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recommended if the index procedure included the lower lumbar spine. The
posterior iliac crest is palpated, and a full-thickness flap is created over the
dorsolumbar fascia. An assistant can use a Meyerding retractor on the flap as
the surgeon uses a Cobb elevator and electrocautery to approach the iliac
crest. A vertical incision is made along the middle of the iliac crest, and
electrocautery facilitates subperiosteal release of the fascia and gluteal
muscles laterally. If tricortical bone graft is needed, both the inner and outer
tables of the ilium are exposed. An oscillating saw then can be used to
harvest a tricortical graft. If only cancellous bone is needed, a cortical “cap”
of the ilium can be removed with an osteotome, and bone gouges can then be
used to scoop cancellous bone from between the inner and outer tables. It is
recommended that the outer table be exposed to a depth of 3 inches. A Taylor
retractor, which can retract the gluteus muscle as well as the entire superficial
tissue flap, is inserted. A 0.5-inch osteotome is then used to remove a
triangular piece of cortex from the external table. Large curets can then be
used to harvest the graft to the depth of the inner table. After sufficient bone
has been obtained, large pieces of thrombin-soaked cottonoid pledget can be
packed against the exposed bone surface to achieve hemostasis.
Alternatively, the posterior iliac bone graft can be obtained through a separate
lateral skin incision placed along the border of the posterior iliac crest within
6 to 8 cm from the midline. Remaining steps are similar to those described
previously. The complications associated with this technique are donor site
pain, injury to cluneal nerves, and injury to the sciatic nerve or superior
gluteal nerve or artery if dissection is too deep.
Anterior Iliac Bone Graft
The anterior iliac crest is a potential source of tricortical bone graft for
anterior cervical fusions, and bone marrow aspirate from this region is a rich
source of stem cells used for supplementing other bone graft material. An
incision is made along the border of the iliac crest 4 cm posterior to the ASIS
to avoid iatrogenic injury to the lateral femoral cutaneous nerve and avulsion
of the ASIS. To obtain tricortical graft, the periosteum is elevated along with
muscle attachments from inner and outer tables of the ilium. It is preferable to
use an oscillating saw over the osteotome to avoid microfracture of the graft,
and care should be taken to preserve the ASIS by ensuring that the graft
harvest is at least 2 cm proximal to the ASIS. After tricortical bone graft is
removed, more cancellous graft can be obtained, if needed, using a bone
gouge. After removal of the bone graft, the fascial edges should be
reapproximated with No. 1 synthetic absorbable sterile suture. to reduce the
risk of hernia. The complications associated with this technique are donor site
pain, meralgia paresthetica, avulsion fracture of the ASIS, hematoma
formation, pelvic instability, and infection.
Summary
Each surgical approach to the spine has advantages and limitations. The use
of minimally invasive approaches and muscle-sparing approaches is
increasing rapidly. Minimally invasive surgical approaches facilitate earlier
patient recovery and decrease the need for narcotics in the immediate
postoperative period; however, long-term benefits have yet to be proved.
Spine surgeons should monitor the literature for reports of complications
associated with newer procedures and be mindful of the learning curve
associated with incorporating new approaches and techniques into clinical
practice.
Key Study Points
The conventional anteromedial approach to the cervical spine is the
preferred standard approach to manage disorders of the anterior subaxial
spine (C3-C7).
The surgical steps used for the posterior midline approach are similar
when performing laminectomy or laminoplasty. Preservation of muscular
attachments at C2 and C7 are of paramount importance in laminoplasty.
The transpedicular approach is a circumferential approach to the thoracic
spine. It has been effectively used in the treatment of thoracic vertebral
body tumors and infection and may eliminate the need for aggressive
thoracotomy.
LLIF and OLIF are newer minimally invasive surgical approaches for
performing lumbar interbody fusion anteriorly. Knowledge of the involved
anatomy and careful evaluation of preoperative imaging studies are
essential to avoid complications.
Preserving the muscular attachments along the lateral facet joint is the key
to keeping the midline approach minimally invasive when performing
TLIF with a cortical bone trajectory.
Annotated References
1. Smith GW, Robinson RA: The treatment of certain cervical-spine disorders by anterior
removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 1958;40A(3):607-624.
2. Beutler WJ, Sweeney CA, Connolly PJ: Recurrent laryngeal nerve injury with anterior
cervical spine surgery risk with laterality of surgical approach. Spine (Phila Pa 1976)
2001;26(12):1337-1342.
3. Lu J, Ebraheim NA, Nadim Y, Huntoon M: Anterior approach to the cervical spine:
Surgical anatomy. Orthopedics 2000;23(8):841-845.
4. Ebraheim NA, Lu J, Yang H, Heck BE, Yeasting RA: Vulnerability of the sympathetic
trunk during the anterior approach to the lower cervical spine. Spine (Phila Pa 1976)
2000;25(13):1603-1606.
5. Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al: Anterior cervical discectomy and
fusion associated complications. Spine (Phila Pa 1976) 2007;32(21):2310-2317.
6. Lee MJ, Bazaz R, Furey CG, Yoo J: Risk factors for dysphagia after anterior cervical
spine surgery: A two-year prospective cohort study. Spine J 2007;7(2):141-147.
7. Menezes AH, VanGilder JC: Transoral-transpharyngeal approach to the anterior
craniocervical junction: Ten-year experience with 72 patients. J Neurosurg
1988;69(6):895-903.
8. McAfee PC, Bohlman HH, Yuan HA: Anterior decompression of traumatic
thoracolumbar fractures with incomplete neurological deficit using a retroperitoneal
approach. J Bone Joint Surg Am 1985;67(1):89-104.
9. Haller JM, Iwanik M, Shen FH: Clinically relevant anatomy of high anterior cervical
approach. Spine (Phila Pa 1976) 2011;36(25):2116-2121.
This anatomic study defines the relationship of various neurovascular structures
encountered during anterior cervical dissection. The anatomic relationships of the
hypoglossal nerve, internal and external superior laryngeal nerves, superior thyroid
artery, and superior laryngeal artery to the cervical spine are defined. The authors
concluded that these structures did not show any side-to-side variation.
Spine (Phila Pa 1976) 2003;28(17):E329-E333.
high anterior cervical approach. J Neurosurg 2000;92(suppl 1):24-29.
the occipito-cervical junction. Injury 2005;36(suppl 2):B44-B53.
Neurochir (Wien) 1994;129(1-2):47-53.
Spine (Phila Pa 1976) 2001;26(22):2467-2471.
fixation angle in posterior instrumented occipitocervical fusion. Neurol Med Chir
(Tokyo) 2008;48(6):279-282, discussion 282.
study of the spatial relationship between C1 transpedicular screw trajectory and V3
segment of vertebral artery. Spine J 2017;17(1):120-128.
A close relationship was found between the C1 transpedicular screw trajectory and the
V3 segment of the vertebral artery in a study of 62 patients using CT angiography. The
authors recommended a medial inclination technique, especially for female patients.
Level of evidence: IV.
transection during C1 lateral mass screw fixation: Does it affect functionality and
quality of life? Neurosurgery 2014;74(5):475-480, discussion 480-481.
Twenty-eight patients were included in a study performed to determine the
consequences of C2 nerve root sectioning during placement of C1 lateral mass screws.
C2 transection was performed in 8 patients and C2 was preserved in 20 patients. All
patients were prospectively followed (mean follow-up, 27 months). It was concluded
that even though C2 nerve root transection is associated with increased occipital
numbness, clinical outcomes were not affected by C2 nerve root transaction. Level of
evidence: III.
laminoplasty with C3 laminectomy compared with conventional C3-C7 laminoplasty: A
modified laminoplasty preserving the semispinalis cervicis inserted into axis. Spine
(Phila Pa 1976) 2005;30(22):2544-2549.
laminoplasty for cervical myelopathy: Average 14-year follow-up study. Spine (Phila
Pa 1976) 2006;31(26):2998-3005.
foraminotomy for the operation of lateral disc herniations using 5.9-mm endoscopes: A
prospective, randomized, controlled study. Spine (Phila Pa 1976) 2008;33(9):940-948.
approaches for the cervical spine. Orthop Clin North Am 2007;38(3):339-349, abstract
v.
spine foraminotomy and lateral mass screw placement. Spine (Phila Pa 1976)
2012;37(5):E318-E322.
This article describes posterior cervical decompression and lateral mass screw
placement through a tubular retraction system. The posterior cervical spine was
approached through the paramedian median muscle-splitting approach and lateral mass
fixation was performed using tubular retractors.
laminoforaminotomy. Neurosurg Focus 2008;25(2):E2.
transpedicle approach for spondylectomy, epidural decompression, and circumferential
fusion of spinal metastases. Spine (Phila Pa 1976) 2000;25(17):2240-2249, discussion
250.
for resection of epidural metastatic spine tumors involving the vertebral body with
circumferential reconstruction: Results in 140 patients. Invited submission from the
Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J
Neurosurg Spine 2004;1(3):287-298.
posterolateral transpedicular approach with posterior instrumentation. Surg Neurol
2009;71(4):424-433.
thoracolumbar corpectomy with nerve preservation and bilateral cage reconstruction. J
Clin Neurosci 2014;21(6):988-992.
Early results of single-stage posterolateral transpedicular corpectomy and fusion in the
thoracolumbar spine are reported for five patients. At a mean follow-up of 3.3 months,
patients with a preoperative neurologic deficit showed improvement in neurologic
status.
symptomatic thoracic disc herniation: Initial multicenter clinical experience. J
Neurosurg Spine 2012;16(3):264-279.
This retrospective study highlights the safety and early results of a minimally invasive
lateral approach for symptomatic thoracic herniated intervertebral disks. The authors
evaluated 60 patients with symptomatic thoracic herniated disks treated using a mini
open lateral approach and found a 6.7% overall complication rate. The results were
comparable with open conventional modalities. It was concluded that minithoracotomy
is a less invasive and viable option for the treatment of thoracic disk herniation.
located thoracic herniated disc? Spine (Phila Pa 1976) 2007;32(20):E581-E584.
Minimally Invasive Spine Surgery, ed 2. Berlin, Springer, 2006, pp 129-137.
for degenerative conditions: Early complication profile. J Spinal Disord Tech
2009;22(1):34-37.
(XLIF): A novel surgical technique for anterior lumbar interbody fusion. Spine J
2006;6(4):435-443.
and thoracolumbar fusion: Preliminary results. Eur Spine J 2012;21(suppl 1):S37-S42.
This retrospective cohort review of 97 consecutive patients from three centers found
that XLIF is a safe and effective technique for interbody fusion. No permanent
neurologic impairment or vascular or visceral complications were reported. Transient
neurologic complications were seen, but overall success was reported in 92% of cases.
complications. J Am Acad Orthop Surg 2016;24(2):96-105.
This review article focuses on various aspects of LLIF, including indications, relevant
anatomy, surgical technique, complications, and outcomes. The authors suggest LLIF
could provide safe and effective clinical outcomes with technical advancement and
better understanding of the anatomy.
electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine
2011;14(1):31-37.
This prospective multicenter study provides insight into the role of EMG in a surgical
approach of LLIF. The authors strongly recommend using the real-time EMG threshold
during the transpsoas approach to avoid lumbar plexus injury.
the minimally invasive lateral transpsoas approach. J Neurosurg Spine 2012;17(3):227-
231.
This retrospective chart review of 118 patients identified motor injuries in patients who
had undergone LLIF. The study reported a 1.7% incidence of femoral nerve injury, with
a level-specific incidence of 4.8% for procedures performed at the L4-L5 disk space,
whereas other lumbar levels showed less risk. The authors recommended that care be
taken to avoid injury to the T11 and T12 nerve roots during surgical closure. Proper
closure of the abdominal wall is needed to avoid abdominal muscle weakness and
hernias.
minimally invasive lateral transpsoas interbody fusion. Neurosurg Focus
2011;31(4):E18.
This retrospective review reports on 568 patients who were treated with the minimally
invasive lateral retroperitoneal transpsoas approach for interbody fusion. Abdominal
wall paresis occurred in 10 patients as a complication of surgery. Abdominal wall
paresis resolved in 8 of the 10 patients by the 6-month follow-up visit; the remaining 2
patients were lost to follow-up. It was concluded that abdominal wall paresis is a rare
but known potential complication of lateral interbody fusion. Level of evidence: IV.
lateral lumbar interbody fusion. J Spinal Disord Tech 2015;28(2):71-75.
This case report concerns a rare intraoperative aortic injury that occurred during LLIF at
level of L3-L4. While performing direct LLIF through a right-side mini transpsoas
approach, the proximal aspect of the interbody implant broke. An attempt to impact the
implant further resulted in violation of the L3 end plate and the anterior cortex, which
subsequently injured the aorta.
indirect neural decompression through oblique lateral interbody fusion for degenerative
lumbar disease. Spine (Phila Pa 1976) 2015;40(3):E175-E182.
In this prospective study of 28 patients with lumbar canal stenosis, OLIF was used to
treat all the patients. Indirect decompression was performed by placing an interbody
cage through an oblique lateral approach to the lumbar spine and then stabilizing the
construct with posterior percutaneous pedicle screws.
underwent oblique lateral interbody fusion surgery: Perspectives and indications from a
retrospective, multicenter survey. Spine (Phila Pa 1976) 2017;42(1):55-62.
This retrospective multicenter review identified perioperative complications during
OLIF. The study, which included 155 patients, reported 75 complications, including
end plate fracture/subsidence (18.7%), transient psoas weakness and thigh numbness
(13.5%), and segmental artery injury (2.6%). Most complications were transient, and
only three patients had permanent damage, which included one uretal injury and two
neurologic injuries. Level of evidence: III.
mini-open anterior retroperitoneal lumbar interbody fusion: Oblique lumbar interbody
fusion in 179 patients. Asian Spine J 2012;6(2):89-97.
OLIF was used to treat 179 patients at a single institution. The authors found that
minimally invasive OLIF was an easily performed and safe procedure for treating the
lumbar spine from L2 to L5, and at L1-L2 in select patients.
lumbar interbody fusion (MIS-TLIF); Minimum 5-years follow-up with clinical and
radiologic outcomes. J Spinal Disord Tech 2012;Sept 28 [Epub ahead of print]
This retrospective study evaluated clinical results of 44 patients who had undergone
minimally invasive TLIF. The authors noted a significant decrease in visual analog
scale pain scores and greater improvement in Oswestry Disability Index scores.
Radiologic evidence of fusion was noted in nearly all patients with both isthmic and
degenerative spondylolisthesis. Favorable clinical and radiologic results were achieved
after single-level instrumented fusion.
associated with learning the technique of minimally invasive transforaminal lumbar
interbody fusion (TLIF). J Clin Neurosci 2011;18(5):624-627.
This retrospective comparison study of conventional TLIF and minimally invasive
TLIF reported lower transfusion rates, a decreased need for postoperative surgical
drains, and decreased time to mobility for patients who underwent minimally invasive
TLIF. The authors noted that minimally invasive TLIF was associated with a higher rate
of early complications.
minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila
Pa 1976) 2009;34(13):1385-1389.
fusion surgery based on indication: A prospective study. Neurosurgery 2015;76(1):723, discussion 23-24.
This prospective clinical study of 125 patients who underwent anterior lumbar
interbody fusion reported clinically successful outcomes in 86% of the patients. An
overall 10% complication rate was reported. Complications included retroperitoneal
hematoma, retrograde ejaculation, incisional hernia, and bowel obstruction.
Res 1992;284:47-53.
spine procedures. Am J Surg 2007;194(1):98-102.
retroperitoneal lumbosacral spine exposure: Operative technique and results. Ann Vasc
Surg 2003;17(2):137-142.
splitting approach to the lumbar spine. J Bone Joint Surg Am 1968;50(5):919-926.
extraforaminal disc herniations at the lumbosacral junction using an operating
microscope: Case series and review of the literature. Neurosurg Focus 2008;25(2):E10.
lateral lumbar disc herniation: Identification of compressed root and discectomy by
lateral approach. Spine (Phila Pa 1976) 1999;24(18):1952-1957.
Chapter 4
Spine Mechanics and
Pathomechanics
John A. Hipp, PhD
Abstract
In routine clinical practice, it is challenging to objectively determine
whether the load-bearing, motion-providing, and neurovascular protective
capabilities of the spine have been compromised. An understanding of spine
mechanics and pathomechanics can help identify functional abnormalities.
This knowledge also is important in understanding how available surgical
treatments for spine disorders alter the biomechanics of the spine, either as a
consequence of decompression or in the process of providing stability. It is
essential that clinicians be able to assess the biomechanical success of each
spine surgery and understand the biomechanics of the spine and how
implants can alter motion.
Keywords: cervical; kinematics; load-bearing capacity; lumbar;
mechanics
Dr. Hipp or an immediate family member serves as a paid consultant to or is an
employee of and has stock or stock options held in Medical Metrics.
Introduction
Healthcare providers appreciate that the spine provides structural support for
the body and allows a wide range of movements while providing protection
of the neurovascular elements within and about the spine. Collectively, loadbearing, motion-providing, and neurovascular protective capabilities are
described as the biomechanical functions of the spine. In routine clinical
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