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Syno psis o f Spine Surg e ry
Th ir d Ed it io n
How ard S. An, MD
Th e Mo r to n In t e r n at ion al Pro fe s s o r
Director, Division of Spin e Su r gery a n d Sp in e Fellow sh ip Progr am
Dep ar t m en t of Ort h opaed ic Su rge r y
Ru sh Un ive r s it y Me d ica l Ce n t e r
Ch ic ag o , Il l in o i s
Ke r n Si n gh , M D
Asso ciat e Pr o fess or
Co - Di r e ct or, Min im a lly In va s ive Sp in e In s t i t u t e
Dep ar t m en t of Ort h opaed ic Su rge r y
Ru sh Un ive r s it y Me d ica l Ce n t e r
Ch ic ag o , Il l in o i s
266 illustrations
Th ie m e
New York • St ut t gart • Delh i • Rio d e Jan eiro
Execu t ive Editor: W illiam Lam sback
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Inte rn at ion al Produ ct ion Direct or: Andr eas Scha ber t
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Presid en t: Br ian D. Scan lan
Libr ar y o f Con gr ess Cat a lo gin g- in - Pu b licat ion Dat a
Nam es: An, How ard S., a ut h or. | Singh , Kern , au th or.
Tit le : Sy n op si s o f s p i n e s u rge r y / Ho w ar d S. An , Ker n Si ng h .
Descr ip t ion: Third ed it ion . | New Yor k : Thie m e, [2 016] |
Includ es bibliograp hical refere nces an d in dex.
Iden t ifier s: LCCN 2015 0366 66 | ISBN 97 816 2623 030 9
Subje ct s: | MESH: Spin al Diseases—su rge r y—Outlin es. |
Spin al Diseases—diagn osis—Outlin es. | Sp in e—
ph ysio logy—Out lin es. | Spin e—su rge ry—Ou tlin es.
Classification : LCC RD76 8 | NLM W E 18.2 |
DDC 6 17.5/6 059 —dc23
LC r ecor d availab le at h tt p ://lccn .loc.gov/201 503 666 6
Im p o r t a n t n ot e: Medicine is an ever-changing science
undergoing continual development. Research and clinical
experience are continually expanding our knowledge, in
particular our knowledge of proper treatment and drug
th era py. Insofar a s t h is book m en tion s any do sage or
application, readers m ay rest assured that the authors,
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that such references are in accordance with the state of
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have been newly released on the market. Every dosage
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This bo ok, in clu d ing a ll p ar ts t h ere of, is legally p rote ct ed
by copyright. Any use, exploitation, or comm ercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable
to prosecution. This applies in particular to photostat
reproduction, copying, mimeographing or duplication
of any kind, translating, preparation of micro lms, and
elect ron ic dat a pr ocessin g an d stor age.
I wou ld like to d edicate t h is book to m y m oth er, fath er, my w ife, and m y ch ild ren , w h o
have give n m e u n con dit ion al love and su p p ort t h rou gh out m y life.
How ard S. An
I dedicate t h is book to m y m oth er a n d fat h e r. Th an k you both for alw ays forcin g m e to
be t h e best I cou ld be . Wit h out you r love, pat ience, and dedicat ion , I w ou ld not be th e
physician , fath e r, or son I am today.
Kern Singh
Co n t e n t s
Preface ..................................................................................................................................... ix
1 An a t o m y a n d Su r gi c a l Ap p r o a ch e s ................................................................................... 1
2 Histor y an d Physical Exam in at ion ..................................................................................47
3 Rad io gr ap h ic An at om y.......................................................................................................57
4 Sp in a l Im agin g a n d Diagn o st ic Te st s ..............................................................................6 7
5 In t raop e r at ive Neu r o m on it or in g ....................................................................................80
6 Bio m e ch an ic s o f t h e Sp in e a n d Sp in al In st r u m en t a t io n .......................................... 8 3
7 Physiology of Bon e Healing and Fusion ..................................................................... 104
8 Bo n e Gr a ft s , Su b st it u t e s , a n d Bio lo g i c s ...................................................................... 1 1 1
9 Eva lu at io n a n d M a n a ge m e n t o f Sp in a l Co r d In ju r y ................................................ 1 1 6
10 Ce r v i c a l Sp i n e Tr a u m a ..................................................................................................... 1 22
11 Th o r aco lu m b a r Sp in e Fr a ct u res ................................................................................... 13 4
12 Sp in al Reh ab ilit a t io n a n d Disa b ilit y Eva lu at io n ...................................................... 1 42
13 Bio ch e m ic a l As p ec t s o f In t e r ve r t e b ra l Di s k De ge n e r a t io n ................................... 14 8
14 Dege n e r at ive Cer vical Sp in e Diso r der s ....................................................................... 15 4
15 Dege n e r at ive Th or a cic Sp in e Con d it ion s ................................................................... 167
16 Lu m b a r Di sk Di s e a s e : P a t h o g e n e s is a n d Tr e a t m e n t Op t io n s . . ........... ...... ...... ...... 1 7 1
17 Su r gica l Ma n a ge m en t o f Lu m b a r De ge n e r a t ive Disk Dis e a s e .............................. 1 83
18 Lu m b a r Sp in a l St e n o s i s .... ....... ...... ....... ........ ...... ....... ....... ...... ....... ........ ...... ...... ........ ...... 1 9 7
19 Lu m b a r Sp o n d y l o li s t h e s i s .... ....... ........ ...... ...... ......... ...... ...... ........ ...... ...... ........ ....... ...... . 2 1 0
20 Ad u l t Sp i n a l De fo r m i t y ................................................................................................... 2 2 1
21 Pediat r ic Spin al Deform it y ............................................................................................. 227
22 Pediat r ic Cervical Sp in e Disorders ............................................................................... 252
23 Sp in al Tu m o r s .................................................................................................................... 264
24 Sp in al In fe c t io n s ............................................................................................................... 280
25 Rh e u m ato id Ar t h r it is ...................................................................................................... 2 95
26 Se r o n e g a t ive Sp o n d ylo a r t h r op at h ie s .......................................................................... 3 0 7
In dex .................................................................................................................................... 31 7
vii
Pre face
Th e t h ird ed it io n of t h e Sy nopsis of Sp in e
Surgery reflects the rapid advances in the
field since the first edition—advances that
have changed our approach to patient care,
particularly involving minimally invasive
surgery. In addition, significant advances
have been made in bone physiology and
biologics. The third edition succinctly
summarizes these advances w ith the
reader being able to quickly reference
these new spine surgical developments.
Th e p r e m is e beh in d t h is b o o k is t o
concisely su m m arize inform ation in
an outline format. The reader is able to
references that may provide greater
detail on topics of particular interest. This
book is written primarily for orthopedic
surgeons and neurosurgeons-in-training.
Th e e a sy- t o - r ea d fo r m at a lso m ake s t h is
an excellent resource for practicing spine
surgeons as well as nonoperative spine
physicians.
We hope that this book will provide our
readers with a thorough understanding
of the m odern field of spine surgery in
the most efficacious manner possible,
increasing th e quality of care given to
spine patients.
peruse broad topics in an expeditious
manner, while being directed to key
How ard S. An, MD
Kern Singh, MD
ix
1 Anatomy and Surgical Approaches
1.1 Basic Anatomy of the Spine
I. Ve r t eb ral co lu m n.
A. Th e sp in a l co lu m n h a s s p eci c a lly a d ap t e d a n at o m ical fe at u re s t o m ain t a in
stability, protect neural elements, and allow range of motion.
B. St ab ilit y i s a u gm e n te d b y t h e i n t e r ve r t e b ra l d is k s, lig a m e n t s , a n d m u scle s.
C. Th e r e a r e 3 3 ve r te b r a e in t h e sp in a l co l u m n ( 7 c e r vi c a l, 1 2 t h o r a cic , 5 lu m b a r,
5 sacral, and 4 coccygeal).
D. There are fou r sagit tal cu r ves in th e ver t ebra l colu m n.
1. Ce r vical lordosis (20–40°).
2. Thoracic kyph osis (20 –50°).
3. Lu m ba r lord osis (31– 79°).
4. Sacral kyphosis.
E. Th e k yp h ot ic c u r ve s a r e ca lle d p r im a r y b e ca u s e t h e y fo r m d u r in g t h e fe t a l
period.
1. Caused by the wedge-shaped nature of vertebrae.
F. Th e l o r d o t i c c u r v e s a r e c a l l e d s e c o n d a r y b e c a u s e t h e y b e g i n t o fo r m d u r i n g
the late fetal period and continue to form after birth. Head and body weight
contributes to their form ation.
1. Caused by di erences in the anteroposterior dimensions of the
intervertebral disks.
G. Ea ch ver tebra co n sist s of a p oste r ior bon y a rch an d a n a n t e rior b od y, bot h of
which surround the vertebral canal.
1. Posterior bony arches between two adjacent vertebrae form a foramen for
the spinal nerve roots.
2. Anterior bodies of the lumbar spine support 80% of the axial load on the
spinal colum n.
H. Posterior bony arch com pon en ts (Table 1.1).
II. In ter ver tebr a l d isks (Table 1.2).
A. Th e r e a re 2 3 in te r ve r t e br al d isk s in t h e s p in al colu m n (6 ce r vica l, 1 2 t h or a cic,
5 lumbar).
B. Ea ch d isk is lo ca te d b e t w e e n a dja ce n t ve r te br a l e n d p la te s, w h ich a re co v e r e d
by hyaline and brocartilage and supported by subchondral bone.
C. Ve r t eb ra l d is k s m a ke u p o n e q u ar t e r o f t h e s p in a l co lu m n h e igh t . Th e d isk s
expand when the column is horizontal because water and nutrients enter the
disk, but they collapse under the stress of prolonged standing or sitting.
D. The disk is a relat ively avascu lar st ru ct u re w ith th e ou t e r layers receivin g
nutrients from the end arterioles and the central portions receiving nutrients
by di usion from the vertebral end plates.
E. Ea ch d is k co n sis t s o f a n o u t e r a n n u lu s b r os u s, w h ich su rr ou n ds a ce n t r a l
nucleus pulposus (Fig. 1.1).
1
1 Anatomy and Surgical Approaches
2
Ta b l e 1 . 1 Post erior bony a rch co m po n e nt s
Co m p o n e n t s Fu n c t i o n
Ped icle s and lam ina e Form t he bo rd e rs of t he ve r t eb ral ca n a l wit h t he p o st e rior
border of the vertebral body
Spin ous a nd
At t a c h m e n t s it e s f o r s u p p o r t i n g li g a m e n t s a n d m u s c l e s
transverse processes
Ar t ic u la r p r o c e s s e s Th e su p e r io r a r t ic u la r p r o c e s s o f t h e c a u d a l ve r t e b r a e fo r m s a
facet joint wit h t he inferior art icular process of t he ce ph alad
ve rt ebrae b ilat era lly.
Th e a rt icu la r fa ce t jo in t s su p p o rt 2 0% o f t h e a xia l lo a d o n t h e
spinal colum n.
Th e p ar s in t e ra r t icu la ris is t h e b o ny r e g io n b e t w e e n t h e
superior and inferior articular processes of an individual
ve rt ebra.
Ta b l e 1 . 2 Histolog ical ch a racte rist ics of t he in t ervertebral d isk
In t e r v e r t e b ra l
disk component Characteristics
An n u l u s b r o s u s • 1 0 – 2 0 la y e r s o f c o n c e n t r ic la m e ll a e o f b r o c a r t ila g e
• Type I collagen
• Lattice made of sheets running in opposite directions that give
the disk greater rotational strength
• Thickest portion is anterior. Thinnest portion is posterolateral.
• Outer portions of the annulus are continuous with the anterior
and posterior longitudinal ligaments.
Nucle us p ulpo sus • Mu coid t ype II co llage n a nd wat er-im bibin g p rot e og lyca n s
(e.g., aggrecan)
• Cushions axial load
• Cannot be compressed under pressure due to its uid nature,
but rather will deform in all directions
1 Anatomy an d Surgical Approaches 3
Fi g . 1 . 1 Th e n e r ve s t ru ct ure s o f t he lu m ba r p le xu s.
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