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Synopsis of Spine Surgery
Second Edition
Synopsis of Spine Surgery
Second Edition
Howard S. An, M.D.
The Morton International Endowed Chair
Professor of Orthopedic Surgery
Director, Division of Spine Surgery and Spine
Fellowship Program
Department of Orthopedic Surgery
Rush University Medical Center
Chicago, Illinois
Kern Singh, M.D.
Assistant Professor
Department of Orthopedic Surgery
Rush University Medical Center
Chicago, Illinois
Thieme
New York · Stuttgart
Thieme Medical Publishers, Inc.
333 Seventh Ave.
New York, NY 10001
Editor: Esther Gumpert
Managing Editor: J. Owen Zurhellen
Vice President, Production and Electronic Publishing: Anne T. Vinnicombe
Production Editor: Anitha. K.R
Vice President, International Marketing: Cornelia Schulze
Chief Financial Officer: Peter van Woerden
President: Brian D. Scanlan
Compositor: Thomson Digital
Printer: Maple-Vail Book Manufacturing Group
Cover Illustration: Background illustration of the thoracic spine from M. Scheunke, E. Schulte, U. Schmacher.
Thieme Atlas of Anatomy: General Anatomy and Musculoskeletal System.
Stuttgart: Thieme; p. 86, Figure A, illustrator Karl Wesker.
Library of Congress Cataloging-in-Publication Data
Synopsis of spine surgery/ Howard S. An, Kern Singh, — 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58890-495-9
ISBN 978-3-13-143112-7
1. Spine—Surgery. I. Singh, Kern. II. Title.
[DNLM: 1. Spinal Diseases—surgery—Outlines. 2. Spinal Diseases—diagnosis—Outlines.
3. Spine—physiology—Outlines. 4. Spine—surgery—Outlines. WE 18.2 A531s 2007]
RD768.A5 2007
617.5’6059—dc22
2007014861
Copyright © 2008 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally
protected by copyright. Any use, exploitation, or commercialization 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 microfilms, and electronic data processing and storage.
Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden
our knowledge, changes in treatment and drug therapy may be required. The authors and editors of the
material herein have consulted sources believed to be reliable in their efforts to provide information
that is complete and in accord with the standards accepted at the time of publication. However, in view
of the possibility of human error by the authors, editors, or publisher of the work herein or changes in
medical knowledge, neither the authors, editors, nor publisher, nor any other party who has been
involved in the preparation of this work, warrants that the information contained herein is in every
respect accurate or complete, and they are not responsible for any errors or omissions or for the results
obtained from use of such information. Readers are encouraged to confirm the information contained
herein with other sources. For example, readers are advised to check the product information sheet
included in the package of each drug they plan to administer to be certain that the information
contained in this publication is accurate and that changes have not been made in the recommended
dose or in the contraindications for administration. This recommendation is of particular importance in
connection with new or infrequently used drugs.
Some of the product names, patents, and registered designs referred to in this book are in fact registered
trademarks or proprietary names even though specific reference to this fact is not always made in the text.
Therefore, the appearance of a name without designation as proprietary is not to be construed as a
representation by the publisher that it is in the public domain.
Printed in the United States of America
5 4 3 2 1
The Americas ISBN: 978-1-58890-495-9
Rest of World ISBN: 978-3-13-143112-7
I dedicate this book to my wife, Sue, who has endured good and difficult times
and supported my career for more than two decades. I also dedicate this book to
Jennifer and Steven as they have been a model daughter and son and have given
me joy and happiness.
Howard S. An, M.D.
I dedicate this book to my father. Not only is he my mentor and best friend, but
also he is the man I hope to be.
Kern Singh, M.D.
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
I. Patient Evaluation and Spine Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. Anatomy and Surgical Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. History and Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3. Spinal Imaging and Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4. Biomechanics of the Spine and Spinal Instrumentation . . . . . . . . . . . . . . . . . 60
5. Physiology of Bone Grafts and Bone Graft Substitutes . . . . . . . . . . . . . . . . . . 78
II. Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6. Evaluation and Management of Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . 85
7. Spinal Rehabilitation and Disability Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 90
8. Cervical Spine Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
9. Thoracolumbar Spine Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
III. Degenerative Spinal Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
10. Biomechanical Aspects of Intervertebral Disk Degeneration . . . . . . . . . . . . 115
11. Degenerative Cervical Spine Disorders: Surgical and
Nonsurgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
12. Degenerative Thoracic Spine Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
13. Lumbar Disk Disease: Pathogenesis and Treatment Options . . . . . . . . . . . 137
14. Lumbar Spinal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
15. Surgical Management of Axial Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Contents
IV. Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
16. Lumbar Spondylolisthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
17. Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
18. Kyphotic Spinal Deformities in Children and Adults . . . . . . . . . . . . . . . . . . . 193
V. Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
19. Spinal Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
20. Spinal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
21. Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
22. Seronegative Spondyloarthropathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
23. Pediatric Cervical Spine Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
viii Contents
The second edition of Synopsis of Spine Surgery as offered by Howard S. An and
Kern Singh is a carefully collected compilation of practical information intended
for all persons concerned with the care of spinal disorders. The basis of this new
second edition was the well-received first edition, written in the 1990’s by Dr. An
and 49 additional contributors. As with any medical specialty, continual, objec-
tive reassessment of the way we pass information on to the next generation of
physicians allows spine surgery to grow and patient care to improve, and the
authors have revised and updated this second edition accordingly. Drs. An and
Singh have been well supported in this endeavor by the institution where they
work, Rush University Medical Center, the academic level of their practice, and
their noted research and educational activities.
This book makes plain the local, national, and international milieu in which the
two authors participate. Their work will serve as a vade mecum for junior personnel
and as an interesting treatise for experienced surgeons. One might believe that these
objectives are impossible to fulfill and should have been made through separate
offerings. Nonetheless the two authors have been able to present the material
needed to achieve this goal in a concise manner. In the chapters, Drs. An and Singh
offer clinical observations as well as differential diagnosis prior to conveying treat-
ment plans. Primary nonoperative care is covered, as well as surgical approaches. The
book’s beautifully clear illustrations help define points.
The audience for this book is broad, including beginning and experienced
practitioners, residents and fellows, and medical students. Those in the disciplines
of orthopaedic surgery, neurosurgery, physical medicine and rehabilitation,
occupational medicine, emergency medicine, traumatology, and family practice
will find this book of interest. In addition, this book will be useful for licensure,
certification, or recertification.
Jerome M. Cotler, M.D.
Everett J. and Marian Gordon Professor of Orthopaedic Surgery
Jefferson Medical College
Philadelphia, Pennsylvania