21% 56% 34%
Lower extremity sensory and motor deficits

40-59 22% 50% 59% Should be treated as a surgical emergency; decompression within
60-80 36% 79% 93% 48 hours provides best outcome
* (Ahn et al. 2000.)
* (Boden et al. 1990b.)
76 Spine Core Knowledge in Orthopaedics

Motor and Sensory Examination


See Figs. 611, 613 and 614 for L4, L5, and S1 nerve
functions.

Localization of Lumbar Disk


Herniation
A neurologic physical examination can help determine
the likely location of a herniated lumbar disk.
Several classification systems exist for describing where a
disk herniation occurs.
Wiltse et al. (1997) proposed an anatomic system familiar
Figure 611: L5 nerve root functions. to most surgeons (Figs. 615 and 616).

Femoral stretch testing (performed by extending the hip


with a bent knee and with the patient prone) can Anatomic Features of the
reproduce radicular pain from compression of a higher
lumbar root (L2-L4).
Lumbar Spine
The following Waddell signs should be noted: Lumbar roots exit the dural sac at an acute angle and
Nonanatomic distribution of pain or tenderness to travel inferiorly to exit under the pedicle of the vertebral
light touch body (Fig. 617).
Low back pain when standing with a downward force Depending on the location of the disk herniation,
on the head pressure may be exerted on the exiting or the traversing
Change in findings with posture, distraction, etc. (e.g., nerve root.
SLR) Only far-lateral or extraforaminal disk herniations
Overreaction or symptom magnification should exert pressure on the exiting nerve root

Figure 612: S1 nerve root functions.

L4
nerve root

Sensation

Reflex

Motor

Tibialis anterior muscle


CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 77

S1
L5 nerve root
nerve root Sensation
Sensation

Reflex
Reflex

None

Motor
Motor

Extensor hallucis longus muscle Peroneus longus and brevis muscle


Figure 613: Straight leg raise to test nerve tension. Figure 614: L4 nerve root functions.

(e.g., an extraforaminal disk herniation at L4-L5 may Steroid use in patients under 50 must be weighed against
compress the L4 nerve root) (Fig. 618). the potential for avascular necrosis of the hip and other
Central, posterolateral, subarticular, or foraminal side effects.
lumbar disk herniations will compress the traversing Epidural steroidsRandomized clinical trials and meta-
nerve root (e.g., a foraminal disk herniation at L4- analysis indicate short-term improvement, but long-term
L5 will compress the L5 nerve root) (Fig. 619, relief is lacking (Watts et al. 1995).
Box 69). Manipulative therapy and physiotherapy have been found
equivalent to medical management (medication or
activity modification) of lumbar disk herniation in terms
Treatment of significant short-term pain relief compared with a
placebo, but there has been no proven long-term
Nonsurgical Treatment benefit.
Initial therapy consists of the following:
Bed rest for 1-3 days only Surgical Treatment
Nonsteroidal anti-inflammatory medications See Table 69 and Box 610 for surgical treatment.
Judicious and sparing use of stronger analgesics or The following are positive predictive factors
muscle relaxants (preoperatively) in lumbar disk surgery:
Progressive return to normal activity; both extremes of No workers compensation claim
continued bed rest and rapid strenuous physical Nonsmoker
activity or physiotherapy have been shown to worsen Absence of back pain
symptoms Pain extending to the foot (true radicular pain)
Oral steroids can provide symptomatic relief for leg pain Positive SLR
more than for back pain because of acute inflammation Larger herniation
of a nerve root. Good social support system
Pedicular
Infrapedicular
Discal

A
Extraforaminal
Foraminal
Lateral recess

Central

Central canal zone

Subarticular zone
(lateral recess)

Suprapedicle level Foramnal zone

Pedicle level Extraforaminal zone


Infrapedicle level
Disk level

B
Figure 615: Anatomic zones and levels identified in the coronal plane.

L3 pedicle

L3 spinal nerve

Central canal zone


L3-4 herniated disk
Subarticular zone
(lateral recess) L4 pedicle
Foramnal zone
(pedicle zone)
L4 spinal nerve

Extraforaminal zone L5 pedicle


(far lateral zone)

L5 spinal nerve
Figure 617: Cauda equina and nerve roots with a herniated
Figure 616: Anatomic zones identified on axial images. disk.
CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 79

Figure 619: Axial T2-weighted image. A posterolateral disk


herniation causing effacement of the surrounding fat and
partial displacement the traversing nerve root.

Figure 618: Axial T2-weighted image of a far-lateral disk


herniation compressing the exiting nerve root.

Table 69: Comparison of Techniques for Lumbar


Discectomy

TECHNIQUE PROS CONS


Natural History of Lumbar Disk
Box 69: Open discectomy Standard of care More muscle dissection
Herniations* Better visualization of Longer hospital stay,
nerve increased pain
This was a prospective, randomized trial of nonoperative treatment Potential for iatrogenic
versus surgical discectomy for isolated lumbar disk herniations. All instability
patients that beyond doubt required surgical therapy and those
Open microdiscectomy Becoming more standard Limited visualization
with no indication for operative intervention were excluded from
Limits muscle damage of nerve
the randomized group and results. Decreased pain Potential for nerve
Nonsurgical Headlamps, loupe injury because of
25% were cured, 36% improved significantly. magnification smaller incision
Therefore, these 60% would have had unnecessary surgery if
commonly available size
all went to operation. Microscope-assisted Limited muscle dissection Increased time, cost
On the flip side, the 40% of patients who needed surgery discectomy Better lighting, Equipment may not be
would suffer for months if all were required to wait for opera- magnification available
tive intervention. Potentially shorter
Three months were sufficient to decide.
inpatient stays, less
time off work, better
Surgical results reported by
Significantly better outcomes occurred at a follow-up of one
some authors
year.
Insignificantly better outcomes occurred at four years. Percutaneous Muscle dissection limited Increased cost
Only minor changes took place in patients during the last six
discectomy to portals Steep learning curve
Theoretically less Longer operative time
years of observation. morbidity, blood loss,
* (Weber 1983.) etc.
80 Spine Core Knowledge in Orthopaedics

by 3 independent neurologists.The scans were interpreted as


Indications for Operative Disk demonstrating an abnormality in 19% of the asymptomatic
Box 610:
Excision subjects; 14% of those less than 40 years old and 28% of those
older than 40. Of the subjects less than 40, 10% had a HNP and
A general review of the literature can provide the following indi- 4% had foraminal stenosis. Of the subjects older than 40, 5%
cations for surgical intervention: had a HNP, 3% bulging of the disk, and 20% foraminal stenosis.
Major or progressive muscle weakness
The disk was degenerated or narrowed at one level in more
Symptoms or signs of cauda equina syndrome
than 25% of the subjects less than 40 and in almost 60% of
Radiculopathy and severe pain unrelieved by conservative man-
those who were older than 40.The prevalence of abnormal
agement and persisting at least 4-6 weeks MRIs of the cervical spine as related in age to asymptomatic
Evidence exists that pain and radiculopathy that persist more individuals emphasizes the dangers of predicting operative
than six months can develop into chronic nerve pain poorly decisions on diagnostic tests without precisely matching those
treated even with surgical intervention at that point. Some findings with clinical signs and symptoms.
authors believe, therefore, that a window of opportunity for surgi- The authors treated 22 thoracic disk herniations in 19 patients
cal treatment is present in the face of persistent pain or radicular with excision using an anterior transthoracic decompression or a
findings. costotransversectomy, and they reported a 48-month follow-up.
Of the patients, 16 had an excellent or a good result, 1 had a fair
result, and 2 had a poor result. Of the 14 patients who had had
References motor weakness preoperatively, 12 had varying degrees of
Ahn UM, Ahn NU, Buchowski JM et al. (2000) Cauda equina improvement in motor function postoperatively. Pain was
syndrome secondary to lumbar disk herniation: A meta-analysis of relieved or reduced in 18 patients. The authors conclude that
surgical outcomes. Spine 25: 1515-1522. although the results were good, the procedure is associated
Pooled outcomes were analyzed in 322 patients.There was a with some risk of damage to the spinal cord. It therefore
significant advantage to treating patients within 48 hours versus requires meticulous preoperative planning and careful surgical
more than 48 hours after the onset of cauda equina syndrome. A technique.
significant improvement in sensory and motor deficits and in Borenstein DG,Wiesel SW, Boden SD, eds. (2004) Low Back and
urinary and rectal function occurred in patients who underwent Neck Pain: Comprehensive Diagnosis and Management, 3rd
decompression within 48 hours versus after 48 hours. Older age edition. Philadelphia: Saunders.
and preexisting bowel or bladder dysfunction were associated
with worse outcomes. Dommisse GF. (1974) The blood supply to the spinal cord: A
critical vascular zone in spinal surgery. JBJS 56B: 225-235.
Boden SD, McCowin PR, Davis DO et al. (1990a) Abnormal The author studied cadavers and radiographs of patients to
magnetic-resonance scans of the cervical spine in asymptomatic outline the normal variants of the blood supply to the spinal
subjects. A prospective investigation. J Bone Joint Surg Am cord. Descriptions of three longitudinal vessels, the differential
72:1178-1184. metabolic demands of grey and white matter, and the radicular
MRI scans of 63 volunteers with no history of symptoms arteries reinforcing the longitudinal arterial channels at various
indicative of cervical disease and 37 patients with asymptomatic levels, including the artery of Adamkiewicz, are presented.
lesion of the cervical spine were mixed randomly and studied
by 3 independent neurologists.The scans were interpreted as Dowd GC,Wirth FP. (1999) Anterior cervical discectomy: Is fusion
demonstrating an abnormality in 19% of the asymptomatic necessary? J Neurosurg (Spine 1) 90: 8-12.
subjects; 14% of those less than 40 years old and 28% of those A prospective, randomized trial of anterior cervical discectomy
older than 40. Of the subjects less than 40, 10% had a HNP and with and without fusion found no difference in patient
4% had foraminal stenosis. Of the subjects older than 40, 5% satisfaction and return to preoperative activity levels.Though
had a HNP, 3% bulging of the disk, and 20% foraminal stenosis. the fusion rate was higher in the fusion group, this did not
The disk was degenerated or narrowed at one level in more correlate with the outcome.The authors suggest that the
than 25% of the subjects less than 40 and in almost 60% of addition of fusion to the procedure may be unnecessary.
those who were older than 40.The prevalence of abnormal
Fardon DF, Milette PC. (2001) Nomenclature and classification of
MRIs of the cervical spine as related in age to asymptomatic
lumbar disk pathology: Recommendations of the combined task
individuals emphasizes the dangers of predicting operative
forces of the North American Spine Society, American Society of
decisions on diagnostic tests without precisely matching those
Spine Radiology, and American Society of Neuroradiology. Spine
findings with clinical signs and symptoms.
26: E93-E113.
Boden SD, Davis DO, Dina TS et al. (1990b) Abnormal magnetic- This work represents the collaborative efforts of the three
resonance scans of the lumbar spine in asymptomatic subjects. societies, offering recommendations for standardized
A prospective investigation. J Bone Joint Surg Am 72:403-408. nomenclature involving disk pathology in the lumbar spine.
Bohlman HH, Zdeblick TA. (1988) Anterior excision of herniated Kelsey J, Githens PB,Walter SD et al. (1984) An epidemiology
thoracic discs. JBJS 70: 1038-1047. study of acute prolapsed cervical intervertebral discs. J Bone Joint
MRI scans of 63 volunteers with no history of symptoms Surg Am 66(6): 907-914.
indicative of cervical disease and 37 patients with asymptomatic The authors conducted an epidemiological study in a patient
lesion of the cervical spine were mixed randomly and studied population of acute prolapsed cervical disks. It was concluded
CHAPTER 6 Herniation of the Nucleus Pulposus in the Cervical, Thoracic, and Lumbar Spine 81

that individuals in the fifth decade were more likely to requiring surgery were from T8 to T11. Evidence of antecedent
experience cervical disk herniation, and men were more likely trauma was present in 37% of the patients; 94% were
to be affected than women. Factors that may contribute to the centrolateral and 6% were lateral. Evidence of calcification was
development of the condition were also described. present in 65% of patients, and in 7% intradural extension was
noted at surgery.The authors found that 10 patients (14%) had
Narayan P, Haid RW. (2001) Treatment of degenerative cervical disk
multiple herniations. Four surgical approaches were used for the
disease. Neurol Clin 19: 217-229.
removal of these 82 disk herniations: transthoracic in 49 (60%),
The article explains both the surgical and the nonoperative
transfacet pedicle-sparing in 23 (28%), lateral extracavitary in 8
approaches to the treatment of various types of cervical disk
(10%), and transpedicular in 2 (2%). Postoperative evaluation
disease. Information regarding the radiologic evaluation of each
revealed improvement or resolution of pain in 47 (87%) of 54,
abnormality is also given.The article focuses on the treatment
hyperreflexia and spasticity in 39 (95%) of 41, sensory changes
of cervical disk disease to relieve any associated radiculopathy or
in 36 (84%) of 43, bowel or bladder dysfunction in 13 (76%) of
myelopathy.
17, and motor impairment in 25 (58%) of 43. Complications
Rushton SA, Albert TJ. (1998) Cervical degenerative disease: occurred in 12 (14.6%) of the 82 disks treated surgically. Major
Rationale for selecting the appropriate fusion technique (anterior, complications were seen in 3 patients and included
posterior, and 360 degrees). Ortho Clin N Am 29: 755-777. perioperative death from cardiopulmonary compromise,
This article reviews the rationale and indications for various instability requiring further surgery, and an increase in the
spinal surgery techniques. Success rates for various procedures, severity of a preoperative paraparesis.
as well as the results and complications associated with each, are
Takhtani D, Melhem ER. (2002) MR imaging in cervical spine
described.
trauma. Clin Sports Med 21: 49-75.
Scherping SC. (2002) Cervical disk disease in the athlete. Clin A review of the continuous improvements in MRI as it applies
Sports Med 21: 37-47. to spine surgery.The specific types of MRI sequence
This article reviews cervical disk disease and presents appropriate for various spinal conditions are described.
information on clinical presentation, imaging and diagnosis, and
Vanichkachorn JS,Vaccaro AR. (2000) Thoracic disk disease:
management. Although the article concludes with information
Diagnosis and treatment. JAAOS 8: 59-169.
regarding the management of cervical disk disease in the athlete,
This is a review of the anatomy, epidemiology, clinical
much of the article is concerned with general cervical spine
presentation, imaging, natural history, and treatment of thoracic
abnormalities.
disk disease.The authors emphasize the natural tendency of
Simpson JM, Silveri CP, Simeone FA et al. (1993) Thoracic disk these patients to improve with nonsurgical care, give indications
herniation: Reevaluation of the posterior approach using a for operative intervention, and explain the relative merits of the
modified costotransversectomy. Spine 18: 1872-1877. various surgical approaches in terms of outcome and
Using a posterolateral approach (costotransversectomy or complications.
transpedicular), 23 thoracic disk herniations were decompressed
Watts RW, Silagy CA. (1995) A meta-analysis on the efficacy of
with a follow-up averaging 58 months. An excellent or good
epidural corticosteroids in the treatment of sciatica. Anesth
result was achieved in 16 patients; 3 patients had a fair result.
Intensive Care 23: 564-569.
There were no poor results. All 6 patients with significant
This meta-analysis included 907 pooled patients. Significant
preoperative lower extremity weakness improved. Pain was
pain relief (75% on average) occurred in patients treated with
relieved in 16 patients and reduced in 3.There were no
epidural steroid injections for the treatment of sciatica. Short-
significant neurologic complications associated with the
term results were significantly different than controls.
procedure.The authors conclude that posterolateral
decompression for thoracic disk herniation remains a viable Weber H. (1983) Lumbar disk herniation: A controlled, prospective
alternative without the inherent risk and morbidity of a study with ten years of observation. Spine 8: 131-140.
transthoracic approach. In this study, 126 patients with uncertain indications for surgical
treatment had treatment chosen by randomization in surgical or
Sonntag VKH, Klara P (1996) Is fusion necessary after anterior
nonsurgical management. Statistically better outcomes were
cervical discectomy? Spine 21: 1111-1113.
reported in the surgical group at one year, less difference was
Sonntag and Klara express opposing views on the need for
seen at four years, and no real changes in the last six years were
fusion after discectomy and support their perspectives with
observed. A high crossover rate, imprecise definitions of
clinical experience and a review of the pathoanatomy of disk
nonsurgical care, and author-evaluated outcomes are criticisms
disease. Sonntag believes that most patients are well served with
of this article.The author concludes that it is safe to wait on
discectomy alone, avoiding the complications of graft harvest
uncomplicated lumbar disk herniations because many patients
and potential nonunion. Klara thinks that the interposed graft
get better without surgery.
restores foraminal height and maintains cervical lordosis, both
of which are important to a good outcome. Williams KD, Park AL. (2003) Lower back pain and disorders of
intervertebral disks. In: Campbells Operative Orthopaedics (Canale
Stillerman CB, Chen TC, Couldwell WT et al. (1998) Experience
ST, ed.), 10th edition. Philadelphia: Mosby.
in the surgical management of 82 symptomatic herniated thoracic
discs and review of the literature. J Neurosurg 88: 623-33. Wiltse LL, Berger PE, McCulloch JA. (1997) A system for
The authors surgically treated 71 patients with 82 herniated reporting the size and location of lesions of the spine. Spine 22:
thoracic disks.The most common sites of disk herniation 1534-1537.
82 Spine Core Knowledge in Orthopaedics

Anatomic zones and levels are defined, using a system intuitive Wood KB, Blair JM, Aepple DM et al. (1997) The natural history of
to most surgeons, and recommendations are made for reporting asymptomatic thoracic disk herniations. Spine 22: 525-529.
pathology in the spine, particularly in relation to lumbar disk This study examines a group of 90 asymptomatic patients with
herniations. MRI scans of their thoracic spines. Based on the results of this
study, the authors believe that asymptomatic disk herniations
Wood KB, Garvey TA, Gundry C et al. (1995) Magnetic resonance
may exist in a state of relative flux yet exhibit little change in
imaging of the thoracic spine: Evaluation of asymptomatic
size and remain asymptomatic.There was a trend, however, for
individuals. JBJS 77: 1631-1638.
small disk herniations either to remain unchanged or to increase
Two studies examine a group of 90 asymptomatic patients with
in size and for large disk herniations often to decrease in size.
MRI scans of their thoracic spines.The authors describe the
incidence and epidemiology of thoracic disk herniations and
follow a subgroup of these patients for an average of 26 months.
7

CHAPTER
Cervical, Thoracic, and Lumbar
Degenerative Disk Disease
Spinal Stenosis

Brady T.Vibert* and Jeffrey S. Fischgrund

* M.D., Resident, Orthopaedic Surgery,William Beaumont Hospital, Royal Oak, MI


M.D., Spine Surgeon,William Beaumont Hospital, Royal Oak, MI

Introduction Pathophysiology
Degenerative disk disease is manifested as loss of fluid, Spinal stenosis can come from advanced degenerative
height, and integrity of the intervertebral disk. It may disk disease.
result in osteophyte formation, ligament hypertrophy, All disks age, but pathologic disk degeneration is an
and synovial cyst formation. accelerated and exaggerated course of normal aging
Spinal stenosis, the narrowing of the spinal canal or (Fig. 71).
neural foramina, may occur because of degenerative
disk disease and resulting hypertrophic changes. Classification
Spinal stenosis may result in radiculopathy,
Arnoldi Classification of Spinal Canal
myelopathy, or both in the cervical and thoracic spine.
Spinal stenosis in the lumbar spine may result in Stenosis
radiculopathy, neurogenic claudication, or cauda I. Congenital or developmental
equina syndromethat is, saddle anesthesia a. Idiopathic
(perineal) and loss of bowel and bladder function in b. Achondroplastic
severe cases. c. Osteopetrosis
Radiculopathy is a nerve root dysfunction that results in II. Acquired
a lower motor nerve lesion only in the affected nerves a. Degenerative
distribution. i. Central
Myelopathy is a condition affecting the spinal cord and ii. Lateral recess and foraminal
resulting in upper motor neuron dysfunction. b. Iatrogenic
Spinal stenosis in the cervical and thoracic spine may i. Postlaminectomy
result in myelopathy ii. Postfusion
Thoracic spinal stenosis caused by degenerative changes is iii. Postdiscectomy
rare because the rib cage, which provides rigid structural c. Miscellaneous disorders
support, minimizes motion at the thoracic intervertebral i. Acromegaly
motion segments. ii. Pagets

83
84 Spine Core Knowledge in Orthopaedics

Figure 71: Disk degeneration flow chart.

iii. Fluorosis Fig. 72 is a schematic that illustrates normal anatomic


iv. Ankylosing spondylitis relationships in the lumbar spine.
d. Traumatic Fig. 73 is an artists illustration revealing advanced lumbar
III. CombinedAny combination of congenital, spine degeneration with central and foraminal stenosis.
developmental, or acquired stenosis
Diagnostic Tools
Lumbar Stenosis History
AgeUsually over 50
Anatomy
The spinal cord usually ends at the L1 level with the Symptoms
nerves of the cauda equina remaining in the dural sac Low back pain
until they exit their respective foramina. Low back stiffness
Osteophyte formation from the vertebral body endplates Mechanical symptoms
and facet joints, synovial cysts from the facet joints, Radiculopathic pain
ligamentum flavum hypertrophy, and disk bulging may all Lower extremity weakness
impinge the dural sac and exiting nerve roots. Neurogenic claudication
CHAPTER 7 Cervical, Thoracic, and Lumbar Degenerative Disk Disease 85

Figure 72: Anatomic relations in the lumbar spine. (Reproduced from Wiesel et al. 1982.)

Symptoms of neurogenic claudication must be Imaging


differentiated from vascular claudication and degenerative
disk disease, as described in Table 71. Plain Films
Table 72 differentiates spinal stenosis from disk An anteroposterior (AP) and lateral lumbar spine, as well
herniation. as an AP pelvis, should be acquired for all patients with
neurologic signs or symptoms and those with more than
Physical Examination and Signs six weeks of back pain.
Plain films frequently reveal the following:
(Table 73) Disk space narrowing or degenerative disk disease
A complete physical examination, focusing on the Endplate osteophytes and sclerosis
neurologic examination, is critical in diagnosing lumbar Facet enlargement or osteophyte formation
stenosis and differentiating it from other disease Narrowed neuroforaminal canals
processes. Loss of lumbar lordosis
Decreased lumbar extension Plain films occasionally reveal the following:
Rarely, muscle atrophy (especially calf ) Degenerative scoliosis
Difficulty with toe or heel walking Spondylolisthesis, usually at L4-L5
Usually no muscle weakness Figs. 74 and 75 reveal these changes.
Negative long tract signs Although plain films may help rule out unusual causes of
Sensory examination is usually normal but may be stenosis, such as ankylosing spondylitis and possibly
abnormal in advanced cases. tumors, they are limited in their ability to evaluate the
Patients walk with lumbar flexion and do not like to lie encroachment of neural structures and other bony
flat or stand straight. pathology.
86 Spine Core Knowledge in Orthopaedics

Figure 73: Illustrations revealing normal anatomic relations (left) and degenerative changes (right) in the lumbar spine.
(Reproduced from Rothman et al. 1982.)

Magnetic Resonance Imaging MRI is excellent for viewing the following:


Magnetic resonance imaging (MRI) is the best modality Spinal stenosis
for evaluating lumbar spinal stenosis (Schnebel et al. 1989). Lateral recess stenosis
Both axial cuts and sagittal cuts should be obtained. Disk bulges and herniations
Gadolinium is only necessary in postsurgical patients or Nerve root impingement
when differentiating from infection, tumor, or other Facet degeneration, hypertrophy, and cyst formation
pathologic processes. Maintenance or loss of epidural fat (lost in stenosis)
CHAPTER 7 Cervical, Thoracic, and Lumbar Degenerative Disk Disease 87

Table 71: Differential Diagnosis of Symptoms*

FINDINGS PAIN NEUROGENIC CLAUDICATION VASCULAR CLAUDICATION DEGENERATIVE DISK DISEASE


Type Vague cramping, aches, sharp burning Tightness, cramping (usually calf) Dull low back pain
in legs
Location Back, buttocks, legs Leg muscles Back
Radiation Common, proximal to distal Localized in legs, distal to proximal Localized to back, anterior thighs
Exacerbation Standing, walking (less so); none Walking, bicycling General activitiesBending, standing twisting,
with bicycling unless the trunk is lifting
extended
Improvement Sitting, flexing, squatting Standing, cessation of activity Decreased activity, rest
Time to relief Slow Rapid Slow
Walking uphill No pain (trunk flexed) Pain Pain possible
Back pain Common Uncommon Common

*
(Adapted from Herkowitz et al. 1999.)

Table 72: Lumbar Stenosis versus Disk Herniation*


The primary weaknesses of CT are decreased resolution
compared with MRI, the inability of CT to demonstrate
CONDITION STENOSIS DISK HERNIATION intrathecal pathology (tumors), and radiation exposure to
Age >50 <50
the patient.
Sex Mostly female Mostly male
CT myelogram has the added disadvantage of being an
Onset Insidious Acute invasive procedure.
Pain location Diffuse Dermatomal
Weakness Uncommon Common Electromyogram
Straight leg raise Negative Positive Limited use for diagnosing lumbar stenosis
*
(Adapted from Herkowitz et al. 1999.)
May be helpful when diagnosing or excluding
other disease processes, such as diabetic neuropathy,
polyradiculopathies, and amyotrophic lateral sclerosis
Ligamentum flavum hypertrophy (contributes to stenosis)
Tumors Nonoperative Treatment of Lumbar
Infections
Figs. 76 and 77 are MRI studies of a patient with
Spinal Stenosis
extensive degenerative changes. Although studies reveal that patients with symptomatic
spinal stenosis have improved outcome with surgical
intervention, patients with mild symptoms and those
Computed Tomography and Computed
who refuse surgery may benefit from conservative
Tomography Myelogram treatment (Johnsson et al. 1991).
Computed tomography (CT) myelogram is still useful in Pharmacologic therapyAttempts to decrease pain and
patients unable to obtain MRI (brain aneurysm clips, nerve irritation or inflammation
metal shavings in the eye, large body habitus, occasionally Anti-inflammatories (nonsteroidal anti-inflammatory

severe claustrophobia, and some postfusion patients with drugs or salicylates)


instrumentation). Steroid dose packs (controversial but may decrease
CT and CT myelogram are both sensitive for spinal symptoms)
stenosis, lateral recess stenosis, and disk herniations. Antidepressants (occasionally)

Table 73: Differential Diagnosis of Physical Findings*

TEST NEUROGENIC CLAUDICATION VASCULAR CLAUDICATION LUMBAR SPONDYLOSIS


Neurologic examination Occasionally abnormal, usually asymmetric Rarely abnormal; symmetric finding if present Normal
Straight leg raise Rarely positive Negative Negative
Femoral stretch Rarely positive Negative Negative
Pulses Present or symmetrically diminished Diminished or absent; often asymmetric Symmetric
Skin Normal appearance Hair loss Normal appearance

*
(Adapted from Herkowitz et al. 1999.)
88 Spine Core Knowledge in Orthopaedics

Endplate
sclerosis
Endplate
osteophyte

Facet
osteophyte

Dark space
narrowing Disk space
narrowing

Figure 75: Lateral lumbar spine plain film. Reveals disk


Figure 74: AP x-ray film. A lumbar spine with degenerative space narrowing, facet hypertrophy, facet degeneration with
scoliosis, degenerative disk disease, and endplate osteophytes. osteophytes, and neuroforaminal encroachment.

Narcotics (avoid if possible because of the risk of


dependence)
Surgical Treatment
Muscle relaxants Indications for surgical intervention include radicular
Injection therapy pain or neurogenic claudication with MRI or CT
Steroid (Depo-Medrol) injections into the epidural myelogram revealing stenosis in the same distribution as
space may benefit those with radicular components to the patients symptoms in a patient who fails to improve
their stenosis. with nonoperative treatment.
This therapy is given in a series of three injections. The goals of surgery are pain relief, increased mobility,
It is relatively easy and safe. prevention of further neurological deficit, and
Physical therapy improvement in the patients quality of life.
Focus on flexion exercises, strengthening, and Appropriate medical clearance should be obtained for all
flexibility of the abdominal muscles and hamstrings. patients over 50 or in younger patients with medical
Cardiovascular training may help the patients overall comorbidities.
health. In decompressions requiring less than 2 operative hours,
Physical therapy may decrease recovery time if the a spinal anesthetic may be used. A general anesthetic is
patient comes to surgery. required for longer cases.
Modalities, such as heat, cold, massage, and
transcutaneous electrical nerve stimulation units, may
Surgical Technique
provide a short-term benefit. Surgical options are dependent upon the following:
Traction, lumbosacral braces, and chiropractic Level of the stenosis
manipulation have no proven long-term benefit. Number of involved segments
CHAPTER 7 Cervical, Thoracic, and Lumbar Degenerative Disk Disease 89

Lateral
recess
stenosis

Central stenosis

Loss of
epidural fat

Foraminal
stenosis

Disk space
narrowing

Figure 77: Axial MRI revealing central and lateral recess


stenosis.

Figure 76: Sagittal MRI. Reveals foraminal stenosis caused


by facet hypertrophy and disk herniation.
Most authors show more than 85% of good to excellent
results following decompressive lumbar laminectomy.
Hansraj et al. reported 95% patient satisfaction in 103
cases (Hansraj et al. 2001).
Location of the stenosis (central, lateral, or Katz et al. revealed progressive return of symptoms in
foraminal) many patients, with 23% requiring revision surgery from
Associated deformities (degenerative spondylolisthesis 7 to 10 years later (Katz et al. 1996).
or degenerative scoliosis)
Presence of instability Decompression with Fusion
In general, stable spines require only decompression. The goal is to decompress neural elements and to
Unstable spines may also require fusion. decrease mechanical back pain.
Fusion is recommended when there is stenosis in
Surgical Options for Decompression conjunction with the following conditions.
(see Fig. 78) Unstable Degenerative Scoliosis or Kyphosis
Central stenosisThis requires decompressive lumbar Only curves of a certain magnitude, or unstable curves or
laminectomy for adequate decompression. progressive curves, require fusion.
Lateral recess and foraminal stenosisIf there is no If proceeding with fusion, the need for realignment is not
central stenosis, the surgeon may perform decompression established.
through one or several laminotomies, decompressing Relative indications for fusion are as follows:
individual roots; some prefer this procedure for bilateral Progressive curves
single-level and ipsilateral two- or three-level radicular Curves greater than 20 degrees
symptoms to preserve the midline structures. Painful curve with back pain
90 Spine Core Knowledge in Orthopaedics

Figure 78: Flow chart for the surgical treatment of spinal stenosis. (Reproduced from Sengupta et al. 2003.)

Loss of sagittal balance and lumbar lordosis Iatrogenic Instability Following


Lateral listhesis in the side bending film
Flexible curves
Decompression
Patients with radicular symptoms on the concave side Abumi et al. revealed that the removal of greater than
of the curve 50% of both facets at one level led to instability (Abumi
et al. 1990).
Degenerative Spondylolisthesis Most believe that the removal of either one complete
Herkowitz and Kurz, in a prospective randomized trial, facet or up to 50% of both facets at a given level is
reported in 1991 better outcomes in patients who had acceptable.
concomitant degenerative spondylolisthesis and If these limits are exceeded, fusion of the affected levels is
underwent a fusion than in those who had recommended.
decompressions alone (Herkowitz et al. 1991).
In 1997, Fischgrund et al. performed a randomized Recurrent Same Level or Adjacent Level
prospective trial.They showed that instrumenting lumbar
fusions increased fusion rates (45% to 83%) but that there
Stenosis (Revision Decompressions)
was no significant difference in the clinical outcome of Herno et al. recommended fusion with instrumentation
the patients (Fischgrund et al. 1997). after decompression at previously decompressed levels
Bridwell et al. studied 44 patients with stenosis and because further decompression of the facets may lead
degenerative spondylolisthesis.They found better fusion to increased instability of the motion segment (Herno
rates and better functional outcomes in those who et al. 1995).
underwent instrumentation compared with those who Sengupta and Herkowitz recommended, in the absence
did not (Bridwell et al. 1993). of instability and when no significant facet excision is
CHAPTER 7 Cervical, Thoracic, and Lumbar Degenerative Disk Disease 91

necessary, that adjacent level stenosis may be treated with


decompression alone; otherwise, fusion is indicated
(Sengupta et al. 2003).
Fig. 78 is a flow chart for patients with degenerative
lumbar spine stenosis.

Postoperative Care
Patients remain in the hospital for 1-3 days after an
operation.
All patients should have sequential compression
devices and thigh-high thromboembolic deterrent
stockings to prevent deep venous thrombosis and
pulmonary embolus; Anticoagulants are avoided by
Figure 79: Schematic of the anatomic positions of the
some surgeons because of the increased risk of uncovertebral and facet joints. (Reproduced from Brower RS
epidural hematoma. 1999.)
Patients ambulate on the day of surgery.
Physical therapy may be initiated for education and gait
training. Men have a slightly higher incidence of cervical disk
Patients should be discouraged from bending, twisting, degeneration, and they tend to have more severe
squatting, and lifting for six weeks. degeneration than women.
After six weeks, outpatient therapy may be instituted for
abdominal and low back strengthening, cardiovascular
Symptoms
conditioning, and stretching. Symptoms of cervical spondylosis are usually chronic or
Also at six weeks, patients may begin a slow progression subacute in nature in contrast to herniations, which are
to full activities. usually acute in nature.
Patients will often have axial neck pain and stiffness.
Radiating arm pain, weakness, and numbness
Cervical Spondylosis occurs most often in the C5, C6, and C7
Cervical spondylosis refers to the degeneration of the distributions.
cervical spine intervertebral disks and may result in
radiculopathy or myelopathy.
Differential Diagnosis
Cervical spondylosis (Table 74 differentiates cervical
spondylosis from cervical disk herniation)
Anatomy Disk herniation
Cervical spine anatomy Cervical strain or mechanical pain
Each motion segment in the subaxial cervical spine Tumor
consists of five joints: the intervertebral disk space, Multiple sclerosis
two facets, and two false uncovertebral joints (joints of Amyotrophic lateral sclerosis
Luschka). Guillain-Barr syndrome
Impinging osteophytes may form at each of these Nerve entrapment syndromes
joints, and synovial cysts may form at the facets, all Thoracic outlet syndrome

of which may impinge upon the surrounding


neurologic structures.
Fig. 79 shows a typical cervical vertebra. Note the Table 74: Cervical Spondylosis versus Disk
relationship between the facet joint and the Herniation
uncovertebral joint.The cervical nerves exit between
these two joints and may be impinged by osteophytes CONDITION CERVICAL SPONDYLOSIS DISK HERNIATION
from either structure.
Age >50 <50
Sex Male > female Male = female
Diagnostic Tools Onset Insidious Acute
Pain location Neck and arm Arm
History Neck stiffness Yes No
Weakness Yes Yes or no
AgeDegeneration in the cervical spine usually becomes
Myelopathy More common Less common
radiographically apparent in the fourth or fifth decade Dermatomes One or multiple One
and becomes more prevalent with increasing age.
92 Spine Core Knowledge in Orthopaedics

Brachial plexopathy or neuritis Use swimmers view if the initial films do not show the
Pronator syndrome C7-T1 junction.
Anterior interosseous nerve syndrome Evaluate overall alignment; those with spondylosis will
Carpal tunnel syndrome often have loss of lordosis or spondylolisthesis.
Ulnar nerve compression (cubital tunnel or Guyons Evaluate for degenerative disk disease and disk space
canal) narrowing on the laterals.
Radial nerve compression The obliques reveal the foramen, and they should be
Long thoracic nerve compression evaluated for stenosis.
Suprascapular nerve compression Figs. 710 and 711 are plain films illustrating
degenerative changes in the cervical spine.
Physical Examination and Signs Magnetic Resonance Imaging
(Table 75) MRI is the best modality for imaging the cervical spine.
Decreased range of motion for the neck Axial and sagittal sections should be obtained.
Dermatomal numbness and weakness (most commonly Evaluate the space available for the cord; less than
C6-C7) 13 mm is relative stenosis and less than 10 mm is critical
Diminished reflex stenosis.
Myelopathy MRI is excellent for viewing the following:
Wide, ataxic gait pattern Herniated disks
Poor hand dexterity Degenerative disk disease and spur formation
Weakness Facet arthritis and spur formation
Lhermittes phenomenaA sensation of electric shocks Uncovertebral joint degeneration and spur formation
radiating down the arms when axial pressure is applied to Nerve root impingement
the head Cord compression or impingement
DysdiadochokinesiaLoss of coordination and Myelomalacia
dexterity of the hands, especially during rapid Tumor

movements Infection
Bowel or bladder dysfunction Syrinx and other cord pathology
Hyperreflexia Figs. 712 and 713 are sagittal and axial MRI photos
Positive Babinskis signExtension of great toe when showing degenerative disk disease, spur formation, nerve
plantar foot is stimulated root impingement, and cord compression.
Positive Hoffmans signFlicking the distal phalanx
of the middle finger causes the thumb to adduct Myelography and CT Myelography
Diminished proprioception Modality of choice for those who cannot undergo an MRI
Good for postoperative imaging if hardware was placed
Imaging AdvantagesGood patient tolerance, excellent imaging
of the cervical spine, and may be performed in many
Plain Films situations in which an MRI is contraindicated
This cervical spine series includes an AP view, a lateral DisadvantagesInvasive, requires a dye load, requires
view (neutral, flexion, and extension views), obliques, and radiation, difficult for those with a large body habitus,
an open mouth view. and difficult for patients with claustrophobia

Table 75: Physical Examination Findings by Level

ROOT LEVEL PAIN LOCATION MUSCLE WEAKNESS REFLEX NOTES


C2 Occipital region None None Very rare
C3 Posterior neck, ear None None Uncommon
C4 Base of neck, medial shoulder None None Uncommon
C5 Base of neck, top of shoulder, Deltoid, some biceps weakness None or biceps Difficult to distinguish from
lateral upper arm cuff tear
C6 Base of neck, anterior arm, Wrist extensors, biceps Biceps Most common
lateral forearm, radial hand
C7 Middle finger, posterior arm, Triceps Triceps Common
posterolateral forearm
C8 Ulnar hand Finger flexors, intrinsics None Uncommon
CHAPTER 7 Cervical, Thoracic, and Lumbar Degenerative Disk Disease 93

Uncovertebral
joint
degeneration

Posterior
endplate
osteophyte
Disk space
narrowing Disk
space
narrowing

Figure 710: AP of a cervical spine with advanced Figure 711: Plain film of the lateral cervical spine. Illustrates
degenerative changes. extensive degenerative disk disease and loss of lordosis.

Stenotic region
secondary to
anterior and
posterior Narrow central
impingement stenosis due to
endplate osteophytes

Anterior stenosis
from endplate
osteophytes and Lateral stenosis
disk protrusion with nerve root
impingement

Figure 712: Sagittal MRI of the cervical spine revealing Figure 713: Axial MRI through a portion of the cervical
multilevel stenosis. spine. Reveals central and foraminal stenosis.
94 Spine Core Knowledge in Orthopaedics

Note that for cervical spondylotic myelopathy, surgery


Electromyogram may not improve neurologic function but is aimed at
Unlike lumbar spinal stenosis, the electromyogram preventing a progressive deficit.
(EMG) plays a role when evaluating cervical stenosis or Appropriate medical clearance should be obtained.
radiculopathy. A general anesthetic is required.
EMG is useful for including or excluding peripheral
neuropathies and central causes of weakness when the Surgical Options for Cervical
diagnosis is not clear.
Decompression
Nonoperative Treatment Anterior cervical discectomy and fusion with or without
Nonoperative treatment of cervical spondylosis without instrumentation
myelopathy will frequently improve or completely resolve Anterior cervical corpectomy and fusion with
neck pain and radiculopathy. instrumentation
In general, patients with myelopathy are surgical Laminaplasty
candidates; nonoperative treatment is of limited value. Laminectomy
GoalsDecrease pain and improve function Laminectomy and fusion with or without
Physical therapythe mainstay of nonoperative instrumentation
treatment, it should be performed 2-3 times per week for A combination of the preceding options
4-6 weeks The surgical technique of choice depends upon the level
Range of motion exercises or levels involved, the number of levels involved, the
Progressive resistance training presence of central canal stenosis, the presence of
Modalities (heat, ultrasound, and massage) foraminal stenosis, and other associated factors such as
Home exercise education spondylolisthesis, kyphosis, instability, and ossification of
Medical treatment the posterior longitudinal ligament (OPLL).Table 76
Anti-inflammatoriesNonsteroidal anti-inflammatory analyzes the various techniques.
drugs and celecoxib cyclooxygenase-2 inhibitors are
useful for decreasing the inflammation around the
Anterior Cervical Discectomy and Fusion
entrapped nerve root or roots; a regular dosing Cloward (1958) and Smith and Robinson (1958)
protocol should be instituted. independently described techniques of anterior cervical
Narcotics should be avoided except for limited use in discectomy and fusion in 1958.
acute flare-ups. The Smith-Robinson technique entails using a

Antidepressants may be necessary for emotionally tricortical iliac crest bone graft to lever open the disk
depressed patients with chronic cervical spine space and, thereby, indirectly decompressing the neural
conditions. foramina; the osteophytes then resorb over time.
Muscle relaxants have been shown to have some Cloward recommended manually removing impinging
benefit when there is a component of cervical osteophytes, removing a central core of bone from
muscle spasm; however, sedatives should be avoided adjacent vertebral bodies, and replacing it with a
because of their high risk for the development of similar sized and shaped iliac crest bone graft.
dependency. Today, many surgeons perform a direct decompression

Chiropractic care may be contraindicated; it has not been and fuse with a Smith-Robinsontype bone graft.
proved to be of any long-term benefit. There has been no definitive study showing an autograft
to be superior to an allograft; in single-level surgery, the
allograft is becoming more popular based upon favorable
Surgical Treatment of Cervical
fusion rates and the lack of donor site morbidity.
Spondylosis Allografts may be fibular wedge, tricortical iliac wedge, or
Indications for surgical intervention include the patellar wedge.
following: Some studies have shown that discectomy alone, without
Failed nonoperative treatment of radiculopathy fusion, is adequate for single-level disease in the
(minimum 3 months) treatment of cervical radiculopathy but that it leads to
Progressive neurologic deficit long-term neck pain (Maurice-Williams et al. 1996).
Presence of myelopathy Use of instrumentation is also controversial; no study has
Unrelenting pain shown a definitive long-term benefit for instrumenting
Goals include pain relief, improved function, and single-level fusion; two-level or more fusions should
prevention of further neurologic deficit. usually be instrumented.
CHAPTER 7 Cervical, Thoracic, and Lumbar Degenerative Disk Disease 95

Table 76: Techniques for Cervical Spondylosis Decompression

SURGERY* INDICATIONS CONTRA-INDICATIONS ADVANTAGES DISADVANTAGES INSTRUMENTATION


ACDF Single- or two-level Three-level or more stenosis Safe, well-tolerated Risk of pseudarthrosis +/ for single level
radiculopathy Good long-term results
Instability (single level)
ACCF Broad areas of stenosis Isolated foraminal Common procedure Risk of vertebral artery injury Yes
(multilevel OK) stenosis Excellent anterior and Risk of iatrogenic instability
Instability foraminal Risk of graft extrusion
Deformity (including decompression Pseudarthrosis
swan neck)
Kyphosis
Laminaplasty Long area of canal Instability Maintains stability C5 palsy No
stenosis
OPLL Kyphosis Long decompressions
Buckled ligamentum
flavum
Laminectomy Long area of canal Kyphosis Long decompressions C5 palsy Yes or no
stenosis
Degenerative anterior Instability Best surgery for those with May create instability
ankylosis anterior ankylosis

*
ACDF, anterior cervical discectomy and fusion; ACCF, anterior cervical corpectomy and fusion.

Anterior Cervical Corpectomy and Fusion Laminaplasty


(ACCF) Laminaplasty has become more popular because of the
Areas of spondylotic change may result in cervical lower incidence of postoperative kyphosis when
myelopathy. compared with laminectomy.
If the canal is congenitally narrow, there is a broad area GoalsDecompress the spine while maintaining cervical
of cervical stenosis; if there is OPLL, ACCF is indicated spine stability
because it allows wider decompression. IndicationsMyelopathy caused by degenerative stenosis,
Anterior stabilization of the cervical spine OPLL, or multilevel spondylotic myelopathy
following anterior corpectomy requires the placement ContraindicationsPresence of kyphosis
of a strut graft (an iliac crest autograft or allograft Types of laminaplasty include the Z-plasty and the open
or a fibular autograft or allograft) (Bernard et al. door laminaplasty, which has many modifications.
1987). A long-term follow-up study found that postsurgical
improvement was relatively maintained after almost
Complications of the Anterior Approaches 13 years (Miyazaki et al. 1996). Subsequent studies have
Pseudarthrosis questioned the maintenance of improvement for those
Graft dislodgement, resumption, or collapse with OPLL (Kawai et al. 1998).
Dysphasia
Hoarseness Laminectomy
Vertebral or carotid artery injury GoalDecompress the spine
Neurologic injury, including injury to the recurrent IndicationsSimilar to those for laminaplasty, especially
laryngeal nerve in the presence of anterior ankylosis
Iliac crest donor site morbidity (infection, hematoma, ContraindicationsKyphosis
pain, lateral femoral cutaneous nerve palsy, bowel Biomechanical alterations may result in cervical spine
herniation, or iliac wing fracture) instability following laminectomy and concomitant fusion.
Hardware complications (pull out or screw
breakage) Complications of the Posterior Approaches
Dural tears Neurologic deficit
Inadequate decompression Redevelopment of stenosis
Esophageal or tracheal injury Instability after laminectomy because of kyphosis
Respiratory embarrassment caused by hematoma C5 nerve root palsy can occur; when the spinal cord
formation migrates posteriorly, the C5 root can be stretched,
96 Spine Core Knowledge in Orthopaedics

resulting in shoulder pain and possibly deltoid or biceps J, Mackay M, Herkowitz H et al. (1997) Degenerative lumbar
weakness. The palsy usually has a decent recovery spondylolisthesis with spinal stenosis: A prospective, randomized
within 1 year. study comparing decompressive laminectomy and arthrodesis with
and without spinal instrumentation (1997 Volvo Award winner in
Postoperative Care clinical studies). Spine 22: 2807-2812.
This was a prospective, randomized study of 66 patients with
Patients generally remain hospitalized for at least one
degenerative lumbar spondylolisthesis and spinal stenosis who
evening and longer for more extensive procedures. underwent decompressive lumbar laminectomy with fusion
A rigid cervical collar is often used for all anterior fusions either with or without instrumentation. At a follow-up after
greater than one level and is often replaced with a soft 2 years, the fusion rate was much higher in instrumented
collar for single-level cases with instrumentation. patients, 82% versus 45%, but successful fusion did not
However, if no instrumentation is used for a single-level significantly improve back or leg pain.
fusion, a rigid collar should be prescribed.
Cloward RB. (1958) The anterior approach for removal of ruptured
For anterior approaches, the head of the hospital bed cervical disks. J Neurosurg 15:602617.
should be elevated at least 30 degrees for the first
24 hours to help prevent hematoma formation. Hansraj K, Cammisa F, OLeary P et al. (2001) Decompressive
Regular neurologic examinations should be performed. surgery for typical lumbar spinal stenosis. Clin Orthop 10-17.
The authors evaluated 103 consecutive patients who underwent
Patients should be advised against bending or twisting
decompressive laminectomy for typical lumbar spinal stenosis.
their head, heavy lifting, strenuous activity, and overhead
Patients younger than 65 had greater improvement in function
activity. and severity scores, but overall satisfaction was similar in both
Rigid collars should be discontinued by 6 weeks after the groups. Only 5% required revision surgery.
operation, and outpatient physical therapy for range of
motion and strengthening should be started. Herkowitz HN, Garfin SR, Balderston RA et al. (eds.) (1999) In:
Rothman-Simeone:The Spine, 4th edition. Philadelphia: Saunders.
Patients may begin to slowly advance to regular activities
at the 6-week mark. Herkowitz H, Kurz L. (1991) Degenerative lumbar spondylolisthesis
with spinal stenosis: A prospective study comparing decompression
with decompression and intertransverse process arthrodesis. J Bone
References Joint Surg (Am) 73: 802-808.
Abumi K, Panjabi M, Kramer K et al. (1990) Biomechanical This prospective, randomized study looked at 50 patients who
evaluation of lumbar spinal stability after graded facetectomies. underwent either decompression alone or decompression with
Spine 15: 1142-1147. posterolateral fusion without instrumentation.The patients were
Fresh human lumbar spines were biomechanically evaluated followed for approximated 3 years, and results showed improved
following unilateral facetectomy, bilateral facetectomy, unilateral back and leg pain relief in the group that had concomitant
medial facetectomy, or bilateral medial facetectomy.Testing arthrodesis.
revealed that medial facetectomy (unilateral or bilateral) did not Herno A, Airaksinen O, Saari T et al. (1995) Surgical results of
affect lumbar spinal stability. Conversely, either unilateral or lumbar spinal stenosis: A comparison of patients with or without
bilateral complete facetectomy rendered the lumbar spine unstable. previous back surgery. Spine 20(8): 964-969.
Bernard T,Whitecloud T. (1987) Cervical spondylitic myelopathy This retrospective study revealed that patients undergoing
and myeloradiculopathy: Anterior decompression and stabilization revision surgery for recurrent spinal stenosis had a significantly
with autogenous fibula strut graft. Clin Orthop 221: 149-160. worse outcome than those undergoing a primary procedure. Of
Twenty-one patients were followed for an average of 32 months those undergoing a primary procedure, 67% stated excellent to
after having anterior decompression and fusion with autogenous good results versus 46% of those undergoing revision surgery.
fibular strut graft. Of the 21 patients, 16 showed functional Johnsson KE, Uden A, Rosen I. (1991) The effect of decompression
improvement.The authors recommend fibular strut autograft on the natural course of spinal stenosis: A comparison of surgically
over iliac crest autograft because of the excellent structural treated and untreated patients. Spine 16: 615.
stability afforded by the fibular strut and high union rates. Nineteen patients with spinal stenosis were treated without
Bridwell K, Sedgewick T, OBrien M et al. (1993) The role of fusion surgery and were compared with a cohort of 44 patients treated
and instrumentation in the treatment of degenerative spondylolisthesis surgically with decompression at follow-up times of 31 and
with spinal stenosis. J Spinal Disorders 6(6): 461-472. 53 months. Of the patients who elected surgery, 60% felt better
Forty-four patients with degenerative spondylolisthesis underwent based on a visual analog scale versus only 33% of those treated
decompressive lumbar laminectomy. Of those patients, 9 did not without surgery. No proof of deterioration was found in the
have a fusion performed, 11 underwent concomitant posterolateral untreated patients.
fusion, and 18 had fusions with instrumentation. The group with
Katz J, Lipson S, Chang L et al. (1996) Seven- to ten-year outcome
fusion and instrumentation had a significantly better fusion rates
of decompressive surgery for degenerative lumbar spinal stenosis.
than those without instrumentation.
Spine 21: 92-98.
Brower RS. (1999) Cervical disk disease. In:The Spine (Herkowitz This study was a retrospective review of 88 patients who had
HN et al. eds.), 4th edition. Philadelphia:W.B. Saunders. Fischgrund decompressive laminectomies with or without fusion. A 7- to
CHAPTER 7 Cervical, Thoracic, and Lumbar Degenerative Disk Disease 97

10-year follow-up revealed that 23% required reoperation and some improvement and almost 65% had good or excellent
33% complained of severe back pain but that 75% were satisfied results.
with the results of surgery.
Rothman RH, Simeone FA. (1982) The Spine, 2nd edition.
Kawai S, Sunago K, Doi K et al. (1988) Cervical laminaplasty Philadelphia: Saunders.
(Hattoris method): Procedure and follow-up results. Spine 13: 1245.
Schnebel B, Kingston S,Watkins R et al. (1989) Comparison of
This paper describes the Z-shaped laminaplasty developed by
MRI to contrast CT in diagnosis of spinal stenosis. Spine 14:
Hattori in 1971 and provides a follow-up for 78 patients who
332-337.
received the procedure. Satisfactory results were maintained for
A retrospective review of MRI and CT scans from 41 patients.
long periods.
The studies were reviewed by a single, blinded examiner and
Maurice-Williams R, Dorward N. (1996) Extended anterior were evaluated for stenosis (central and lateral) and disk disease.
cervical discectomy without fusion: A simple and sufficient Results showed a 96.6% correlation between CT and MRI for
operation for most cases of cervical degenerative disease. evaluating stenosis, but MRI revealed disk disease almost three
Br J Neurosurg 10: 261-266. times more often than CT.
This retrospective review evaluated 187 patients who had been
Sengupta D, Herkowitz H. (2003) Lumbar spinal stenosis:Treatment
treated by extended anterior discectomy without fusion for
strategies and indications for surgery. Orthop Clin N Am 34:
cervical radiculopathy or myelopathy. Of the patients, 94.5%
281-295.
showed clear neurologic improvement and only 1% complained
This is a review article evaluating the diagnosis and treatment
of persistent neck pain.
from lumbar spinal stenosis.
Miyazaki K, Hirohuji E, Ono S et al. (1986) Extensive simultaneous
Smith G, Robinson R. (1958).The treatment of certain cervical
multisegment laminectomy for myelopathy due to the ossification
spine disorders by anterior removal of the intervertebral disc and
of the posterior longitudinal ligament of the cervical region. Spine
interbody fusion. J Bone Joint Surg 40A: 607-624.
11(6): 531-542.
The study followed 155 patients who underwent multilevel Wiesel SW, Bernini P, Rothman RH. (1982) The Aging Spine.
laminectomies for the treatment of OPLL. In all, 81.9% showed Philadelphia: Saunders.
8

CHAPTER
Surgical Management of Low
Back Pain
Brian K. Kwon*, Eric Levicoff , and Alexander R.Vaccaro

* M.D., FRCSC; Orthopaedic Spine Fellow, Department of Orthopaedic Surgery,Thomas The decision is
Jefferson University and the Rothman Institute, Philadelphia, Pa.; Clinical Instructor,
Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia; more important
and Gowan and Michele Guest Neuroscience Canada Foundation/CIHR Research Fellow,
International Collaboration on Repair Discoveries, University of British Columbia,
than the
Vancouver, Canada incision.
M.D., Orthopaedic Surgery Resident, University of Pittsburgh Medical Center, Pittsburgh, PA
M.D., Professor of Orthopaedic Surgery, Thomas Jefferson University and the Rothman
Institute, Philadelphia, PA

Lumbar fusion for discogenic pain or lumbar laminectomies


Introduction for radicular symptoms are the most common spine
Low back pain is an extremely common source of surgeries performed; both have had estimated failure rates of
disability worldwide, with an enormous societal and between 15% and 40% (Turner et al. 1992).
health care effect (Frymoyer 1996) (Box 81).
More than 14% of all new-patient visits to physicians are
for problems related to the lower back, and the lifetime Clinical Etiologies of Low Back
incidence of low back pain in the general population has
been estimated at nearly 70%.
Pain
Low back pain ranks only behind upper respiratory The etiologies of low back pain are extremely diverse.
infections as the most common cause of work absence. Idiopathic or NonspecificUp to 85%, with no
Low back pain is the fifth most common cause of specific diagnosis, although the validity of this
hospitalization and the third most common reason for categorization has been recently questioned (Abraham
surgical procedures in the United States, with an estimated et al. 2002)
economic effect of between $25 and $85 billion annually. Degenerative disk diseaseA large category that
As the natural history of low back pain is generally includes discogenic pain, disk herniation, and
favorable, surgery is seldom offered as an initial treatment degenerative scoliosis
option. DevelopmentalFor example, isthmic
Despite this, approximately 165 lumbar spine operations per spondylolisthesis and idiopathic scoliosis
100,000 individuals occur each year in the United States, a CongenitalFor example, scoliosis secondary to
rate that has been estimated to be more than 5 times that of failures of formation and segmentation
England and Scotland (Cherkin et al. 1994). Traumatic

98
CHAPTER 8 Surgical Management of Low Back Pain 99

InfectiousFor example, osteomyelitis and discitis


Box 81: Risk Factors for Low Back Pain InflammatoryFor example, ankylosing spondylitis
Previous history of low back pain and other spondyloarthropathies
Increasing age NeoplasticBenign, primary malignant, and
Smoking metastatic
Medical comorbidities MetabolicOsteoporosis
Lower socioeconomic status ReferredDissecting aortic aneurysm, renal vein
Psychological distress thrombosis, acute myocardial infarction, pancreatitis,
Heavy occupational demands and duodenal ulcer
In general, the outcomes of operative intervention for the
Red Flags in the Clinical Presentation idiopathic or nonspecific category of patients are
Box 82: unsatisfactory because patients within this category
That Require Further Investigation
inherently lack a firm diagnosis.The remaining spinal
History of significant trauma etiologies can, under certain circumstances, mandate
History of previous malignancy surgical intervention.
Ageolder than 50 years Although most patients have mechanical low back pain
Systemic symptomsfever, chills, anorexia, and recent weight that requires little investigation, there are certain
loss red flags in the clinical presentation that mandate
Severe or progressive neurologic deficit, particularly saddle anes- further careful evaluation (Box 82).
thesia, bowel or bladder dysfunction, and multiroot deficits
Ongoing infection
History of immunosuppression (corticosteroids, immunosuppres- Diagnostic Tools
sant use, and HIV)
The key to successful outcomes after surgery for low
back pain is to first establish a pathoanatomic diagnosis
with an understanding of the components of the low
back that can cause pain (Box 83).

Box 83: What Structures Are Sources of Pain in the Lumbar Spine?
As surgery is largely an exercise in anatomic modification, it is useful to at least conceptually understand the anatomic components of the lum-
bar spine thought to contribute to the generation of pain signals.
Intervertebral Disks
This is thought to be the primary pain generator in the setting of degenerative disk disease.
Pain fibers have been demonstrated in the outer third of the anulus fibrosus but not in the deeper anulus or nucleus pulposus.
A variety of biochemical factors are found in the disk that can mediate painful stimuli, including prostaglandins, lactic acid, and substance P.
During the process of disk degeneration, nerve ingrowth has been observed to occur into the deeper aspects of the anulus fibrosus and even
into the nucleus. It is thought that this expansion of sensory innervation within degenerative disks may significantly contribute to low back pain.
Facet Joints
The facet joint capsule is extensively innervated with pain fibers that can be activated by pressure and stretch and sensitized by inflammatory
mediators.
The synovial folds of the joint lining also possess pain fibers.
Also present are several types of proprioceptive nerve endings thought to mediate protective muscular reflexes.
Musculoligamentous Structures
Both the anterior and posterior longitudinal ligaments possess sensory innervation; in particular, the PLL has been found to have substance P
containing fibers.
Unencapsulated nerve fibers are found in the paraspinal musculature; these may respond to metabolites accumulated during prolonged muscle
contraction or spasm.
Neural Structures
Pain from mechanical nerve root compression is thought to require the presence of inflammation.
The dorsal root ganglion itself has been shown to be extremely responsive to both direct pressure and vibratory forces. An increase in the genetic
expression of neuropeptides such as substance P or other inflammatory mediators in response to mechanical nerve root compression may be an
important element of increased pain signaling.
100 Spine Core Knowledge in Orthopaedics

Many diagnostic tools are available, but to use them


Box 84: Neurophysiology of Low Back Pain
effectively you must recognize both the advantages and
limitations of each. Though much research has been done recently on the neurophys-
Unfortunately, because of our incomplete understanding iology of pain in the lumbar spine, it is still relatively poorly
of the pathophysiology of low back pain (Box 84), understood (Cavanaugh 1996).
arriving at a conclusive diagnosis is not possible in as Painful stimuli are mediated by one of two nerve types, both with
many as 85% of patients who are categorized as having unencapsulated endings:
idiopathic low back pain (Deyo 2002).You must resist 1. Small, myelinated (A-delta) fibers
the temptation to offer such individuals an operation. 2. Unmyelinated C fibers
It is assumed that structures containing either of these nerve
Not unlike the rest of clinical medicine, a thorough
types have the capacity to cause pain. Many elements of the lum-
history and detailed physical examination are the most bar spine contain such pain fibers.
important diagnostic tools. The recurrent sinuvertebral nerve is thought to be an important
Plain X-ray Film sensory nerve for transmitting painful stimuli from pain fibers
within the anulus and the posterior longitudinal ligament.
At a low cost, plain x-ray films provide a tremendous The threshold at which these pain fibers are stimulated is nor-
amount of information about the general anatomy of the mally quite high.
vertebral bodies, spinal alignment, bone quality, and disk Inflammatory biochemical factors such as bradykinin, histamine,
height. substance P, prostaglandins E1 and E2, and leukotrienes lower
Flexionextension films are used frequently to this threshold, thus promoting pain transmission.
demonstrate dynamic instability, particularly among
This biochemical sensitization of pain fibers is likely a key com-
ponent of back pain. Also, the increased ingrowth of pain fibers
degenerative motion segments (Fig. 81).Their role in
into structures of the lower back may contribute to low back pain.
the routine evaluation of low back pain is limited. Lateral Individual differences in this phenomenon of nerve ingrowth and
bending films are useful in the preoperative planning of sensitization might explain why some people with degenerative disk
adult scoliosis patients undergoing corrective surgery. disease in their lower back have severe pain but others do not.
Oblique x-ray films may be helpful in evaluating
integrity of the pars intra-articularis in the setting of
spondylolisthesis.

Figure 81: Lateral standing flexion x-ray films of the lumbar spine to detect dynamic instability. Notice that
the patient has a subtle anterolisthesis of L3 on L4 when standing in the neutral position (shown by the white
arrow), suggestive of a mild degree of instability at this level. The extent of the dynamic instability, however, is
more clearly delineated on the flexion view (note the increase in anterolisthesis, indicated by the black arrow).
CHAPTER 8 Surgical Management of Low Back Pain 101

For the patient who has new onset low back pain but
does not have any of the red flags, lumbar spine films
have been viewed as unnecessary for at least 4 weeks
(Andersson 1998).
Computed Tomography
Computed tomography (CT) provides excellent
visualization of the bony anatomy of the vertebral
column.
Soft tissue windows and the use of intravenous contrast
can help with the delineation of disk material, but soft
tissues are generally better visualized with magnetic
resonance imaging (MRI).
CT myelography is an excellent investigation for
spinal stenosis, rivaling MRI for visualization
(although the invasiveness of myelography is a
substantial drawback).
Magnetic Resonance Imaging
MRI provides excellent axial, coronal, and sagittal
visualization of soft tissues and neural structures both
surrounding and within the vertebral column.
It provides excellent study for evaluating neural
compression within the canal and foramen.
MRI is noninvasive but relatively expensive. Patient
factors such as claustrophobia and ferromagnetic bodies
(e.g., cardiac pacemakers, cochlear implants, and
intracranial aneurysm clips) may make it unsuitable.
The loss of water content within intervertebral disks
during the natural process of disk degeneration
produces a low signal on T2-weighted MRI, a finding
described as the dark disk (Fig. 82). It is important to Figure 82: Isolated degenerative lumbar disk on MRI. On
interpret the MRI findings of dark disks or disk T2-weighted MRI images, water appears bright (hence the
herniations or bulges because they are found in a high bright signal in the thecal sac within the spinal canal). During
percentage of individuals with no previous history of the process of degeneration, the disks lose their water content
and thus appear darker on T2-weighted images. Notice the
low-back pain, sciatica, or neurogenic claudication
dark appearance of the L5-S1 disk in this patient compared
(Boden et al. 1990).
with the appearance of the adjacent levels.
Similarly, the presence of these MRI findings in
asymptomatic patients does not reliably predict the
subsequent development of back pain or root
compression (Borenstein et al. 2001). The use of facet injections to predict surgical outcomes
for patients with low back pain is not supported.
Facet Injections
Facet injections or facet nerve blocks have been
Discography
rationalized by the hypothesis that facet arthrosis The role of provocative discography as a method of
contributes to low back pain; hence joint provoking identifying surgically amenable disk pathology in the
with saline injections or anesthetizing with local setting of low back pain is highly controversial.
anesthetic, steroids, or both might be diagnostic and Discography is performed by introducing a needle into
therapeutic. the nucleus pulposus (Fig. 83). An injection of contrast
Well-designed studies to evaluate the efficacy of facet medium confirms the accurate placement of the needle
injections are rare; only one well-controlled and visualizes internal fissures or tears in the disk that
prospective, randomized trial of methylprednisolone might not be shown with other imaging modalities.The
versus saline injection has been performed with no significance of these morphologic findings is questionable.
demonstrable efficacy for methylprednisolone (Carette An injection of saline to distend the disk and stretch the
et al. 1991). anular fibers is performed to provoke the patients pain.The
102 Spine Core Knowledge in Orthopaedics

A B

C D
Figure 83: X-ray film, discogram, and MRI images of degenerative lumbar disks. Notice the radiographic loss of disk space
height, most marked at L5-S1 but also evident at L4-L5 (A). The discogram (B and C) demonstrates the dye being inserted into
the nucleus pulposus with normal containment at L3-L4 but extravasation at L4-L5 and L5-S1, suggestive of disk disruption at
these levels. Upon injection of the dye, the patient reported concordant pain, which is recorded at the time of the procedure. The
MRI findings (D) correlate with the discogram results, with the L3-L4 disk appearing normal but with dehydration and collapse
at the L4-L5 and L5-S1 levels. Such correlation between MRI and discogram findings strongly suggests an etiologic role of that
particular disk as a source of pain.
CHAPTER 8 Surgical Management of Low Back Pain 103

saline injections reproduction of pain concordant with that ble single-level static or dynamic instability, or both
typically experienced by the patient is thought to be useful (e.g., isthmic or degenerative spondylolisthesis)
for identifying disks that might benefit from fusion.
The combination of concordant pain on discography
with MRI findings of disk degeneration is not Surgical Procedures
confirmatory, but it does strengthen the argument that a The surgical management of low back pain largely
particular disk is a significant component of a patients focuses on spinal fusion.
back pain. Decompression is indicated in the setting of leg pain
It has been suggested that the combination of concordant and nerve root compression (e.g., disk herniations and
discographic pain with MRI findings predicts an spinal stenosis).
increased likelihood for a good surgical outcome after Nucleus pulposus or intervertebral disk
fusion (Gill et al. 1992).This predictive value, however, is replacement are emerging options for low back pain
refuted by others who did not observe the predictive secondary to single-level degenerative disk disease but
effect of positive discography on the surgical outcome are still being investigated.
(Parker et al. 1996).
Furthermore, a retrospective review of 25 patients with Spinal Fusion Principles
single-level degenerative disk disease and positive The basic goal of spinal fusion is to prevent further
discograms who were not operated on demonstrated that segmental motion; hence the objectives of spinal fusion
68% improved with nonsurgical treatment at an average are most appropriate for patients with evidence of spinal
follow-up of 4.9 years, suggesting that the natural history instability (e.g., spondylolisthesis of either an isthmic or a
of such discogenic pain is relatively favorable (Smith degenerative nature).
et al. 1995). Surgical interventions are compelled to The application of spinal fusion to patients with
improve upon this natural history. degenerative disk disease but without gross instability is
based on the perception that low back pain is mediated
by motion among spinal segments. As indicated
General Surgical Indications previously, the disk itself is thought to be a major source
In general, when faced with spinal pathology and trying of this pain (the anterior pain generator), so preventing
to decide if surgical intervention is warranted, adhere to motion across the disk or removing the disk altogether is
basic principles and ask yourself the following: postulated to relieve such discogenic pain.
1. Does this patient warrant an operation for mechani- The keys to attaining a solid arthrodesis include the
cal stability? following:
2. Does this patient warrant an operation for neurologic 1. The meticulous preparation of the graft bed (i.e.,
reasons? decortication to maximize the surface area of cancel-
3. Are there specific patient considerations that lous bone)
influence the decision to operate or which operation 2. Supplementation with an appropriate type and
to perform (e.g., psychological factors, nicotine expo- amount of bone graft materialautograft, allograft,
sure, and expectation of high physical demands)? bone morphogenetic proteins, or bone substitutes
The most difficult treatment decisions are in patients with (Table 81)
degenerative disk disease and low back pain but without 3. Careful consideration of lumbar spine biomechanics
radicular symptoms.Whether surgery has a role in the maintaining correct sagittal alignment and optimally
management of such individuals, and what surgical placing the graft in compression rather than tension
technique to perform, are extremely contentious questions. (Box 85)
Surgical indications proposed for patients with low 4. Optimizing systemic conditions that influence bone
back pain without radicular symptoms include the healingnicotine, corticosteroids, nonsteroidal anti-
following: inflammatory drugs, nutrition, and infection
1. Unremitting pain and disability for more than 1 year Problems with subsequent degeneration of levels adjacent
2. Failure of a lengthy, aggressive trial of physical ther- to fused segments mandate that a minimum number of
apy and nonoperative treatment modalities (nons- spinal levels fused, particularly in younger individuals.
teroidal anti-inflammatory drugs, nonnarcotic It is worth noting that despite the current obsession with
analgesics, local heat or ice, activity modification, and technologies to promote lumbar spine fusion, it has been
weight loss) difficult to definitively prove that the clinical outcomes of
3. Absence of psychiatric disorders and compensation or patients undergoing lumbar spine procedures are
litigation issues significantly improved by the achievement of bony
4. Isolated single-level disk degeneration on MRI with fusion. Although this suggests that patient outcome has
concordant pain response on discography, demonstra- little to do with whether bony ankylosis occurs or not,
104 Spine Core Knowledge in Orthopaedics

Table 81: Choices for Bone Graft in Lumbar Spinal Fusion


TYPE ADVANTAGES DISADVANTAGES
Osteogenic, osteoinductive, and osteoconductive properties Significant donor site morbidity (pain, infection,
fracture, nerve damage during acquisition)
Large trabecular surface provides optimal scaffold for Increased blood loss
bone remodeling Increased operating room time
Autograft No immune response or chance for blood-borne infection Limited amount of available graft material; also,
structural autograft is available only from iliac
crest, fibula, tibia
Historically the most successful and currently the gold standard
against which all bone graft substitutes must be compared
Eliminates the need for autogenous bone graft harvesting Provides osteoconductive scaffold without
osteoinductivity and osteogenicity
Potentially unlimited graft material Small risk of disease transmission
Allograft Structural graft can be acquired from any bone (e.g., femur, Lack of osteogenicity and decreased strength
humerus) Potentially lower fusion rates than with autograft in
Long shelf life the lumbar spine
Prolonged incorporation time
Eliminates the need for autogenous bone graft harvesting Expensive
Bone graft substitutes (both Osteoinductive substances such as the bone morphogenetic Clinical efficacy has only been recently established in
osteoinductive and proteins may equal autograft in their ability to specific conditions
osteoconductive) facilitate fusion Possible inflammatory or immune reaction
Potentially unlimited availability

2. Posterior lumbar interbody fusion (PLIF) with or


Box 85: Biomechanics of the Lumbar Spine
without adjunctive pedicle screw instrumentation
The spinal column is made up of functional motion segments 3. Transforaminal lumbar interbody fusion (TLIF) with
composed of adjacent vertebral bodies articulating with an inter- or without adjunctive pedicle screw instrumentation
vertebral disk anteriorly and facet joints posteriorly (the triple- 4. Anterior lumbar interbody fusion (ALIF)
joint complex). 5. Circumferential (combined anterior and posterior)
Most of the axial load (approximately 80%) is transmitted fusion
through the anterior column of the spine, consisting of the verte- Interbody fusions in which bone graft material is placed
bral bodies, intervertebral disks, and longitudinal ligaments. into the intervertebral space enjoy higher fusion rates
The posterior elements, including pedicles, lamina, facets, trans-
than posterolateral intertransverse process fusions because
verse and spinous processes, and intervening ligaments resist ten-
sile, shear, and rotational forces.
the interbody grafts are placed under compression and
The sagittal alignment of the lumbar spine normally demonstrates the posteriorly placed grafts are subject to more tension.
some degree of lordosismaintaining or restoring this lordosis Interbody fusion devices, however, incur the risk of
during spinal fusion is thought to be an important element of extruding, settling into the endplate, or both with loss of
promoting normal spinal mechanics and function. disk space height.
Successful fusion rates from 75% to 95% have been
reported for each technique, but it is difficult to
the spectrum of disorders subjected to spinal fusion and determine the superiority of one technique over another
the difficulties in determining whether fusion has in terms of promoting fusion for several reasons:
occurred make the literature hard to interpret. 1. Most reports are retrospective reviews of a single institu-
tions experience with one particular fusion technique.
Techniques for Achieving Fusion Few studies have performed comparisons of different
techniques in a prospective randomized fashion.
in the Lumbar Spine 2. Reported fusion techniques have employed wide vari-
Several techniques have been developed and advocated ations in surgical technique, particularly in choices of
for achieving fusion in the lumbar spine. Each has its autograft, allograft, pedicle screw instrumentation sys-
own potential advantages and disadvantages (Table 82). tems, and interbody devices.
In general, the more circumferential the fusion, the 3. Study subjects with low back pain represent a hetero-
higher both the fusion and the complication rate. geneous population, making it difficult to control
Fusion techniques include the following: across studies for variables such as age, symptomatol-
1. Posterolateral intertransverse process fusion with or ogy, radiographic diagnosis, psychological disturbances,
without adjunctive pedicle screw instrumentation and compensation or litigation status.
CHAPTER 8 Surgical Management of Low Back Pain 105

Table 82: Summary of Fusion Techniques


TECHNIQUE ADVANTAGES DISADVANTAGES ADDITIONAL COMMENTS
Posterolateral intertransverse Technically straightforward with Leaves the intervertebral disk intact, allowing Most common method of lumbar fusion
process fusion reasonable fusion rates it to potentially remain a source of pain
instrumentation marginally enhanced by the Posterior approach inflicts damage to the
addition of instrumentation dorsal paraspinal soft tissues
Posterior lumbar interbody Excises much of the disk, thus Access to disk requires significant retraction of Current versions commonly employ pedicle
fusion (PLIF) removing one potential pain neural elements, with resultant radiculopathy screw fixation to enhance the stability of
instrumentation generator secondary to epineural or perineural fibrosis the motion segment and lock the
Places bone graft in compression Wide posterior exposure and anterior discectomy interbody device or graft in place to
Increases disk height potentially destabilizes the motion segment, prevent extrusion
warranting additional pedicle screw fixation
Technically demanding
Incomplete disk excision (compared with ALIF)
Transforaminal lumbar Similar to those of PLIF but Technically demanding In comparative studies, fewer neurologic
interbody fusion (TLIF) approaches the disk more Removes only part of the disk complications than with PLIF
instrumentation laterally, thus requiring less (compared with ALIF)
retraction of neural elements
Near-total disk removal maximizes Risk of catastrophic vascular injury or Classically a low back pain operation
the surface area for bony intra-abdominal injury during approach because it is not designed to address
fusion and allows maximal Risk of damaging autonomic fibers in leg symptomatology
restoration of disk height presacral plexus, leading to retrograde
ejaculation
Anterior lumbar interbody Generally well-tolerated anterior Relative lack of stability because it depends
fusion (ALIF) approach compared with the solely on compressive fit of interbody
posterior exposure device or graft
May be accomplished with Does not reliably decompress neural elements
minimally invasive technology posteriorly, although an increase in disk
Circumferential stabilization space height may provide some indirect
increases fusion rates decompression
Theoretically increased complications and Difficult to determine if the increased
morbidity than a single-stage morbidity is sufficiently offset by the
procedure increased fusion rates to improve
patient function
Circumferential (anterior and Combines the benefits of the
posterior) wide surface area for interbody
fusion (ALIF) with the ability
to decompress and fuse with
instrumentation posteriorly

4. All reports of fusion rates are subject to uncertainty clinical outcome in terms of pain, disability, depressive
regarding the reliability of assessing bony fusion radi- symptoms, and overall satisfaction 2 years after the
ographically. operations (Fritzell et al. 2002).
In general, whether the fusion rate significantly influences Posterolateral Intertransverse Process
the patient outcome after surgery for low back pain is
highly debatable. As a good example of this, a recent Fusion
prospective, randomized comparison was performed using Such a process is a time-honored, straight-forward
222 patients with chronic low back pain that underwent method of promoting fusion among motion segments; it
one of the following: is likely the most common technique for fusion in the
1. Uninstrumented posterolateral fusion lumbar spine.
2. Instrumented posterolateral fusion (with pedicle This fusion, a posterior or a posterolateral muscle-
screws) splitting approach, involves decortication of the transverse
3. Instrumented posterolateral fusion (with pedicle processes, then the laying down of an autogenous bone
screws) and an interbody fusion placed either posteri- graft along the transverse processes (Figs. 84 and 85).
orly (PLIF) or anteriorly (ALIF) The pseudarthrosis rate for single-level uninstrumented
The authors found that although fusion rates increased fusions is estimated to be between 5% and 25%, although
with the more technically demanding procedures (72 %, pseudarthrosis rates as high as 57% have been described
87 %, and 91%, respectively), there was no difference in (Lorenz et al. 1991).
106 Spine Core Knowledge in Orthopaedics

Figure 85: Radiograph of a solid posterolateral


uninstrumented fusion. This AP x-ray film of a posterolateral
Figure 84: Schematic of posterior lumbar spine approach and uninstrumented L4-L5 fusion demonstrates full incorporation
uninstrumented posterolateral fusion. The posterior approach of the bone graft between the transverse processes (white
(A) requires dissection of the paraspinal musculature off the arrow). Unfortunately, this degree of incorporation is not
posterior elements of the spine out enough far enough to always present, often making it difficult to determine whether
expose the transverse processes. It is important to visualize the fusion has successfully occurred.
transverse processes laterally because these need to be
decorticated to promote the fusion posterolaterally (B).
The theoretical drawback to posterolateral intertransverse
process fusion in the setting of low back pain is that
The addition of pedicle screw fixation (Figs. 86 although it reduces motion at the particular segment,
and 87) has been popularized with the expectation that some residual motion still occurs anteriorly in the
the increase in immediate stability would enhance the otherwise intact intervertebral disk. If motion at the disk
likelihood of bony fusion, lower the pseudarthrosis rate, is indeed an element of pain generation, the
and improve patient outcomes. posterolateral intertransverse process fusionwith or
Although it appears that the addition of instrumentation without instrumentationdoes not completely address it.
increases fusion rates for posterolateral intertransverse
process fusion to some degree (pseudarthrosis rates from
Posterior Lumbar Interbody Fusion
5% to 10%), there is little evidence to suggest that this is This approach was described by Cloward (1958) more
accompanied by an improvement in clinical outcomes than 50 years ago as a fusion technique that involved the
(Fritzell et al. 2002,Thomsen et al. 1997). extraction of much of the disk through a posterior
Again, when interpreting results of fusion in the lumbar approach and wide laminectomy, then the insertion of
spine, remember the difficulties in radiographically bone graft into the intervertebral space to achieve fusion
evaluating bony fusion in the lumbar spine. of the anterior column.The approach can be widened by
CHAPTER 8 Surgical Management of Low Back Pain 107

Figure 86: Schematic of posterolateral fusion with pedicle screws. Pedicle screws need to be inserted with great caution because
they pass just lateral to the spinal canal (A) and just superior to the exiting nerve root (B). Rigid segmental fixation is achieved
by connecting the screws to rods. Fusion is still performed by decorticating the transverse processes and laying bone in the
posterolateral gutters.

Figure 87: Radiographs of a L4-L5 posterolateral fusion instrumented with pedicle screws. This patient underwent a
laminectomy and instrumented fusion at L4-L5. Note the slight degenerative spondylolisthesis at L4-L5, with 3-4 mm of forward
translation of the body of L4. Notice the autogenous bone graft (asterisks) placed along the transverse processes. In the acute
state, these cancellous and corticocancellous pieces of autogenous bone have a fluffy appearance, but over time, as the fusion
mass matures, this consolidates to look more like that in Fig. 85.

removing the lower one third of the inferior facet and by the wide decompression, which may involve some of
medial two thirds of the superior facet, although this the facet joint (Figs. 88 and 89).
increases the risk of iatrogenic instability. Many different interbody spacers have been used,
Current iterations of this technique involve the including tricortical iliac crest graft, bone dowels, loose
placement of a structural interbody device in addition to cancellous bone, and an increasing variety of interbody
bone graft into the intervertebral space and the pedicle cage devices thought to provide structural support for the
screw instrumentation posteriorly to provide immediate anterior column support and to maintain disk space
stability, offsetting to some extent the instability induced height when the bone graft consolidates.
108 Spine Core Knowledge in Orthopaedics

Figure 88: Schematic of posterior lumbar interbody fusion. The PLIF (and TLIF) technique is a method of performing both
posterolateral and anterior interbody fusion all from the posterior approach. The posterior elements of the spine are exposed (A)
and a wide laminectomy (shaded area in B) is performed. Currently, it is common to apply pedicle screw fixation, provide more
rigid posterior fixation, prevent posterior graft migration, and allow some temporary distraction during the insertion of the graft.
The disk is excised and removed through the laminectomy, and the graft is inserted (C and D). Great care must be exercised to
limit the amount of medial dural retraction when putting in the cage device.

Pedicle screw instrumentation allows one to distract The disadvantages of the PLIF procedure include the
across the disk space for improved access then compress following:
after the insertion of the interbody graft to resist its 1. The need to extensively retract the neural elements to
extrusion and to restore lumbar lordosis. access the intervertebral disk and insert the interbody
The advantages of the PLIF procedure include the device and bone graft; this has resulted in a relatively
following: high incidence of root injury and radiculopathy from
1. Removal of much of the disk as a source of pain forcible manipulation and epidural or perineural
2. Increased disk space height that helps to restore sagittal fibrosis, particularly of the traversing root descending
alignment and increases the vertical height of the neu- around the pedicle of the distal vertebral body
ral foramen (thus indirectly decompressing the exiting 2. Destabilization created by the need to perform a wide
nerve root) laminectomy or decompression posteriorly and a com-
3. Placement of the intervertebral bone graft in a setting plete discectomy anteriorly
of compression 3. The potential for graft or interbody device extrusion;
4. Increased fusion rates compared with the rates of pos- this and the destabilization are less of a concern with
terolateral intertransverse process fusion the use of pedicle screw instrumentation posteriorly
CHAPTER 8 Surgical Management of Low Back Pain 109

4. Although much of the disk is removed, the discectomy


is incomplete; hence the surface area for bony fusion
anteriorly is not maximized
5. Technically demanding
Transforaminal Interbody Fusion
This modification of PLIF was developed by Harms to
lessen the manipulation of neural elements during
interbody fusion and thus reduce the rate of
radiculopathy from the epineural and perineural scarring
that had been observed with PLIF.
Rather than a wide laminectomy, in TLIF, the pars inter-
articularis and half of the facet are removed unilaterally,
and the disk is then accessed along a path that lies beside
the lateral aspect of the vertebral foramen (hence
transforaminal interbody fusion). Because the access to
the disk is more lateral than that of the PLIF technique,
there is less need to retract the thecal sac and descending
roots medially (Fig. 810).
The approach can be done bilaterally to improve the
completeness of disk excision and directly decompress
the exiting and traversing nerve roots on both sides.
Otherwise,TLIF differs little from PLIF. Both are
Figure 89: Radiograph of a posterior lumbar interbody typically performed with interbody devices to provide
fusion. This patient underwent a PLIF for discogenic back pain
anterior column support when bony consolidation
and L4 radicular symptoms. A titanium cylindrical mesh cage
(black arrow) was used as the interbody device. Autogenous
occurs. Both are often supplemented with pedicle screw
bone is packed into the anterior aspect of the disk space and instrumentation to provide distraction intraoperatively for
into the cylindrical cage. interbody access then compression to restore lumbar
lordosis and enhanced immediate stability.

Figure 810: Differences between PLIF and


TLIF. With PLIF, a wide laminectomy is
performed. Note on the left side that the
exposure of the disk is limited even with the
medial part of the facet resected. This
requires fairly significant retraction of the
neural elements medially to gain access to
the disk (on the right side) for both the
resection and the insertion of the interbody
device. Alternatively, with TLIF, the facet is
excised and the exposure to the disk is more
lateral, requiring much less medial retraction
of the dura to access the disk.
110 Spine Core Knowledge in Orthopaedics

In a relatively recent comparison of PLIF versus TLIF in generator of pain and promoting fusion with an anterior
74 patients with degenerative disk disease, central disk graft placed under compression. It is not a procedure
herniations, or low grade spondylolisthesis, the PLIF designed to address radicular symptoms secondary to root
group suffered far more complications, including four compression because the posteriorly located neural
radiculopathies (compared with none in the TLIF elements are not visualized.The restoration of disk space
patients) (Humphreys et al. 2001). and foraminal height achieved with the ALIF procedure
The advantages of the TLIF procedure include the may indirectly reduce the exiting roots, but such a
following: decompression is more reliably performed with a
1. Less retraction on the neural elements than PLIF with posterior procedure such as a PLIF or TLIF.
lower incidence of iatrogenic nerve injury or damage Approaching the intervertebral disk anteriorly rather than
2. Less destruction of posterior elements than PLIF posteriorly provides wider exposure to the disk and
3. Removal of part of the disk as a source of pain allows a more complete excision, thus providing a much
4. Increased disk space height, which helps to restore larger surface area for fusion than the area that can be
sagittal alignment and increases the vertical height of obtained with posterior procedures.
the neural foramen (thus indirectly decompressing the An optimally sized interbody device can then be precisely
exiting nerve root) placed to restore disk height and sagittal alignment.
5. Placement of the intervertebral bone graft in a setting The intervertebral disks can be approached anteriorly
of compression through an open left-sided retroperitoneal approach, an
6. Increased fusion rates compared with posterolateral open transperitoneal approach, or a laparoscopic
intertransverse process fusion. approach.Transperitoneal approaches incur far more
The disadvantages of this TLIF procedure include the immediate postoperative morbidity than retroperitoneal
following: approaches.
1. More lateral visualization of the disk space, making it After adequate exposure, the disk is excised as completely
difficult to excise much of it on the contralateral as possible and the disk space is distracted to restore
sidethis can be resolved by performing bilateral TLIF height and lordosis. Morcellized autogenous bone graft
2. Achieves an incomplete removal of the disk, poten- and some form of structural interbody device are inserted
tially even less than with PLIF (although the TLIF to promote fusion (Fig. 811).
approach to the disk can be performed bilaterally) Many of the same bone grafts and interbody devices used
3. Technically demanding in PLIF and TLIF are used in ALIFautogenous
tricortical iliac crest bone, structural allograft (e.g.,
Anterior Lumbar Interbody Fusion Femoral ring), and cages.The purpose of each is to
The ALIF procedure is fundamentally a low back pain provide structural support of the disk space while bony
operation that focuses on eliminating the disk as a fusion occurs.

Figure 811: Restoration of disk height and sagittal alignment with anterior lumbar interbody fusion. To some extent, all
interbody fusions (ALIF, PLIF, and TLIF) can increase disk height and restore sagittal alignment. However, during ALIF, the most
complete discectomy can be performed; hence the largest correction in height and alignment can be achieved. The restoration of
disk height anteriorly increases the height of the foramen posteriorly and thus indirectly decompresses the exiting nerve root,
although a nerve root decompression is more reliably done from a posterior approach. The interbody cage is one of many devices
that can be inserted into the interbody space to provide structural support until fusion occurs.
CHAPTER 8 Surgical Management of Low Back Pain 111

Strictly speaking, supplementary instrumentation is not 2. Optimal disk space distraction and hence optimal
added to the ALIF procedure.The stability rests on the restoration of disk height and sagittal alignment
compressive fit of the interbody device within the 3. Placement of the intervertebral bone graft in the bio-
intervertebral space; hence a slightly oversized device is mechanically favorable setting of compression
recommended after distraction of the disk space. An 4. The avoidance of a posterior dissection to the spine,
external orthosis may be used postoperatively to help to which inevitably damages the lumbar musculature and
stabilize the motion segment. other soft tissues; in general, the anterior procedure has
Bony fusion occurs readily with ALIF procedures, likely less blood loss and is better tolerated than posterior
because of the biomechanical advantage of having the procedures and minimally invasive techniques further
graft under compression. diminish operative morbidity
Significant complications may arise from the surgical 5. Can be performed as a salvage procedure in the setting
approach. At L5-S1, the disk is shown between the iliac of previous posterior surgery; if a posterior laminec-
vessels, but autonomic nerves in the prevertebral space tomy has been performed, an ALIF gains access to the
may be damaged, leading to retrograde ejaculation disk without having to dissect the posterior scar that
(Fig. 812). At L4-L5, the left common iliac vessels encases the dura
obscure access to the disk and must be moved out of the The disadvantages of the ALIF procedure include the
way.The left-sided iliolumbar vein is a major hazard in following:
this area and must be identified and ligated prior to 1. The potential for catastrophic vascular or intra-
moving the common iliac vein. Peritoneal violation can abdominal injury during the surgical approach
lead to internal hernias and bowel obstruction. 2. The inability to reliably decompress neural elements
The advantages of the ALIF procedure include the 3. The risk of retrograde ejaculation from injury to auto-
following: nomic fibers
1. Maximal removal of the disk as a source of pain, thus 4. Possibly a higher pseudarthrosis rate than instrumented
providing a larger surface area for interbody fusion fusions performed posteriorly because no additional
than in PLIF or TLIF instrumentation is placed to stabilize the interbody

Transverse
Vena Psoas
process
Cava Aorta Muscle

L5-S1
disc
L4 Presacral
Right common
iliac vein plexus
L5 Middle sacral
artery
Right Left common
ureter iliac vein
S1 Right Left
common ureter
Sacral iliac artery
promontory Left common
iliac artery
Sigmoid
colon
Sacrum

A B
Figure 812: Anatomic considerations during anterior approaches to the lower lumbar spine. The anterior approach allows the
most complete disk excision and restoration of disk height and avoids the muscle-damaging posterior approach. However,
important neurologic, urologic, and vascular structures lay within the retroperitoneum in front of the lower lumbar spine. Damage
to the presacral plexus of autonomic fibers can lead to retrograde ejaculation. Inadvertent damage to the large vessels, particularly
the left common iliac vein that must be moved laterally, can lead to profuse, uncontrollable hemorrhage.
112 Spine Core Knowledge in Orthopaedics

graft, which depends solely on compressive fit within fusion has had relatively high fusion rates and good
the disk space clinical outcomes.
The advantages of circumferential fusion include the
Circumferential (Anterior and
following:
Posterior) Fusion 1. Enhanced immediate stability and thus increased
The supplementation of the ALIF procedure with fusion rates and less graft extrusion
pedicle screws and posterolateral intertransverse process 2. Possibly a role as a salvage procedure to achieve fusion
fusion is considered to be a 360 degree fusion after previously failed surgery
(Fig. 813); an ALIF plus pedicle screw stabilization The disadvantages of circumferential fusion include the
without the intertransverse process fusion is described as following:
a 270 degree fusion. 1. Increased operative time, blood loss, infection (two
The addition of posterior pedicle screws is thought to incisions), and acute postoperative morbidity
mitigate the relative lack of stability characteristic of 2. Strong evidence that such an extensive effort to
otherwise uninstrumented ALIF, thus improving fusion achieve bony fusion translates into better clinical out-
rates. come is lacking
Because of the fairly extensive nature of the surgery, it
has been applied to patients with previously failed Pedicle Screw Instrumentation
lumbar surgery with the rationale that every measure The use of pedicle screws to provide segmental fixation
should be taken to achieve fusion in what could be in the lumbar spine is widespread in North America.
considered a last-effort salvage procedure for these The pedicle is the strongest point of screw fixation
patients (Leufven et al. 1999). In this rather within the vertebral body; that is, the pedicle screw
challenging population of patients, circumferential gains its rigidity primarily from its fixation within the
pedicle, not from its length within the vertebral body.
The increased construct stiffness is associated with slightly
higher union rates for posterolateral intertransverse
process fusion and helps to stabilize interbody devices or
grafts in PLIF,TLIF, and ALIF.
Pedicle screw strength and stability is related to several
factors, including the inner and outer diameter of the
threaded shaft and the quality of the host bone.Although
wider screws are less prone to breakage, they are at a higher
risk of plastically deforming or fracturing the pedicle.
In the setting of osteoporosis, the interface between the
pedicle screw threads and the host bone is weakened and
may warrant supplementation with wires, hooks, or
cement.
Complications of pedicle screw instrumentation include
late-onset discomfort requiring removal, neurologic
injury, vascular injury, pedicle fracture, and screw fracture.
Also, their use is associated with increased operative time,
blood loss, infection, and cost. In experienced hands, the
complication rate was reported as 2.4% in 4790 pedicle
screws (Lonstein et al. 1999). Careful preoperative
planning and attention to anatomic landmarks
intraoperatively can reduce the risk of improper pedicle
screw placement (Box 86 and Fig. 814).
Circumstances in which the use of pedicle screws may
have greater justification include the following:
1. Revision surgery, particularly in patients with painful
pseudarthrosis from previous attempts at lumbar
Figure 813: Circumferential fusion of L4-S1. Note the
maintenance of disk height at L4-L5 and L5-S1 with the ALIF fusion
performed with structural allograft spacers (black arrows). The 2. Correction of significant sagittal or coronal deformity
addition of pedicle screws at the back and posterolateral 3. Multilevel fusionsThe rate of pseudarthrosis in non-
intertransverse bone grafting makes this a circumferential, instrumented fusions increases significantly as more
360 degree fusion. levels are incorporated into the fusion mass
CHAPTER 8 Surgical Management of Low Back Pain 113

Box 86: Tips for Pedicle Screw Insertion in the Lumbar Spine
Careful preoperative evaluation of axial imaging (CT or MRI) is helpful in determining the starting point, trajectory, and size of pedicles. Look at
the where the widest part of the pedicle meets the transverse process.
For the insertion of a screw in line with the axis of the pedicle, the starting point is located where the transverse process meets the base of the
superior articular process; in the proximaldistal direction, this point is usually in line with the vertical midpoint of the transverse process (confirm
this on the axial imaging). As an additional visual cue, in the mediallateral direction, the insertion point is just adjacent to the lateral border of
the pars. Expending the effort to clearly visualize the juncture of the transverse process, superior articular process, and pars is well worth the time!
In degenerative spines, the facet joint are often osteophytic and will require some resection to identify the correct landmarks. The lateral aspect
of the superior facet may need to be burred down to find the true juncture between the facet and the transverse process, or it may deceive you
into starting too far to the side.
The cortical bone at the starting point for screw insertion is removed with a burr or rongeur, and the channel or path for the screw is made ini-
tially with a solid, blunt-tipped probe with great care and control to prevent plunging.
From the preoperative images, you can estimate how medial the screw must be directed from the starting point at the lateral border of the supe-
rior articular process. Typically, the axis of the pedicles is aimed medially in the lower lumbar spine but becomes nearly perpendicular to the ver-
tebral body at the thoracolumbar junction.
In the lower lumbar spine in particular, where the pedicles are directed most medially, your hands must swing out laterally to sufficiently toe in
the probe or screw. Do not let the soft tissue walls of the dorsal exposure push your hand medially, or you will fail to toe in and risk putting the
screw out laterally. Alternatively, you can start the screw hole slightly more medially (in line with the actual joint surface of the facet) and direct
the screw in a straighter trajectory.

Figure 814: Pedicle screw starting points. Intraoperatively, make sure you have good visualization of the entire transverse process
(it needs to be exposed anyway so that it can be decorticated and bone graft can be laid on top of it). For the superiorinferior
position of the starting point, look at the vertical height of the transverse process and pick its midpoint when it arrives at the
pedicle (A). The mediallateral position is where the transverse process meets the superior articular process (B). Notice how this
is just to the side of the lateral border of the pars (A and B). This point can be obscured in the degenerative spine if the articular
processes are severely osteophytic. Note that from this starting point, the screw trajectory can be directed down the middle of the
pedicle on both the lateral (C) and the axial (D) view.
114 Spine Core Knowledge in Orthopaedics

4. Degenerative or isthmic spondylolisthesis or degenera- multidisciplinary panel commissioned through the Agency for
tive scoliosis requiring posterior decompression Health Care Policy and Research.
5. Interbody fusions (PLIF,TLIF, and ALIF) to stabilize Boden SD, Davis DO, Dina TS et al. (1990) Abnormal magnetic
the segment and prevent extrusion of the interbody resonance scans of the lumbar spine in asymptomatic subjects: A
device or graft prospective investigation. J Bone Joint Surg Am 72: 403-408.
This important and extensively quoted study demonstrates that
a significant percentage of individuals with no previous history
Conclusions of low back pain, sciatica, or neurogenic claudication had disk
Low back pain is an extremely complex, multifactor abnormalities identified on MRI.This study highlights the
problem that presents many diagnostic and therapeutic importance of interpreting MRI findings with great caution
and that they must be correlated to clinical signs and symptoms.
challenges.
The role of surgical management is controversial and is Borenstein DG, OMara JW Jr, Boden SD et al. (2001) The value
constantly being redefined as surgeons attempt to of magnetic resonance imaging of the lumbar spine to predict low
intervene in a clinical entity whose natural history is not back pain in asymptomatic subjects: A 7-year follow-up study.
completely understood. J Bone Joint Surg Am 83-A: 1306-1311.
It is felt that the key to successful surgical outcomes is a This is an important follow-up to the previous study of Boden
et al. 1990 in which the asymptomatic individuals who had the
thorough diagnostic evaluation leading to the
MRI scans of their lumbar spines were followed for the next
identification of anatomic pathology that may be
7 years to determine whether their MRI findings predicted the
amenable to surgical treatment. Operating without later development of low back pain. Interestingly, the authors
establishing such a diagnosis is unlikely to succeed. found that the MRI findings were not predictive for the
Numerous techniques for fusing the lumbar spine have subsequent development of low back pain, again emphasizing
been described. Each has its particular limitations and the need to carefully interpret the results of this imaging study.
advantages. Interbody fusions that address the anterior
Carette S, Marcoux S,Truchon R et al. (1991) A controlled trial of
pain generator are thought to be superior to posterior
corticosteroid injections into facet joints for chronic low back pain.
fusions alone. N Engl J Med 325: 1002-1007.
In general, large differences in fusion rates and clinical This was a randomized, placebo-controlled trial to evaluate the
patient outcomes have not been demonstrated among the efficacy of fluoroscopically guided facet injections of either
various types of lumbar fusions. In this regard, the methylprednisolone or saline in patients with chronic low back
decision about who to operate on is likely to be far more pain.The authors conclude that there was no significant benefit
important than the particular fusion operation from the methylprednisolone injection.
performed.
Cavanaugh JM. (1996) Neural mechanisms of idiopathic low back
pain. In: Low Back PainA Scientific and Clinical Overview
(Weinstein JN et al., eds.). Rosemont: American Academy of
References Orthopaedic Surgeons, pp 583-606.
This is an excellent review of the neurophysiology of low back
Abraham I, Killackey-Jones B. (2002) Lack of evidence-based
pain in an outstanding textbook that comprehensively covers
research for idiopathic low back pain:The importance of a specific
many clinical and basic science aspects of low back pain.The
diagnosis. Arch Intern Med 162: 1442-1444.
author describes the phenomenon of sensitization, which
This perspective provides an argument against the validity of
promotes an exaggerated pain response, and summarizes the
the concept of idiopathic low back pain accepted as a
neuroanatomy of potential pain generators in the lumbar spine.
diagnosis for a large percentage of patients for whom a more
specific diagnosis has not been made. (See Deyo 2002 for the Cherkin DC, Deyo RA, Loeser JD et al. (1994) An international
opposing argument). The authors contend that significant comparison of back surgery rates. Spine 19: 1201-1206.
methodological flaws exist in the studies performed in the This interesting study reviewed lumbar spine surgery rates in 11
1960s upon which the concept of idiopathic low back pain developed nations and found that the rate of such surgery was
was based and that more refined research is needed now to at least 40% higher in the United States than in any other
rethink the pathogenesis and specific diagnoses of low back country. Interestingly, the rates of back surgery also increased
pain. with the numbers of orthopedic and neurosurgical surgeons per
Andersson GB. (1998) Diagnostic considerations in patients with capita.
back pain. Phys Med Rehabil Clin N Am 9: 309-322. Cloward RB. (1958) The anterior approach for removal of ruptured
This review emphasizes the importance of a careful history and cervical disks. J Neurosurg 15:602617.
physical examination in the diagnosis of low back pain and the
need for a sensible, evidence-based approach to the use of Deyo RA (2002) Diagnostic evaluation of LBP: Reaching a specific
diagnostic modalities (such as x-ray films, CT scan, and MRI). diagnosis is often impossible. Arch Intern Med 162: 1444-1447.
The author summarizes some of the guidelines for a thorough, This is the counterargument to the position statement of
diagnostic approach to low back pain established by a Abraham et al. 2002 in which Deyo contends that because
CHAPTER 8 Surgical Management of Low Back Pain 115

anatomic abnormalities are readily identified by imaging studies This is a retrospective review of the accuracy and associated
in asymptomatic patients, assigning an exact pathoanatomic complications from 4790 pedicle screws inserted over a 10-year
diagnosis to patients with low back pain is often impossible.The period at the authors institution.They describe a complication
author emphasizes the need for a rationale, evidence-based rate of 2.4%, with painful hardware being the most common
approach to patients with low back pain. complaint.
Fritzell P, Hagg O,Wessberg P et al. (2002) Chronic low back pain Lorenz M, Zindrick M, Schwaegler P et al. (1991) A comparison of
and fusion: A comparison of three surgical techniquesA single-level fusions with and without hardware. Spine 16:
prospective, multicenter, randomized study from the Swedish S455-S458.
Lumbar Spine Study Group. Spine 27: 1131-1141. This was one of many studies to evaluate fusion rates in lumbar
In the mid-1990s, the Swedish Lumbar Spine Study Group spine surgery. Accepting the difficulties in determining fusion
performed a large, prospective randomized study of patients radiographically, these authors noted a 58.6% pseudarthrosis rate
with chronic low back pain, comparing nonoperative treatment in patients undergoing an uninstrumented fusion; no
to three forms of operative treatment.This study reports a instrumented fusions had a pseudarthrosis.
comparison among the operatively treated groups.The
Parker LM, Murrell SE, Boden SD et al. (1996) The outcome of
comparison found no significant differences in 2-year outcomes
posterolateral fusion in highly selected patients with discogenic low
among the three surgical treatments despite higher fusion rates
back pain. Spine 21: 1909-1916.
in the more extensive procedures.
This was a prospective analysis of a consecutive series of 23
Frymoyer JW. (1996) EpidemiologyMagnitude of the Problem. patients undergoing posterior lumbar fusion for discogenic low
In:The Lumbar Spine (Weisel SW et al., eds.). Philadelphia:W.B. back pain. All patients had MRI and discography. Of the
Saunders Company, pp 8-16. patients, 48% had a poor result. Discography was not predictive
This is an excellent review of the epidemiology and societal of a good surgical outcome.
effect of low back pain.
Smith SE, Darden BV, Rhyne AL et al. (1995) Outcome of
Gill K, Blumenthal SL. (1992) Functional results after anterior unoperated, discogram-positive low back pain. Spine 20: 1997-2000.
lumbar fusion at L5-S1 in patients with normal and abnormal MRI This study retrospectively evaluated the outcomes of 25 patients
scans. Spine 17: 940-942. who had discogram-positive disks and were considered surgical
This study attempted to determine the predictive value of candidates but did not undergo operative treatment. After a
preoperative discography and MRI findings for outcomes after mean follow-up of 4.9 years, the authors found that 68% of
ALIF in patients with chronic low back pain.These authors patients improved, suggesting that natural history is favorable
found that patients with abnormal MRI and discography had and that operative treatment must surpass such results to be
better surgical outcomes than those who underwent the same justifiable.
operation but with normal MRI findings.
Thomsen K, Christensen FB, Eiskjaer SP et al. (1997) The effect of
Humphreys SC, Hodges SD, Patwardhan AG et al. (2001) pedicle screw instrumentation on functional outcome and fusion
Comparison of posterior and transforaminal approaches to lumbar rates in posterolateral lumbar spinal fusion: A prospective,
interbody fusion. Spine 26: 567-571. randomized clinical study (1997 Volvo Award winner in clinical
This study compared a consecutive series of patients who studies). Spine 22: 2813-2822.
underwent either a TLIF or a PLIF.The authors found that the This prospective randomized study compared uninstrumented
complication rate was higher in patients who underwent the and instrumented posterolateral lumbar spine fusions in 130
PLIF. In particular, the incidence of radiculopathy postoperatively patients with grade 1 or 2 spondylolisthesis. Fusion rates were
was higher with the PLIF group, in keeping with the smaller not significantly different, and the authors did not observe any
retraction of neural elements required for the TLIF. significant improvement in patient outcomes with the addition
of pedicle screws (the rate of significant complications from
Leufven C, Nordwall A. (1999) Management of chronic disabling
their insertion was 4.8%).The authors concluded that the use of
low back pain with 360 degrees fusion: Results from pain
pedicle screws was not justified to supplement posterolateral
provocation test and concurrent posterior lumbar interbody fusion,
lumbar fusion.
posterolateral fusion, and pedicle screw instrumentation in patients
with chronic disabling low back pain. Spine 24: 2042-2045. Turner JA, Ersek M, Herron L et al. (1992) Patient outcomes after
The authors present a 2-year follow-up using a consecutive lumbar spinal fusions. JAMA 268: 907-911.
series of patients in which a circumferential fusion was This was an extensive review of success and complication rates
performed for chronic low back pain. High fusion rates were after lumbar spine surgery.The authors were unable to find
achieved, and approximately half of the patients had a good or literature to support that the achievement of or attempt at
excellent result. fusion conferred any advantage over surgery without fusion.
Unfortunately, the literature at this time contained no sound
Lonstein JE, Denis F, Perra JH et al. (1999) Complications
prospective randomized studies.
associated with pedicle screws. J Bone Joint Surg Am 81:
1519-1528.
9

CHAPTER
Management of the Failed Back
Surgery Patient
David H. Kim*, Robert J. Banco , Louis G. Jenis , Frank F. Rand , Kevin P. Sullivan ,
and Scott G. Tromanhauser

*M.D., Orthopaedic Spine Surgeon,The Boston Spine Group, Boston, MA


M.D.,The Boston Spine Group, New England Baptist Hospital, Boston, MA
M.D., Metro West Medical Center, Framingham, MA; Nashoba Valley Medical Center,
Ayer, MA; The Boston Spine Group, Southboro, MA

pain diagrams (Fig. 91), nonanatomic pain


Introduction distribution, inconsistent history and examination, and
Patients with persistent, recurrent, or worsened symptoms a history of psychiatric diagnosis
following spinal surgery represent the most challenging Narcotic addiction and, for fusion surgery, nicotine
diagnostic and therapeutic group in any adult spinal addiction
surgical practice.These patients are often severely Noncompliant behavior
frustrated, angry, and depressed.There is a high rate of Incorrect diagnosisCommonly missed causes of lower
narcotic dependence, and clinical evaluation is frequently extremity pain, weakness, and sensory changes
confounded by the presence of secondary gain issues. Hip arthritis
Knee arthritis
Definition Peripheral vascular disease (i.e., vascular claudication)
Failed back syndrome (also failed back surgery Diabetic peripheral neuropathy
syndrome)Chronic and persistent unrelieved, Multiple sclerosis
worsened, or recurrent pain in the low back, lower Amyotrophic lateral sclerosis

extremity, or both of a patient following lumbar spinal Ankylosing spondylitis

surgery Incorrect surgical levelCheck postoperative


Persistent lower extremity weakness, sensory changes, or radiographic studies to correlate surgical level with
reflex abnormalities are not elements of failed back preoperative symptoms
syndrome Incorrect surgical procedure
Compressive radiculopathy or spinal stenosis requires
Classification appropriate decompression.
Causes of Failed Back Syndrome
Preoperative spondylolisthesis may represent segmental
instability that can be worsened by decompressive
(Table 91) laminectomy alone, and many surgeons advocate
Inappropriate patient selection including an instrumented or noninstrumented fusion
Presence of secondary gain issues (e.g., active litigation in the surgical procedure for such patients; if fusion
or workers compensation) was not performed, flexionextension radiographs
Functional as opposed to clinical illnessClues should be checked for segmental instability.
include positive Waddells signs (Table 92), bizarre Inadequate surgery or poor surgical technique
116
CHAPTER 9 Management of the Failed Back Surgery Patient 117

Overly aggressive laminectomy


Table 91: Classification of Failed Back Syndrome
Idiosyncratic
TYPE CAUSE Epidural fibrosis
Type I Improper patient selection Junctional degeneration
Type II Incorrect diagnosis Fusion disease

Type III Incorrect indication Three out of five positive Waddells signs suggest that the
Type IV Incorrect level patient may be a poor candidate for surgery (Waddell
Type V Incorrect surgery
Type VI Iatrogenic
et al. 1980)
Type VII Idiosyncratic Overreaction is the most significant Waddells sign.

Table 92: Waddells Nonorganic Physical Signs Additional Considerations for


SIGN FINDING Specific Diagnoses
Tenderness Broad lumbar tenderness to light touch Lumbar Disk Herniation
Widespread tenderness to deep palpation in
nonanatomic distribution History and Physical
Simulation Low back pain produced with axial loading of Timing of any period of symptomatic improvement and
skull or shoulders
Low back pain with passive rotation of
nature of recurrent symptoms are the most important
shoulders and pelvis in plane through hips diagnostic elements (Table 93).
Distraction Negative seated straight leg raise test in a
setting of a positive supine straight leg Type I
raise May be most common
Regional Regional sensory and motor abnormalities in a
nonneuroanatomic distribution (e.g., give
Consider the presence of secondary gain issues (e.g.,
way weakness and stocking sensory active litigation or workers compensation)
loss)
Overreaction Overreaction during examination; excessive Type II
verbalization, facial expressions, tremors,
collapse
High prevalence of disk protrusions and herniations in
asymptomatic population
Preoperative symptoms may be wrongly attributed to
incidental herniation; consider alternative diagnoses

Type III
Candidates for lumbar discectomy should have dominant
lower extremity pain preoperatively, ideally pain radiating
below the level of the knee (L4, L5, and S1
radiculopathy) and in a radicular pattern correlating with
the side and location of herniation on preoperative
magnetic resonance imaging (MRI).
Dominant back pain is a relatively poor indication for
decompression alone (Herron et al. 1985).
Timing of surgeryOptimal results for discectomy occur
when surgery is performed within 3 months of symptom
onset; surgery delayed 1 year or longer is associated with
inferior rates of symptomatic relief, possibly because of
Figure 91: Characteristic bizarre pain drawing suggesting
that the patient may be a poor candidate for surgical
treatment. (Williams et al. 2003.) Table 93: Timing of Recurrent Symptoms

Inadequate decompression of foraminal or PERIOD OF POSTOPERATIVE POSSIBLE NONINFECTIOUS


IMPROVEMENT DIAGNOSES
extraforaminal nerve root compression, especially with
far lateral disk herniations None Incorrect patient selection, diagnosis,
level of surgery
Inadequate decompression of lateral recess in patients
Days to weeks Postoperative scar tissue formation
with disk herniation or central stenosis Weeks to months Recurrent disk herniation
Iatrogenic nerve root injury (i.e., battered root)
118 Spine Core Knowledge in Orthopaedics

permanent root injury, the formation of adhesions, and


the development of chronic pain syndrome.
Dysesthetic pain (hyperalgesia, or painful sensation provoked
by light touch) may reflect permanent nerve root injury.
Type IV
Compare preoperative and postoperative radiographic
studies to confirm correct level or side of surgery.
Type V
Review preoperative imaging studies for lateral and
foraminal stenosis and for far lateral disk herniation
(extraforaminal root compression). Review the operative
report to determine whether all potential sites of root
compression were appropriately addressed.
Type VI
Dysesthetic pain may represent iatrogenic nerve root injury. Figure 92: Gadolinium-enhanced MRI image of epidural
fibrosis following lumbar microdiscectomy. Note the enhancing
Type VII scar tissue filling the left-sided laminotomy defect. Adhesion to
Epidural fibrosisSymptomatic improvement for weeks the thecal canal contents is suggested by the displacement of
to months followed by recurrent pain, often distributed the thecal sac and the nerve root toward the tissue.
across multiple roots and often described as burning
pain with occasional lancinating pain and dysesthesia Physical therapy, including aerobic conditioning and
abdominal and back strengthening exercises
Radiographic Studies Consider specific gait assessment and retraining,
Plain filmsCheck the site of laminotomy on the especially with a chronic limp.
anteroposterior view and correlate with the Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen,
patients preoperative symptoms and location of naproxen, or selective celecoxib cyclooxygenase-2
herniation on preoperative MRI; check for subtle inhibitors)If used continuously longer than 6 weeks,
spondylolisthesis on the lateral view, indicating possible consider laboratory tests to evaluate renal and hepatic
instability from aggressive facetectomy. function.
Segmental instability can result in mechanical low back Avoid narcotic pain medication.

pain and may cause radicular pain from mechanical nerve Injection therapy (i.e., epidural steroids or selective
root irritation (Kramer 1987). nerve root block) may provide both therapeutic and
MRISuch imaging is minimally informative within 3 diagnostic value; with extension-dominant back and
months of surgery; the appearance typically is unchanged buttock pain, consider facet block.
even in patients who are completely asymptomatic. Consider a trial of orthotic stabilization for segmental
Request a gadolinium contrast to differentiate residual or instability (Fritsch et al. 1996).
recurrent disk herniation from postoperative scar tissue and Revision surgery
epidural fibrosis. Recurrent disk herniations or retained disk MicrodiscectomyThe ideal candidate has a period
fragments will demonstrate minimal border enhancement of symptomatic relief lasting several months prior to
and causes positive mass effect with the thecal sac and recurrent lower extremity pain. MRI with
nerve root displaced from the herniation. Epidural fibrosis gadolinium shows recurrent, nonenhancing disk
demonstrates diffuse enhancement and causes negative mass herniation correlating with patient symptoms (may
effect, with the thecal sac and nerve root displaced toward be the same or a different side or level). Surgery is
the scar tissue mass (Ross 2000) (Fig. 92). often effective.With clear root impingement because
EMG or NCSUtility is controversial. Studies are often of recurrent herniation, surgery has a 70%-80%
normal in the setting of radiculopathic pain; appropriate success rate (Fager et al. 1980, Cauchoix et al. 1978)
changes following successful decompression are unknown. (Box 91).
In a setting of brief postoperative pain relief lasting
Treatment days to weeks and with an MRI showing enhancing
Revisit the trial of conservative management for several tissue compression of the nerve root, the patient may
months; symptoms may continue to improve up to 6 have postoperative epidural fibrosis. Surgery results in
months following surgery. no change or worsening symptoms in 50%-80% of
CHAPTER 9 Management of the Failed Back Surgery Patient 119

Factors Associated with Improved Type III


Box 91: Results Following Revision This is a less common cause.
Discectomy Relatively advanced stenosis on MRI or myelogram
Symptomatic relief for >6 months following initial surgery may be asymptomatic. Appropriate candidates for
Radicular lower extremity pain greater than back pain surgery should have significant lower extremity
MRI with gadolinium clearly showing recurrent disk herniation complaints, including claudication, radiculopathy, or
and nerve root impingement both. Patients with radiographic stenosis and
predominant back pain are not good candidates for
laminectomy.
patients (Fager et al. 1980, Spengler et al. 1980,
Waddell et al. 1979, Benoist et al. 1980).
Type IV
Consider more extensive decompression, especially if Compare preoperative and postoperative imaging studies
imaging studies suggest lateral or foraminal stenosis not to confirm surgery at the correct level.
addressed by the original surgery; consider performing
the Wiltse approach for far lateral herniation.
Type V
Back-dominant pain complaints may represent Segmental instability (i.e., spondylolisthesis) often coexists
discogenic pain from degenerative disk disease. with stenosis, and most surgeons recommend
Consider provocative lumbar discography if the instrumented or noninstrumented fusion in conjunction
patient is a candidate for lumbar fusion surgery, with decompression.
although this test is less informative following Check preoperative radiographs for L4-L5 or L3-L4
discectomy. Consider that 40% of patients will have a (usually degenerative) or for L5-S1 (usually isthmic)
positive result from discography following even a spondylolisthesis.
successful discectomy (Carragee et al. 2000).
Multiply revised patients have better results with
Type VI
inclusion of a fusion procedure. Consider that Type VI has inadequate decompression.
symptomatic epidural fibrosis may also be caused by The most common cause of failed back following
persistent root irritation from instability (Fritsch et al. decompression surgery may be failure to decompress the
1996). lateral recess, foramen, or both.
Severe dysesthetic pain from permanent root injury or Review the preoperative MRI, CT, or CT myelogram
chronic radiculopathic pain in the setting of epidural scar and the operative note.
or adhesions may respond to placement of a spinal cord Dural tears occur in up to 13% of cases and do not
stimulator (Devulder et al. 1997). compromise the outcome if they are repaired
Consider referral to a pain clinic for the development of immediately (Jones et al. 1989).
a chronic pain management strategy, including
medication such as antidepressants, amitriptyline,
Type VII
transcutaneous electrical nerve stimulation unit Epidural fibrosis
application, and various nerve ablation therapies.
Radiography
Lumbar Spinal Stenosis Plain filmsAssess the extent of laminectomy on an
History and Physical anteroposterior view. Minimal laminectomy defect
suggests possible inadequate decompression, especially of
Type I the lateral recess and foramen; overly wide laminectomy
Much less common than failed back syndrome following without fusion may cause segmental instability (Fig. 93)
disk herniation from excessive facet resection or iatrogenic pars
interarticularis fracture (lateral view).
Type II MRI or CT myelogramDirectly assess the adequacy of
Vascular claudication and neurogenic (pseudo) decompression of the canal, lateral recess, and foramen;
claudication are symptomatically similar and often check for stenosis at adjacent levels.
confused.
Neurogenic claudication is relieved by lumbar
Treatment
flexion (e.g., sitting down or leaning over a grocery Conservative management is less effective; patients
cart); vascular claudication may be relieved by often have limited ability to participate in physical
standing still. therapy.
Check lower extremity pulses. Medication
120 Spine Core Knowledge in Orthopaedics

Figure 93: A, Wide laminectomy for spinal stenosis with bilateral facetectomies, pars interarticularis resection, and attempted
noninstrumented posterolateral fusion. B, Development of postoperative segmental instability and grade II or III iatrogenic
spondylolisthesis at the level of decompression.

Antidepressants may be effective in patients with


symptoms or signs of depression.
History and Physical
Amitriptyline or other membrane stabilizers can be Any period of postoperative symptomatic improvement
used, particularly in the setting of dysesthetic pain. and the length of time are informative. Particularly with
Avoid narcotics. instrumented fusions, initial symptomatic relief for several
Consider referral to a pain center for the management months followed by recurrent back pain suggests possible
of medication. pseudarthrosis.
Consider epidural steroid injections or selective nerve Patient reports of painless cracking or shifting in the
root blocks under fluoroscopic guidance. back with trunk motion are common and do not
Revision surgery indicate pseudarthrosis or instrumentation failure.
Consider revision decompression only if a clear site of Cracking or shifting sensations associated with pain are
residual stenosis or root compression can be identified concerning for pseudarthrosis or complications associated
on MRI or CT myelogram. with instrumentation (Box 92).
Consider posterior instrumented fusion if there is
radiographic evidence of postoperative instability from
Radiographic Signs of Pseudarthrosis
preoperative spondylolisthesis, iatrogenic instability, or Plain films
pars interarticularis fracture (Markwalder et al. 1993, Posterolateral fusionCheck for bridging bone between
Parts 1 and 2). transverse processes on an anteroposterior view.The use of
Following Fusion Surgery
This is the most challenging subgroup of failed back Risk Factors for Postoperative
patients. It is essential to review the preoperative history Box 92:
Pseudarthrosis
and diagnostic testing to determine the indication for
fusion surgery. Lack of appropriate indications for fusion Revision procedure
surgery may be an explanation for persistent pain. If the Postoperative wound infection
indication was appropriate, the next and often most Cigarette smoking
difficult steps are to determine whether the fusion is Poor nutrition
solid and to rule out the development of a Systemic illness
pseudarthrosis.
Steroid and nonsteroidal anti-inflammatory medication
CHAPTER 9 Management of the Failed Back Surgery Patient 121

certain bone graft substitutes, such as coralline images for bridging trabecular bone, most commonly
hydroxyapatite, can result in persistent radio-opacity, anterior to or through an interbody device (Box 93).
obscuring the interpretation of fusion. Look for a transverse
radiolucent line with a sclerotic margin suggesting Postoperative Infection
pseudarthrosis, most commonly at the proximal or the distal Early acute postoperative wound infections are typically
level of multilevel fusion. Compare lateral flexion and easily recognized with fever, chills, systemic signs and
extension views to identify motion (more than 5 degrees of symptoms, local wound erythema and drainage, and
angulation or 2 mm of motion suggests pseudarthrosis). increased back pain. Late postoperative infections,
Anterior interbody fusionSuch fusion is more easily especially in the presence of implanted instrumentation,
assessed on a lateral view. Check for bridging can be less apparent and should be considered when
trabecular bone crossing the interbody space. If an other causes for failed back are not present (Box 94).
interbody device is in place, examine the space
anterior to the device. Compare flexion and extension History and Physical
views to identify any gapping anteriorly with Fevers, chills, systemic complaints, weight loss, fatigue,
extension.The fracture of a structural allograft or the and anorexia
subsidence of an interbody spacer does not necessarily Swelling, tenderness, and erythema around the surgical
indicate pseudarthrosis. wound on examination
InstrumentationCheck for disengagement of
components, implant breakage, haloing around pedicle Radiography
screws, and screw back out. Examine the quality of MRI is usually diagnostic for significant osteomyelitis of
bone fusion at the level of any instrumentation failure vertebral bodies or discitis (Fig. 96). It is less useful for
(Fig. 94). following the treatment of known infection because of
CT scan the delay of several months between successful treatment
In the presence of radiculopathy, obtain CT myelogram and improvement of MRI changes. MRI obtained too
to identify possible root impingement from a misplaced early in the course of infection can sometimes lead to
pedicle screw. missed diagnosis.
To evaluate the quality of fusion, obtain thin cut Nuclear medicine bone scan is less informative because
(1.5-2 mm) axial images with sagittal and coronal of the increased metabolic bone activity associated with
reformatted images. For posterolateral fusion, examine recent surgery.
coronal images for bridging intertransverse process
bone; for anterior fusion, examine sagittal and coronal

Box 93: Junctional Degeneration


Successful spinal fusion creates a lever arm proportional to the
number of segments fused and transmits increased biomechanical
forces to adjacent unfused segments. Although difficult to prove,
most surgeons believe that this accelerates the degeneration of
spinal segments adjoining the fusion. Look for evidence of
junctional degeneration on plain films, CT, and MRI when patients
have been asymptomatic for several years and then develop
recurrent mechanical back pain (Fig. 95).

Risk Factors for Postoperative


Box 94:
Infection
History of any infectious condition occurring in the preoperative
or postoperative period (e.g., skin infections, tooth abscess, uri-
nary tract infection, or open sores)
History of prolonged drainage from surgical wound
Diabetes mellitus or history of immune disorder
History of steroid use or chemotherapy
Revision surgery
Figure 94: Haloing around the S1 pedicle screw suggesting
Lengthy surgery
loosening and possible pseudarthrosis.
Morbid obesity
122 Spine Core Knowledge in Orthopaedics

Box 95: Fusion Disease


A hypothetical and controversial cause of failed back syndrome.
Standard posterior surgical exposure of the lumbar spine using a
midline incision and subperiosteal dissection of paraspinal muscle
off posterior bony and ligamentous structures unavoidably causes
injury to paraspinal musculoligamentous tissue, resulting in vari-
able amounts of denervation, scarring, and local muscular dys-
function. Several investigators have attributed cases of failed
back syndrome to this condition and used this potential to argue
for the use of minimally invasive surgical techniques.
However, the anatomic or biomechanical basis of pain in this situ-
ation is unknown. Moreover, all patients undergoing standard
posterior lumbar spinal surgical procedures should have similar
degrees of tissue injury for similar procedures, and it is unclear
why a relatively small percentage would develop fusion disease.

General Principles
Avoid unnecessary surgery; in most patients with failed
Figure 95: Junctional degeneration resulting in segmental
back syndrome, repeat surgery is of limited benefit and
instability proximal to successful instrumented lumbar fusion. can result in clinical worsening (Goupille 1996).
The success rate of revision surgery decreases with the
number of revisions performed (Waddell et al. 1979).
Fusion is associated with better results in patients
undergoing multiple revision decompressive surgeries
(Fritsch et al. 1996).

References
Benoist M, Ficat C, Baraf P et al. (1980) Postoperative lumbar
epiduroarachnoiditis. Spine 5: 432-436.
This study reviewed 38 patients with the finding of
postoperative epiduroarachnoiditis at the time of revision
surgery. Results of scar excision were considered good in 13,
fair in 8, and failed in 17.
Carragee EJ, Chen Y,Tanner CM et al. (2000) Provocative
discography in patients after limited lumbar discectomy: A
controlled, randomized study of pain response in symptomatic and
asymptomatic subjects. Spine 25: 3065-3071.
This prospective observational study compared results of
provocative lumbar discography in a group of 20 patients who
were asymptomatic following lumbar discectomy with those of
a group of 27 patients who had intractable low back pain
following discectomy. Positive injections were found in 40%
Figure 96: Postoperative vertebral osteomyelitis following of the asymptomatic group and 63% of the symptomatic group.
lumbar microdiscectomy. Note the diffusely increased Psychometric testing of the symptomatic group revealed a 43%
intramedullary signal on the T2-weighted MRI. positive rate in patients with normal psychometric scores
compared with a 70% rate in patients with abnormal scores.
[Note:The data from this study has been reexamined by other
Laboratory Tests investigators using alternative protocols for discography
Complete blood count, erythrocyte sedimentation rate, interpretation with significantly different results.]
and C-reactive protein Cauchoix J, Ficat C, Girard B. (1978) Repeat surgery after disk
Blood cultures insensitive excision. Spine 3: 256-259.
Consider CT or fluoroscopic biopsy for culture This retrospective review of 60 patients undergoing revision
(Box 95) surgery following lumbar discectomy identified a 5.9%
CHAPTER 9 Management of the Failed Back Surgery Patient 123

reoperation rate.The most common findings in patients with back and leg pain and demonstrate bilateral, positive straight leg
recurrent sciatica were perineural fibrosis and recurrent raise testing. Proposed treatments include steroid injections or
herniation, with the latter patients responding most favorably to lumbosacral distraction spondylodesis.
revision surgery.
Markwalder T, Battaglia M. (1993) Failed back surgery syndrome
Devulder J, De Laat M,Van Bastelaere M et al. (1997) Spinal cord Part 1: Analysis of the clinical presentation and results of testing
stimulation: A valuable treatment for chronic failed back surgery procedures for instability of the lumbar spine in 171 patients. Acta
patients. J Pain Symptom Manage 13: 296-301. Neurochir (Wien) 123: 46-51.
This study reviewed the results of spinal cord stimulation in 69 This review of 171 patients with failed back surgery syndrome
patients with failed back surgery syndrome. Of the patients, 26 suggests methods for identifying specific types of postoperative
had stopped using the treatment.There were 43 who instability and the selection of patients for instrumented fusion
experienced good pain relief.The study found that 16 using facet blocks and plaster immobilization.
continued to require narcotic pain medication, but a synergistic
Markwalder T, Battaglia M. (1993) Failed back surgery syndrome
effect was reported in 11. Of the patients, 11 returned to work.
Part 2: Surgical techniques, implant choice, and operative results in
Fager CA, Froidberg SR. (1980) Analysis of failures and poor results 171 patients with instability of the lumbar spine. Acta Neurochir
of lumbar spine surgery. Spine 5: 87-94. (Wien) 123: 129-134.
This retrospective study of 105 patients attempted to identify the Using the protocols described in the preceding study, excellent
cause of failure in postoperative patients following lumbar spine or good results were obtained in 89%, satisfactory in 14%, and
surgery.Two thirds of patients had suffered work-related or moderate or poor in 7%.
vehicular accidents. Most patients did not have evidence of
Ross JS. (2000) Magnetic resonance imaging of the postoperative
significant nerve root compression on preoperative imaging studies.
spine. Semin Musculoskelet Radiol 4: 281-291.
Fritsch EW, Heisel J, Rupp S. (1996) The failed back surgery This review describes the use of MRI evaluation of the
syndrome: Reasons, intraoperative findings, and long-term results postoperative spine in patients with persistent or recurrent
A report of 182 operative treatments. Spine 21: 626-633. symptoms. Standard imaging protocols and MRI characteristics
This retrospective study presents the results of 182 revision of the most common postoperative conditions are presented.
surgeries performed over a 25-year period. Short-term results
Spengler DM, Freeman C,Westbrook R et al. (1980) Low back
were satisfactory in 80% but declined to 22% with long-term
pain following multiple lumbar spine procedures: Failure of initial
follow-up (2-27 years). Multiple revision patients were associated
selection? Spine 5: 356-360.
with rates of epidural fibrosis and instability exceeding 60%.
This retrospective study evaluated 30 patients who had failed
Laminectomy, as the index procedure, was associated with a
multiple lumbar surgeries. All patients had acceptable indications
higher rate of revision surgery. Fusion may be more successful
for surgery preoperatively.The most common cause of poor
than multiple fibrinolyses in severe discotomy syndrome.
results was thought to be poor patient selection in terms of
Goupille P. (1996) Causes of failed back surgery syndrome. Rev psychosocial problems such as drug abuse, alcoholism, marital
Rheum 63: 235-239. discord, and personality disturbance.
This topical review describes the evaluation and treatment of
Waddell G, Kummell EG, Lotto WN et al. (1979) Failed lumbar
various causes of failed back surgery syndrome.
disk surgery and repeat lumbar surgery following industrial injuries.
Herron LD,Turner J. (1985) Patient selection for lumbar J Bone Joint Surg [Am] 61-A: 201-207.
laminectomy and discectomy with a revised objective rating system. This retrospective study examined 103 Workmens
Clin Orthop 199: 145-152. Compensation Board patients who underwent revision lumbar
This prospective study of 275 patients evaluated a rating system spine surgery with a 1-2 year follow-up. Of the second
for selecting patients with lumbar disk herniation for surgery. operations, 40% were considered successful. Multiply revised
Among the patients with compensation or litigation issues, good patients [AU3]demonstrated progressively worse percentages of
outcomes were observed in 58% and fair or poor outcomes successful results, with more patients experiencing clinical
were seen in 42%. Among the patients without such issues, good worsening as opposed to improvement. Revision surgery was
outcomes were observed in 94% and fair or poor outcomes more successful if patients experienced at least 6 months of
were seen in 6%. relief from the index surgery, if the primary complaint was
sciatica, and when a recurrent herniation was found.
Jones AAM, Stambough JL, Balderston RA et al. (1989) Long-term
results of lumbar spine surgery complicated by unintended Waddell G, McCullough JA, Kummel E et al. (1980) Nonorganic
incidental durotomy. Spine 14: 443-446. physical signs in low back pain. Spine 5: 117-125.
Incidental durotomy was reported at a rate of 0.3%-13%.This This classic paper won the 1979 Volvo Award in clinical science.
retrospective review of 17 patients undergoing primary repair of Five nonorganic physical signs in low back pain patients are
incidental durotomy revealed no adverse effect on the outcome succinctly described.These signs serve as a screen for patients
at a mean follow-up of 25 months. who require more detailed psychological assessment.
Kramer J. (1987) The discectomy syndrome. Z Orthop 125: Williams KD, Park AL. (2003) Lower back pain and disorders of
622-625. intervertebral disks. In: Campbells Operative Orthopaedics (Canale
This review describes the postdiscectomy syndrome, ST, ed.), 10th edition. Philadelphia: Mosby.
attributing it to epidural scar formation. Patients experience
10

CHAPTER
Kyphosis of the Cervical, Thoracic,
and Lumbar Spine
Roberto Lugo*, Jonathan N. Grauer , John M. Beiner , Brian K. Kwon ,
Alexander R.Vaccaro ||, and Todd J. Albert

* M.D., Medical Student,Yale University School of Medicine, New Haven, CT


M.D., Assistant Professor, Co-Director Orthopaedic Spine Surgery,Yale-New Haven
Hospital; Assistant Professor, Department of Orthopaedics, Yale University School of
Medicine, New Haven, CT
M.D., B.S., Attending Surgeon, Connecticut Orthopaedic Specialists, Hospital of Saint
Raphael; Clinical Instructor, Department of Orthopaedics,Yale University School of
Medicine, New Haven, CT.
M.D., Orthopaedic Spine Fellow, the Rothman Institute at Thomas Jefferson University,
Philadelphia, PA; Clinical Instructor, Combined Neurosurgical and Orthopaedic Spine
Program, University of British Columbia; and Gowan and Michele Guest Neuroscience
Canada Foundation/CIHR Research Fellow, International Collaboration on Repair
Discoveries, University of British Columbia, Vancouver, Canada
|| M.D., Professor of Orthopaedic Surgery, the Rothman Institute at Thomas Jefferson
University, Philadelphia, PA
M.D., Professor and Vice Chairman, Department of Orthopaedics,Thomas Jefferson
University Medical College and the Rothman Institute, Philadelphia, PA

Introduction Most of the causes of kyphosis can be explained in terms


of a shortening of the anterior column, a weakening or
General lengthening of the posterior column, or both.
The spine is normally lordotic in the cervical and lumbar Once kyphosis is initiated it may progress because of
regions and kyphotic in the thoracic and lumbosacral increased loading of the anterior vertebral structures and
regions (Fig. 101).Together, these curves allow the weakening or lengthening of posterior ligamentous
occiput to be held in a balanced fashion over the pelvis. structures.
Kyphosis, from the Greek word kyphos, means bowed or As the deformity increases, neurologic compromise may
bent.When used clinically, this term often implies an occur.
increased curvature of the spine causing angulation with
an excessive posterior convexity and anterior concavity. History and Physical Examination
Increased kyphosis is, by far, the most common sagittal A thorough history should be obtained from any patient
plane deformity. Many etiologies for this have been who has a spinal deformity.The nature of a deformity
described (Table 101). Furthermore, increased kyphosis and any noted progression should be documented.
is less tolerated clinically than increased lordosis. Comorbid diseases such as osteoporosis, inflammatory

124
CHAPTER 10 Kyphosis of the Cervical, Thoracic, and Lumbar Spine 125

C2 disorders, and a history of infection bear specific


mention. Furthermore, any prior spinal surgeries should
Cervical spine be defined. Family history of spinal deformity is
lordosis important as well.
C7 It is crucial to understand a patients complaint
T1 because it will often dictate treatment. Patients
with kyphosis generally have with pain, a neurologic
deficit, or a cosmetic deformity.
Thoracic spine
Axial pain is often related to muscle fatigue or
kyphosis instability.
If a focal, sharply angulated kyphosis is seen in the
thoracolumbar spine, it is referred to as a gibbus
deformity.
In the setting of kyphosis, range of motion in extension
T12
L1 will be most limited.
Compensatory deformities may develop when
Lumbar spine
patients try to maintain forward gaze. For example,
lordosis
thoracic kyphosis may lead to a compensatory
L5
cervical or lumbar hyperlordosis. Additionally,
S1 compensatory hip and knee flexion may
Sacrum be seen.
kyphosis A neurologic examination will identify abnormalities if
Coccyx there is compression of the neural elements.There may
be signs and symptoms of radiculopathy if there is nerve
Figure 101: Normal spinal curvature with cervical and
root compression or of myelopathy if there is spinal cord
lumbar lordosis. Note that the plumb line dropped from the
odontoid passes through the cervicothoracic, thoracolumbar, compression.
and lumbar sacral junctions. Diagnostic Evaluation (Table 102)
Plain radiographs are useful in defining the nature of
sagittal plane deformities.These should be taken with the
patient standing and should include standing
anteroposterior and lateral films of the entire spine on
Table 101: Etiologies of Spinal Kyphosis 36-inch cassettes.
In addition to static films, dynamic films are useful to
CATEGORIES SPECIFIC CAUSES characterize the flexibility of a deformity.
Traumatic Single-event trauma Cobb measurements are used to quantify deformities
Microtrauma in the coronal or sagittal planes. Lines are drawn
Iatrogenic Postlaminectomy
parallel to the endplates of the vertebrae at the
Postirradiation
Inflammatory disorders Rheumatoid arthritis borders of a curve. A second set of lines is
Ankylosing spondylitis drawn perpendicular to the first lines, and the
Infectious Pyogenic infection angle of their intersection is the Cobb measurement
Tuberculosis (Fig. 102).
Postural N/A The plumb line is a vertical line dropped from the
Scheuermanns kyphosis See Table 103
Degenerative conditions Cervical disk disease odontoid or C7 vertebral body. In both the sagittal and
Osteoporotic fractures coronal planes, this should fall through the L5-S1 disk
Pagets disease space. Any other alignment suggests decompensation in
Congenital Defect of formation the sagittal or coronal plane.
Defect of segmentation Bone scans are sensitive but not specific for detecting
Neoplastic Primary tumors
Metastatic tumors subtle abnormalities that may contribute to spinal
Skeletal dysplasias Achondroplasia deformities.
Pseudoachondroplasia Computed tomography (CT), CT myelogram, and
Diastrophic dysplasia magnetic resonance imaging (MRI) are imaging
Developmental Idiopathic scoliosis
modalities that can be used to further define bony, soft,
Neuromuscular Myelodysplasia
Cerebral palsy or both types of tissue anatomy comprising a sagittal
plane deformity.
126 Spine Core Knowledge in Orthopaedics

Table 102: Diagnostic Evaluation of Spinal Kyphosis


DIAGNOSTIC MODALITY MEASUREMENTS CLINICAL UTILITY COMMENTS
Plain radiographs Cobb measurement
C7 plumb line Anteroposterior films determine coronal Should be taken in standing position
plane abnormalities (scoliosis)
May focus on cervical, thoracic, or lumbar spine
Lateral films determine sagittal plane Full-length (36-inch) films are better to assess
abnormalities (kyphosis or lordosis) overall alignment and to measure deformity
Dynamic radiographs Change in Cobb angles Reveal spinal instability Excursion may be limited if painful
Define the flexibility of the deformity
Bone scan Assessment of blood flow associated with Can distinguish between old and new compression
increased bone turnover as seen in fractures
infection, fracture, malignancy Cannot differentiate between lesions; therefore
should be followed by CT or MRI for
characterization
CT Defines bony anatomy Soft tissue visualization limited
CT myelography Demonstrates bony anatomy, compression Can pick up subtle lesions
of neural elements Disadvantage is the invasiveness of the
procedure
If the patient has spinal hardware, the image will be
attenuated and visualization will be impaired
MRI Defines soft tissue structures
MRI Compression of neural elements may be
identified
MRI Ligamentous disruption can be determined

Treatment musculature. Nevertheless, bracing has demonstrated


Nonoperative treatment is generally the initial treatment efficacy in the treatment of certain types of kyphosis in
for any spinal deformity. Such treatments generally the skeletally immature patient.
involve anti-inflammatory medications and physical Surgery is generally considered when deformities are
therapy with an emphasis on extension exercises. progressive, cause neurologic compromise, or lead to pain
Consideration can be given to bracing. However, in the unresponsive to conservative treatment.
skeletally mature population, this is not a lasting cure, and Anterior surgery should be considered with significant
the use of bracing risks deconditioning of spinal kyphotic deformities that are not corrected on dynamic
extension radiographs. In these cases, anterior releases
and, possibly, anterior column reconstructions should be
performed.
Posterior-only surgery can be considered for flexible
deformities. Segmental compression is generally applied
to several levels above and below the apex of the
pathology being addressed.
Alternatively, posterior surgery can be used to improve
correction or further stabilize a sagittal plane deformity
following an anterior release and reconstruction.
Complications specifically common in deformity surgery
include pseudarthrosis, neurologic deterioration, implant
failure, and progression of deformity.

Cervical Kyphosis
General
The cervical spine is normally lordotic, with an average
Xo lordosis of 34-42 degrees (Harrison et al. 1996). A line
Figure 102: Calculation of the intervertebral angle in the dropped from the odontoid should pass behind C3 to C6
sagittal plane using the Cobb technique. and through the cervicothoracic junction.
CHAPTER 10 Kyphosis of the Cervical, Thoracic, and Lumbar Spine 127

Developmentally, cervical lordosis is a secondary Early in the postlaminectomy period, there is often good
curvature.Therefore the vertebral bodies have similar resolution of radicular or myelopathic symptoms because
anterior and posterior heights, and the disks have greater of the decompression of the neural elements. However, if
height anteriorly than posteriorly (Moore et al. 1999). kyphosis develops, the patient may begin to complain of
If surgical intervention is required, this region of the recurrent or new neurologic symptoms. Axial neck pain
spine is well suited to preoperative or intraoperative caused by muscle fatigue and loss of forward gaze may
traction to allow gradual deformity correction.This follow.
technique offers the advantage of allowing serial Because of the instability of this situation, combined
examinations of the awake patient to ensure that anterior and posterior approaches are most commonly
neurologic worsening does not develop. performed if conservative measures fail (Albert et al.
Postoperative immobilization with a collar or halo 1998) (Fig. 104).
is possible if necessary. The risk of kyphosis may be avoided by performing a
fusion at the time of the laminectomy.This can be done
Degenerative Kyphosis with lateral mass (C3-C6) and isthmus or pedicle screw
The cervical spine, which allows significant mobility, (C2, C7, or below) fixation.The disadvantage of this
is prone to spondylosis (degenerative changes). technique is the associated loss of motion.
As explained in Chapter 6, this can lead to the loss of Cervical laminaplasty is another potential means of
normal lordosis or kyphosis when intervertebral disk avoiding postlaminectomy kyphosis.This procedure uses
height is lost and forward settling or flexion occurs. one of several techniques to elevate, but not remove, the
The mainstay of treatment for cervical radiculopathy and posterior bony arch. In doing so, the area for the neural
axial neck pain is conservative treatment. elements is expanded, but the integrity of the
If the previously noted symptoms are resistant to interspinous ligaments is maintained. Matsunaga et al.
conservative treatment, or if myelopathy is present, (1999) reported a significantly lower incidence of
restoration of alignment and decompression is postlaminectomy kyphotic after laminaplasty than after
recommended. laminectomy.
In general, correction is best achieved from anterior
approaches where the anterior column can be Inflammatory Disorders
reconstructed. Constructs longer than three levels may Inflammatory disorders, such as ankylosing spondylitis,
require additional posterior stabilization (Fig. 103). may lead to spinal kyphosis.
As explained in Chapter 14, signs and symptoms of
Post-traumatic Kyphosis ankylosing spondylitis may range from loss of flexibility
Traumatic injuries to the cervical spine can cause to fixed gross sagittal plane deformities. Eventually, a
deformity acutely or subacutely if inadequately treated chin on chest deformity may result in the face pointing
(Vaccaro et al. 2001). toward the floor.
Cervical spine trauma is covered in Chapter 21. The chief complaint in patients with loss of forward
Flexiondistraction and flexioncompression injuries are gaze is generally restriction of their activities of daily
most prone to post-traumatic kyphosis. living.
Injuries to the posterior ligamentous structures are Ankylosing spondylitis is initially managed with
associated with post-traumatic deformities if aggressive nonsteroidal anti-inflammatory medications and with
management is not instituted. Particular attention routine exercises.
should be given to such injuries in the lower cervical Extension osteotomies can be considered for ankylosing
spine. spondylitis patients with severely limiting deformities
(Fig. 105).
Postlaminectomy Kyphosis Patients with cervical kyphosis secondary to ankylosing
Laminectomy involves the decompression of the neural spondylitis are predisposed to extension distraction
elements by the removal of the posterior bony arch. In fractures. If such fractures occur, consideration should be
the degenerative cervical spine, this may be performed given to fixing patients in their newly extended posture
for the treatment of spondylotic myelopathy or if they are neurologically stable. If neurologic
spondylotic radiculopathy. compromise occurs, they may have to be returned to
As introduced in Chapter 7, laminectomy may be their previously flexed posture.
predisposed to kyphosis because of the disruption of the
posterior ligamentous and facet structures.
Skeletal Dysplasias
Risk factors for the development of postlaminectomy The most common form of skeletal dysplasia manifested
instability include young age, lack of preoperative in the cervical spine is diastrophic dysplasia.This
lordosis, and disruption of facet joints. autosomal recessive disorder may be associated with
128 Spine Core Knowledge in Orthopaedics

Figure 103: A 59-year-old woman with


degenerative kyphosis of the cervical spine.
She had radiculopathy and myelopathy.
Radiograph (A) reveals kyphosis; MRI (B)
reveals spinal cord compression. Follow-up
radiograph (C) reveals the restoration of
lordosis after the reconstruction of the anterior
column with supplemental posterior
stabilization.

severe cervical or thoracolumbar kyphosis that is


generally self-limiting. Congenital Kyphosis
Radiographs of patients with this disorder may Although congenital cervical kyphosis is uncommon, it
demonstrate anterior wedging of the apical vertebrae. may result in significant deformities, progressive disability,
If the deformity is progressive, bracing may be considered. and neurologic deterioration.
Surgery is considered only if a deformity is refractory to Congenital kyphosis usually arises from a vertebral
bracing or if neurologic deterioration is observed. segmentation defect (termed Klippel-Feil syndrome).
Posterior fusion in situ can be considered for the younger This may be associated with other congenital
patient.This allows continued anterior growth to partially abnormalities, most commonly in the heart or kidneys.
correct the deformity. Therefore patients should be counseled to rule out
CHAPTER 10 Kyphosis of the Cervical, Thoracic, and Lumbar Spine 129

Figure 104: A 52-year-old woman with progressive


postlaminectomy kyphosis. She underwent C3 and
C4 corpectomies with a strut allograft packed with
local bone and an antikick plate followed by a
posterior C2-C7 instrumented fusion.

these abnormalities if Klippel-Feil syndrome is Developmentally, thoracic kyphosis is a primary spinal


diagnosed. curvature. Therefore the vertebral body heights are
The classic triad of Klippel-Feil syndrome includes a larger posteriorly than anteriorly, and the disks have
short neck, a low posterior hairline, and limitations in similar anterior and posterior heights (Moore et al.
neck motion.This syndrome is associated with scoliosis 1999).
more than with kyphosis. The thoracic spine is unique in that it is stabilized by the
rib cage.
Patients with increased thoracic kyphosis may have back
Thoracic Kyphosis pain (often in the low back, neck, or periscapular area),
fatigue, or a round back deformity.
General
The thoracic spine is normally kyphotic within a range Postural Thoracic Kyphosis
of 20-45 degrees (Canale 1998). An average has been Thoracic kyphosis may simply be postural.This is most
quoted at 31 degrees (Stagnara et al. 1982). common in adolescents and young adults.
130 Spine Core Knowledge in Orthopaedics

Figure 105: A 56-year-old man with ankylosing spondylitis. He had progressive loss of forward gaze as seen by the lateral
radiograph (A) and the sagittal MRI (B). He underwent a cervicothoracic corrective extension osteotomy (C and D).

Such deformities are generally smooth, flexible, and kyphosis. Although usually a thoracic deformity, SD may
measure less than 60 degrees. be found in the lumbar spine.
These deformities are rarely progressive. Improvements of Patients usually complain of back pain or cosmetic
posture and extension exercises are recommended. deformity.
Because this disease is common in athletes and
Scheuermanns Disease laborers, a mechanical etiology is likely. However,
Along with postural round back, Scheuermanns disease several potential causes of SD have been proposed
(SD) is one of the most common causes of adolescent (Table 103).
CHAPTER 10 Kyphosis of the Cervical, Thoracic, and Lumbar Spine 131

More than 5 degrees of anterior wedging in three or


Table 103: Multifactorial Potential Causes of
Scheuermanns Kyphosis* more vertebrae at the apex of the kyphosis (also
known as Sorensons criteria)
THEORETICAL CAUSES AUTHORS Cobb angle of more than 45 degrees
Avascular necrosis of the ring apophysis of the Scheuermann 1921 Irregular vertebral endplates and narrowing of the disk
vertebral body spaces in the kyphotic region of the spine
Herniation of disk material into the vertebral Schmorl 1930 Thoracic kyphosis of less than 50 degrees with no
body (Schmorl nodes) causing disturbances
evidence of progression should be followed with lateral
of endochondral bone formation with
subsequent wedging films until growth is complete. An exercise program can
Persistence of anterior vascular grooves in Ferguson 1956 also be instituted.
vertebral bodies creating a point of structural Lumbar kyphosis (loss of lumbar lordosis) patients should
weakness avoid heavy lifting.
Osteoporosis Bradford 1976 Bracing may be useful in skeletally immature patients.
Mechanical stresses causing tightness of the Lambrinudi 1934
anterior longitudinal ligament It has been shown that teenagers with SD treated
Abnormal collagen and matrix of vertebral Aufdermaur 1981 with a Milwaukee brace have better kyphosis
endplate cartilage, including a decreased correction than older patients with more excessive
ratio between collagen and proteoglycan wedging.
*
The primary indication for surgery in the skeletally
(Canale 1998.)
immature is less than 75 degrees of kyphosis in spite of
Pain generally localizes to the region of the deformity brace treatment.
and stops with growth. In skeletally mature patients, the presence of back pain,
If pain is primarily in the lumbar area and the deformity kyphosis more than 75 degrees, and possibly
is in the thoracic region, the presence of a spondylolysis unacceptable cosmetic appearance are all relative surgical
should be considered. indications.
Neurological abnormalities are not usually present. If surgery is required, anterior release with posterior
Measurements and findings necessary for a diagnosis of instrumentation and fusion is recommended
SD include the following (Canale 1998): (Fig. 106).

Figure 106: An 18-year-old boy


with thoracic kyphosis. The patient
has thoracic kyphosis of 75 degrees
and vertebral wedging consistent
with Scheuermanns disease (A).
Back pain persisted despite
conservative treatment. The patient
underwent anterior releases and
posterior instrumented correction
and fusion (B).
132 Spine Core Knowledge in Orthopaedics

Neoplastic Spinal Kyphosis Osteoporotic Fractures


Spinal tumors are covered in Chapter 17. In decreasing Osteoporosis is a systemic skeletal disorder characterized
order, such lesions appear in the thoracic, by a decrease in bone mass and the deterioration of bone
sacrococcygeal, lumbar, and cervical regions tissue with an increase in bone fragility and in the
(Weinstein et al. 1987). susceptibility to fractures.
Metastatic tumors are, by far, the most common tumors As described at greater length in Chapter 13, the
in the spine. spine is the most common site of such fractures. In fact,
Metastatic and other malignant primary lesions have a each standard deviation decrease in bone mass density is
predilection for the anterior spinal column.When associated with a twofold increase in spine fractures.
anterior destruction occurs, kyphosis can result. Major sequelae of osteoporotic compression fractures are
Metastatic lesions are often treated with radiation with or back pain, vertebral height loss, and kyphosis.
without chemotherapy. However, instability, neurologic Kyphotic deformities in the thoracic and lumbar spine
compromise, pain, or a combination of these may prompt can precipitate a decrease in lung capacity that further
the consideration for surgical intervention. increases functional impairment.
The surgical approach for metastatic lesions depends on Noninvasive treatment alternatives include the following:
their location, but anterior column reconstruction with Temporary narcotics

posterior stabilization has been associated with overall Bed rest or orthotics (however, these are associated
improved outcomes. with accelerated bone loss and deconditioning of
Primary malignant lesions are ideally excised marginally spinal musculature)
but are often limited to intralesional excision secondary Medical management of the underlying cause for the
to anatomic constraints. Adjuvant therapy is tailored to osteoporosis
the type and the stage of a lesion and to the extent to Continued progressive deformity, neurologic
which it can be excised. deterioration, and pain are indications for more
Benign primary lesions require excision only if associated aggressive treatment methods.
with structural compromise, neurologic impingement, or Open fracture repair is fraught with difficulties because of
pain unresponsive to conservative modalities. poor bone quality and the frequently compromised
medical status of this patient population.
Postinfectious Kyphosis Minimally invasive methods to restore sagittal balance
Spinal infections are covered in Chapter 16. and decrease spinal pain are gaining popularity.
Two types of infection bear descriptionbacterial Vertebroplasty involves the percutaneous injection of

infections and tuberculosis infections (Potts disease). polymethylmethacrylate (PMMA) into a fractured
Bacterial infections generally begin in the disk space as vertebral body.
discitis and can then progress to involve the vertebral Kyphoplasty involves the insertion of a balloon that is
bodies as osteomyelitis. inflated in the vertebral body prior to the
Initially, attempts may be made to identify an organism in percutaneous injection of PMMA.
bacterial infections of the spine, especially in the adult. The relative merit of these two procedures remains a
Antibiotic and brace immobilization are initiated. topic of significant debate.
Infections that are identified late in their course or that Overall, kyphoplasty and vertebroplasty lead to 95%
fail noninvasive treatments may progress to kyphotic improvement in pain and functional status for patients not
collapse. If this occurs, open debridement, reconstruction, responding to conventional therapy (Garfin et al. 2001).
and stabilization must be considered (Fig. 107).
Similar to bacterial infections, Potts disease is associated Skeletal Dysplasias
with the narrowing of disk spaces and kyphotic Achondroplasia is a skeletal dysplasia associated with
collapse.This affects the thoracic spine most frequently, thoracolumbar kyphosis.This autosomal-dominant
followed by the cervical and lumbar regions (Al-Sebai genetic disorder is the most common dwarfing condition.
et al. 2001). Kyphosis can be categorized as rigid or flexible with the
Initially, medical and brace treatments are initiated. latter being more likely to spontaneously resolve, as
In a study by Wimmer et al. (1997), conservative would be expected.
treatment was found to be a reasonable alternative to Although brace treatment is often sufficient, surgical
surgery in kyphotic deformities measuring less than 35 therapy has been recommended for the following
degrees. situations (Kornblum et al. 1999):
However, surgical treatment is advocated for the Triangular apical vertebrae

treatment of resistant infection or progressive deformity. Thoracolumbar kyphosis of more than 30 degrees

This involves debridement and stabilization. Thoracic kyphosis of more than 50 degrees
CHAPTER 10 Kyphosis of the Cervical, Thoracic, and Lumbar Spine 133

Figure 107: A 64-year-old man with thoracic pain


and fevers. Workup revealed him to have discitis or
osteomyelitis, thoracic kyphosis, and myelopathy. CT
(A) and MRI (B) reveal focal kyphosis and cord
compression. The patient underwent T4 and T5
corpectomies with iliac crest bone grafting and
posterior T1-T8 instrumented fusions. Antibiotics
were started.

Pseudoachondroplasia, an autosomal dominant disorder Developmentally, lumbar lordosis is a secondary curvature


characterized by short-limbed dwarfism, is associated similar to the cervical curvature. As such, lordosis
with gradual kyphotic deformities that are not sharply develops from an anterior-greater-than-posterior disk
angular like in achondroplasia. space height rather than from trapezoidal-shaped
vertebral bodies (anterior-greater-than-posterior vertebral
body heights) (Moore et al. 1999).
Lumbar Kyphosis Because of the large compressive loads experienced
by the lumbar spine and the long moment arm
General of the body above this region, there is a risk of
The lumbar spine normally has 30 to 50 degrees of progression of sagittal plane deformities in this region
lordosis (Canale 1998). of the spine.
134 Spine Core Knowledge in Orthopaedics

Post-traumatic Kyphosis directly above and below the fractured segment,


As noted previously, trauma can lead to kyphosis acutely or respectively (Kuklo et al. 2001).
subacutely. Initial, deformity is largely based on the injury Indications for surgical intervention include the
pattern. Later deformities are generally seen only if following (Vaccaro et al. 2001):
treatment is inadequate in providing stability during healing. Progression of kyphotic deformity
Fractures with significant comminution of the anterior New or progressive neurologic deficit
spinal column or disruption of the posterior column are Localized kyphotic deformity of greater than 30 degrees
most likely to progress to kyphosis (flexion compression Unacceptable cosmetic appearance with a rigid
and flexion distraction injuries are particularly prone to deformity
such deformities). Goals of surgery are neural decompression, spinal
The kyphotic deformity is best measured by comparing reconstruction, and stabilization to restore lumbar lordosis
the superior and inferior endplates of the vertebrae (Fig. 108).

Figure 108: A 31-year-old woman. She sustained a T12


burst fracture (A) with splaying of the posterior elements (B).
She underwent a T12 corpectomy with an expandable cage
and anterior rod fixation.
CHAPTER 10 Kyphosis of the Cervical, Thoracic, and Lumbar Spine 135

In the setting of a chronic lumbar deformity, Smith- lumbar fractures, stating that most compression fractures can be
Peterson or pedicle subtraction osteotomies are managed conservatively. Denis classification of lumbar fractures
alternatives to combined anterior and posterior was drawn from this article.
reconstruction procedures. Garfin SR,Yuan HA, Reiley MA. (2001) New technologies in
spine: Kyphoplasty and vertebroplasty for the treatment of
Degenerative Kyphosis painful osteoporotic compression fractures. Spine 26(14):
As with the cervical spine, the lumbar spine is prone to 1511-1515.
spondylosis. Literature review providing useful facts and the results of the
As degenerative changes progress, lumbar kyphosis or use of vertebroplasty and kyphoplasty in the treatment of
scoliosis may develop. osteoporotic compression fractures.
Conservative treatment is the mainstay of treatment for Harrison DD, Janik TJ,Troyanovich SJ et al. (1996) Comparison of
such conditions. lordotic cervical spine curvatures to a theoretical ideal model of the
If conservative treatment fails and the lumbar deformity static sagittal cervical spine. Spine 21(6): 667-675.
is progressive, surgical intervention may be considered. This article is useful in providing an average measurement of
In addition to the anterior and posterior surgical options cervical lordosis.
described for other regions of the spine, transforaminal Kornblum M, Stanitski DF. (1999) Disorders of the pediatric and
lumbar interbody fusion and posterior lumbar interbody adolescent spine: Spinal manifestations of skeletal dysplasias. Orthop
fusion are additional posterior surgical alternatives for Clin N Am 30(3): 501-520.
focal deformities in this region of the spine. This article provides a comprehensive review of different
The method of surgical correction must be tailored to etiologies in spinal deformity caused by skeletal dysplasias.
the patients symptoms and underlying pathology. Pertinent information is provided in specific cases of skeletal
dysplasias that cause eventual spinal kyphosis, such as in
achondroplasia and diastrophic dysplasia.
References Kuklo TR, Polly DW, Owens BD et al. (2001) Measurement of
Albert TJ,Vaccaro A. (1998) Postlaminectomy kyphosis. Spine 23: thoracic and lumbar fracture kyphosis: Evaluation of intraobserver,
2738-2745. interobserver, and technique variability. Spine 26(1): 61-65.
Review of risk factors, biomechanics, workup, and surgical Statistical analysis of various measurement techniques for
treatment of postlaminectomy kyphosis.This review promotes thoracolumbar burst fracture kyphosis on lateral radiographs to
understanding of biomechanical principles to prevent and determine the most reliable measurement technique. Fifty lateral
surgically treat postlaminectomy kyphosis. radiographs were studied and reviewed by three spine surgeons.
Of the five methods used, measuring from the superior endplate
Al-Sebai MW, Al-Khawashki H, Al-Arabi K et al. (2001) Operative of the vertebral body one level above the injured vertebral body
treatment of progressive deformity in spinal tuberculosis. Int to the inferior endplate of the vertebral body one level below
Orthop 25(5): 322-325. showed the best interobserver and intraobserver reliability
Report on 14 patients with spinal tuberculosis treated surgically. overall.
All had progressive kyphotic deformity.The report states that
anterior and posterior debridement with fusion and Matsunaga S, Sakou T, Nakanisi K. (1999) Analysis of the cervical
instrumentation can improve correction in deformity in patients spine alignment following laminaplasty and laminectomy. Spinal
with progressive deformity, disease of three or more vertebrae, Cord 37: 20-24.
or destruction of anterior and posterior columns. Comparative retrospective study involving patients who had
undergone either laminaplasty or laminectomy to assess the
Bradford DS. (1977) Juvenile kyphosis. Clin Orthop 128: 45. incidence of the buckling-type alignment that follows these
Review of SD as a cause of juvenile kyphosis.The article procedures.The purpose was to know the mechanical changes in
describes the use of bracing for successful therapy. Surgery may the alignment of the cervical spine in these patients. Results
be necessary with severe kyphosis, pain, neurologic compromise, favor laminaplasty over laminectomy from the aspect of
or a combination of these. mechanics.
Canale ST. (1998) Scheuermanns disease. In: Campbells Operative Moore KL, Dalley AF. (1999) Curvatures of the vertebral column.
Orthopaedics, 9th edition. St. Louis: Mosby, pp. 2942-2947. In: Clinically Oriented Anatomy, 4th edition, pp. 434-435.
This chapter provides a detailed review of literature and modern Philadelphia: Lippincott Williams and Wilkins.
approaches to treatment and surgical intervention in SD. It This section includes embryologically relevant information
provides an overview of etiology and comprehensive review of about the development of the different spinal curvatures. It
diagnosis and treatment.The chapter also provides a range of provides useful information for anatomic background.
lumbar lordosis and thoracic kyphosis.
Stagnara P, Mauroy JC, Dran G et al. (1982) Reciprocal angulation
Dai LY. (2002) Low lumbar spinal fractures: Management options. of vertebral bodies in a sagittal plane: Approach to references for
Injury 33(7): 579-582. the evaluation of kyphosis and lordosis. Spine 7: 335-412.
Retrospective review of 54 patients with low lumbar spinal This article is useful in providing an average measurement of
fractures.The article reviews the management options for low thoracic kyphosis.
136 Spine Core Knowledge in Orthopaedics

Vaccaro AR, Silber JS. (2001) Post-traumatic spinal deformity. Spine The series justifies an aggressive surgical approach in the
26(24S): 5111-5118. treatment of spinal tumors with prolonged survival.
Review article that provides useful information about the
Wimmer C, Ogon M, Sterzinger W et al. (1997) Conservative
etiology, diagnosis, and treatment of cervical, thoracic, and
treatment of tuberculous spondylitis: A long-term follow-up study. J
lumbar post-traumatic deformity.The article focuses on the
Spinal Disorders 10(5): 417-419.
importance of reestablishing integrity of compromised spinal
Retrospective follow-up study of 40 tuberculosis patients
columns so that spinal stability can be restored when
treating spondylitis with orthotic supports for an average of 16
considering surgical management.
months and with antituberculous agents. Conservative treatment
Weinstein JN, McLain RJ. (1987) Primary tumors of the spine. is proposed as an alternative to surgical intervention in kyphotic
Spine 12: 843-851. angles of less than 35 degrees.
Review of 82 cases of primary neoplasms of the spine in an
attempt to identify common diagnostic and prognostic features.
11

CHAPTER
Spinal Scoliotic Deformities
Adolescent Idiopathic, Adult Degenerative,
and Neuromuscular
Daniel J. Sucato

M.D., M.S., Assistant Professor, Department of Orthopaedics, University of Texas


at Southwestern; and Staff Orthopaedist,Texas Scottish Rite Hospital for Children, Dallas,TX

Others have demonstrated normal fibers on the


Adolescent Idiopathic Scoliosis convexity but low frequency of type I (slow twitch)
fibers on the concavity.
Anatomy and Pathophysiology A decrease has been found in the muscle spindles of the
The etiology of adolescent idiopathic scoliosis (AIS) has paraspinous muscles.
not been elucidated; however, several theories have been
studied and developed.
Muscle Contractile Mechanisms
The contractile systems (actin and myosin) of platelets
Genetics and muscle are similar and are partially regulated by
A familial predisposition has been accepted. calmodulin.This has been studied in AIS patients.
Studies of monozygous twins demonstrate a concordance Platelet calmodulin levels are higher in progressive curves.
rate of 73%. Melatonin (the antagonist of calmodulin) is lower in
The mode of inheritance is debated. progressive curves.
Contractile mechanisms have been studied in
Effect of Connective Tissue pinealectomized rats (produces decreased melatonin levels).
Collagen and elastic fibers are the principal elements
supporting the spine.
Neurology
An abnormal collagen/proteoglycan ratio of the Inconsistent data
intervertebral disks has been demonstrated. Impaired peripheral, visual, and spatial proprioception
Elastic fiber abnormalities have been demonstrated in
patients with AIS.
Role of Growth and Development
Hypokyphosis has been seen in AIS. It may be a result of
Skeletal Muscle imbalance of anterior and posterior growth.
A decrease has been seen in type II (fast twitch) fibers in Some authors have found patients with scoliosis to be
the paraspinous muscles. taller with less kyphosis.

137
138 Spine Core Knowledge in Orthopaedics

Accelerated spinal growth starts earlier when compared


with controls. Other Examination
Lower extremities
Ensure no asymmetry in leg circumference, size, or length
Diagnostic Tools Look for asymmetric foot deformities (intracanal
History pathology)
Pain
Radiographic Examination
Occurs in 30% of patients with AIS
Uncharacteristic pain (awakens from sleep, continuous, PosteroanteriorAnterior Standing
radiating, or severe)unusual and requires further study Measure upper thoracic, thoracic, and thoracolumbar or
lumbar curves (Cobb method)
Age at Onset Determine the deviation of C7 plumb line from the
Patients may present symptoms in the adolescent period; centersacralvertical line (CSVL)
however, they may have had earlier onset. It is important Trunk shiftDeviation of the mid-distance of the rib
to determine the etiologyit may be juvenile or margins to CSVL
infantile onset. Risser stageSee Fig. 111
Status of triradiate cartilage (acetabular physis)Open or
Growth Potential closed
AgeGirls peak growth occurs from 11 to 12 years; boys
peak from 13 to 14 years.
Menarcheal statusPremenarcheal girls are a greater risk
for progression and may crankshaft following posterior-
only surgery.
Family History
It is important to determine sibling occurrence to allow
evaluation.

Physical Examination
Assessment of Deformity
Standing examination
Coronal imbalance assessment
Coronal curve assessment
Shoulder height or asymmetry
Adams forward bend test
Patient bends at the waist until the trunk is at 90 degrees
Rotational deformity assessment of the upper
thoracic, thoracic, and thoracolumbar or lumbar curves
Assessment for symmetry of movement with flexion

(absence of list to one side may denote nonidiopathic


scoliosis)
Neurologic Examination
Motor and sensory examinationUsually intact even
with intracanal pathology
Deep tendon reflexesKnees and ankles
Abdominal reflexes
A lateral-to-medial gentle stroke of the abdomen,

which elicits movement of the umbilicus Figure 111: Risser stages to determine skeletal maturity.
Should be symmetric (absent or present) Risser 0 = No ossification of the iliac apophysis. Risser 1-4 =
If asymmetric, then high correlation with neural axis Ossification beginning laterally and finishing medially when
pathology (syringomyelia, tethored cord)obtain the iliac wing is divided into four sections. Risser 5 = Fusion
magnetic resonance imaging (MRI) of the ossified iliac apophysis to the ilium.
CHAPTER 11 Spinal Scoliotic Deformities 139

Lateral Radiograph
Thoracic kyphosis and lumbar lordosis (Cobb method)
Junctional kyphosis
Between the structural upper thoracic and middle
thoracic curves
Between the structural middle thoracic and the
thoracolumbar or lumbar curves
Sagittal balanceC7 plumb normally falls at the
posterior edge of L5-S1
Presence of thoracic hypokyphosis or apical lordosis is
normal in AIS; absence may indicate neural axis
pathology

Bend Films
Purpose
Determine the curve typemore than 25 is structural
(Lenke et al. 2001)
Determine the flexibility index for each curve:
Subtract the bend Cobb angle from the
posteroanterioranterior (PA) Cobb angle and divide
by PA Cobb 100
Determine fusion levels in the lumbar spine:
Flexibility of the disk below the distal fusion vertebra,
which helps determine the distal extent of fusion
Ability of the planned distal fusion level to center over

the sacrum
Types of Bend Films
Supine anteroposterior best-effort bend Figure 112: Magnetic resonance image of the cervical spine
Patient lies supine on a table and bends to the right in a patient with a left thoracic curve. Note the large cervical
and the left syrinx.
Most commonly used
Push-prone testPatient is prone and the examiner Relative indications
pushes medially and anteriorly on the rotational Atypical curve pattern, i.e., left thoracic curve or

prominence thoracic kyphosis


Fulcrum bend film Rapidly progressing curve
Patient lies in a lateral position with the apex of curve Painful scoliosisOften difficult to sort out the pain
on a large roll
May be better for the assessment of thoracic curve
Bone Scan
flexibility Indications
Traction films Painful scoliosis without known etiology
Supine patient has manual traction applied (more
common)
Standing patient has halter traction applied
Natural History
The prevalence of AIS is 2% in the normal population
Magnetic Resonance Imaging with curves greater than 10 degrees. Of these patients,
(Fig. 112) 5% will demonstrate progression greater than 30
degrees.
Absolute indications
Neurologic abnormalities Gender Distribution
Juvenile and infantile onset Small curvesGirls equal boys
Congenital vertebral abnormalities Larger curves8 times more common in girls than in
Cutaneous manifestations of dysraphism boys
140 Spine Core Knowledge in Orthopaedics

Risk Factors for Progression


Table 111: Curve Progression Risk*
Skeletal immaturity (open triradiate cartilage, Risser sign
0-1, and premenarcheal) CURVE MAGNITUDE CURVE MAGNITUDE
Curve locationThoracic curves progress less often than (10-19 DEGREES) (20-29 DEGREES)
lumbar curves Risser sign 0-1 22% 68%
Curve magnitude Risser sign 2-4 1.6% 23%
Larger curves progress more often than smaller ones
*
At maturity, thoracic curves greater than 50 degrees (Lonstein JE et al.1984.)
progress into adulthood (average one per year)
(Table 111) LumbosacralApex between L4 and S1
Thoracolumbar/lumbar curves greater than 40 degrees King classificationTraditional classification of thoracic
progress into adulthood (especially with coronal curves
decompensation) King ILumbar curve greater than the thoracic curve
King IIThoracic curve with a compensatory lumbar
Curve Classification curve that crosses the midline
Based on the apex of the curve King IIIThoracic curve with a lumbar curve that
CervicalApex between C1 and C6 does not cross the midline
CervicothoracicApex between C7 and T1 King IVLong thoracic curve in which L4 is tilted
ThoracicApex between T2 and the T11-T12 disk into the curve
space King VDouble thoracic curve
ThoracolumbarApex between T12 and L1 Lenke et al. (2001) classificationA more comprehensive
LumbarApex between the L1-L2 disk space and L4 and newer classification (Fig. 113)

Figure 113: Lenke et al. (2001) curve classification. The three-part classification consists of curve type, lumbar modifier, and
thoracic sagittal profile.
CHAPTER 11 Spinal Scoliotic Deformities 141

Reliability has been tested with varying results


Three components of the spine analyzed to produce
Goal of Bracing
the classification Maintain the present curve magnitude or prevent it
from progressing to a level that means surgery is
Six Curve Types required
The larger curve is always considered structural; smaller
curves are structural if the patient fails to bend to less
Effectiveness
than 25 degrees. Still questioned today despite many studies (limited by
1Single thoracic the ability to measure compliance)
2Double thoracic SRS 1995 publication: Braced versus nonbraced
3Double major patientsProgression was seen in 64% of nonbraced
4Triple major patients compared with 26% of braced patients
5Lumbar curve without thoracic curve Unpublished data from Texas Scottish Rite Hospital by
6Lumbar curve with compensatory thoracic curve Katz et al.
Measured compliance with heat sensor
Lumbar Modifier Preliminary results demonstrate the dose response
Based on where the CSVL falls in relation to the apical to bracing; more than 12 hours in a brace was
lumbar vertebra more effective in the skeletally immature
ACSVL falls between the pedicles patients
BCSVL falls on the pedicle or lateral to the pedicle
within the vertebral body
CCSVL falls outside of the vertebral body Operative Treatment
Thoracic Kyphosis Modifier Indications
Measured from T5 to T12 Thoracic curves
Kyphosis less than 10 Immature patientsCurve magnitude greater than
NKyphosis between 10 and 40 40-50 degrees
+Kyphosis greater than 40 Mature patientsCurve magnitude greater than 50
degrees
Thoracolumbar/lumbar curves
Nonoperative Treatment Curve magnitude greater than 40 degrees with
significant coronal decompensation
Observation
Most patients who have AIS do not progress to the point
Goals of Operative Treatment
of treatment. Halt curve progression with fusion
Radiographs should be performed every 4-6 months Curve and deformity correction using instrumentation
depending on the risk of progression.
PA radiographs are used to determine the curve
Fusion Techniques
magnitude (Cobb method). Complete facetectomies at all instrumented levels
Bone Graft
Bracing (Table 112)
Autologous iliac crest
Indications Most commonly used
Curve progression to 25-30 degrees but less than 45 degrees Relatively high morbidity because of pain
Potential for growth (Risser sign less than 4) RibFrom concomitant thoracoplasty

Table 112: Types of Braces for Adolescent Idiopathic Scoliosis

TYPE OF BRACE INDICATIONS WEAR SCHEDULE COMPLIANCE


TLSO (Boston overlap)* All curve types 16-22 hours Middle compliance
Bending brace (Charleston) Thoracolumbar, lumbar curves 8-10 nighttime hours Best compliance
(25-35 degrees)
CTLSO (Milwaukee) Thoracic curves with apex above T7 16-22 hours Least compliance

*
TLSO, Thoracolumbosacral orthosis.

CTLSO, Cervical thoracolumbosacral orthosis.


142 Spine Core Knowledge in Orthopaedics

AllograftFusion rates similar to autologous Generally used in the lower thoracic and the lumbar
Local onlyRare spine
Becoming used more often in the thoracic spine
Fixation Anterior structural support
Modern segmental spinal instrumentation uses multiple Mesh cages or ring allografts
fixation points and dual rods posteriorly and single or Provides improved structural stiffness when
dual rods anteriorly. performing anterior instrumentation and fusion
Hooks Posterior Correction Maneuvers
Pedicle All correction maneuvers attempt to translate the spine
Up-going hooks under the lamina or inferior facet posteriorly and laterally and to derotate the spine in the
engaging the pedicle axial plane
Can be placed in thoracic spine to T10 Rod rotation
SublaminarCan be up-going or down-going Popularized by Dubousset
Transverse processcan be placed as up-going or down- Rod contouring and placement on the concavity are
going weakest hook followed by a counterclockwise rotation (for a right
Wires thoracic curve)
SublaminarExcellent for translation (laterally and Translation or cantileverDistal attachment of a
posteriorly) contoured rod and then translation of the spine to
Through the spinous process:Wisconsin (Drummond) the rod
wires In situ contouringThe rod is attached to the contour
Pedicle screws of the spine and then shaped to improve spinal
Provide optimal fixation of all three columns deformity

Figure 114: Preoperative and


postoperative radiographs following
anterior fusion from T9 to L2 using a
single 0.25-inch rod and anterior
structural support at the T12-L1 and
L1-L2 levels for a 53 degree curve.
Restoration of coronal and sagittal
balance is achieved.
CHAPTER 11 Spinal Scoliotic Deformities 143

Anterior Correction Maneuvers Fusion Levels


Rod rotation (usually for thoracolumbar or lumbar Nearly always proximal end vertebra to distal end
curves) vertebra
The rod is contoured to the convexity of the spine,

and rod rotation is performed to improve the coronal Posterior Instrumentation and Fusion
plane and restore or maintain lumbar lordosis.
Compression (usually for thoracic curves) (Fig. 116)
The rod is seated completely or more often distally All curves may be treated
initially or proximally initially followed by Always indicated for double or triple curves
compression.
A cantilever maneuver can be used (for the partially
Fusion Levels
seated rod) followed by compression at each level. Single thoracic curves
Proximal end vertebra to one level proximal to the
Treatment Options stable vertebra with hook fixation
Proximal end vertebra to one or two levels
Anterior Instrumentation and Fusion
proximal to the stable vertebra; may often stop at the
(Fig. 114) distal end vertebra with pedicle screw
Most common method used to treat thoracolumbar or Double thoracic curves
lumbar curves As for single thoracic curves except proximal fixation

Single thoracic curves can be treated either through an is most often to T2


open thoracotomy or thoracoscopically (Fig. 115) Double major curves

Figure 114: Contd


144 Spine Core Knowledge in Orthopaedics

Figure 115: Radiographs of a 12-year-old female who had a 53 degree thoracic curve.
She underwent a thoracoscopic anterior spinal fusion and instrumentation from
T5 to T12 with excellent correction of the coronal curve and restoration of
coronal and sagittal balance.

Proximal end vertebra Performed open or thoracoscopically in the thoracic spine


Distal fixation most common to the lumbar distal end Advantages of thoracoscopy include smaller incisions,

vertebra less postoperative pain, less postoperative pulmonary


Distal fixation is best performed with pedicle screws problems, and improved cosmesis
for improved correction and maintenance of curve Disadvantages of thoracoscopy are that it is technically
correction demanding and more costly because of the use of
disposable items
Anterior Release or Fusion and
Posterior Instrumentation or Fusion Aftercare and Follow-up
Anterior release required Postoperative antibiotics, diet advancement, and walking
Stiff curvesMore than 75 degrees that fail to bend to while in the hospital
less than 50 degrees Postoperative bracing is not required when using modern
Skeletally immature segmental instrumentation
Open triradiate cartilage or Risser 0-1 Activities are slowly advanced until patients are
Prevent crankshaft performing full activities between 6 and 12 months
CHAPTER 11 Spinal Scoliotic Deformities 145

Figure 115: Contd

Outcome of Surgical Treatment Adult Scoliosis and Deformity


Long-term follow-up only available for Harrington
instrumentation Introduction
Average correction is approximately 50% Defined as a coronal plane Cobb angle greater than 10
Distal fusion below L3 results in greater incidence of degrees in a patient older than 20 years.
low back pain The natural history of the curve in the mature patient is
Midterm follow-up of segmental spinal instrumentation variable.
Average coronal curve correction is approximately De novo curves of the lumbar spine may progress
60% with hook fixation rapidly.
Improved maintenance and correction of sagittal plane The rate of curve progression is not constant.
Short-term follow-up using segmental pedicle screw Lumbar curves progress more rapidly than thoracic curves.
fixation (Suk et al. 2000) Adult scoliosis more often presents symptoms of
Average coronal curve correction is approximately 75% associated back pain, leg pain, or both.
Rare neurologic injury Treatment of adult deformity can be more challenging
than that of adolescent deformity because of the following:
Greater curve stiffness
Complications Presence of degenerative changes
The reoperation rate for posterior spinal instrumentation Associated medical comorbidities

is 5%-19% for all causes (Boxes 111 through 113) Need for neural element decompression, thus extending
(Cook et al. 2000). surgical time and removing areas for bony fusion
146 Spine Core Knowledge in Orthopaedics

Figure 116: Radiographs of a 13-year-old female with a triple major curve (Lenke 4). She underwent a posterior spinal fusion
and instrumentation from T2 to L3. Proximal hook fixation, apical sublaminar wire fixation, and distal pedicle screw fixation were
used to achieve excellent correction with restoration of coronal and sagittal balance.

Osteopenia
Sagittal and coronal plane imbalance Classification
Difficulty in determining pain generators See Box 114.
Frequent need for longer fusions and more common
combined anterior or posterior procedures
Pathophysiology and Natural
Box 111: Late Onset Surgical Pain History
Incidence5%
Adult Scoliosis
Treatmenthardware removal Curve progression is usually not seen if less than 40
degrees.
Curve progression averages 1 degree per year if greater
Box 112: Pseudarthrosis
than 50 degrees.
Incidence3% Risk factors for the progression of lumbar curves include
TreatmentCompression instrumentation or bone graft the following:
Large apical rotation
Lateral and rotatory listhesis
Box 113: Delayed Infection For double curves, the lumbar curve tends to progress
more rapidly than the thoracic curve.
Incidence1%-7%
TreatmentHardware removal and short-term antibiotics
There is no difference in pulmonary function among
age-matched, normal patients.
CHAPTER 11 Spinal Scoliotic Deformities 147

Figure 116: Contd

Back pain incidence is similar; however, the severity is The average curve progression is approximately 3.3
worse and more recurrent when compared with controls. degrees per year.
The reasons for presenting symptoms to the physician A greater number of males are affected than in adult
could be as follows: scoliosis (females are still more common in both).
Pain at the location of the curve The reason for presenting symptoms is pain caused by
Progression of the curve one, or combinations, of the following:
Neurogenic claudication
De Novo Scoliosis Radicular symptoms
Prevalence is approximately 6%. Back painNot usually the main complaint
The average age at which symptoms are presented is the
sixth and seventh decade of life.
Diagnostic Tools
Adult Scoliosis and Deformity Plain Radiographs
Box 114:
Classification
IndicationsAll patients should have initial PA and
Adult scoliosis lateral long-cassette radiographs.
Previous AIS Long-cassette radiographsPA and lateral
Without degenerative changesUsually younger than 40 years
radiographs should include the cervical spine down to
With degenerative changesUsually older than 40 years
the pelvis.
De novo scoliosis (adult onset scoliosis) Supine right-sided and left-sided bend films should be
Develops secondary to degenerative changes of the lumbar
used to assess flexibility (especially when determining
spine
Usually in elderly patients
whether anterior surgery is necessary).They also are
helpful when choosing fusion levels.
148 Spine Core Knowledge in Orthopaedics

Traction films are useful in assessing flexibility and AdvantagesNo radiation exposure and excellent
choosing fusion levels. visualization of osseous and soft tissue structures
Ferguson viewAn x-ray beam directed 30 degrees DisadvantagesArtifact and distortion in the presence of
cephalad and focused on the lumbosacral junction metal implants and claustrophobia for some patients
provides an excellent view of the lumbosacral junction.

Assessment Parameters
Nonoperative Treatment
Aerobic conditioning
PosteroanteriorAnterior Radiograph Strengthening
Cobb measurement of all curves (upper thoracic, Stretching
thoracic, lumbar, and lumbosacral fractional curves) Nonsteroidal anti-inflammatory medications
Coronal imbalanceMeasured as a trunk shift from the With associated lumbar radiculopathy or neurogenic
CSVL or a deviation of a C7 plumb from the CSVL claudication, nerve blocks or epidural steroid injections
(most important in adult deformity) may be helpful.
Rotatory listhesis or subluxation For lumbar curves, a lumbar corset may be beneficial in
Disk height and wedging improving pain control.
Osteophyte formation noted of the vertebral bodies and
facet joints
Lateral Radiograph
Operative Treatment of Adult
Cobb measurementThoracic kyphosis (T5 to T12) and
Scoliosis
lumbar lordosis (L1 to L5)Loss of lumbar lordosis is See Box 115.
usually seen.
Sagittal balanceThe C7 plumb line should fall on the Algorithm for Operative Treatment of
posterior aspect of the L5-S1 disk level. Adult Scoliosis
Disk space height
Osteopenia of the vertebral bodies Approach
Degree of degeneration the facet joints Based on curve type, magnitude, flexibility, and sagittal
balance
Computed Tomography and Curve Type
Computed Tomography Myelography Thoracic curves
IndicationsCT largely has been replaced by MRI, so Posterior approach more commonly used
indications today are as follows: Only the thoracic curve is fused, leaving distal lumbar
Inability to get MRI ( presence of certain motion
ferromagnetic implants or claustrophobia) Thoracolumbar curves
Assessment of central and lateral recess stenosis and Anterior (more common) or posterior approach

presence of disk herniations in the setting of previous Double major curves


spine surgery Posterior approach to include both curves
Best for assessment of the integrity of a spinal fusion Indications to include an anterior (combined) fusion
May be better for patients with large curves to assess Large stiff curves
canal stenosis Kyphosis (use structural anterior grafts)
AdvantagesStill an accurate method of evaluating bone
density and anatomy (osteophyte and facet arthropathy),
canal and foraminal stenosis, and bony fusion Indications for Operative Treatment
DisadvantagesRadiation exposure and its invasive nature Box 115:
of Adult Scoliosis
Magnetic Resonance Imaging Documented curve progression
Technique Increased coronal imbalance, sagittal imbalance, or both
Usually T1- and T2-weighted axial and sagittal images Symptoms unresponsive to nonoperative treatment
May add gadolinium in the face of previous surgery Relative indications
Pulmonary symptoms (rare)
IndicationsAssessment of central and lateral recess
Back painNot an indication alone for surgical intervention
stenosis, presence of disk herniation, and morphology and Leg pain (with lumbar curves) because of objective nerve root
degree of degeneration of the intervertebral disks when
compression
planning fusion levels
CHAPTER 11 Spinal Scoliotic Deformities 149

Rotatory subluxation or listhesis Anterior surgery assists in creating lumbar lordosis


Fusion to L5 or S1 Anterior structural grafting assists fusion and creates a
Performance of anterior and posterior surgery on the ligamentotaxis effect
same day is dependent on the medical condition of Anterior surgery (structural support) of L4-L5 and
the patient and the duration and clinical status of the L5-S1 increases fusion success, maintains or improves
patient at the completion of the initial stage of sagittal fusion success, and maintains or improves
surgery sagittal alignment when fusing to the sacrum
Fusion Levels Internal Fixation
Similar to AIS especially for the younger adult (younger Segmental internal fixation is always recommended
than 40 years) Pedicle screw fixation
End-instrumented vertebra should be neutral (no Improved three-dimensional correction when
rotation) and stable (bisected by the center sacral line) compared with hooks
For a patient older than 40 years with degenerative Always used in the lumbar spine

changes Can be used in the thoracic spine safely when the


Assessment of the distal lumbar disk levels below L3 morphology of the thoracic pedicle is of adequate size
with MRI is recommended to ensure that fusion does Sacropelvic fixation
not require inclusion of these levels because of the Many implants available
presence of advanced degeneration Galveston, iliac screws, intrasacral rods, and S2 screws
Levels of decompression for spinal stenosis are included provide fixation to backup S1 screws
in the fusion levels
Treatment of Fixed Sagittal
Operative Treatment of De Novo Imbalance
(Degenerative) Scoliosis Indications for Treatment
See Boxes 116 through 119. Fixed kyphosis with pain
Anterior surgery accomplishes the following: Significant sagittal imbalanceC7 plumb line falling
Anterior release improves correction and fusion rates
anterior to the L5-S1 disk
Smith-Petersen Osteotomies
Indications for Operative Treatment Multiple osteotomies done posteriorly (may also need
Box 116:
of De Novo (Degenerative) Scoliosis anterior surgery; see Fig. 117)
Closes the posterior column and opens the anterior and
Progressive deformity middle columns (often requiring structural graft)
Spinal imbalance
Neurogenic claudication unresponsive to conservative treatment

Box 117: Decompression Only


Before After
Mild scoliosis coronal curve less than 10 degrees Area of
No instability, lateral listhesis, or rotatory subluxation bony resection

Decompression, ASF and PSF, or


Box 118:
Instrumentation
Scoliosis >30 degrees
Sagittal imbalance, coronal imbalance, or both

Decompression, PSF, or Vertebral


Box 119:
Column Resection
Figure 117: Smith-Petersen osteotomy. Correction is achieved
Scoliosis >30 degrees
by closing the posterior column (location of the osteotomy) and
Fixed coronal imbalance
opening the anterior column. (Reprinted from Bridwell 2003.)
150 Spine Core Knowledge in Orthopaedics

Indications for posterior surgery only Pseudarthrosis


Young patient The most common complication

Fusing short of sacrum with mild or moderate Incidence5% to 25%


correction needed in the setting of normal disks Risk factorsRevision surgery, use of allograft bone,
Indications for anterior and posterior surgeryNarrow and use of nonsegmental hardware
disks that may not compensate for a significant correction Infection
of sagittal imbalance in a patient requiring greater than Incidence0.5% to 8%
30 degrees of correction Risk factorsNo perioperative antibiotics,
poor nutrition (use total parenteral nutrition
Pedicle Subtraction Osteotomy in staged surgery), poor soft tissue handling,
Technically more challenging (Fig. 118) (Bridwell et al. and posterior surgery more common than anterior
2003) surgery
Closes the posterior and middle columns and hinges on Neurologic compromise
the anterior column IncidenceLess than 1% to 5%
Should be done at L1 or distal (below the conus Risk factorsCombined anterior and posterior
medullaris) surgery, revision surgery, or osteotomy surgery
Advantages over Smith-Petersen osteotomy Pulmonary embolism
Done through the posterior approach alone, gains Incidence1% to 20%
more than 30 degrees of correction, and does not Spinal decompensation
lengthen the anterior column Risk factorsImproper selection of fusion levels and
Greater potential for healing without stretch on aorta possibility of error on longer fusions; ideally stop at
or viscera neutral and stable vertebra
DisadvantagesTechnically difficult, increased blood loss,
and greater potential for neurologic injury
Neuromuscular Scoliosis
Introduction
Results and Complications Scoliosis is common in patients with neuromuscular
following Adult Spine Deformity diseases.
Larger curves cause difficulties with sitting or ambulation.
Surgery Bracing generally does not affect the natural history of
Pain (Ahlert et al. 1995, Grubb et al. 1994, Schwab et al. scoliosis in these patients.
2003) Progressive severe curves require operative treatment.
A balanced patient with solid fusion usually has The goals and treatment methods for neuromuscular
improvement in the severity of pain scoliosis are slightly different than those for idiopathic
The frequency of pain usually continues curves.
Longer fusions, often to the pelvis
Fusions often for smaller curves
Complication rates high

Classification
Before After
See Box 1110.

Area of
bony resection Anatomy and Pathophysiology
(of the more Common Diagnoses)
Cerebral Palsy (Fig. 119)
Nonprogressive encephalopathy with varying degrees of
severity
Damage to the brain occurs prenatal, perinatal, or
Figure 118: Three-column pedicle subtraction osteotomy. postnatal
The osteotomy closes all three columns of the spine. PrenatalInfections or toxins (drugs or alcohol)
(Reprinted from Bridwell 2003.) PerinatalAnoxic brain injury
CHAPTER 11 Spinal Scoliotic Deformities 151

Lower lumbarCommunity ambulator with ankle


Neuromuscular Scoliosis
Box 1110: foot orthoses (AFOs)
Classification SacralCommunity ambulator with or without
Neuropathic AFOs
1. Upper motor neuron
Beware of the 15% incidence of latex allergy, which leads
Cerebral palsy
to anaphylaxis and subsequent death
Spinocerebellar degeneration

Friedrichs ataxia

Charcot-Marie-Tooth disease
Spinal Deformity
Roussy-Lvy disease Common and complex
Syringomyelia Causes of spine deformity
Spinal cord tumor
Congenital anomalies leading to scoliosis and
Spinal cord trauma
kyphosis
2. Lower motor neuron Muscle imbalance
Poliomyelitis

Traumatic
Hydrocephalus
Spinal muscular atrophy
Tethered cord
Werdnig-Hoffmann
Duchennes Muscular Dystrophy
Kugelberg-Welander

Letterer-Siwe This is an X-linked recessive disorder.


Myelomeningocele Encoding for dystrophin protein is abnormal, leading to
3. Dysautonomia (Riley-Day syndrome) complete absence.
Myopathic
Becker muscular dystrophy has a decreased amount of
dystrophin.
1. Arthrogryposis The dystrophy is characterized by progressive weakness in
2. Muscular dystrophy
Duchennes
boys who begin walking late (18 months) and eventually
Limb-girdle
lose ambulatory ability by 12 years.
Fascioscapulohumeral
The life span is shortened to less than 25 years because of
3. Fiber-type disproportion pulmonary compromise.
4. Congenital hypotonia Histology includes muscle necrosis and fibrofatty muscle
5. Myotonia dystrophica infiltration.
Spinal deformity develops because of muscle imbalance
and only appears following the loss of ambulatory
PostnatalMeningitis, near drowning, trauma, or child status.
abuse Beware of the occurrence of malignant hyperthermia
Classifications with anesthesia.
Muscle toneSpastic, hypotonic, dystonic, athetosis,
or ataxic
Spinal Muscular Atrophy
GeographicHemiplegic, diplegic, or quadriplegic This progressive muscular weakness is caused by a loss of
Spine affected by abnormal tone and imbalance of the anterior horn cells of the spinal cord.
paraspinal muscles Type I (Werdnig-Hoffmann disease)
Spinal deformity more common in nonambulatory, Severe weakness in the neonatal period and death by
quadriplegic, and spastic patients 2 years from respiratory failure
Type II
Myelomeningocele Normal development until 5-6 months then failure to
Birth defect characterized by exposure of the meninges stand or walk
and dysplasia of the underlying neural elements, resulting Spinal deformity is universal and can be rapidly
in bowel, bladder, motor, and sensory paralysis distal to progressive
the malformation Type III
Incidence1 in 1000 live births in the United States; Onset before 3 years and progressive loss of
50% caused by dietary folate deficiency ambulatory ability by 15 years
ClinicallyWide spectrum depending on the level of the Spinal deformity is common
lesion Type IIIb (Kugelberg-Welander syndrome)

Thoracic levelSitter Onset after 3 years


Upper lumbarHousehold or community ambulator Weakness is often mild (foot drop) with limited

with assistive devices endurance


152 Spine Core Knowledge in Orthopaedics

Diagnostic Tools Gastrostomy feedings are often necessary to improve


nutritional status.
Radiographs
Standard PA and lateral radiographsAssess curve Duchennes Muscular Dystrophy
severity (Cobb method) and the rate of progression Pulmonary function tests ensure the following:
Supine bending radiographsDetermine flexibility Forced vital capacity greater than 30%-40% of
predicted capacity
Imaging Studies Cardiology referral for echocardiography of heart
Specific imaging studies are diagnosis dependent. contractility
MyelomeningoceleMRI is used to identify tethered
cord, syringomyelia, Chiari malformations, and
hydrocephalus. Nonoperative Treatment
Laboratory Examination Bracing
Laboratory examination is important to assess nutritional The natural history of neuromuscular scoliosis is not
status. affected by bracing.
Thoracolumbosacral orthosis may be used in the
Cerebral Palsy skeletally immature child with cerebral palsy,
Good nutritional status is denoted by the following: myelomeningocele, and spinal muscular atrophy with
Albumin >35 g/L a supple spine deformity to buy time prior to surgical
Total lymphocyte count >1500 cells/mm3 treatment.

Figure 119: Scoliosis in a patient with cerebral palsy.


CHAPTER 11 Spinal Scoliotic Deformities 153

Modification of Seating Systems


Significant improvements in sitting balance can be
achieved with wheelchair modifications for the
patient who is nonambulatory or partially
ambulatory.
It is difficult to achieve better sitting in stiff curves.

Operative Treatment
In general, neuromuscular curves require longer fusions
than idiopathic curves.
For nonambulatory patients, fusion usually extends from
T2 to the sacrum.
Fixation
Traditionally segmental Luque wires have been used.

Hooks, screws are more often used today. Figure 1110: Galveston method of pelvic fixation with
Pelvic fixation has many variations (Figs. 1110 and sublaminar Luque wires.
1111,Table 113).
Cerebral Palsy
Indications
Ambulatory patientsCurves greater than 50 degrees

Figure 119 Contd: Figure 1111: Dunn-McCarthy method of pelvic fixation.


154 Spine Core Knowledge in Orthopaedics

Table 113: Types of Pelvic Fixation

TYPE OF PELVIC FIXATION MODE OF FIXATION ADVANTAGES DISADVANTAGES


Galveston (Fig. 1110) Smooth rod in the iliac wing Provides good initial fixation to the pelvis Loosening over time
Learning curve to bend the rod
Dunn-McCarthy (Fig. 1111) Smooth rods over the sacral ala Technically easy Smaller moment arm to correct pelvic
obliquity
Close to L5 nerve root
Iliosacral screws Engages ilium and sacrum with a Single implant Technically difficult
single implant Medium stability
Iliac screws Threaded screw into the iliac wing Excellent purchase into the hardest bone Occasionally difficult to make
of the ilium connection to rod
VersatileMay be connected to any rod
system

Nonambulatory patientsControversial; some affected Duchennes Muscular Dystrophy


early (greater than 50 degrees)
Levels IndicationsProgressive thoracolumbar scoliosis of
Ambulatory patientsProximal stable to distal stable greater than 25-30 degrees
vertebra Levels
T2 to the sacrum
Nonambulatory patientsT2 to the pelvis
Approach Some advocate stopping at L5 for patients with little
Predominantly posterior pelvic obliquity
Anterior fusion may be necessary in very large (more ApproachAll posterior
than 100 degrees) stiff curves Spinal Muscular Atrophy
Myelomeningocele IndicationsProgressive scoliosis
Levels
Scoliosis Dependent on the ambulatory status, the age of the
IndicationsProgressive curves which limit sitting ability patient, and the pulmonary status
or lead to pressure sores. Stop short of the sacrum in ambulatory patients
Levels Approach
The level depends on the curve magnitude, Anterior and posterior for the young patient with a

ambulatory status, and pelvic obliquity. large curve


The level is usually T2 to the sacrum in the older All posterior for the older patient with a smaller

child. curve
In the growing child, the surgeon may instrument the
thoracic curve without fusion to allow for growth.
Approach
Complications
A combined anterior and posterior approach is The incidence of complications is generally higher
necessary to ensure fusion because posterior elements following surgery for neuromuscular scoliosis.
are missing.
For select ambulatory patients with a thoracolumbar
Excessive Intraoperative Blood Loss
curve, an anterior approach and instrumentation may Aggressive blood transfusion intraoperatively is
be sufficient. necessary.
Kyphosis Infection
Kyplaectomy indications Often dependent on the nutritional status of the patient
Significant soft tissue breakdown over the gibbus Prevention
Difficulty with sitting Good nutritional status prior to surgery
LevelsT2 to the sacrum Preoperative and postoperative antibiotics
ApproachAll posterior with kyphus resection and Intermittent irrigation of the soft tissues during surgery
spinal cord resection Meticulous handling of the soft tissues
CHAPTER 11 Spinal Scoliotic Deformities 155

Pulmonary Compromise Adult Scoliosis and Deformity


Prevention
Good preoperative assessment of pulmonary status Albert TJ, Purtill J, Mesa J et al. (1995) Health outcome assessment
Aggressive postoperative pulmonary toilet before and after adult deformity surgery: A prospective study. Spine
20: 2002-2005.
This prospective study analyzed 55 adult scoliosis patients
References following surgery using the SF-36 outcome instrument. It
demonstrated significant improvement in self-reported health
Adolescent Idiopathic Scoliosis assessment and function without losing the beneficial effects
Cook S, Asher M, Lai SM et al. (2000) Reoperation after primary over time.There were no differences in outcome related to age
posterior instrumentation and fusion for idiopathic scoliosis. Spine (older than 40 years versus younger 40 years), distal extent of
25: 463-468. fusion, or the occurrence of a complication.The authors suggest
The authors analyzed a consecutive series of 182 patients who that a more disease-specific outcome measurement tool would
were treated with posterior spinal fusion for idiopathic scoliosis be appropriate in future studies.
and demonstrated that the frequency for reoperation was 19%. Bradford DS,Tay BK, Hu SS. (1999) Adult scoliosis: Surgical
The most common reason was late onset surgical pain in which indications, operative management, complications, and outcomes.
the patients thought that the hardware was problematic. Spine 24: 2617-2629.
Removal of the hardware improved their symptoms. Other This excellent review article provides an up-to-date description
reasons for reoperation were pseudarthrosis, infection, and of the treatment of adult scoliosis and a good explanation of
miscellaneous causes. some of the controversial issues.
Lenke LG, Betz RR, Harms J et al. (2001) Adolescent idiopathic Bridwell KH. (2003) Adult deformity: Scoliosis and sagittal plane
scoliosis: A new classification to determine extent of spinal deformities. In: Principles and Practice of Spine Surgery (Vaccaro
arthrodesis. J Bone Joint Surg Am 83-A: 1169-1181. AR et al., eds.). Philadelphia: Mosby.
The authors describe a new classification for AIS that is more
comprehensive than the King classification using a two- Bridwell KH, Lewis SJ, Lenke LG et al. (2003) Pedicle subtraction
dimensional analysis of curves. The classification defines three osteotomy for the treatment of fixed sagittal imbalance. J Bone
components of the spinal deformity: curve type (1 through Joint Surg Am 85: 454-463.
6), a lumbar modifier (A, B, or C) and a sagittal thoracic The authors report on 27 consecutive patients treated at a single
modifier (-, N, or +). The authors demonstrate greater institution with lumbar pedicle subtraction osteotomy for fixed
intraobserver and interobserver reliability than the King sagittal imbalance. A radiographic and functional outcome
classification. assessment was performed.The average increase in lordosis was
34 degrees with an associated improvement in sagittal balance of
Lonstein JE, Carlson JM. (1984) The prediction of curve 13.5 cm.There was significant improvement in the Oswestry
progression in untreated idiopathic scoliosis during growth. J Bone and pain scores, and most patients were satisfied with the
Joint Surg Am 66: 1061-1071. procedure overall.There was one pseudarthrosis at the level of
Richards BS. (1992) Lumbar curve response in type II idiopathic the osteotomy.
scoliosis after posterior instrumentation of the thoracic curve. Spine Grubb SA, Lipscomb HG, Sug PB. (1994) Results of surgical
17: S282-286. treatment of painful adult scoliosis. Spine 19: 1619-1627.
The author reviewed 24 patients with King type II curves This study analyzed the outcome of spinal fusion in 20 patients
to determine whether preoperative assessment of lumbar with painful adult scoliosis and 25 patients with painful
curve flexibility could predict postoperative outcome when degenerative scoliosis.The follow-up was between 2 and 7
treated with segmental spinal instrumentation. Despite 73% years. Pain rating; activity level related to standing, sitting, and
lumbar curve correction on the preoperative supine bend walking tolerance; ability to work; and period of disability was
films, the magnitude of the lumbar curve remained larger assessed.The authors report a pseudarthrosis rate of 17.5% (all
than the instrumented thoracic curve and was partially patients fused to the sacrum with posterior-only surgery). Pain
caused by the residual obliquity of the fourth lumbar relief was correlated with a solid fusion and was seen in 80% of
vertebra. patients with idiopathic scoliosis and 70% with degenerative
Suk SI, Lee CK, Kim WJ et al. (2000) Segmental pedicle screw scoliosis. Improvement in sitting, walking, and standing was
fixation in the treatment of thoracic idiopathic scoliosis. Spine 20: seen.
1399-1405. Schwab F, Dubey A, Pagala M et al. (2003) Adult scoliosis: A health
This retrospective clinical study compared the results of assessment analysis by SF-36. Spine 28: 602-606.
correction of AIS using pedicle screw fixation and hook The authors analyzed 22 patients with adult scoliosis and 27
fixation.The major coronal curve correction was 55% with patients with degenerative scoliosis (using the SF-36 outcome
hooks and 72% with screws. Patients who had hypokyphosis instrument) who had not had surgical treatment and compared
had better improvement and improved rotational correction them with norms for the US population.The results
when segmental screws were used. demonstrate that the patients with scoliosis had lower scores in
all eight categories when compared with the general population
156 Spine Core Knowledge in Orthopaedics

and lower scores in seven of eight categories when compared patients, 37 had an average increase of 3.2 cm in height of the
with the US population 55 to 64 years old.The authors lumbar spine.
conclude that adult scoliosis is a medical condition with a
Sponseller PD, LaPorte DM, Hungerford MW et al. (2000) Deep
significant effect in the fastest growing population in the US.
wound infections after neuromuscular scoliosis surgery: A
multicenter study of risk factors and treatment outcome. Spine 25:
Neuromuscular Scoliosis 1461-2466.
This multicenter study analyzed 210 surgically treated patients
Comstock CP, Leach J,Wenger DR. (1995) Scoliosis in total- and identified 21 patients who had a deep wound infection.
bodyinvolvement cerebral palsy: Analysis of surgical treatment and Patients were analyzed and compared with 50 uninfected
patient and caregiver satisfaction. Spine 23: 1412-1424. patients matched for age, diagnosis, and year of surgery.The risk
This retrospective review demonstrated that at a minimum factors for deep wound infection following spine surgery in
follow-up of 2 years there was a 30% rate of late progression of these neuromuscular patients were severe cognitive impairment
the scoliosis, pelvic obliquity (>75), and decompensation and the use of allograft. Identification of gram-negative
(>4 cm). Of the patients, 21% had revision surgery; however, organisms was common, and infection often led to the
85% of the parents and caregivers were satisfied with the results development of a pseudarthrosis.
of surgery. Sussman MD. (1984) Advantage of early spinal stabilization and
Lintner SA, Lindseth RE. (1994) Kyphotic deformity in patients fusion in patients with Duchenne muscular dystrophy. J Pediatr
who have a myelomeningocele: Operative treatment and long-term Orthop 4: 532-537.
follow-up. J Bone Joint Surg Am 76: 1301-1307. The author reports improved outcome when surgical
The authors reviewed 39 patients who had myelomeningocele stabilization and fusion of scoliosis is performed in patients with
and resection of the kyphotic deformity.The average age at the Duchenne muscular dystrophy.This improvement in outcome is
time of surgery was 6 years and follow-up was 11 years.The seen as a lower complication rate, shorter hospital stay, improved
correction of the kyphosis was from 111 degrees to 40 degrees curve correction and overall balance, and more rapid return to
postoperatively and 62 degrees at final follow-up. Of the 39 daily life.The author recommends surgical treatment when the
curve progresses to between 30 and 40 degrees.
12

CHAPTER
Lumbar Spondylolisthesis
Bilal Shafi*, John M. Beiner , Jonathan N. Grauer , Brian K. Kwon ,
and Alexander R.Vaccaro ||

*M.D., M.S., Surgical Resident, Hospital of University of Pennsylvania, Philadelphia, PA


M.D., B.S., Attending Surgeon, Connecticut Orthopaedic Specialists, Hospital of Saint
Raphael; Clinical Instructor, Department of Orthopaedics,Yale University School of
Medicine, New Haven, CT.
M.D., Assistant Professor, Co-Director Orthopaedic Spine Surgery,Yale-New Haven
Hospital; Assistant Professor, Department of Orthopaedics,Yale University School of
Medicine, New Haven, CT
M.D., Orthopaedic Spine Fellow, Department of Orthopaedic Surgery,Thomas Jefferson
University and the Rothman Institute, Philadelphia, PA; Clinical Instructor, Combined
Neurosurgical and Orthopaedic Spine Program, University of British Columbia; and Gowan
and Michele Guest Neuroscience Canada Foundation/CIHR Research Fellow, International
Collaboration on Repair Discoveries, University of British Columbia,Vancouver, Canada
|| M.D., Professor of Orthopaedic Surgery,Thomas Jefferson University and the Rothman
Institute, Philadelphia, PA

Introduction Classification
See Table 121.
Definitions
SpondylolisthesisDisplacement of one vertebra on Radiographic Measurements
another The severity of the spondylolisthesis is assessed by the
From Greek magnitude of the slip and the slip angle using plain lateral
spondylosvertebra radiographs.
olisthesisslippage Taillard method (Wiltse et al. 1983)The degree of the slip
SpondylolysisDefect in the pars interarticularis, defined is expressed as a percentage of the anterior displacement of
as the bone between the superior and the inferior the inferior vertebral endplate of the cephalad body over the
articular processes superior endplate of the caudal vertebra.
Anatomy (Fig. 121)
The inferior articular process of each lumbar vertebra
Congenital or Dysplastic
articulates with the superior articular process of the Spondylolisthesis
subjacent vertebra in an overlapping or shingle
fashion.
Epidemiology
The pars interarticularis is the bony connection between Displacement occurs early, usually during the adolescent
the superior and the inferior processes. growth spurt (Newman 1963,Wiltse et al. 1976).

157
158 Spine Core Knowledge in Orthopaedics

Posterior longitudinal
ligament
Vertebral body L3 Cauda equina nerve roots
Dural tube
Pedicle (cut) Ligamentum flavum

Lamina

Nerve root L3 Facet joint

Superior
articular process Transverse process

L5 spinous process
Pars
interarticularis

Inferior
articular process
Figure 121: Normal lumbar spinal anatomy. The superior articular process overlaps the inferior articular process with a variable
angle to the coronal and sagittal planes, forming the facet joint.

Table 121: Modified Wiltse Classification of Spondylolisthesis

TYPE NAME DESCRIPTION VERTEBRAL LEVEL


I Congenital or dysplastic Forward displacement because of dysplasia of the sacral or fifth Usually L5-S1
lumbar arch, the facets, or both
II Isthmic or spondylolytic Forward displacement because of a defect in the pars Usually L5-S1
interarticularis
III Degenerative Forward displacement because of segmental instability and L4-L5 (90%)
degeneration of the disks and facets L3-L4 or L5-S1 (10%)
IV Traumatic Forward displacement because of a fracture of the neural arch at Usually L5-S1
a site other than the pars interarticularis
V Pathologic Secondary forward displacement because of a pathologic lesion Any level
in the pars interarticularis, pedicle, or facet or a generalized
metabolic disturbance
VI Postsurgical Iatrogenic disruption of facet, ligament, disk, or bone, which Any level
causes instability

There is a 2:1 female-to-male ratio. The pars interarticularis is intact but poorly developed,
This type represents 14%-21% of all spondylolisthesis elongated, or lysed.
cases (Newman 1976). In contrast to isthmic slips (described later in this chapter),
Genetic componentThere is an increased incidence of this type of spondylolisthesis has an intact neural arch,
dysplastic lesions in affected first-degree relatives. which increases the chances that even low grade slips
(25%-35%) will have associated compression of the cauda
Etiology and Pathogenesis equina or exiting nerve roots (Fig. 123,Table 122).
There is a congenital or dysplastic abnormality of the
L5-S1 facet joint that prevents proper articulation.This Signs and Symptoms
allows the superior vertebra to slide forward over the Pain radiating into lower extremities (rarely below the
inferior vertebra (Fig. 122). knee) with little or no back pain
Displacement is early but limited based on the intact Cauda equina compression
posterior neural arch. Incontinence of bowel or bladder
CHAPTER 12 Lumbar Spondylolisthesis 159

Isthmic Spondylolisthesis
Epidemiology
This is the most common spondylolytic disorder among
children and young adults.
Of patients, 50% have spondylolysis alone (Wiltse et al.
1975).
Males predominate in a 2:1 ratio. Males are twice as
likely to have a pars interarticularis defect, but females are
4 times more likely to have a high-grade slip
(Fredrickson et al. 1984).
The disorder is related to the upright posture. It is absent
Figure 122: Illustration of a dysplastic spondylolisthesis in quadrupeds. In humans, it occurs after walking begins,
showing a defect of the superior facet of S1 that prevents a most commonly from 7 to 8 years. It is absent in
true articulation between L5 and S1. nonambulators and bed-ridden patients.
The incidence is 5% in children from 5 to7 years,
Superior articular Inferior
increasing to the adult level of 6%-7% by 18 years.
process of S1 articular
process of L5 Etiology and Subtypes
The isthmic defect is caused by hereditary dysplasia of
the pars interarticularis.
An erect posture, combined with the normal 40-60
degree of lumbar lordosis, produces a constant downward
axial force combined with an anterior vector force or
thrust, subjecting the pars interarticularis to repetitive
trauma.
S1
This repetitive trauma causes microfractures, which heal
incompletely; the basic defect is a fatigue fracture of the
Figure 123: Illustration of type IB dysplastic pars interarticularis (Wiltse et al. 1975) (Fig. 124,
spondylolisthesis, with sagittal orientation of the facet joints.
Table 123).
The isthmic defect develops before skeletal maturity.
Saddle anesthesia Risk factors include vigorous exercise, participation in
Fatigue or weakness in lower extremities
competitive sports involving repetitive lumbar extension,
Diagnostic Evaluation and Scheuermanns disease (Box 121).
Plain radiographs are anteroposterior (AP), lateral, and
A strong genetic component is involved, with 28%-69%
oblique x-ray films with lateral flexion and extension views. of family members affected. Certain ethnic populations
One should consider repeating these films every 4-6 months are more commonly affected (e.g., Inuit, or Alaskan
until skeletal maturity to follow slips considered stable. natives) (Wiltse et al. 1975).
Four histopathologic patterns have been observed: thin
Treatment fibrous bands, thick fibrous columns, a bony bridge, or a
Most congenital spondylolisthesis patients with false joint (Lauerman et al. 1996).
progression of the slip require decompression and The abnormal pars interarticularis tissue is richly innervated
arthrodesis of the involved motion segment. and considered a source of pain during movement.

Table 122: Subtypes of Congenital or Dysplastic Spondylolisthesis

SUBTYPE DESCRIPTION SIGNS OR SYMPTOMS ASSOCIATED DEFECTS


A Dysplastic articular processes in a horizontal Severe hamstring spasm, early olisthesis Spina bifida occulta (Fredrickson et al. 1984)
orientation
B Dysplastic facet with an asymmetric sagittal Leg pain, altered gait, back and hamstring Commonly cauda equina syndrome, nerve root
malorientation and an intact neural arch spasm compression
(Fig. 123)
C OtherFailed vertebral body formation, Congenital kyphosis None
lumbosacral angular deformities
160 Spine Core Knowledge in Orthopaedics

Figure 124: Illustration of the subtypes of isthmic


(or Wiltse type II) spondylolisthesis. A, A stress
Fibrous
fracture that does not heal normally. B, An elongated
tissue
but intact pars interarticularis. C, An acute fracture of
the pars interarticularis.

Elongated pars
(micro-fractures)
Type IIA Type IIB

Acute
fracture of
the pars

Type IIC

Table 123: Isthmic Spondylolisthesis Subtypes (see Risk Factors for Isthmic
Fig. 124) Box 121:
Spondylolisthesis
SUBTYPE DESCRIPTION COMMENTS Repetitive extension activities (e.g., those of football linemen,
A Early fatigue fracture that persists Fibrous tissue exists gymnasts, divers, tennis players, and butterfly swimmers)
because of the constant motion between the Increased loading of posterior elements of the spine
of a poor mechanical fracture edges Male genderPossible increased level of high-risk athletic activ-
environment ity during adolescence
B Elongated intact pars interarticularis
Inuit racePersistent stooped posture during common employ-
because of repeated ment in harvesting seal blubber; high incidence (26%-50%) con-
microfractures that heal tinues to increase in this population until individuals are 34 years
C Acute fracture because of trauma Slippage is rare old (Newman 1963)
Heals with A known relative with the defectUnclear but distinct hereditary
immobilization diathesis that predisposes to the spondylolysis and olisthesis
(Wiltse et al. 1975)

Up to 40% of patients with isthmic defects have an Because many patients with spondylolysis or even low-
accompanying spina bifida contributing to the added grade slips are asymptomatic, other causes of the pain
stress on the pars interarticularis. (infection, neoplasm, fracture, or disk herniation) should
be explored before attributing symptoms to the
Signs and Symptoms spondylolisthesis.
Most symptomatic patients present symptoms in late Of symptomatic children, 92% complain of recurrence
adolescence for evaluation. during adulthood; 55% complain of sciatica at the
The most common complaint is a dull aching pain in the affected nerve root or roots (Saraste 1987).
back, buttocks, or thighs beginning during the adolescent True radicular symptoms are rare. Paresthesias and
growth spurt and exacerbated by activity. weakness are sometimes present in the distribution of the
CHAPTER 12 Lumbar Spondylolisthesis 161

affected nerve roots, reflecting compression of the root by In high-grade slips, the posterior body of L5 rests on the
the hypertrophic callus at the pars interarticularis defect. sacral promontory, concentrating the axial forces over a
Higher-grade slips may have additional symptoms referable small area.This results in a trapezoidal or wedge-shaped
to the stretching of the superjacent nerve root as well. L5 body and a rounded sacral dome, which can be seen
Pain appearing after patients are 40 years old is unlikely on AP radiograph as the reverse Napoleons hat sign
to be related to a pars interarticularis defect unless (Fig. 126).
significant trauma has disrupted the stability of the Long-cassette AP and lateral radiographs are useful to
fibrous union, if present. evaluate coronal and sagittal balance and the presence of
Disk degeneration starts at an earlier age in spondylolytic scoliosis.
patients. If no defect is visible on plain radiography but suspicion
is high, a single-photon emission computed tomography
Physical Findings (SPECT) is a sensitive modality that can detect and
Deep palpation over the affected area may reproduce illustrate the metabolic activity at the region of a
local and possibly radicular pain. suspected pars interarticularis defect.
Of symptomatic patients, 80% have spasm and A technetium bone scan, a component of a SPECT
foreshortening of the paraspinal and hamstring muscles as imaging study, can be used to assess acute injury or to
part of the bodys attempt to stabilize the pelvis document the healing process.
(Amundson et al. 1999). Computed tomography (CT) can be used to define the
Limited forward flexion and decreased straight leg raise bony anatomy more clearly; this can miss the defect in
correspond to hamstring tightness. the pars interarticularis if the cuts or intervals are too large.
Lumbosacral kyphosis and trunk shortening is apparent Magnetic resonance imaging (MRI) is the study of
with an absence of a waistline, abdominal, and flank skin choice for spinal stenosis because it allows visualization of
folds with higher-grade slips. soft tissue structures. It is also invaluable for
A posterior step-off along the spinous processes can be demonstrating the presence of disk degeneration.The
seen in patients with a grade II or higher slip. wide canal sign or ratio, measured as the AP
To stand erect, the hamstrings and iliopsoas contract to diameter of the canal at the slip level divided by the AP
rotate the pelvis, arching the thoracolumbar spine into diameter at the L1 level, has been offered as a means of
maximal lordosis. Sometimes the patient must also flex detecting the presence of bilateral pars interarticularis
the hips and knees to attain an erect posture (Phalen- defects with spondylolisthesis when the ratio is greater
Dickson sign). than 1.25 (Amundson et al. 1999).
The kyphotic deformity and thoracolumbar hyperlordosis Provocative discography is a useful provocative study to
leads to flat, square buttocks, a widened sweetheart assess the presence of coexisting symptomatic disk
pelvis, and a protruding inferior rib cage. disease. If concordant pain is reproduced at the level of
Gait abnormalities are characterized by a waddle with the spondylolysis or olisthesis, this contraindicates
limited hip flexion, shortened stride length, and a wide direct repair of the pars interarticularis defect in favor
base of support. of arthrodesis in patients considering surgical
Physical findings correlate with the degree of slip and slip intervention.
angle. Depending on the degree of slippage, patients should be
Abnormal disks were found in 10% to 39% of patients followed every 3-6 months with plain radiographs (static
with a pars interarticularis defect (Saraste 1987). and dynamic) until skeletal maturity to assess for the
A flexible scoliosis occurs in 5%-7% of all patients with presence of progressive instability.
spondylolisthesis (which usually corrects spontaneously
following surgery for the slip). Radiographic Measurements
Diagnostic Evaluation (Fig. 127)
Plain radiographs should include AP and lateral views in Meyerding classification
the standing position. 1. Grade I0%-25% slip
Oblique views increase the sensitivity of plain 2. Grade II26%-50% slip
radiography by a small amount but at significantly 3. Grade III51%-75% slip
increased gonadal radiation (Roberts et al. 1978). 4. Grade IV76%-99% slip
Dynamic lateral flexion and extension plain radiographs may 5. Grade VSpondyloptosis, or 100% slip
illustrate the degree of instability of the olisthetic segment. The slip angle or angle of kyphosis is measured as
Classically, the defect in the pars interarticularis can be the angle between the superior endplate of L5 and a
seen as a collar on the Scottie dogs neck on oblique line perpendicular to the posterior border of the
views (Fig. 125). sacrum.
162 Spine Core Knowledge in Orthopaedics

Spondylolysis
A B
Figure 125: Illustration (A) and oblique radiograph (B) of a lytic pars interarticularis defect classically described as a collar on a
Scottie dog.

The slip angle is the most sensitive indicator of


potential instability and clinical symptoms (Boxall et al.
1979).
Correction of the kyphotic deformity, as measured by the
slip angle, is the most important goal of surgical reduction.
The lumbar index is a measure of the wedging of the
anterior L5 vertebral body, expressed as the quotient
between anterior and posterior height of the slipped
vertebra.
Other measures include the percentage of rounding of
the sacral dome, the degree of lumbar lordosis, and the
degree of sagittal rotation (Box 122).
Treatment
The truly asymptomatic patient with an incidental
finding of a pars interarticularis defect without a slip can
be followed on an as-needed basis if symptoms develop.
If a spondylolisthesis is present, most authors advocate
serial radiographs on a 3- to 6-month basis to determine
Figure 126: AP radiograph of a high-grade isthmic the stability of the slip until skeletal maturity before
spondylolisthesis illustrating the inverted Napoleons hat sign. discharging the patient.
CHAPTER 12 Lumbar Spondylolisthesis 163

I
II

III
25%
50%
75% IV

A
Figure 127: Schematic drawing illustrating the two most common radiographic measurements of spondylolisthesis. A, The
percent slip. B, The slip angle. (Reprinted from Drummond et al. 2003.)

A positive bone scan or SPECT scan in a young child


Natural History of Isthmic
Box 122: or adolescent implies the potential for possible healing at
Spondylolisthesis* the pars interarticularis defect with external
In patients with lytic defects, 68% have a slip. If a slip is going to immobilization.
develop, it will develop by adolescence in most patients. A traumatic spondylolysis or olisthesis should be treated
Female patients with a documented slip often experience pro- with brace or cast immobilization unless surgical
gression more than males. intervention is required because of gross instability or
Of adults with a slip, the following percentages have been found: symptomatic neural compression.
40% will not progress
Nonoperative treatment is effective in two thirds of
40% will progress less than 5 mm
patients with low-grade slips diagnosed early
Only 15% will progress more than 1 cm
(Table 124).
Isthmic progresses more than degenerative spondylolisthesis.
Disk degeneration adds to the potential for slip progression (in Operative Treatment
isthmic not in degenerative slips).
Some authors associate a high slip angle with a higher likelihood
Goals of surgery include reduction in pain, prevention of
of progression. further slip, stabilization of the spine, restoration of
Traumatic pars interarticularis fractures are rare but usually heal normal posture and gait, reversal and prevention of
well with conservative care. neurological deficit, and improved cosmetic appearance.
Surgical procedures include direct repair of the pars
* (Fredrickson et al. 1984, Saraste 1987.)
interarticularis defect, posterolateral fusion with or
without decompression, slip reduction or
instrumentation, and possible interbody fusion
(Table 125).
Nonoperative Treatment of a
Smokers have lower fusion rates (57% versus 95%)
(Amundson et al. 1999).
Symptomatic Patient Pseudarthrosis or nonunion develops in approximately a
Activity modification includes restriction of high-risk third of patients with spondylolisthesis after
athletics, avoiding repetitive extension maneuvers. posterolateral in situ arthrodesis without
Physical therapy emphasizing flexibility and strengthening instrumentation because of the altered anatomy of the
exercises should be employed. slip. Low surface area for fusion, increased stress across
Immobilization with a lumbosacral orthosis or plaster the fusion, and difficulty in exposing the L5 transverse
jacket can be used for refractory cases. process without exposing the L4 transverse process may
164 Spine Core Knowledge in Orthopaedics

motivate the surgeon to fuse from L4 to S1 in the


Table 124: Treatment Recommendations for Isthmic
Spondylolisthesis setting of an L5-S1 slippage in anything other than a
grade I spondylolisthesis.
STATUS RECOMMENDATION Slip progression (translation and angulation) occurs
Incidental pars interarticularis Periodic observation, no restrictions
in 33% of cases regardless of the presence of a solid
defect fusion (uninstrumented), especially in patients with
Grade I Periodic observation, no restrictions high-grade slips, after a Gill laminectomy, or when
Grade II If asymptomatic, observe with periodic no postoperative immobilization is used (Boxall et al.
radiographs; consider restriction of 1979).
high-risk athletics.
If symptomatic, restrict high-risk athletics
Gill laminectomy alone for decompression of the L5 or
and avoid heavy-labor occupations. S1 nerve roots is controversial:
Bracing or casting for acute symptomatic Rates of slip progression with decompression without
relief may be considered. fusion have been reported as high as 27% (Osterman
If prolonged nonoperative measures fail, et al. 1976).
consider surgical intervention.
Grade III-IV or high slip angle Surgical intervention should be
Many nerve root symptoms (e.g., radicular pain,
considered in the symptomatic hamstring tightness, and weakness) will resolve
immature patient to correct after fusion without decompression (Wiltse et al.
deformity, prevent slip progression, 1975), calling into question the need for
and provide symptomatic relief. decompression.
In adults with isthmic slips, the addition of
decompression to a fusion procedure significantly
increases the pseudarthrosis rate, leading to more
unsatisfactory results in one study (Carragee
1997).
The use of instrumentation (pedicle screw fixation) is not
without potential drawbacks:

Table 125: Operative Treatment of Isthmic Spondylolisthesis

PROCEDURE ADVANTAGES DISADVANTAGES RESULTS


Pars interarticularis defect Preserves the motion segment Does not address intervertebral instability 60%-90% success in selected patients
repair Technically difficult (Dreyzin 1994)
Decompression (Gill Avoids fusion Residual back pain, increased instability with further Mostly unsuccessful
laminectomy) slippage, increased lumbosacral kyphosis after
surgery
Posterolateral Significantly improves pain, gait, Possible failure of fusion (pseudarthrosis) in up to Variable; 60%-100% success
uninstrumented hamstring tightness 40% of patients
in situ fusion Prevents slip progression Need long-term postoperative bracing for improved Improved outcome with a solid
outcomes fusion in children
Adults not as successful (Amundson
et al. 1999)
Decompression with in Same as decompression alone but Higher rates of pseudarthrosis reported than with Up to 100% success rates with solid
situ fusion with the benefit of decreased fusion without decompression fusion (Carragee 1997)
slip progression and Greater risk of slip progression than with fusion Results poor if pseudarthrosis develops
instability alone
In situ fusion with or Improved fusion rates Technical difficulty associated with Success rate correlates with patient
without decompression instrumentation placement selection, the presence of a solid
and instrumentation fusion
Some authors report no added benefit
with internal fixation (Schnee et al.
1997)
Reduction and Adds stability to fusion, with Increased complication rate because of Results correlate with fusion rates, any
instrumented higher fusion rates reported reduction maneuver presence of residual neurologic
fusion Allows correction of deformity, Many instrumentation systems require dysfunction
restores body posture and fusion to L4 for reduction
mechanics, improves body
image
CHAPTER 12 Lumbar Spondylolisthesis 165

Operative times are prolonged and blood loss may be This type is more common in women (5-6 times more
increased. frequent than in men).
Clinical outcomes may be only minimally affected Presenting symptoms usually appear after the patient is 40
(Moller et al. 2000). years old.
Reduction of a high-grade slip is associated with a high Black women are 3 times more likely to develop
complication rate (chiefly L5 radicular symptoms degenerative slips than the average population (as
occurring at the final stage of reduction). Full correction described later in this chapter).
of the olisthesis is not needed; correction of the kyphosis Approximately 10% of women older than 60 years
is most important. have a degenerative slip (Frymoyer 1994).
Reduction improves the fusion rate and outcome.
Bradford (1988) offers the following indications for Etiology
reduction in the adult patient with isthmic Multiple factors contribute to the development of a
spondylolisthesis:
Vertebral slippage >60%
degenerative spondylolisthesis, including disk
degeneration, degenerative arthritis of the facet joints,
Slip angle >50 degrees
Age between 12 and 30 years
and anatomic factors specific to the affected motion
segment.
Symptoms uncontrollable by nonoperative means The slip rarely exceeds 33% and progression occurs in
The addition of anterior column fusion (through
only 30% of patients (Herkowitz 1995) (Box 123).
anterior, posterior, or transforaminal lumbar interbody
fusion) provides additional stability and decreases
pseudarthrosis rates, improving clinical outcome
Signs and Symptoms
(Table 126). Patients typically complain of low back pain radiating
into the buttocks or lateral thighs.
Stiffness is not a common finding; many patients are
Degenerative Spondylolisthesis hyperflexible, reflecting a generalized ligamentous laxity.
Hamstring tightness is not common, in contrast to
Epidemiology isthmic slips.
Most often this type occurs at the L4-L5 level True radicular symptoms occur in approximately 50%
(Rosenberg 1975, Herkowitz 1995). of patients and when present are often referable to the
It is often called spondylolisthesis with an intact L5 nerve root (Matsunaga et al. 1990).Tingling and
neural arch; there is no pars interarticularis defect numbness can occur down the lateral calf into the
(Fig. 128). lateral toes.

Table 126: Approaches to Reduction and Internal Fixation of Isthmic Spondylolisthesis*

PROCEDURE INDICATIONS TECHNIQUE RESULTS COMPLICATIONS


Posterior reduction Young patients with a significant Following L4-S1 in situ fusion, Two thirds reduction in slip Reported cases of transient L5
and in situ kyphotic deformity patients are placed in serial angle but little change weakness, nonunion, partial
fusion with extension casts for three in trunk height or slip loss of reduction in
extension months degree high-grade slips
casting Up to 40% pseudarthrosis
rates
Posterior instrumented Patients older than 10 years with Nerve root decompression 88% fusion with high 4% transient radiculopathy
reduction and high-grade spondylolisthesis followed by posterior patient satisfaction 1% neurological deficit
fusion instrumented reduction On average, 50% reduction 1.5% infection
through the application of in slip translation, slip 2% hardware failure
gradual corrective forces angle
Anterior and posterior Patients with high-grade Anterior L5 or S1 body partial Experienced surgeon can Technically difficult surgery with
reduction and deformities requiring additional resection, grafting, and achieve 90% correction high morbidity
fusion stability or release to achieve fusion followed by posterior of slip angle with a 30%-40% neurological deficit
fusion nerve root decompression residual grade I, II slip (unilateral foot drop most
and gradual instrumented common) 10%-15%
reduction nonunion

* (Bradford 1988, Edwards 1990, Amundson et al. 1999.)


166 Spine Core Knowledge in Orthopaedics

Figure 128: Drawing illustrating Degenerative Spondylolisthesis


degenerative versus isthmic spondylolisthesis.

Isthmic Spondylolisthesis
"Slipped spine"

Fracture
of the pars
interarticularis

Anatomy of the Degenerative Diagnostic Evaluation


Box 123:
Spondylolisthesis Motion Segment Plain radiographs
A standing lateral radiograph is more sensitive than a
The normal lumbar lordosis of 40-60 degrees causes an anteriorly
directed force vector across the middle lumbar vertebrae. nonweight-bearing film in detecting a
The L5-S1 articulation is unusually stable because of coronally spondylolisthesis.
oriented facets, the strong iliolumbar ligaments, and frequent An AP film is used to detect degenerative scoliosis,

partial sacralization of L5 (more common in patients of African lateral olisthesis, or sacralization of L5.
descent). Flexion and extension lateral x-ray films can reveal the
The facet joints have a more sagittal orientation at the level of a rare case of translational or angular dynamic instability.
degenerative spondylolisthesis (Grobler et al. 1993). Excessive translational motion is generally defined as
These factors concentrate stresses most frequently across the L4-
greater than 4 mm of motion with flexion, and
L5 and sometimes the L3-L4 motion segment.
Degenerative disk disease shifts a larger part of the axial load to
angular instability is considered present when there is
the facet joints. a greater-than-10-degrees difference between flexion
Generalized ligamentous laxity (greater in females) further and extension radiographs.
reduces the resistance to forward slippage. A CT myelogram may be ordered to delineate the extent
Microinstability of the segment results in hypertrophic facet joints of spinal stenosis in these patients.This also gives valuable
and osteophytes that stretch the joint capsules, leading to ante- information about the amount of osteoporosis present and
rior and lateral olisthesis, rotary subluxation, and stenosis with a detailed view of the facet joint hypertrophy.The
root compression. traversing nerve root is compressed by the superior articular
process of the inferior vertebral segment (Fig. 129).
Mild weakness exists in 15%-20% of patients in the L5 Myelography has historically been the test of choice to
nerve root distribution (Herkowitz 1995), including the evaluate spinal stenosis. Findings include traversing nerve
extensor hallucis muscle and sometimes the tibialis root cutoff because of the facet hypertrophy and
anterior or gastroc-soleus complex. spondylolisthesis. Plain radiographs can be taken standing to
The following symptoms of spinal stenosis are extremely accentuate the slip. However, complications of myelography
common and are usually the reason these patients seek include headache and nausea in up to 20% of patients.
medical attention: MRI has become the standard in evaluating these
Proximal muscle weakness patients because it provides information about the nerve
Intolerance to walking or even standing, relieved by roots and about the soft tissue component of stenosis,
leaning over or sitting such as hypertrophied ligamentum flavum or synovial
Intermittent claudication cysts. Synovial cysts in the facet joint can be a source of
Claudication must be differentiated between neurogenic compression of the nerves and an indicator of instability
and vascular causes (Table 127). at the motion segment.
CHAPTER 12 Lumbar Spondylolisthesis 167

Table 127: Comparison of Neurogenic and Vascular Claudication

CLINICAL CHARACTERISTICS NEUROGENIC CLAUDICATION VASCULAR CLAUDICATION


Location of pain Back, thighs, calves, buttocks Buttocks, calves
Quality of pain Burning, cramping Cramping
Aggravating factors Erect posture, ambulation, extension of the spine Any leg exercise, usually triggering calf pain at a
reproducible interval
Relieving factors Squatting, bending forward, sitting Rest
Leg pulses and blood pressure Usually normal Blood pressure decreased
Pulses decreased or absent
Bruits, murmurs may be present
Skin or trophic changes Usually absent Often present (pallor, cyanosis, nail dystrophy)
Autonomic changes Bladder incontinence (rare) Impotence may coexist with other symptoms of
vascular claudication

Natural History of Degenerative


Box 124:
Spondylolisthesis*
Of such patients, 25%-30% will experience progression of the
spondylolisthesis.
In the postoperative patient, progression of the slip after an

attempted fusion correlates with a poor outcome.


It is rare for a degenerative spondylolisthesis to slip more than
30%.
Spinal Stenosis
Nonoperative measures succeed in most patients.
A progressive neurologic deficit is rare.
Symptoms of cauda equina syndrome can be insidious. Urgent
surgical decompression is often recommended in the presence of
spinal stenosis and cauda equina syndrome.
*
(Rosenberg 1975, Matsunaga et al. 1990, Frymoyer 1994, Herkowitz 1995.)

Figure 129: Axial CT scan revealing facet hypertrophy and


lateral recess stenosis. Physical therapyIsometrics followed by range of
motion exercises followed by active flexion exercises,
MRI is used by some practitioners in place of abdominal and low back strengthening, and weight
myelography, though many surgeons still use both in reduction are used. Progression to aerobic conditioning
preoperative planning for these patients. is recommended.
Electromyography and nerve conduction studies Epidural steroids and selective nerve root injections are
differentiate neuropathy from neurogenic claudication in valuable treatments for significant pain (leg pain is more
diabetics. reliably relieved than back pain).
Operative Treatment
Treatment (Box 124)
Goals
Nonoperative Treatment Pain relief
Short-term bed rest (1-2 days) followed by activity Improvement or prevention of neurological deficit
modification, combined with anti-inflammatory Increased tolerance to walking and standing
medication, is the mainstay of treatment. Improvement in quality of life
Nonsteroidal anti-inflammatory drugs have no proven IndicationsPersistent or recurrent severe leg pain
efficacy over aspirin or acetaminophen. despite conservative treatment and progressive
Oral steroid medications are best reserved for acute neurological deficit in the setting of confirmatory
exacerbations of leg pain in the older patient. imaging studies demonstrating significant spinal stenosis
Gastrointestinal acid prophylaxis is important. (Herkowitz 1995) (Table 128, Box 125)
168 Spine Core Knowledge in Orthopaedics

Table 128: Operative Treatment of Degenerative Spondylolisthesis

PROCEDURE DESCRIPTION ADVANTAGES DISADVANTAGES COMPLICATIONS


Decompressive Removal of lamina Least invasive surgery Does not address instability Slip progression occurs in 25%-50%
laminectomy and part of medial Provides rapid, substantial relief May cause iatrogenic instability of patients and may correlate
facet joints of pain with a poor clinical outcome
Avoids morbidity of fusion (Mardjetko et al. 1994)
Decompression with Full laminectomy and Decreased slip progression and Possible failure of fusion Longer operative times with
posterolateral partial facetectomy increased spinal stability if Bone graft harvest site morbidity attendant complications
fusion with exposure and a solid fusion is obtained Increased operative times and Persistent bone graft site
fusion of the blood loss with some studies pain in up to 20% of patients
transverse processes showing no effect on outcome
Decompression with Decompression and Most studies show increased Loss of lumbar lordosis Complications related to instrument
instrumented fusion fusion as described fusion rates with improved (flatback deformity) placement including increased
previously with functional outcomes seen with older techniques infection, problems related
segmental that involve distraction to implant migration or failure
instrumentation Can allow partial reduction of Longer operative times are
deformity common
Allows more aggressive Increased cost
decompression

spontaneously reduced; the clinician should be aware of


Fusion and InstrumentationThe this possibility and should initiate the appropriate
Box 125:
Controversy diagnostic workup, including plain radiographs, CT, and
Several randomized, prospective clinical trials and a meta-analysis MRI when appropriate.
examining the variables of fusion versus decompression alone
and instrumented versus noninstrumented fusion support the fol-
lowing conclusions (Herkowitz et al. 1991, Bridwell et al. 1993,
Pathologic Spondylolisthesis
Zdeblick 1993, Mardjetko et al. 1994, Fischgrund et al. 1997): Generalized bone disease
Radical decompression fares poorly without the addition of Osteoporosis and osteomalaciaInstability results from

fusion. continuous fatiguing stresses applied to the osteoporotic


Fusion may not be necessary in all patients, but predicting
pedicles and facet joints, which undergo microfractures.
which patients do not need the added procedure is elusive. When the microfractures heal, they remodel in an
Pedicle screw instrumentation significantly increases the fusion
elongated position leading to segmental instability
rate in most studies.
Correlating the success of fusion with a better clinical outcome
(Tabrizi et al. 2001).
is complicated because many patients with a pseudarthrosis
Other causes include Pagets disease and osteogenesis
seem to be stable enough to enjoy a good outcome. imperfecta (high-grade slips related to elongation of the
Nevertheless, most studies demonstrate better outcomes with a pedicle).
solid fusion of the spondylolisthesis segment. TumorsPrimary or secondary neoplasm can disrupt
Device-related complications (such as screw breakage), as well bony architecture leading to instability.
as surgeon-related complications (such as incorrect instrumen-
tation placement), have decreased in more recent studies with
better instrumentation systems and increased surgeon familiar- Iatrogenic Spondylolisthesis
ity with the techniques of insertion. Spondylolisthesis can be caused by the surgical
disruption of ligaments, bone, or the intervertebral
disk.
The most common cause is wide decompression without
Traumatic Spondylolisthesis fusion. Discectomy further destabilizes the motion
This acute fracture or dislocation of the facet or lamina segment.
creates instability. Resection of more than 50% of each facet joint or an
These are extremely rare injuries. entire facet joint unilaterally predisposes the spine to
Treatment should follow the guidelines for isthmic increased instability (Abumi et al. 1990).
spondylolisthesis. Treatment should involve an instrumented posterolateral
A posterior fracture may be part of a much larger injury, fusion with or without an interbody fusion depending on
including a fracture or dislocation of the spine that has the degree of instability.
CHAPTER 12 Lumbar Spondylolisthesis 169

Carragee EJ. (1997) Single-level posterolateral arthrodesis, with or


References without posterior decompression, for the treatment of isthmic
Abumi K, Panjabi MM, Kramer KM et al. (1990) Biomechanical spondylolisthesis in adults. J Bone Joint Surg 79A: 1175-1180.
evaluation of lumbar spinal stability after graded facetectomies. Here, 42 patients who failed nonoperative treatment for grade I
Spine 15: 1142-1147. or II spondylolisthesis without neurological deficit were treated
This was a serial sectioning study of cadaver lumbar spines with with decompression with fusion, fusion alone, fusion with
a stepwise increase in the amounts of the facets sacrificed instrumentation, or decompression with fusion and
followed by flexibility testing.When 50% of the facets, or 100% instrumentation.The authors found that decompression
of a unilateral facet, were removed, instability developed increased the rate of pseudarthrosis and negatively affected the
(defined according to Panjabis criteria). clinical outcome.

Amundson G, Edwards CC, Garfin SR. (1999) Spondylolisthesis. Dreyzin V, Esses SI. (1994) A comparative analysis of spondylolysis
In:The Spine (Rothman RH et al., eds.), 4th edition. Philadelphia: repair. Spine 19: 1909-1915.
WB Saunders Co., pp. 835-885. Twenty patients with type IIA grade 0 or grade I spondylolytic
This is a detailed chapter on spondylolisthesis including defect were treated with one of two surgical techniques for pars
congenital, isthmic, and degenerative types.The authors focus interarticularis repair. Both techniques yielded a poor clinical
mostly on isthmic spondylolisthesis.They present the etiology, outcome with a high failure rate.
pathophysiology, presentation of symptoms, diagnosis, treatment
Drummond DS, Scott AR. (2003) Pediatric spondylolisthesis. In:
options, and outcome data for each of these groups.
Principles and Practice of Spine Surgery (Vaccaro AR et al., eds.).
Boos N, Marchesi D, Zuber K et al. (1993) Treatment of severe Philadelphia: Mosby.
spondylolisthesis by reduction and pedicular fixation: A 4-6-year
Edwards CC. (1990) Prospective evaluation of a new method for
follow-up study. Spine 18: 1655-1661.
complete reduction of L5-S1 spondylolisthesis using corrective
Ten patients with severe spondylolisthesis were treated with
forces alone. Orthop Trans 14(3): 549.
reduction and pedicular screw fixation.The slip was reduced
The author describes a novel method of reducing a high-grade
from 78.5% to 39.6%, and the slip angle was reduced from 43%
spondylolisthesis, explaining the surgical technique and
to 17%. It was found that pedicular fixation was only successful
complications.
in treating high-grade spondylolisthesis if it was combined with
an anterior or posterior interbody fusion. Fischgrund JS, Mackay M, Herkowitz HN et al. (1997)
Degenerative lumbar spondylolisthesis with spinal stenosis:
Boxall D, Bradford DS,Winter RB et al. (1979) Management of
A prospective randomized study comparing decompressive
severe spondylolisthesis in children and adolescents. J Bone Joint
laminectomy and arthrodesis with and without spinal
Surg 61A: 479-495.
instrumentation. Spine 22: 2807-2812.
In this study, 43 patients with high-grade spondylolisthesis
In this study, 76 patients with symptomatic spinal stenosis
were treated nonoperatively and operatively. Operative
caused by degenerative spondylolisthesis were treated with
treatments included fusion, decompression with fusion, and
posterior decompression and posterolateral fusion. Half the
reduction with fusion.The slip angle was found to be a much
patients were randomized to receive internal fixation with
better predictor of the severity of disease and the risk for
transpedicular screws. Higher fusion rates were achieved in the
slip progression.The authors indicate that postoperative
instrumented group, but there was no difference in clinical
extension casting reduced the risk of slip progression. Fusion
outcome between the two groups.
alone had a successful outcome, but the risk of slip progression
still existed. Fredrickson BE, Baker D, McHolick WJ et al. (1984) The natural
history of spondylolysis and spondylolisthesis. J Bone Joint Surg
Bradford DS. (1988) Closed reduction of spondylolisthesis: An
66A: 699-707.
experience in 22 patients. Spine 13: 580-587.
The authors studied 500 first-grade children radiographically to
A technique is presented for a combined anterior and posterior
find the incidence of spondylolisthesis among children: 4.4%
reduction and fusion of an isthmic spondylolisthesis, and results
increasing to 6% in adulthood.The progression of olisthesis in
are presented for 10 patients.The technique offered good
adulthood was unusual. Spina bifida occulta and a trapezoidal L5
success in terms of reduction, but 6 of 10 patients had major
vertebra were found to be significantly associated with
complications.
spondylolisthesis.The authors note a strong genetic factor
Bridwell K, Sedgewick T, OBrien M et al. (1993) The role of contributing to the pars interarticularis defect.They also
fusion and instrumentation in the treatment of degenerative recommend no limitation to the lifestyle of children with
spondylolisthesis with spinal stenosis. J Spinal Disord 6: 467-472. spondylolisthesis.
In this study, 44 patients were prospectively randomized
Frymoyer JW. (1994) Degenerative spondylolisthesis: Diagnosis and
(with exceptions and some bias) into three groups:
treatment, JAAOS 2: 9-15.
decompression without fusion, decompression plus in situ
This is a general review article addressing the epidemiology,
posterolateral fusion, and decompression plus instrumented
etiology, pathophysiology, presentation of symptoms, diagnosis,
fusion.They were followed for a minimum of 2 years.
and treatment options for degenerative spondylolisthesis.The
Instrumentation significantly improved the fusion rate and
most common complaint is back pain, which may progress to
prevented slip progression, which correlated with better clinical
claudication-type leg pain. Of people who receive conservative
outcomes.
treatment, 15% fail and require surgical treatment.The author
170 Spine Core Knowledge in Orthopaedics

suggests decompression and fusion as the ideal surgical option nonoperative treatment. If this fails, then fusion with or without
with careful selection of surgical candidates when morbidity decompression is the surgery of choice. Reduction and fixation
increases with age. are presented as surgical alternatives for severe cases of
spondylolisthesis with their associated complications.
Grobler L, Robertson P, Novotny J et al. (1993) Etiology of
spondylolisthesis: Assessment of the role played by lumbar facet Mardjetko SM, Connolly PG, Schott S. (1994) Degenerative lumbar
joint morphology. Spine 18: 80-92. spondylolisthesis: A meta-analysis of the literature 1970-1993. Spine
CT was used in this study to characterize the facet joint 10: 2256S-2265S.
morphology in normal people and in patients with isthmic or The authors conducted a meta-analysis on an extremely varied
degenerative spondylolisthesis. A gradually more coronal set of papers dealing with the treatment of this disorder over
orientation was found from proximal to distal in the lumbar several years, seeing vast changes in techniques and
spine. Patients with degenerative spondylolisthesis had instrumentation options. Instrumentation was found to increase
significantly more sagittal orientation to their facets at the L4- the rate of fusion, and fusion seemed to portend a better
L5 level, leading to the conclusion that these patients are outcome, but there was no direct benefit of instrumentation on
predisposed to the slip by a developmental abnormality of the outcomes.There was no significant difference between anterior
facet joints. and posterior procedures in terms of outcome.
Herkowitz H. (1995) Spine update: Degenerative lumbar Matsunaga S, Sakou T, Morizono Y et al. (1990) Natural history of
spondylolisthesis. Spine 20(9): 1084-1090. degenerative spondylolisthesis: Pathogenesis and natural course of
This is a review article on degenerative spondylolisthesis with the slippage. Spine 15: 1204-1210.
an emphasis on associated spinal stenosis.The author outlines This was a retrospective observational study of 40 patients with
the epidemiology, presenting symptoms, physical examination degenerative slips followed for 5 years. Progression was noted in
findings, diagnostic findings, and treatment options.Treatment 30%, was greater (75%) in laborers, and was less in the presence
options addressed include fusion alone, decompression alone, of advanced degenerative disk disease. Notably, progression did
decompression with fusion, and decompression with fusion and not correlate with symptoms.The mean progression observed
internal fixation. was 13%, leading to the conclusion that the innate mechanisms
of spinal restabilization prevent progression of the disease.
Herkowitz HN, Kurz LT. (1991) Degenerative lumbar
spondylolisthesis with spinal stenosis: A prospective study Moller H, Hedlund R. (2000) Instrumented and noninstrumented
comparing decompression with decompression and intertransverse posterolateral fusion in adult spondylolisthesisA prospective
process arthrodesis. J Bone Joint Surg 73A: 802-808. randomized study (Part 2). Spine 25: 1716-1721.
Fifty patients with spinal stenosis because of degenerative A prospective randomized study was performed to determine
spondylolisthesis at L4-L5 or L3-L4 were treated with whether transpedicular fixation improves the outcome of
decompression (n = 25) or decompression and intertransverse posterolateral fusion in patients with adult isthmic
process arthrodesis (n = 25) and followed for a mean of 3 spondylolisthesis. At a 2-year follow-up assessment, the level of
years. Patients who underwent arthrodesis had a better clinical pain and functional disability were strikingly similar in the two
result with respect to pain relief and a decreased risk of slip groups, and there was no significant difference in fusion rate.
progression than patients who underwent decompression The authors conclude that the use of supplementary
alone. transpedicular instrumentation does not add to the fusion rate
or improve the clinical outcome.
Hu SS, Bradford DS,Transfeldt EE et al. (1996) Reduction of high-
grade spondylolisthesis using Edwards instrumentation. Spine Newman PH. (1963) The etiology of spondylolisthesis:With a
21(3): 367-371. special investigation by KH Stone. J Bone Joint Surg 45B: 39-59.
Sixteen patients with high-grade spondylolisthesis underwent An excellent study of the contributing factors involved in the
reduction and fixation using Edwardss instrumentation, pathogenesis of spondylolisthesis, introducing many of the
reducing the degree of slip from 89% to 29% and the slip angle currently held theories from an observational study of cadavers
from 50% to 24%. Most patients reported good to excellent and patients.
results, proving this technically demanding method to be
Newman PH. (1976) Stenosis of the lumbar spine in
effective for reducing severe deformity and pain.
spondylolisthesis. Clin Orthop 115: 116-121.
Johnsson KE,Willner S, Johnsson K. (1986) Postoperative instability The author describes the pathophysiology and treatment
after decompression for lumbar spinal stenosis. Spine 11: 107-110. options of spinal stenosis for patients with congenital, isthmic,
Here, 45 patients were evaluated for slipping following and degenerative spondylolisthesis.
decompression for spinal stenosis because of degenerative
Osterman K, Lindholm TS, Laurent LE. (1976) Late results of removal
spondylolisthesis or acquired spinal stenosis. Patients with slip
of the loose posterior element (Gills operation) in the treatment of
progression postoperatively demonstrated worse clinical
lytic lumbar spondylolisthesis. Clin Orthop 117: 121-128.
outcomes.
This study presents the late results of the Gill operation for the
Lauerman WC, Cain JE. (1996) Isthmic spondylolisthesis in the treatment of lytic lumbar spondylolisthesis in 75 patients.
adult. JAAOS 4(4): 201-208. Follow-up averaged 12 years. Primary results were excellent,
This article addresses isthmic spondylolisthesis in the adult good, or fair in 83% at the end of the first year. However, the
population. Adult patients usually have low back pain with or figures dropped to 75% when the cases were evaluated 5 or
without radicular pain. Most patients improve with more years after operation. Progression of olisthesis was observed
CHAPTER 12 Lumbar Spondylolisthesis 171

in 27% of the patients, usually in connection with progression of and pedicle screw fixation. In the absence of compensation
disk degeneration.This progression did not affect the clinical claims, previous surgeries, and smoking habits, fusion with screw
result of treatment. In nine patients, a fusion was later performed fixation resulted in 90% fusion rate and good clinical outcome.
as a secondary operation. In these, the late result was still
unsatisfactory in all but two cases.The operation is Tabrizi P, Bouchard JA. (2001) Osteoporotic spondylolisthesis:
contraindicated in adolescents except in exceptional cases with A case report. Spine 26: 1482-1485.
signs of compression of the cauda equina. It is not recommended The authors present a case report of spondylolisthesis caused by
for patients younger than 30 years.The main indication for the osteoporosis and a theory of the pathophysiology.They propose
Gill operation by these authors was painful spondylolisthesis with the slipping of the vertebra is caused by insufficiency of the
nerve root symptoms in patients older than 40 years. bone structure causing elongation of the pedicles because of
remodeling.
Roberts FF, Kishore PR, Cunningham ME. (1978) Routine
oblique radiography of the pediatric lumbar spine: Is it really Wiltse LL, Jackson DW. (1976) Treatment of spondylolysis and
necessary? Am J Roentgen 131: 297-298. spondylolisthesis in children. Clin Orthop 117: 92-100.
A series of 86 pediatric lumbar spine abnormalities was evaluated This article describes the two most common types of
to determine the diagnostic benefit of radiography in the oblique spondylolisthesis in children: isthmic and dysplastic. Most
projection compared with that of frontallateral projections alone. children do not develop symptoms; if they do, the authors
In only four patients was an abnormality apparent on the oblique outline initial nonoperative treatments and follow-up protocols.
view that had not already been demonstrated by the If this treatment fails or olisthesis progresses, the authors
frontallateral series. Because the diagnostic yield was low at a advocate fusion using a paraspinal approach.
patient cost of more than double the gonadal radiation dose, it is Wiltse LL, Newman PH, MacNab I. (1976) Classification of
recommended that oblique views be eliminated in the routine spondylolysis and spondylolisthesis. Clin Orthop 117: 23-29.
radiography of the pediatric lumbar spine. The authors classify spondylolysis and spondylolisthesis into six
Roca J, Ubierna MT, Caceres E et al. (1999) One-stage groups based on etiology. For each classification, the anatomic
decompression and posterolateral and interbody fusion for severe findings and pathophysiology are explained.
spondylolisthesis: An analysis of 14 patients. Spine 24(7): 709-714. Wiltse LL,Widell EH Jr., Jackson DW. (1975) Fatigue fracture:The
This was a retrospective study of 14 patients with severe basic lesion in isthmic spondylolisthesis. J Bone Joint Surg 57A: 17-22.
spondylolisthesis (76% slip with 36% slip angle), severe radicular This was an observational study contending that all isthmic
pain, and neurologic deficits treated with one-stage decompression spondylolytic defects start as fatigue fractures.These occur
and an anteriorposterior fusion.This procedure was found to be earlier than other fatigue fractures, heal slowly or not at all,
safe and effective in eliminating radicular pain in 13 of 14 patients come with a hereditary diathesis, and infrequently form the
with improvement in motor deficits and cosmetics. fluffy callus observed with other fractures of this type.
Rosenberg NJ. (1975) Degenerative spondylolisthesis: Predisposing Spondylolisthesis developed in 50% of cases.
factors. J Bone Joint Surg 57A: 467-474. Wiltse LL,Winter RB. (1983) Terminology and measurement of
The author studied 20 cadavers and 200 patients with spondylolisthesis. J Bone Joint Surg 65A: 768-772.
degenerative spondylolisthesis to identify predisposing factors This is an illustrated description of the various radiographic and
and common epidemiological traits. Causative factors included clinical measurements of spondylolisthesis.
hemisacralization of L5, ligamentous laxity, and increased
lumbosacral kyphosis. Slips never exceeded 30% and were not Wood KB, Popp CA,Transfeldt EE et al. (1994) Radiographic
seen in patients younger than the fifth decade or concomitantly evaluation of instability in spondylolisthesis. Spine 19: 1697-1708.
with an isthmic slip. Of those studied, 80% were treated The authors analyzed 50 patients with spondylolisthesis to
successfully without surgery. determine if there was any difference in intervertebral motion
during dynamic radiography (flexion and extension films) while
Saraste H. (1987) Long-term clinical and radiological follow-up of standing or in the lateral decubitus position.The authors found
spondylolysis and spondylolisthesis. J Pediatr Orthop 7: 631-638. that to maximize abnormal motion flexion and extension, films
Here, 255 patients with spondylolisthesis or spondylolysis were should be obtained in the lateral decubitus position.There was
followed to correlate clinical findings with radiological findings no difference in dynamic angulation based on patient position.
over 20 years. Symptoms correlated with radiological findings of
disk degeneration, low lumbar index, greater than 25% slip, and Zdeblick T. (1993) A prospective randomized study of lumbar
spondylolysis at L4. Progression of slip was not correlated to fusion. Spine 18: 983-991.
initial degree of slip or age at diagnosis, but patients were found This study evaluated the results of fusion for a multitude of
to have early disk degeneration. diagnoses based on fusion without instrumentation, fusion with
semirigid instrumentation, and fusion with rigid
Schnee CL, Freese A, Ansell LV. (1997) Outcome analysis for adults instrumentation.The success of fusion and clinical outcomes
with spondylolisthesis treated with posterolateral fusion and were related to the stiffness of the construct; more solid fusions
transpedicular screw fixation. J Neurosurg 86: 56-63. and better outcomes were seen in the pedicle screw rigid
A retrospective review of 52 adult patients with symptomatic fixation group.The study has several design flaws, including
low-grade spondylolisthesis treated with a posterolateral fusion incomplete randomization and a high crossover rate.
13

CHAPTER
Osteoporosis
Medical Management and Surgical Treatment
Options
Eeric Truumees

M.D., Attending Spine Surgeon,William Beaumont Hospital, Royal Oak, MI;


Adjunct Faculty, Bioengineering Center,Wayne State University, Detroit, MI

Introduction Box 131:


Spinal Manifestations of
Osteoporosis
Populations worldwide, and especially in North America,
are rapidly aging. 1. Hyperkyphosis with chronic spine pain
The prevalence of osteoporosis, already the most 2. Loss of height
common metabolic bone disorder, is increasing. 3. Acute VCFs
Spine practitioners need to be aware of the risk factors 4. Sacral insufficiency fracture
for and the treatment of osteoporosis. 5. Osteoporotic burst fracture
Spine practitioners will be called upon to treat the 6. Poor spinal fixation in the treatment of degenerative instability
manifestations of osteoporosis itself (e.g., compression of the spine
fractures) and to understand the ramifications of
osteoporosis in the treatment of other spine diseases
(e.g., placement of spinal instrumentation). Because lifestyle has a significant effect on its
Previously, osteoporotic vertebral compression fractures development, surgeons must recognize risk factors and
(VCFs) of the spine were thought to be benign, self- help their patients prevent osteoporosis.
limited entities. Newer medical therapies are increasingly potent in
It is becoming clear that VCFs, like hip fractures, are halting the decline of bone load-bearing capacity.
part of a vicious spiral of increasing pain, dysfunction, Even physicians who are uncomfortable managing
and mortality. osteoporosis should understand its natural history to
Newer treatments, such as vertebroplasty and be able to screen their patients and initiate referrals.
kyphoplasty, seek to stabilize these fractures and
minimize physiologic decline (Box 131).
Even in the best of circumstances, fixation of spinal and
Pathophysiology
hip fractures may not return patients to previous levels of Bone is a dynamic, well-organized, composite material
activity. composed of the following:

172
CHAPTER 13 Osteoporosis 173

Mineral (inorganic) phase Cortical bone, 80% of the bone mass, has a fairly uniform
Collagenous (organic) phase density. Cortical bone forms the envelope of cuboid
Cells and water bones and the diaphysis of long bones.
The mineral phase, principally composed of Three cell types carry out bone metabolismosteoblasts,
hydroxyapatite [Ca10(PO4)6(OH)2], is 60% to 70% of osteocytes, and osteoclasts.
bones dry weight. Osteoblasts and osteocytes differ in function and
Organic matrix, of which 90% is collagen, makes up 30% location but arise from the same lineage. Osteoblasts are
of the dry weight. found lining the bone surface and trailing osteoclasts in
Osteoporosis causes both inorganic and collagenous phase cutting cones, where they produce osteoid.
bone loss. As bone is created, osteoblasts become encased in a

Loss of bone crystal weakens the bone to compressive mineralized matrix and are known as osteocytes.These
loading. cells remain in contact with the osteoblasts on the
Loss of the organic matrix of bone makes it more bone surface by cellular processes within canaliculi.
brittle. Endocrine signals are typically transmitted by the
The crystalline structure is regulated both at the osteoblasts, and strain-generated signals within the
molecular level by the strain patterns in the trabecular bone are regulated by osteocytes.
network and at the organ level by systemic (often The major bone resorptive cell is the osteoclast,

hormonal) influences. characterized by large size (20 to 100 m) and


Most adult bone is lamellar, characterized by highly multiple nuclei.These cells are derived from
organized, stress-oriented collagen. Stress orientation pluripotent cells of bone marrow and bind to the
gives mature bone anisotropic properties wherein the bone surface through cell attachment proteins
mechanics of loading lamellar bone depend on the (integrins).
direction of force application. Throughout life, the body constantly remodels bone by
Bone is strongest parallel to the collagen molecule removing old bone and creating new bone.
long axis. Osteoporosis is a host of systemic regulatory changes
In the mature skeleton, the architecture of lamellar bone that alter the normal balance between formation and
takes two forms: resorption.
Trabecular (spongy or cancellous) In contradistinction, in osteomalacia, an osteoid is formed
Cortical (dense or compact) at an appropriate rate but is not normally mineralized
In trabecular bone, internal spicules form a three- (Table 131).
dimensional branching lattice aligned along areas of With lower rates of bone formation in osteoporosis, the
mechanical stress (Fig. 131).Trabecular bone is 8 times overall mineral density of the bone decreases. Increased
more metabolically active than cortical bone.Trabecular osteoclast activity decreases connectivity among
bone, 20% of the total bone mass, is found in long bone trabeculae.The combination of decreased mass and
metaphyses and epiphyses and in the cuboid bones discontinuity of the normal latticework leads to decreased
(e.g., vertebrae). resistance to fracture (Box 132).

A B
Figure 131: Scanning electron micrographs of normal (A) and osteoporotic (B) bone. Note both the thinner
trabeculae and the lack of continuity among them in the osteoporotic specimen.
174 Spine Core Knowledge in Orthopaedics

osteoporosis are the peak bone mass and the rate of


Table 131: Comparison of Osteoporosis and
Osteomalacia bone loss.
The most effective way to prevent the devastating

OSTEOPOROSIS OSTEOMALACIA complications of VCF is to increase peak bone mass.


Definition Bone mass decreased Bone mass variable
Eating disorders, exercise-induced amenorrhea, lack
Mineralization Normal Decreased of weight-bearing exercise, and low dairy or calcium
Age of onset Generally elderly Any age diets each contribute to the increasing rates of
Etiology Endocrine abnormality Vitamin D deficiency osteoporosis among young women.
Age Abnormality of vitamin Several factors, such as genetic, environmental, and
D pathway
Idiopathic
nutritional conditions and chronic disease, are associated
Renal tubular acidosis with accelerated bone loss (Box 133).
Hypophosphatasia One of the most common causes of osteoporosis is
Symptoms Pain referable to fracture Generalized bone pain decreased gonadal hormone levels (i.e., menopause).
Signs Tenderness at fracture Generalized tenderness Bone-forming cells have estrogen receptors. Estrogen
Laboratory findings
Serum Ca++ Normal or nl ( in
blocks the action of parathyroid hormone (PTH) on
hypophosphatasia)* osteoblasts and marrow stromal cells.
Serum P Normal or nl ( in renal Without estrogen, osteoblasts and marrow stromal cells

osteodystrophy) secrete increased levels of interleukin 6, which


Alkaline Normal (not in stimulates the osteoclasts to resorb bone.
phosphatase hypophosphatasia)
Urinary Ca++ High or normal or nl ( in
Estrogen deficiency accelerates bone loss up to 2%-3%
hypophosphatasia) per year for 10 years.
Bone biopsy Normal Abnormal Although hypogonadic men may get type I

osteoporosis, this form affects women more often than


* nl, Normal.
men.
Type I osteoporotics are typically in their 50s and 60s

Several environmental, genetic, and pharmacologic factors and are susceptible to fractures of trabecular bone
affect the development of osteoporosis. Root etiology, (wrist and spine).
although likely multifactorial, is not yet understood. Type II osteoporosis affects both men and women
Osteoporosis is grossly divided into three types based on equally, arises when they are in their 70s and 80s, and
presumed etiology. increasingly affects cortical bone.
Type IPostmenopausal Bone loss caused by various medications and disease
Type IISenile states are termed secondary, or type III osteoporosis.
Type IIISecondary Endogenous or exogenous hypercortisolism is
Most individuals will increase bone mass until the early frequently implicated in type III osteoporosis. Cortisol
part of the fourth decade.Thereafter, bone mass is lost at negatively affects bone mass through decreased
a rate of approximately 0.5% per year. intestinal calcium absorption, increased renal calcium
The mechanism of bone loss resulting from normal

aging is poorly understood, but its rate is equivalent in


women and men. Box 133: Risk Factors for Osteoporosis
Yet not everyone develops osteoporosis.The two most

important determinants for the development of


Advanced age
Endocrine abnormalities
Hypercortisolism

Hyperthyroidism
Structural Changes in Osteoporotic
Box 132: Hyperparathyroidism
Bone Hypogonadism

Material characteristics Other diseases


Tumors
Loss of bone mineral

Chronic disease
Loss of bone collagen

Expression of abnormal collagen or bone matrix genes


Loss of tissue density

Structural characteristics Inactivity or immobilization


Microarchitectural decay
Dietary issues
Calcium-deficient diet
1. Loss of trabeculae
Alcoholism
2. Propagation of microcracks
Body mass index <22 kg/m2
Decrease in bone mass

Altered in bone geometry


Smoking
CHAPTER 13 Osteoporosis 175

loss, and direct inhibition of bone matrix formation. Three fracture types are common in the axial skeleton
Alternate-day dosing of corticosteroids decreases bone VCFs, osteoporotic burst fractures, and sacral insuffi-
damage. ciency fractures.
Bone mineral density (BMD) defines the severity of Also, osteoporosis complicates the treatment of other

osteoporosis. With factors such as cardiovascular status, spine interventions, such as instrumented stabilization
medications, neuromuscular disorders, and body of a degenerative spondylolisthesis.
habitus, BMD is the major determinant of fracture Spinal fractures are classified morphologically.
threshold. The most common injury is the VCF.There are a wide
T-score represents the number of standard deviations range of fracture patterns including failure of the
of mineral content in the patients bone from the superior, inferior, and both endplates. Furthermore, lateral
mean young adult value. For each standard deviation compression deformities may worsen preexisting coronal
below the norm, fracture risk increases 1.5-fold to plane deformities (Fig. 133).
3-fold. A T-score of 1 implies a 30% chance of In the lumbar spine, the central portion of both
fracture. endplates collapses, resulting in a biconcave or codfish
Z-score compares BMD with age-matched controls. vertebra.
Z-scores less than 1.5 should prompt a more In the thoracic spine, maximal height loss occurs at
extensive workup for osteomalacia or neoplasm. the anterior portion of the superior endplate and leads
By World Health Organization criteria, a T-score of less to a wedge-compression fracture.
than 1 is defined as osteopenia. Less than a 2.5 The senile burst fracture represents increased axial

standard deviation from the mean defines osteoporosis. loading and failure of the middle column with
Patients with T-scores below a 2.5 standard deviation retropulsion of bone into the spinal canal.
and with fragility fractures have severe osteoporosis
(Fig. 132).
This definition of osteopenia differs from the
Incidence
radiographic term, which implies only decreased bone In North America today, 35 million people are at risk for
mineral and could represent other disease processes, osteoporosis. Over the next 3 decades, this number is
such as bone loss from wear debris, osteomalacia, or expected to triple.
neoplasm. The most common manifestation of spinal osteoporosis
Like hypertension, the bone loss of osteoporosis is usually is the VCF, which will affect one third of all North
gradual and silent. Unless carefully sought, the disease Americans. The 700,000 VCFs per year in the United
may manifest itself with an acute eventthat is, a States outnumber hip and wrist fractures combined.
fracture. In the United States alone, the annual direct medical
costs associated with osteoporotic fractures exceed
$13.8 billion. By 2030, these annual costs may exceed
$60 billion, or $164 million per day.The indirect costs of
early retirement, lost independence and productivity, and
Normal
human pain and suffering are incalculable.

Clinical Features
Osteopenia
Osteoporosis per se is asymptomatic.The clinician should
suspect osteomalacia in patients with radiographic
osteopenia and bone pain.
Osteoporosis At risk populations should be screened (Box 134).
Fragility fractures often involve the spine, ribs, hip, and
1400 1300 1200 1100 1000 900 800 700 600 500
wrist.The patient will report localized pain, dysfunction,
Standardized total hip BMD, young white women, mg/cm2
and deformity.
Evaluation of a suspected osteoporotic spine fracture
Figure 132: Bone mineral density exhibits a normal (bell-
begins with a careful history. Note the amount of energy
shaped distribution) in the population at large. Osteopenia is
defined as BMD lower than one standard deviation (T = 1)
sustained. Severely osteoporotic patients can fracture
from the mean for a same-gender young adult. By these World while sneezing or rolling in bed.
Health Organization criteria, osteoporosis exists when the Patients complain of focal, intense, deep midline spine
BMD is more than 2.5 standard deviations below the norm. pain. Diffuse, paravertebral pain often is a muscle spasm
Severe osteoporosis exists when the T-score is less than 2.5 and may also be present, but it should not be the chief
and the patient has sustained a fragility fracture. complaint.
176 Spine Core Knowledge in Orthopaedics

A B
Figure 133: A 74-year-old man with degenerative scoliosis and secondary osteoporosis. He sustained a lateral
compression vertebral fracture with progression of his coronal plane deformity (A). He continued to have focal
pain at 12 weeks. A kyphoplasty afforded partial reduction of the fracture and improvement of his Cobb angle
to the prefracture level (B).

Pain symptoms are mechanical and worsen with loading.


Although recumbency often relieves symptoms, patients
with a prominent kyphosis will have a pain lying directly
on their back.
Ask about associated thoracic or lumbar radicular

problems.
Dual-Energy X-ray Absorptiometry
Box 134: Note the time course of the patients current
Screening Criteria symptoms and the course of any previous fractures.
All patients
Red flags such as night pain, fevers, chills, unusual weight
Sustained a low energy fracture loss, or bowel or bladder changes require thorough
Have osteopenia on plain radiographs investigation.
Have diseases that place them at risk for osteoporosis Ensure that BMD testing has been performed and the
On medications that place them at risk for osteoporosis
appropriate antiosteoporotic regimen has been initiated.
Women Ask about a history of cancer, tuberculosis, systemic
Postmenopausal
infection, or other fractures.
Older than 65 years
Begin the physical examination by observing the patient
Younger than 65 with one or more risk factors

On HRT for prolonged periods


closely, assessing general condition and comfort, sagittal
Considering HRT if BMD will affect decision
spinal balance, body shape, difficulty in breathing, and
obesity.
CHAPTER 13 Osteoporosis 177

Palpate the ribs. Coexisting and iatrogenic rib fractures The cross-sectional image of the vertebral body
are common. generated by quantitative computed tomography (qCT)
Acute fractures are typically point tender over the allows preferential measurement of trabecular bone
spinous process. density.The higher trabecular bone turnover makes qCT
Undertake a complete neurologic examination. a sensitive indicator of bone density in these vulnerable
Although major neurologic deficits are rare (0.05%), skeletal areas. qCT is accurate to within 5% to 10%, but
patients may have stenosis or neuropathy. the radiation dose is higher than with DEXA.
Sacral insufficiency fractures may cause pain in the Ultrasound is attractive as a means of measuring bone
tailbone or sacroiliac (SI) joint regions. Patricks test and density because it is rapid, is inexpensive, and does not
other SI joint-loading maneuvers will increase pain. expose a patient to ionizing radiation. However, it is
Laboratory evaluation is used to exclude other causes of not as precise as DEXA and is mainly for initial
osteopenia, such as osteomalacia. screening.
Occasionally, serum blood tests alone are insufficient In patients with known fractures, the goals of imaging are
to exclude the diagnosis of osteomalacia, at which to determine the following:
time a transiliac bone biopsy may be indicated. Extent of vertebral collapse
Bone biomarker assays are being increasingly requested, Location and extent of any lytic process
as a complementary modality to densitometry, to Visibility and degree of pedicular involvement

monitor the effectiveness of treatment and assess Presence of cortical destruction


fracture risk. Markers of bone formation include bone- Presence of epidural or foraminal stenosis
specific alkaline phosphatase (an osteoblast enzyme) and Age or acuity of the fracture

osteocalcin (a bone matrix protein). Collagen Standing radiographs reveal overall sagittal and coronal
degradation products (cross-linked telopeptides and spinal balance.
pyridinolines) are markers of bone destruction. Thoracolumbar fractures are obvious, but sacral fractures
In patients with unusual fracture patterns or histories may be difficult to see.
suggestive of malignancy or infection, laboratory Comparison films, including chest radiographs, may
evaluation may include erythrocyte sedimentation reveal fracture age.
rate, white blood cell count with differential, Apparent sclerosis may be healing or compressed

C-reactive protein, serum and urine protein trabeculae.


electrophoresis, and prostate antigens. Consider spot films orthogonal to the fracture,
particularly at the thoracolumbar junction.
Obtain serial lateral radiographs to assess for further
Diagnostic Tools collapse.
Although plain radiographs are appropriate in the Signs of posterior cortical compromise include
evaluation of symptomatic patients, they are the least widened pedicles and more than 50% height loss.
accurate and least precise method of assessing bone Endplate erosion suggests infection.
density. A 30% decrease in bone mass is necessary to Signs of neoplasm include pedicular destruction
detect osteopenia on plain films. (the winking owl sign) and fractures above T6.
On the other hand, a variety of noninvasive bone Magnetic resonance imaging (MRI) allows more definitive
densitometry tests provide information about the density assessment of canal involvement and fracture acuity. In
of bone at the measured site. Lumbar spine measurements acute fractures, fracture edema is reflected by increased
correlate well with the incidence of spontaneous signal on T2 or short T1 inversion recovery (STIR)
vertebral fracture. sequences and decreased T1 signal (Fig. 134). Both T1
Dual photon absorptiometry (DPA) measures axial and T2 marrow signal changes normalize over time. Key
skeletal BMD through the radioisotope soft tissue features differentiating malignant from osteoporotic
signal attenuation. fractures include pedicular and soft tissue extension.
In the last decade, dual-energy x-ray absorptiometry Chronic, unhealing VCFs may be caused by avascular
(DEXA) has supplanted DPA and become the necrosis of the vertebral bone (Kummels disease). Such
standard. DEXAs advantages are superior precision continuing collapse of the vertebra after minor trauma is
(1%-2% at the spine and 3%-4% at the femur), lower particularly common in patients with known risk factors
radiation dose, shorter examination time, higher image for avascular necrosis such as previous radiation therapy
resolution, and greater technical ease. or chronic corticosteroid use.
1. DEXA is used both to assess baseline bone density and On MRI, these fractures demonstrate the double line
to track response to therapy. sign of discrete fluid collections within a vacuum
2. Scoliosis,VCFs, osteophytes, extraosseous calcifications, cleft with areas of diminished T2 signal surrounding
and vascular disease may falsely increase DEXA scores. the cleft (Fig. 135).
178 Spine Core Knowledge in Orthopaedics

Figure 134: This T2-weighted parasagittal MRI demonstrates


an acute fracture at T11 with edema in the vertebral body. T10
and T6 demonstrate healed fractures with height loss but a
normalized marrow signal.

In patients unable to undergo MRI, a CT scan offers


high bone and soft tissue contrast and clearly delineates
posterior cortical compromise. Fracture acuity may then
be determined by bone scan (Fig. 136).
Both MRI and CT demonstrate sacral insufficiency
fractures. On bone scan, these lesions may have the classic Figure 135: This T2-weighted parasagittal MRI (from the
H configuration or may appear as a linear band of same patient as Fig. 133) demonstrates typical findings of
increased uptake in the region of the sacral ala (Fig. 137). Kummels disease. Despite a 12-week interval, the fracture had
not healed and edema remains apparent. An area of decreased T2
signal is seen just below the fracture plane representing avascular
Nonoperative Care necrosis of bone. Fig.133, A, demonstrates a vacuum sign
within the bone, also an indication of Kummels disease.
Nonoperative care is divided between management of
the underlying osteoporosis and management of any
spinal fractures. calcium supplements sustain one quarter of the hip
Previously, successful management of osteoporosis was fractures of those with low calcium intake.
frustrated by delayed and inaccurate diagnosis, insufficient In menopausal women, estrogen supplementation may
understanding of the disease process, and inadequate be appropriate. Women on estrogen have fewer
follow-up. Before the first fracture, at risk patients must be fractures. Estrogen does not increase bone formation; its
screened. primary effect lies in bone mass maintenance.
For osteopenia, recommendations include oral calcium, Recent studies appear to show increased rates of
physiologic vitamin D, and weight-bearing exercise. coronary artery disease, stroke, pulmonary embolus,
Increasingly, tai chi and other low-impact, balance- and cancer in women on hormone replacement
promoting exercises are recommended.These measures therapy (HRT).
decrease bone resorption and help mineralize osteoid but These untoward side effects have increased interest in

do not increase total bone mass. Individuals taking the selective estrogen receptor modulators such as
CHAPTER 13 Osteoporosis 179

raloxifene (Evista).These agents appear to have bone


preserving effects similar to those of estrogen without
the cancer and coronary complications.
Patients with true osteoporosis (femoral T-score below
2.5) or a history of fragility fracture should receive
more aggressive pharmacologic management.
Calcitonin, administered through subcutaneous
injection or nasal spray, decreases osteoclastic bone
resorption. Over short-term treatment, calcitonin
enhances bone formation, leading to a slight net bone
accretion. Over long-term treatment, osteoblastic
activity slows and bone mass stabilizes.
Bisphosphonates are recommended for their dramatic
suppression of bone resorption and have been shown