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© 2005 Mosby Inc.All r ights reserved. ISBN 0-323-02731-8
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Notice
Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and
clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current product information provided by the manufacturer
of each drug to be administered to verify the recommended dose, the method and duration of administration,
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The Publisher
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. Spine–Diseases–Treatment. 2. Spine–Pathophysiology. 3. Spine–Surgery. 4. Orthopedics. I.Vaccaro,
Alexander R.
[DNLM: 1. Spinal Diseases–Handbooks. 2. Spine–surgery–Handbooks, 3. Back Pain–therapy–Handbooks. 4.
Orthopedic Procedures–Handbooks.WE 39 S757 2005]
RD768.S674 2005
616.7¢306–dc22
2004059217
Printed in the United States of America
Last digit is the print number: 987654321
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. E ICHENBAUM,
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. F ISICARO,
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. F RIED,
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
J
AMES 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
R
EBECCA S. OVSIOWITZ,
M.D., Thomas Jefferson University, Philadelphia, PA
EVIN F. R AND,
K
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. S HARAN,
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
J
EFF 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. S ILVA,
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. S ULLIVAN,
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. V IBERT,
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 format 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 accomplish 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, anesthesiologists, 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 information. 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, residents, 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 physicians 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 particular topic while actively participating in clinical rounds.
The book begins with a basic overview of spinal anatomy, surgical approaches, and physical examination 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 spondylolisthesis. 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 understanding of the principles of spinal care.
xv
CHAPTER
1
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
Introduction
●
A thorough understanding of spinal anatomy is crucial for
a comprehensive evaluation of a patient with spinal
disorders (Moore 1999,An 1998, Frymoyer et al. 2001,
Rothman et al. 1999, Hoppenfeld et al. 1994).
●
The primary roles of the spine are maintaining stability,
protecting the neural elements, and allowing range of
motion. Specifically adapted anatomic features facilitate
these functions.
●
The vertebra is the structural building block of the spine,
with specific morphologic and functional roles based on the
vertebra’s position in the spinal column. The intervertebral
disks, ligaments, and muscles add stability and control.
●
The spinal cord travels within, and is protected by, the
spine. Paired nerve roots exit at each spinal level.
Bony Vertebral Column
●
The vertebral column consists of 33 vertebrae—7
cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal
(Fig. 1–1). The 24 cervical through lumbar vertebrae are
mobile.
●
The vertebral column has four distinct curves—cervical
lordosis, lumbar lordosis, thoracic kyphosis, and sacral
kyphosis. In stance, the sagittal vertical axis passes through
the odontoid, posterior to the cervical vertebrae, through
the C7-T1 intervertebral disk, anterior to the thoracic
vertebrae, through the T12-L1 intervertebral disk,
posterior to the lumbar vertebrae, through the L5-S1
intervertebral disk, and anterior to the sacrum.
●
The primary curves are those of the kyphotic thoracic
and sacral regions.These form during the fetal period.
The secondary curves are those of the lordotic cervical
and lumbar regions.These are initiated during the late
fetal period but do not become significant until after
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
vertebrae, whereas secondary curves are caused by
differences in the anterior and posterior dimensions of
the intervertebral disks.
1
2 Spine Core Knowledge in Orthopaedics
Thoracic spine
kyphosis
Lumbar spine
lordosis
Cervical spine
lordosis
Sacrum
kyphosis
Coccyx
T12
T1
C7
C2
L1
L5
S1
Vertebral
canal or foramen
Posterior
bony arch
Anterior
vertebral body
Figure 1–2: Anatomic configuration of a lumbar vertebra.
processes changes when one moves down the vertebral
column.The bony region between the two articular
processes of an individual vertebra is termed the pars
interarticularis.
●
The vertebral bodies of the lumbar spine support an
average of 80% of the axial load experienced by the
spinal column; the facet joints support the other 20%.
Figure 1–1: Lateral view of the spine demonstrating the
normal spinal curvatures.
●
Each vertebra consists of an anterior body and a posterior
bony arch (Fig. 1–2).Together these surround the
vertebral canal or foramen. Lateral spaces between the
posterior arches of adjacent vertebrae form the foramen
through which the spinal nerve roots pass (Fig. 1–3).
●
The posterior vertebral arch consists of the pedicles,
laminae, spinous processes, facet joints, and transverse
processes.The pedicles and laminae form the borders of
the vertebral canal with the posterior border of the
vertebral body.The spinous and transverse processes are
sites of attachment of supporting ligaments and muscles.
Of note, the posterior arches include the thickest cortex
of the vertebra (Doherty et al. 1994).
●
The superior articular process is the portion of the
posterior elements that articulates with the supra-adjacent
vertebra.The inferior articular process articulates with the
subadjacent vertebra.The orientation of the articular
Figure 1–3: Borders of the intervertebral
foramen through which the spinal nerve roots
pass.
Specific Vertebral Anatomy
Atlas (C1)
●
The atlas is the first cervical vertebra (Fig. 1–4).This is a
ring-like structure that does not have an anterior body or
a posterior spinous process.There is an anterior and a
much longer posterior arch.
●
The posterior arch has a groove along its superior border
where the vertebral artery passes in its tortuous path
toward the foramen magnum of the skull.
●
The superior articular facets are saucer-like and form the
atlanto-occipital articulation with the occipital condyles.
Because of the orientation of these facets, the majority of
cervical flexion and extension of the upper cervical spine
is possible in this region.
●
The inferior articular facets are flatter, more circular, and
contribute to the atlantoaxial articulation with the second
cervical vertebra, or axis. The remainder of this
articulation is through the unique relationship of the
Intervertebral foramen
Pedicle above
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
articulates with the occipital condyles
Transverse
process C1
Lamina C1
Posterior arch C1
Transverse
process C1
Lateral
masses
Figure 1–4: C1 and C2 vertebrae.
Anterior arch C1
Dens C2
Groove for
vertebral artery
Spinous process C2
Atlas C1
Axis C2
Dens C2
Transverse
foreamen C2
Lamina C2
Body C2
Anterior tubercle C2
Posterior tubercle C2
Pedicle C2
Inferior articular
facet C2
Spinous process C2
View from belowView from above
Atlano-axial
articulation
Spinous process C2
View from posteriorView from anterior
posterior border of the anterior arch of the atlas and the
dens.
●
The transverse processes of the atlas are longer and larger
than those of the other cervical vertebrae.Within the
transverse processes is the transverse foramina through
which the vertebral artery passes.
Axis (C2)
●
The axis is the second cervical vertebra (Fig. 1–4).This
includes the dens, or odontoid, which projects superiorly
from the anterior vertebral body to articulate with the atlas.
●
The atlas contacts the axis through the posterior facet
joints and the anterior atlantodens articulation.A synovial
joint is present between the anterior arch of C1 and the
dens and transverse ligament that bonds the odontoid to
the anterior C1 arch.The majority of upper cervical
rotation occurs at the atlantoaxial joint.
●
The transverse ligament is a stout ligament that runs from
one side of the atlas to the other and holds the dens
Alar ligament
Transverse
ligament
against the posterior surface of the anterior C1 arch
(Fig. 1–5). Extensions of this ligament superiorly and
inferiorly create the cruciform ligament.
●
The dens is further stabilized by the alar ligaments that
connect the odontoid tip to the occipital condyles.The
apical ligament, at the tip of the dens, is a remnant of the
notochord.
●
The C2-C3 articulation is anatomically similar to the rest
of the subaxial cervical levels.
●
The C2 pedicle is relatively large and projects 30 degrees
medially and 20 degrees superiorly (Xu et al. 1995).
●
The C2 spinous process is large, bifid, and often
palpable.This serves as the site of attachment for several
muscles.
●
The transverse processes of this vertebra are similar in
morphology, but smaller, than those of the other
cervical vertebrae.The vertebral artery passes
through the transverse processes in the transverse
foramen.
Figure 1–5: Ligaments specific to the
Dens
atlantoaxial ar
ticulation.
C1
C2
Cruciform
ligament
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