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Contributors
J. Patrick Johnson, MD, FACS
Neurosurgeon, Spine Specialist
Director of Education, Spine Fellowship and Academic Programs
Co-Director, Spine Stem Cell Research Program
Director, California Association of Neurological Surgeons
Los Angeles, CA, USA
Jaro Karppinen, PhD, MD
Professor
Physical and Rehabilitation Medicine
Institute of Clinical Sciences
University of Oulu
Oulu, Finland
Tony M. Keaveny, PhD
Professor
Departments of Mechanical Engineering and Bioengineering
University of California
Berkeley, CA, USA
Larry T. Khoo, MD
Los Angeles Spine Clinic
Los Angeles, CA, USA
Choll W. Kim, MD
Associate Clinical Professor
Department of Orthopaedic Surgery
University of California San Diego
Spine Institute of San Diego
Center for Minimally Invasive Spine Surgery at Alvarado Hospital
Executive Director, Society for Minimally Invasive Spine Surgery
San Diego, CA, USA
Lonnie E. Loutzenhiser, MD
Orthopaedic Spine Surgeon
Panorama Orthopedics & Spine Center
Golden, CO, USA
Malary Mani, BS
University of Washington
Seattle, Washington, WA
Satyajit Marawar, MD
Spine Fellow
Upstate University Hospital
Syracuse, NY, USA
Jason Marchetti, MD
Medical Director of Inpatient Rehabilitation
Mayhill Hospital
Denton, TX, USA
H. Michael Mayer, MD, PHD
Professor of Neurosurgery
Paracelsus Medical School
Salzburg, Austria;
Medical Director and Chairman
Schön-Klink München Harlaching
Munich, Germany
Vivek Arjun Mehta, BS
Medical Student
Department of Neurosurgery
e Johns Hopkins Hospital
Baltimore, MD, USA
Terrence Kim, MD
Orthopaedic Surgeon
Cedars Sinai Spine Center
Los Angeles, CA, USA
Woo-Kyung Kim, MD, PhD
Professor and Chair of Neurosurgery
Gachon University
Gil Medical Center
Spine Center
Incheon, South Korea
Joseph M. Lane, MD
Professor of Orthopaedic Surgery
Assistant Dean, Medical Students
Weill Cornell Medical College
Orthopaedics
Hospital for Special Surgery
Chief, Metabolic Bone Disease Service
Hospital for Special Surgery
New York, NY , USA
Jared T. Lee, MD
Resident
Harvard Combined Orthopaedic Residency Program
Boston, MA, USA
Robert E. Lieberson, MD, FACS
Clinical Assistant Professor
Department of Neurosurgery
Stanford University Medical Center
Stanford, CA, USA
Fiona E. Mellor, BSc (Hons)
Research Radiographer
Institute for Musculoskeletal Research and Clinical Implementation
Anglo-European College of Chiropractic
Bournemouth, Dorset, UK
Christopher Meredith, MD
Desert Institute for Spine Care
Phoenix, AZ, USA
Vincent J. Miele, MD
Neurosurgical Spine Fellow
Cleveland Clinic
Cleveland, OH , USA
Jack Miletic, MD
Interventional Spine/Pain Management
Institute for Spinal Disorders
Cedars Sinai Medical Center
Los Angeles, CA, USA
Christopher P. Miller, BA
Department of Orthopaedics and Rehabilitation
Yale University School of Medicine
New Haven, CT, USA
Florence Pik Sze Mok, MSc, PDD, GC, BSc
PhD Candidate
Orthopaedic & Traumatology
Li Ka Shing Faculty of Medicine
e University of Hong Kong
Hong Kong
Contributors
xi
Joseph M. Morreale, MD
Spine Surgeon
Center for Spinal Disorders
ornton, CO, USA
Kieran Murphy, MB, FRCPC, FSIR
Professor and Vice Chair
Department of Medical Imaging
University of Toronto
Toronto, Ontario, Canada
Frank John Ninivaggi, MD, FAPA
Assistant Clinical Professor
Yale Child Study Center
Yale University School of Medicine
Associate Attending Physician
Yale-New Haven Hospital
New Haven, CT, USA
Donna D. Ohnmeiss, Dr.Med.
President
Texas Back Institute Research Foundation
Plano, TX, USA
Chukwuka Okafor, MD, MBA
Orthopaedic Surgery
Bartow Regional Medical Center
Lakeland, FL, USA
Robert Pflugmacher, MD
Associate Professor
Department of Orthopaedic and Trauma Surgery
University of Bonn
Bonn, Germany
Frank M. Phillips, MD
Professor, Spine Fellowship
Co-Director, Orthopaedic Surgery
Head, Section of Minimally Invasive Spinal Surgery
Rush University Medical Center
Chicago, IL, USA
Luiz Pimenta, MD, PhD
Associate Professor
Neurosurgery Universidade Federal de São Paulo
São Paulo, Brazil;
Assistant Professor
University of California San Diego
San Diego, CA, USA
Colin S. Poon, MD, PhD, FRCPC
Assistant Professor of Radiology
Director of Head and Neck Imaging;
Director of Neuroradiology Fellowship
Department of Radiology
University of Chicago
Chicago, IL, USA
Wayne J. Olan, MD
Clinical Professor Radiology and Neurosurgery
e George Washington University Medical Center
Washington, DC;
Director
Neuroradiology/ MRI
Suburban Hospital
Bethesda, MD, USA
Leonardo Oliveira, BSc
Masters Degree (in course)
Radiology
Universidade Federal de São Paulo
São Paulo, Brazil
Manohar Panjabi, PhD
Professor Emeritus
Orthopaedics and Rehabilitation
Yale University School of Medicine
New Haven, CT, USA
Jon Park, MD
Director, Comprehensive Spine Neurosurgery
Director, Spine Research Laboratory and Fellowship Program
Stanford, CA, USA
Scott L. Parker, BS
Medical Student
Department of Neurosurgery
e Johns Hopkins University School of Medicine
Baltimore, MD, USA
Rajeev K. Patel, MD
Associate Professor
University of Rochester Spine Center
Rochester, NY, USA
Ann Prewett, PhD
President and CEO
Replication Medical, Inc.
Cranbury, NJ, USA
Kamshad Raiszadeh, MD
Spine Institute of San Diego
Center for Minimally Invasive Spine Surgery at Alvarado Hospital
San Diego, CA, USA
Amar D. Rajadhyaksha, MD
New York University Hospital for Joint Diseases
Department of Orthopaedic Surgery
Division of Spine Surgery
New York, NY, USA
Kiran F. Rajneesh, MD, MS
Research Fellow
Department of Neurological Surgery
University of California, Irvine
Orange, CA, USA
Ravi Ramachandran, MD
Resident Physician
Department of Orthopaedics and Rehabilitation
Yale University School of Medicine
New Haven, CT, USA
Luis M. Rosales
Assistant Professor
School of Medicine
Universidad Nacional Autonoma de Mexico
Mexico City, DF, Mexico
xii
Contributors
Hajeer Sabet, MD, MS
Spine Surgery Fellow
Department of Orthopaedic Surgery
Rush University
Chicago, IL, USA
Barton L. Sachs, MD, MBA, CPE
Professor of Orthopaedics
Executive Assistant Director of Neurosciences and
Musculoskeletal Services
Medical University of South Carolina
Charleston, SC, USA
Nelson S. Saldua, MD
Staff Spine Surgeon
Department of Orthopaedic Surgery
Naval Medical Center San Diego
San Diego, CA, USA
Dino Samartzis, DSc, PhD (C ), MSc, FRIPH, MACE,
Dip EBHC
Research Assistant Professor
Department of Orthopaedics and Traumatology
University of Hong Kong
Pokfulam, Hong Kong
Srinath Samudrala, MD
Neurosurgeon
Cedars-Sinai Institute for Spinal Disorders
Los Angeles, CA, USA
Harvinder S. Sandhu, MD
Associate Professor of Orthopedic Surgery
Weill Medical College of Cornell University;
Associate Attending Orthopaedic Surgeon
Hospital for Special Surgery
Assistant Scientist
Hospital for Special Surgery
New York, NY, USA
Karl D. Schultz, Jr. MD, FRCS
Practicing Neurosurgeon
Northeast Georgia Medical Center
Gainesville, GA, USA
Josef B. Simon, MD
Division of Neurosurgery
New England Baptist Hospital
Boston, MA, USA
Kern Singh, MD
Assistant Professor
Orthopaedic Surgery
Rush University Medical Center
Chicago, IL, USA
Zachary A. Smith, MD
Department of Neurosurgery
UCLA Medical Center
Los Angeles, CA, USA
David Speach, MD
Associate Professor
Orthopaedics and Rehabilitation
University of Rochester School of Medicine
Rochester, NY, USA
Sathish Subbaiah, MD
Assistant Professor
Neurosurgery
Mount Sinai School of Medicine
New York, NY, USA
Deydre Smyth Teyhen, PT, PhD, OCS
Associate Professor, Doctoral Program in Physical erapy
U.S. Army-Baylor University Doctoral Program in Physical erapy
Fort Sam Houston, TX, USA
Gordon Sze, MD
Professor of Radiology
Section Chief of Neuroradiology
Yale University School of Medicine
New Haven, CT, USA
G. Ty Thaiyananthan, MD
Assistant Clinical Professor of Neurosurgery
Department of Neurological Surgery
University of California, Irvine
Irvine, CA, USA
Stephen Scibelli, MD
Neurosurgeon
Cedars-Sinai Institute for Spinal Disorders
Los Angeles, California
Christopher I. Shaffrey, MD
Harrison Distinguished Professor
Neurological and Orthopaedic Surgery
University of Virginia
Charlottesville, VA, USA
Jessica Shellock, MD
Orthopedic Spine Surgeon
Texas Back Institute
Plano, TX, USA
Ali Shirzadi, MD
Senior Resident
Neurological Surgery Residency Program
Department of Neurosurgery
Cedars-Sinai, Los Angeles, CA
William Thoman, MD
Northwestern University
Chicago, IL, USA
Eeric Truumees, MD
Adjunct Faculty
Bioengineering Center
Wayne State University
Detroit, MI, USA
Aasis Unnanuntana, MD
Fellow
Orthopaedic Surgery
Hospital for Special Surgery
New York, NY, USA
Alexander R. Vaccaro, MD, PhD
Professor of Orthopaedics and Neurosurgery
Co-Director
omas Jefferson University/Rothman Institute
Philadelphia, PA, USA
Contributors
xiii
Sumeet Vadera, MD
Neurosurgery Resident
Cleveland Clinic
Department of Neurological Surgery
Cleveland, OH, USA
Shoshanna Vaynman, PhD
e Spine Institute Foundation
Los Angeles, CA, USA
Michael Y. Wang, MD, FACS
Associate Professor
Departments of Neurological Surgery and Rehabilitation Medicine
University of Miami Miller School of Medicine
Miami, FL, USA
Peter G. Whang, MD
Assistant Professor
Department of Orthopaedics and Rehabilitation
Yale University School of Medicine
New Haven, CT, USA
Andrew P. White, MD
Instructor in Orthopaedic Surgery
Harvard Medical School
Spinal Surgeon
Beth Israel Deaconess Medical Center
Boston, MA, USA
Timothy F. Witham, MD, FACS
Assistant Professor of Neurosurgery
Director, e Johns Hopkins Bayview Spine Center
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Huilin Yang
Professor
Department of Orthopedics
Suzhou University Hospital
Suzhou, China
Weibin Yang, MD, MBA
Physical Medicine and Rehabilitation Service
VA North Texas Health Care System
University of Texas Southwestern Medical School
Dallas, TX, USA
Anthony T. Yeung, MD
Desert Institute for Spine Care
Phoenix, AZ, USA
Christopher A. Yeung, MD
Desert Institute for Spine Care
Phoenix, AZ, USA
Philip S. Yuan, MD
Memorial Orthopedic Surgical Group
Long Beach, CA, USA
James Joseph Yue, MD
Associate Professor
Yale School of Medicine
Department of Orthopaedic Surgery and Rehabilitation
New Haven, CT, USA
Navid Zenooz, MD
Musculoskeletal Radiology Fellow
Yale University School of Medicine
New Haven, CT, USA
Kirkham B. Wood, MD
Chief, Orthopaedic Spine Service
Department of Orthopaedic Surgery
Massachusetts General Hospital
Boston, MA, USA
Eric J. Woodard, MD
Division of Neurosurgery
New England Baptist Hospital
Boston, MA, USA
Kamal R.M. Woods, MD
Department of Neurosurgery
Loma Linda University Medical Center
Loma Linda, CA, USA
Kris Wai-ning Wong, PhD
Senior Lecturer
Discipline of Applied Science
Hong Kong Institute of Vocational Education
Hong Kong
Yinggang Zheng, MD
Desert Institute for Spine Care
Phoenix, AZ, USA
Linqiu Zhou, MD
Department of Rehabilitation Medicine
Jefferson Medical College
omas Jefferson University
Philadelphia, PA, USA
Dewei Zou, MD
China PLA Postgraduate Medical School
Orthopedic
Surgical Division
Beijing, China
Preface
The treatment of spinal disorders is often challenging and de mandi ng for
both patient and clinician. These challenges and demands are often amplified i n the elderly patient. The concepts and methods presented in The
Comprehensive Treatment of the Aging Spine: Minimally Invasive and
Advanced Techniques
complexities of the aging spine. Osteoporosis, diabetes, cardiovascular and
cerebral vascular disease, po or nutrition, and other co-morbidities often
mandate a collective decision making process. In addition, the fundamentals of spinal anatomy, spinal embryology, biomechanics, biochemistry of
spinal implants, and radiologic changes that occur in the aging spine are
delineated for the clinician. Knowledge of non-operative/conservative treatment modalities such as land and aquatic therapy, acupuncture, injections,
medication, and yoga therapies is a prerequisite to the initial management of
the aging spine, especially in the presence of such co-morbidities.
are aimed at assisting the clinician in approaching the
If non-operative care does not sufficiently remedy the patient’s symptoms, operative intervention may be necessary. An emphasis on decision
making and operative options for differing pathologies such as spinal stenosis, spondylolisthesis, scoliosis, cervical myelopathy, osteoporotic fractures
and fixation, and spinal tumors are presented. Each chapter underscores the
relevant pathology, surgical technique, outcomes, and complications that can
occur in the operative treatment of the aging spine.
New developments and emerging technologies are introduced to the
clinician. The use of cyberknife therapy, nanotechnologies, endoscopic,
and ozone therapies are reviewed. Innovative approaches such as the lateral approach to the spine (Extreme Lateral [XLIF] and Guided Lateral
[GLIF]) are reviewed and described. Lastly, the economic impact of the
aging spine is reviewed in terms of the cost benefit of caring for spinal disorders in the aging population.
xv
Embryology of the Spine
Zair Fishkin and John A. Bendo
1
k e y p o i n t s
Gastrulation is the beginning of organogenesis and the time when the
embryo is most susceptible to internal and external insults that may lead to
congenital defects.
Congenital spinal defects are often associated with abnormalities of the
cardiac and renal systems because both these organ systems arise out of
embryonic mesoderm precursors and develop at the same time as the spine.
Failure of the cranial and caudal neural pores to close in the first 25 to 27
days post gestation results in anencephaly and spina bifida, respectively.
Segmental shift of adjacent somites during embryogenesis may lead to defects
of formation.
Defects of segmentation may result from hemimetamer hypoplasia, osseous
metaplasia of the intervertebral disc, or a bony bar in the posterior elements.
e resulting deformity depends on the location of the congenital defect and
remaining active growth centers.
INTRODUCTION
Although a thorough understanding of mammalian embryology may not
be required for the spine clinician, a fundamental grasp of the concepts of
organogenesis, especially pertaining to the spine and central nervous system,
may provide insight to the pathoanatomy and pathophysiology of common
ailments affecting the spine. The following chapter is a summary of the key
points that drive embryogenesis and result in common orthopedic diseases
of the spine.
the ectoderm (Figure 1-2). The migrating cells that are sandwiched between
the endoderm and ectoderm layers will become the mesoderm. Control of
these migrations is maintained through various cell-signaling pathways that
also contribute to establishment of the body axes in all planes. The signaling
pathways, or organizer genes, are secreted by the primitive streak and mesoderm. The cranial direction of the embryonic disc is established by a specialized area of cells, referred to as the anterior visceral endoderm, that expresses
genes required for formation of the head and cerebrum. The dorsal-ventral
axis is regulated by growth factors in the TGF-β family including bone morphogenic protein-4, fibroblast growth factor, and the sonic hedgehog gene.
Amnion
Connecting
stalk
Yolk sac
Embryonic
disc
GASTRULATION
The intrauterine process by which the human form develops can be divided
into two phases, the embryonic period and the fetal period. The embryonic
period lasts from conception to approximately 52 days post gestation. It is
a vital period for organogenesis, occurring at a time when the embryo is
most prone to external and internal teratogenic insults. The next 7 months
encompass the fetal period, a time for tissue specialization and growth.
Immediately following fertilization, the zygote undergoes rapid cell division. Approximately 16 cells make up a ball-like structure called the morula.
By the eighth day of gestation, the morula develops two fluid-filled cavities,
the primitive yolk sac and the amniotic cyst. The cysts are separated by a
double-layer disc of cells. Of these two cell layers, the epiblast lies adjacent to
the amniotic sac; it will eventually give rise to all three germ layers during gastrulation, the process by which a two-layer disc becomes a three-layer disc.
Gastrulation begins in the third week of gestation and gives rise to three
distinct germ layers, the ectoderm, the meso d erm, and the endoderm. The
initial phase of ga strulation begins with formation of the primitive streak,
which is sometimes named the primitive groove (Figure 1-1). This midline
thickening of the germinal disc terminates in the primitive node. Under control of embryonic growth factors, cells of the epiblast layer migrate inward to
form the mesoderm and the endoderm through the process of invagination.
Cells migrating farthest from the epiderm and closest to the yolk sac become
the endoderm. The remaining epiblast cells will eventually differentiate into
Embryonic
ectoderm
Primitive
Intraembryonic
mesoderm
Embryonic
endoderm
FI G UR E 1 -1 Top: Approximately 8 to 12 days after gestation, the
embryo contains two fluid-filled cavities, the primitive yolk sac and amnion,
which are separated by the embryonic disc, a double layer of cells containing
the epiblast. Bottom: Beginning in the third week following gestation, a primitive streak or groove forms in the epiblast. This thickening marks the beginning
of gastrulation, the process by which the two-layer disc becomes three layers:
ectoderm, mesoderm, and endoderm.
groove
Trilaminar
embryonic
disc
3
4
Cut edge
P A R T I Introduction to the Aging Spine
of amnion
Prechordal
plate
Embryonic
ectoderm
Primitive node
Primitive pit
Primitive groove
in primitive streak
FI G UR E 1 -2 During the process of invagination, cell migration begins in the primitive streak and progresses in a predictable pattern.
The deepest cells form the endoderm, while the cells staying superficial form the ectoderm. Cells migrating between the two layers will be
the precursors to the mesoderm layer.
Yolk sac
covered with
extraembryonic
mesoderm
Level of
Section B
Connecting stalk
Control of sidedness is regulated by fibroblast growth factor-8, Nodal, and
Lefty-2, all of which are secreted on the left side of the germinal disc. An
additional protein, Lefty-1, is secreted to prevent migration of the left sided
growth factors across the midline.
1
At the cranial end of the primitive streak is a specialized collection of
cells, the primitive node. Cells migrating cranially into the primitive node
will eventually form the prechordal plate, while those migrating more posterior will fuse with cells in the hypoblastic layer to form the notochordal
process. By day 16 or 17 of gestation, the lateral edges of the endoderm
continue to invaginate; the two edges will eventually meet and pinch off
the notochordal process, forming the definitive notochord. This is the earliest beginning of the bony vertebrae and the remainder of the skeleton. Cell
migration continues for approximately 7 days, at which point the primitive
streak begins to close in a cranial to caudal direction.
Primitive groove
in primitive streak
Primitive
node
Migrating cells
Embryonic endoderm
a
Embryonic
ectoderm
Mesoblast
Cut edge
of amnion
SOMITE PERIOD
The presence of the notochord induces proliferation of the mesoderm. At
approximately 17 days of gestation the mesoderm thickens into two masses,
each located directly adjacent to the notochord. This initial layer, termed the
paraxial mesoderm, continues to spread laterally to eventually differentiate
into three distinct areas, paraxial mesoderm, intermediate mesoderm, and
lateral mesoderm. During the somite period, lasting from approximately
19 to 30 days post fertilization, the paraxial mesoderm will develop into
segmental bulbs of tissue on either side of the notochord (Figure 1-3). The
first pair of somites will appear adjacent to the notochord, and they will
continue to develop in a cranial to caudal direction until a total of 42 to 44
pairs of somites appear by the end of the fifth week of gestation. The first 24
somite segments are responsible for the cervical, thoracic, and lumbar spine.
Somites 25 through 29 contribute to formation of the sacrum, while pairs
30 through 35 are responsible for coccyx formation. The rest of the 42 to
44 somite pairs disappear through a process of regression, which occurs at
approximately 6 weeks of gestation.
The somites continue to differentiate into two distinct tissues. Ventromedial cells develop into the sclerotome, while dorsolateral cells develop into
the dermatomyotome. The latter cells will eventually give rise to the integument system and dorsal musculature of the body, while the sclerotome will
migrate to surround the notochord and give rise to the vertebral column.
Regulation of sclerotome formation is controlled by proteins coded by the
sonic hedgehog gene, which is expressed by cells of the notochord. This
process of sclerotome migration will begin by the fourth week of gestation.
Each sclerotome will be divided by an intersegmental vessel and a loose area
b
c
FI G UR E 1- 3 Human embryo at approximately 3 weeks of gestation;
the embryo is approximately 1.5 to 2.5 mm in length at this point of development. Note that the cranial portion is wider than the caudal portion, with open
neuropores at both ends. Ten pairs of somites have formed at this point in
development. Cross-sectional electron micrographs show the neural tube with
sclerotome and dermatomyotome cell masses on both sides of the midline.
(Reprinted from Müller, O’Rahilly: J Anat 203: 297–315, 2003.)