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The Lumbar Spine
Third Edition
Official Publication of the International Society
for the Study of the Lumbar Spine
The Lumbar Spine
Third Edition
Official Publication of the International Society
for the Study of the Lumbar Spine
Edited by
Harry N. Herkowitz, M.D.
Chairman
Department of Orthopaedic Surgery
William Beaumont Hospital
Royal Oak, Michigan
Jiri Dvorak, M.D.
Professor
Department of Neurology
University of Zurich
Chief
Department of Neurology, Spine Unit
Schulthess Clinic
Zurich, Switzerland
Gordon R. Bell, M.D.
Vice-Chairman
Cleveland Clinic Spine Institute
Vice-Chairman
Department of Orthopaedic Surgery
Cleveland Clinic Foundation
Cleveland, Ohio
Margareta Nordin, Dr.Sci., P.T., C.I.E.
Research Professor and Director
Program of Ergonomics and Biomechanics
Departments of Orthopaedics and Environmental
Medicine
New York University School of Medicine
Director
Occupational and Industrial Orthopaedic Center
(OIOC)
Hospital for Joint Diseases
Mount Sinai-NYU Health
New Y or k, New Y ork
Dieter Grob, M.D.
Professor
Department of Orthopedics
University of Zurich
Chief
Department of Orthopedics, Spine Unit
Schulthess Hospital
Zurich, Switzerland
Acquisitions Editor: Robert Hurley
Developmental Editor: Kerry Barrett
Production Editor: Karina Mikhli
Manufacturing Manager: Benjamin Rivera
Cover Designer: Brian Crede
Compositor: Lippincott Williams & Wilkins Desktop Divison
Printer: Maple-Press
© 2004 by LIPPINCOTT WILLIAMS & WILKINS
530 W alnut Street
Philadelphia, PA 19106 USA
LWW.com
All rights reserved. This book is protected by copyright. No part of this book may be reproduced in
any form or by any means, including photocopying, or utilized by any information storage and retrieval
system without written permission from the copyright owner , except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official
duties as U.S. government employees are not covered by the above-mentioned copyright.
Printed in the USA
Library of Congress Cataloging-in-Publication Data
The lumbar spine / official publication of the International Society for the Study of the Lumbar Spine ;
edited by Harry N. Herkowitz . . . [et al.].—3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7817-4297-8
1. Backache. 2. Lumbar vertebrae—Diseases. I. Herkowitz, Harry N. II. International Society for
the Study of the Lumbar Spine.
[DNLM: 1. Lumbar Vertebrae. 2. Spinal diseases. WE 750 L95665 2004]
RD771.B217L86 2004
617.5′6—dc22
2003065939
Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. Howe ver, the authors, editors, and publisher are not responsible for errors or omissions
or for any consequences from application of the information in this book and make no warranty , e xpressed
or implied, with respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional responsibility of the
practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage
set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of
information relating to drug therapy and drug reactions, the reader is urged to check the package insert
for each drug for any change in indications and dosage and for added warnings and precautions. This is
particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care
provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.
10 9 8 7 6 5 4 3 2 1
Dedication
The International Society for the Study of the Lumbar Spine (ISSLS) is a unique organization. Its membership includes representatives from all the continents w ho come to gether
yearly to discuss their unique perspectives on all facets of lumbar disease. It is an organization that thrives on discussion and whose members have dedicated their professional
lives to advancing the knowledge of spine disease so that people may live active and productive li ves. Man y of the membership, past and present, were and are “household names”
in the spine world who, through their research and teaching, have made significant contributions to our understanding of the spine. Many others who are not “household names”
have also contributed to advancing our knowledge through their active participation in the
society. This third edition of the ISSLS textbook is dedicated to the following members
who have passed on; each of them has contributed through their research, teaching, and
discussion that are reflected in the pages of this third edition: Alf Breig, Alexander Brodsky, John Bromley, Ralph Cloward, Stephan Dorhring, George Dommissee, Alan Dwyer,
George Ehni, Harry Farfan, Harry Fahrni, William Fielding, Edward Froning, Jacob Graham, Beckett Howorth, Carlyle Hudson, Shunichi Inoue, Bernard Jacobs, Rae Jacobs,
Henry LaRocca, Bruno Lassale, Ian MacNab, John McCulloch, James Morris, Philip
Newmann, William Park, Homer Pheasant, Frank Raney, Lester Russin, Antonio Martino,
David Selby, Lyman Smith, Arthur Thibodeau, Henk Verbiest, Henrik Weber, Thomas
Whitecloud.
The Editorial Board on behalf of the ISSLS membership
v
Contents
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii
SECTION I. BASIC SCIENCE
1 Epidemiology and the Economics of Low Back Pain . . . . . . . . . . . . . . . . . . . . . . . . 3
Alf Nachemson
2 Pathophysiology of Nerve Root Pain in Disc Herniation and Spinal Stenosis . . . . . . 11
Kjell Olmarker, Robert R. Myers, Shinichi Kikuchi,
and Björn Rydevik
3 Biomechanical Considerations of Disc Degeneration . . . . . . . . . . . . . . . . . . . . . . . . 31
Allison M. Kaigle Holm and Sten H. Holm
4 Morphologic Changes of End Plates in Degenerative Disc Disease . . . . . . . . . . . . . 46
Robert J. Moore
5 Clinical Spinal Instability Resulting from Injury and Degeneration . . . . . . . . . . . . . 51
Manohar M. Panjabi, Vijay K. Goel, Allison M. Kaigle Holm, and
Malcolm H. Pope
6 Spinal Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Vijay K. Goel, Manohar M. Panjabi, Hiroshi Kuroki,
Setti S. Rengachary, D. McGowan, and N. Ebraheim
7 Fracture and Repair of Lumbar Vertebrae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Tony S. Keller, Victor Kosmopoulos, and Thomas Steffen
8 Genetic Transmission of Common Spinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . 98
Michele C. Battié and Tapio Videman
9 Genetic Applications to Lumbar Disc Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Christian Lattermann, Lars G. Gilbertson, and James D. Kang
10 Clinical Neurophysiologic and Electrodiagnostic Testing in
Disorders of the Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Jiri Dvorak and Scott Haldeman
11 Sensorimotor Control of the Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Sten H. Holm and Aage Indahl
Outcomes Assessment
12 Outcome Assessment: Overview and Specific Tools . . . . . . . . . . . . . . . . . . . . . . . . 132
Kevin F. Spratt
vii
viii /CONTENTS
13 The Role of Outcomes and How to Integrate Them into Your Practice . . . . . . . . . . . 139
Richard A. Deyo
SECTION II. ALTERNATIVES TO TRADITIONAL NONOPERATIVE TREATMENT
14 Manual Therapy in Patients with Low Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Jiri Dvorak, Scott Haldeman, and Wolfgang Gilliar
15 Acupuncture and Reflexology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Marianne L. Magnusson and Malcolm H. Pope
16 Retur ning Workers to Gainful Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Margareta Nordin
17 Occupational Ergonomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
William S. Marras
18 Preparation for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Orso L. Osti, Simon Macklin, and Hiroaki Nakamura
SECTION III. THE INJURED WORKER
SECTION IV. SURGERY
Surgical Approaches
19 Surgical Approaches to the Thoracolumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Scott D. Daffner and Todd J. Albert
20 Surgical Approaches to the Lumbar Spine: Anterior and Posterior . . . . . . . . . . . . . . 219
Anthony P. Dwyer
21 Posterior and Anterior Surgical Approaches to the Lumbosacral Junction . . . . . . . . 228
Peter A. Robertson
22 Endoscopic Anterior Lumbar Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Ensor E. Transfeldt and John N. Graber
Bone Graft
23 Biology of Bone Grafting: Autograft and Allograft . . . . . . . . . . . . . . . . . . . . . . . . . 247
Robert Gunzburg and Marek Szpalski
24 Bone Graft Substitutes in Spinal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Anis O. Mekhail and Gordon R. Bell
Spinal Instrumentation Overview in Lumbar Degenerative Disorders
25 Principles of Spinal Instr umentation in Degenerative Disorders
of the Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Ashok Biyani and Howard S. An
26 Spinal Instr umentation Overview in Lumbar Degenerative Disorders: Cages . . . . . . 286
Kenneth M.C. Cheung and John C.Y. Leong
27 Translaminar Screw Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Dieter Grob
ONTENTS / ix
C
SECTION V. SPECIFIC CLINICAL ENTITIES
Lumbar Disc Disorders
28 Lumbar Disc Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Mats Grönblad
Operative Treatment—Disc Degeneration
29 Facet Joint Denervation: A Minimally Invasive Treatment for Low Back Pain
in Selected Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
David J. Hall
30 Intradiscal Electrother mal Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Jeffrey A. Saal and Joel S. Saal
31 Operative Management of the Degenerative Disc: Posterior and
Posterolateral Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Gunnar B.J. Andersson and Francis H. Shen
32 Posterior Lumbar Interbody Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Casey K. Lee and Kenneth J. Kopacz
33 Operative Treatment of Anterior Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Kambiz Hannani and Rick Delamarter
34 Operative Treatment of Anterior and Posterior Fusion . . . . . . . . . . . . . . . . . . . . . . . 338
Björn Strömqvist
35 Degenerative Disc Disease: Fusion Cages and Dowels . . . . . . . . . . . . . . . . . . . . . . . 342
Richard D. Guyer and Donna D. Ohnmeiss
36 Minimally Invasive Procedures for Anterior Column Fusion and Reconstruction . . . 352
H. Michael Mayer
37 Degenerative Disc Disease: Complications of Surgery . . . . . . . . . . . . . . . . . . . . . . . 360
Scott L. Blumenthal and Donna D. Ohnmeiss
38 Dynamic Stabilization in the Treatment of Low Back Pain
Due to Degenerative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Dilip K. Sengupta
Artificial Disc
39 Lumbar Artif icial Disc Replacement: Rationale and Biomechanics . . . . . . . . . . . . . 384
Geoffrey M. McCullen and Hansen A. Yuan
40 Lumbar Disc Replacement: Cur rent Model, Results, and the Future . . . . . . . . . . . . 393
Robert D. Fraser
Disc Herniation
41 Disc Her niation: Definition and Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Tom Bendix
42 Disc Her niation: Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Josef Assheuer and Klaus-Peter Schulitz
43 Disc Her niation: Nonoperative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Kevin P. Singer and Peter J. Fazey
x /CONTENTS
44 Operative Treatment of Disc Herniation: Natural Histor y and Indications for Surgery 437
Charles G. Greenough
45 Operative Treatment of Disc Herniation: Laminotomy . . . . . . . . . . . . . . . . . . . . . . . 443
Charles G. Greenough
46 Chymopapain and Chemonucleolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Jeremy Fairbank
47 Microscopic Lumbar Discectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Robert Kraemer, Alexander Wild, Holger Haak, Joerg Herdmann, and
Juergen Kraemer
Spinal Stenosis Without Deformity
48 Classification, Natural History, and Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . 464
Yong Hai
49 Imaging of Spinal Stenosis and Degenerative Lumbar Spondylolisthesis with Stenosis 472
Donald L. Renfrew and and Kenneth B. Heithoff
50 Spinal Stenosis Without Deformity: Nonoperative Treatment . . . . . . . . . . . . . . . . . . 490
Arto Herno
51 Indications for Surgery and Laminotomy Procedures . . . . . . . . . . . . . . . . . . . . . . . . 495
Franco Postacchini
52 Laminectomy for Spinal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
Brian J.C. Freeman
53 Laminoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Yoshiharu Kawaguchi and Masahiko Kanamori
Degenerative Lumbar Spondylolisthesis with Stenosis
54 Degenerative Lumbar Spondylolisthesis with Spinal Stenosis: Natural History,
Diagnosis, Clinical Presentation, and Nonoperative Treatment . . . . . . . . . . . . . . . . . 514
Mohamed Mostafa Mossaad
55 Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
Bo Jönsson
56 Decompression with Posterolateral Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
Gianluca Cinotti
57 Anterior Lumbar Interbody Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Mamoru Kawakami and T etsuya Tamaki
58 Decompression with Instr umented Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
Dilip K. Sengupta and Harry N. Herkowitz
Spinal Stenosis with Sagittal or Coronal Deformity
59 Degenerative Lumbar Spinal Stenosis with Scoliosis-Kyphosis:
Surgical Techniques, Results,
Hirokazu Ishihara and Hisao Matsui
and Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
Nondegenerative Spondylolisthesis
60 Nondegenerative Spondylolisthesis: Epidemiology and Natural History, Classif ication,
History and Physical Examination, and Nonoperative Treatment of Adults . . . . . . . 556
James Rainville