Spinal Deformities The Comprehensive Text Thieme Spinal Deformities The Comprehensive Text Ronald L DeWald, M.D Professor of Orthopaedic Surgery Rush Medical College Chicago, Illinois Vincent Arlet, M.D Associate Professor of Orthopaedic Surgery McGill University Montreal, Canada Allen L Carl, M.D Associate Professor of Orthopaedic Surgery Albany Medical College Albany, New York Michael F O’Brien, M.D Assistant Professor of Orthopaedic Surgery Colorado Health Sciences Center Denver, Colorado Thieme New York Á Stuttgart Thieme Medical Publishers, Inc 333 Seventh Ave New York, NY 10001 Consulting Editor: Esther Gumpert Assistant Editor: Owen Zurhellen Director, Production and Manufacturing: Anne Vinnicombe Production Editor: Becky Dille Marketing Director: Phyllis Gold Sales Manager: Ross Lumpkin Chief Financial Officer: Peter van Woerden President: Brian D Scanlan Compositor: Thomson Press (India) Limited Printer: Maple-Vail Book Manufacturing Group Library of Congress Cataloging-in-Publication Data Spinal deformities : the comprehensive text / [edited by] Ronald L DeWald p.; cm Includes bibliographical references ISBN 1-58890-089-4 (alk paper) – ISBN 3131305517 (alk paper) Spine–Abnormalities Spine–Diseases I Dewald, Ronald L., 1934[DNLM: Spinal Diseases Spinal Injuries Spine–surgery WE 725 S7548 2003] RD768 S645 2003 617.5’6–dc21 2002075002 Copyright # 2003 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 the 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, or 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 TMP ISBN 1-58890-089-4 GTV ISBN 13 130551 CONTENTS Foreword xi Foreword xii Preface xiii Acknowledgments xiii Dedication xiii List of Contributors xiv SECTION Gross Anatomy—John E Lonstein, section editor 1 2 SECTION Sacrum and Pelvis Lumbar Spine 14 Thoracic Spine 25 Cervical Spine 33 46 Microanatomy—Vincent Arlet, section editor 53 54 SECTION Surgical Anatomy of the Vincent Arlet Surgical Anatomy of the Vincent Arlet Surgical Anatomy of the Michael F O’Brien Surgical Anatomy of the Michael F O’Brien Muscles and Ligaments John E Lonstein Development and Maturation of the Spine and Spinal Cord John A Ogden and Timothy M Ganey Microscopic Anatomy of Bone Harvinder S Sandhu Macro- and Microscopic Anatomy of the Disk and End Plate Vincent Arlet and John Antoniou Nervous System Michael F O’Brien 72 78 90 Physiology—Lawrence G Lenke, section editor 115 10 Physiology of Bone Harvinder S Sandhu 116 v vi Contents SECTION 11 Nerve and Muscle Physiology Daniel E Gelb 12 Pulmonary and Chest Cage Physiology Lawrence G Lenke 13 Electrophysiology Anne P Padberg 14 Cerebral Spinal Fluid Physiology Lawrence G Lenke 121 Biomechanics—Thomas R Haher, section editor 153 126 135 149 15 Biomechanics 154 Thomas R Haher and Steven Caruso 16 Biomechanics of the Intervertebral Disk 172 Andrew Merola, Andrew Castro, Steven Enguidanos, and Thomas R Haher 17 Spine Testing Modalities 176 Amy Yeung, Danielle Ottaviano, Dennis Lee, and Thomas R Haher SECTION SECTION Pharmacology—George H Thompson, section editor 187 18 Antibiotic Therapy in Spine Surgery Robert P Huang and George H Thompson 19 Osteoporosis: Evaluation and Pharmacologic Treatment Edgar G Dawson, Christopher J DeWald, and Aurelia Nattiv 20 Pharmacologic Agents that Minimize Perioperative Blood Loss in Spine Surgery George H Thompson and Laurel C Blakemore 21 Common Medications in Spinal Afflictions Christopher J Bergin 188 Pathology—John P Kostuik, section editor 211 22 Pathophysiology of Lumbar Degenerative Disk Disease Mesfin Lemma and John P Kostuik 23 Spinal Inflammatory Arthritides Uri M Ahn, Khaled Kebaish, Nicholas Ahn, and John P Kostuik 24 Spinal Neuroarthropathy (Charcot’s Spine) Khaled M Kebaish and John P Kostuik 25 Pyogenic Vertebral Infection Cameron Bruce Huckell and John P Kostuik 26 Coagulation Disorders in Spine Surgery Uri M Ahn, and Khaled Kebaish, Nicholas Ahn, and John P Kostuik 212 195 200 206 216 218 221 237 Contents SECTION SECTION SECTION SECTION 10 vii 27 Blood Conservation Strategies in Spine Surgery Michael G Vitale, Benjamin D Roye, and David P Roye 28 Management of Metastatic Disease to the Spine Lee H Riley III, David B Cohen, Khaled Kebaish, and John P Kostuik 239 Clinical Evaluation—Robert W Gaines, Jr., section editor 257 29 Evaluation of the Patient with Congenital Spine Deformity Robert B Winter 30 Clinical Evaluation of the Patient with a Spine Deformity (Scoliosis, Kyphosis) Robert W Gaines 31 Clinical Evaluation for Neuromuscular Scoliosis and Kyphosis Vernon T Tolo 32 Evaluation of Back Pain in the Spinal Deformity Patient Mark B Dekutoski 258 Neurology—James W Ogilvie, section editor 301 33 Spinal Cord Injury, Reflexes, and Syndromes Kirkham B Wood 34 Anterior Horn Cell Disease: Poliomyelitis, Spinal Muscular Atrophy, Acute Transverse Myelitis James W Ogilvie 35 Congenital and Developmental Spinal Cord Abnormalities: Syringomyelia, Tethered Cord, Diastematomyella, Diplomyelia James W Ogilvie 36 The Spine in Friedrich’s Ataxia, Charcot-Marie-Tooth Disease, and Familial Dysautonomia John P Lubicky 37 Cerebral Palsy, Myelodysplasia, Hydrosyringomyelia, Rett Syndrome, and Muscular Dystrophies John V Banta 302 Anesthesia—Kim W Hammerberg, section editor 327 38 Anesthetic Considerations for Spinal Surgery Timothy W Starck, Daniel Levinthal, and Yvonne Lomax Burnett 328 Radiology—Mark Weidenbaum, section editor 349 39 Radiology Mark Weidenbaum and Richard M Shore 350 249 267 272 284 307 311 313 316 viii Contents SECTION 11 SECTION 12 SECTION 13 Rehabilitation—John P Lubicky, section editor 383 40 Rehabilitation John P Lubicky 384 Treatment of the Adult Spine—Donald P K Chan, section editor 391 41 Operative Management of Degenerative Lumbar Stenosis Donald P K Chan and L Erik Westerlund 42 Degenerative Disk Disease and Degenerative Spondylolisthesis of the Lumbar Spine Thomas G Lowe 43 Adult Spine Trauma Allen L Carl 44 Inflammatory Arthritis of the Spine Sanford E Emery 45 Vertebral Osteomyelitis Sanford E Emery 46 Neoplasms of the Spinal Column Allen L Carl, Tipu Nazeer, and David Prybyla 392 Surgical Techniques—Keith H Bridwell, section editor 477 47 Tables and Positioning Christopher L Hamill and Vincent Arlet 48 Halo and Cranial Traction K Daniel Riew, Timothy R Kuklo, and Lawrence G Lenke 49 Approaches to the Cervical Spine K Daniel Riew and Timothy R Kuklo 50 Open Thoracic and Lumbar Spine Surgical Approaches Peter O Newton 51 Cervical Decompression K Daniel Riew and Timothy R Kuklo 52 Decompression for Lumbar Spinal Stenosis K Daniel Riew and Stephen Lewis 53 Spine Fusion Christopher L Hamill 54 Spine Osteotomy and Resection Keith H Bridwell 55 Staging Plus Complications of Approaches Keith H Bridwell 478 397 406 424 443 450 487 497 506 517 528 540 551 562 Contents SECTION 14 SECTION 15 ix 56 Thoracoplasty Peter O Newton 57 Endoscopic and Mini-Open Approaches to the Spine Peter O Newton 568 Instrumentation and Complications—Denis S Drummond, section editor 577 58 Basic Principles of Deformity Correction Marc A Asher 59 A Biomechanical Approach to Posterior Spinal Instrumentation: Principles and Applications Bryan W Cunningham 60 Sacropelvic Fixation in Spinal Deformity Michael F O’Brien 61 Neurological Injury Complicating Surgery Denis S Drummond, Daniel S Schwartz, Douglas R Johnston, and James F Farmer 62 Postoperative Complications B Stephens Richards 63 Revision Surgery Jean-Pierre C Farcy and Frank J Schwab 578 Pediatric Spine—Dennis R Wenger, section editor 655 64 Etiology of Scoliosis Thomas G Lowe, Michael Edgar, Joseph Y Margulies, Nancy H Miller, V James Raso, and Kent A Reinker 65 Idiopathic Scoliosis: Prevalence and Natural History James O Sanders, Morey S Moreland, and George S Bassett 66 Congenital Scoliosis and Kyphosis Randall T Loder 67 Inflammatory and Infectious Disorders of the Child’s Spine Paul Sponseller 68 The Spine in Skeletal Syndromes and Dysplasias Paul Sponseller 69 Neuromuscular Scoliosis Peter O Newton 70 Pediatric Spine Trauma Behrooz A Akbarnia 71 Spine Tumors in Childhood and Adolescence Dennis R Wenger 656 571 588 601 615 626 634 669 684 694 701 718 730 743 Index Pulmonary function testing back pain evaluation, spinal deformities, 292 congenital spinal deformation, 263 idiopathic scoliosis, pediatric patients, 669 neuromuscular scoliosis, 718 nonoperative management, 719 preoperative assessment, 720 respiratory system evaluation, 131, 131 revision surgery, 638 scoliosis and kyphosis cerebral palsy, 276–277 poliomyelitis, 281 spinal surgery, anesthesia monitoring, pediatric patients, 341–342 Pure moment testing, spinal loading measurements, 177, 178 Pyogenic infection See also Wound infection, as postoperative complication See also Vertebral osteomyelitis Halo vest placement, 487–489 vertebrae bacteriology, 222–223 biopsy, 225 childhood diskitis/osteomyelitis, 228 definitions, 221 diagnosis, 223 differential diagnosis, 226 epidemiology, 222 epidural abscess, 231 imaging studies, 223–225, 224–225 nonoperative management, 226, 227 osteomyelitis/diskitis, 228–231, 229–230 antibiotic therapy, 190–191 pathophysiology and pathology, 221–222 postoperative infection management, 231–233, 232–233 prevention, 225–226 spinal instability and, 227–228 surgical management, 228 therapeutic management controversies in, 233–234 strategies for, 226–228, 227 Quadratus lumborum, anatomy, 52 Quadriplegia cerebral palsy, 316–318, 317 clinical definition, 302 Quiescent bone-lining cells, microanatomy, 75–76 Radiation metastatic spinal disease, therapy using, 253 osteogenesis and fusion and, 119 spinal neoplasms, post-surgical management with, 459–460 Radiologic imaging achondroplasia, 710 back pain evaluation, 287–290, 288–290 bone scanning, 371–374, 372–373 computed tomography, 369–371, 371 congenital scoliosis, 684–685, 685 congenital spinal deformation, patient evaluation, 260–265, 261–264 diastrophic dysplasia, 712, 712 diskography, 374–375, 374–375 Ehlers-Danlos syndrome, 768 embolization, 380 epidurals, 375–376, 376 facet blocks, 377, 377 idiopathic juvenile osteoporosis, 767 idiopathic scoliosis, pediatric patients, 674 lumbar spinal stenosis, preoperative assessment, 528, 529 Marfan’s syndrome, 762 medial branch blocks, 377–378 metastatic spinal disease, 249–251, 250–252 mucopolysaccharidoses, 766 myelography, 366–369, 368–370 neoplasms of the spine adult patients, 451–455, 452–456 pediatric patients, 743 nerve root blocks, 376–377 normal radiographic development, 350–351, 351 osteogenesis imperfecta (OI), 764 percutaneous CT-guided biopsy, 378–379, 378–380 plain radiographs, 353–356 erect imaging, 353, 354–355 non-weight-bearing images, 353–355, 355–359 radiation hazards, 351–353, 352 research background, 350 revision surgery computed tomography, 637–638 magnetic resonance imaging (MRI), 638 847 myelography, 637 preoperative assessment, 636–638 spinal balance assessments, 637 x-ray evaluation, 636–637 rheumatoid arthritis (RA), 424–426, 425–426 surgical assessment, 426–433 sacroiliac injections, 377 Scheuerman’s kyphosis, 777–778, 778–781 spinal deformation assessment, 356–358, 359–360 Chiari malformations, 364 computed tomography, 358, 360 diastematomyelia, 362, 363 magnetic resonance imaging (MRI), 358, 361–362 scoliosis/stenosis, 364, 364–367, 366 syringomyelia, 362–364, 364 tethered cord pathology, 362, 362 spinal injury pediatric patients, 731, 731 trauma, adult spine, 407–408, 407–408 spondylolisthesis, 790, 790–791 superior mesenteric artery (SMA) syndrome, 630 tuberculosis, pediatric patients, 697–699, 698–699 vertebral osteomyelitis, 444–445, 445–446 pediatric patients, 696–697 Raloxifene, osteoporosis prevention and treatment, 197–198 Range of motion (ROM) idiopathic scoliosis etiology, mathematical modeling, 664 intervertebral disk biomechanics, 173–175 revision surgery, physical examination, 636 rotational displacement, 176 spinal deformity, clinical evaluation, 271 stability testing, cervical spine, 180 Reactive arthritis, pediatric patients, 694 Realignment strategies, principles of, 579–580 Red blood cells preoperative donation, 771 substitute products, 773 Reflex evaluation congenital spinal deformation, 259 spinal cord injury (SCI), 305–306 848 Index Rehabilitation protocols research background, 384 spinal cord injury (SCI), 387–389 contractures, 389 heterotopic ossification, 389 latex allergy, 389 osteopenic fracture, 389 pressure ulcers, 388 spasticity, 388–389 spinal deformation, 389 spinal orthotics, 385–387 cervical orthoses, 386 thoracolumbosacral orthosees, 386–387 therapeutic exercise and physical therapy, 384–385 wheelchairs and adaptive seating, 387 Reiter’s syndrome pediatric patients, 694 spinal inflammation, 217 Relton-Hall frame blood conservation and management, 771–772 patient positioning in, 478, 479, 480 special adaptations, 485 Renal cell cancer, metastatic disease of the spine, 471, 471–472 Repair mechanisms, bone repair and osteogenesis, 76, 76–77 Resectioning techniques, hemevertebral resection, 558–559, 560 Residual volume (RV) respiratory function testing, 131 spinal deformity and modification of, 131 Resorption mechanisms, bone remodeling, 116 Respiratory system See also Pulmonary complications; Pulmonary function testing applied physiology, lung volume maintenance, 130–131 functional anatomy breathing control, 130 breathing dynamics, 129, 129 elastic properties, 128–129, 129 gas exchange, 129–130, 130 lungs, 126–128, 127–128 muscles of respiration, 126 pleura, 126 rib cage, 126, 127 upper airway, 128, 128 function testing, 131, 131 spinal deformity patient history and examination, 132–133, 133 respiratory function and, 131–132, 132 Retinal artery thrombosis anesthesia management, spinal surgery, 333 patient positioning and risk of, 485 Retroperitoneal surgical technique endoscopic approaches, 574 thoracolumbar spine, 509–512, 510–511 Retropharyngeal technique, cervical spine surgery, 498–501, 500 Retroscapular surgical technique, thoracolumbar spine, 508 Retrosternocleidomastoid technique, cervical spine surgery, 498 Rett syndrome, pathology and management, 320 Reuleaux technique, spinal biomechanics, instantaneous axis of rotation (IAR), 158–159, 158–159 Reversal mechanisms, bone remodeling, 116 Revision surgery adolescents and young adults, 639 complications, 650–651 computed tomography assessment, 637–638 crankshaft phenomenon, 648 decompensation and add-on phenomenon, 647–648 diagnosis, 638–639 early imbalance, 646=657 flatback and sagittal imbalance issues, 650 fusion problems, pseudarthroses, 644–645 indications for, 634 instrumentation failure, 647 junctional failure, 648–650 magnetic resonance imaging, 638 management strategies, 639–641 myelographic evaluation, 637 patient history, 634–635 patient selection criteria, 651 pediatric patients, 638–639 physical examination, 635–636 preoperative assessment, 634–638 radiographic imaging, 636, 636–637 recurrent back and leg pain, 647 sequential, staged, and simultaneous approaches, 642–644 spinal balance, 637 wound infection, 645–646 Rexed’s laminae, spinal cord crosssectional anatomy, 98, 98–99 Rheology, implant biomechanics, 159– 160, 159–160 Rheumatoid arthritis (RA) See also Juvenile rheumatoid arthritis (JRA), pathophysiology clinical diagnosis, 424 indications for surgery, 426–427, 427 juvenile rheumatoid arthritis (JRA), 694, 695 pathophysiology, 424, 425 radiographic evaluation, 424–426, 425–426 spinal inflamation, 216 surgical management techniques, 427–433 atlantoaxial instability, 427 Brooks fusion, 429 clinical outcomes, 433–434 Gallie-type wiring plus bone graft, 427–429, 428 lateral mass plating, 433, 434 occipital-cervical arthrodesis, 431 occipital cervical fusion, 429, 431 occipitocervial plating, 431–432, 432 odontoid resection, 432–433 posterior cervical fusion, 433 subaxial subluxation, 433 transarticular C1-C2 screws, 429, 430 Rib cage, functional anatomy, 126, 127 Rib grafts spinal fusion, 548 thoracoplasty technique, 568–569, 569 Rib-vertebra angle difference (RVAD) infantile scoliosis, 676–677, 676–677 juvenile scoliosis, 677, 677 Rigidity of deformation, revision surgery considerations, 640–641 Riley-Day syndrome See Familial dysautonomia (FD) Ring apophysis anulus fibrosus, microscopic anatomy, 79, 80–81 growth mechanism, 65 microscopic anatomy, development of, 86, 87 Scheuerman’s kyphosis, 777 Risedronate, osteoporosis prevention and treatment, 198 Risk factors combined anterior/posterior surgical techniques, 563 Index osteoporosis evaluation, 196 radiation hazards, radiographic imaging, 351–353, 352 surgical procedures neurologic injury as complication, 615–616, 616 technique selection and, 617 Risser signs idiopathic scoliosis natural history, 753, 753 pediatric patients, 671–672, 672 menarche and, 673 treatment guidelines, 753–754 Risser ossification, crankshaft phenomenon, revision surgery, 648 Rod insertion biomechanics, 589, 592, 592–594 cerebral palsy management, 316–318, 317 Scheuerman’s kyphosis, 782, 783–785 spinal implant mechanics, yield point magnitude, 166, 166–167 stability testing cervical spine, 180 thoracolumbar spine, 181 Rotational displacement coordinate system, empirical spinal measurement, 173, 176 spinal injury, adult spine, rotatory subluxation, 414, 415 Roy-Camille technique, pedicle fixation, lumbar spine surgical anatomy, 16–18, 17 S1 pedicles screw selection criteria, 6–7, surgical anatomy, 3, 5–6 S2 pedicle, surgical anatomy, 3, S3 pedicle, surgical anatomy, Sacral ala, surgical anatomy, 3, 4–5 Sacral canal, sacral anatomy, 3, Sacral hook-claw construct, sacropelvic fixation, 603, 604 Sacral horizontal angle, spondylolisthesis classification, 790 Sacral nerve roots, microanatomy, 105, 107, 108–109, 109–110, 111 Sacral spine neuromuscular scoliosis, fixation techniques, 720 stability testing, 182 strength testing, 183 Sacroiliac (SI) joint ankylosing spondylitis, 216–217 bone harvesting and risk to, 11, 12 radiographic imaging for injections in, 377 surgical anatomy, 2–3, Sacroilitis, ankylosing spondylitis, 216–217 Sacropelvic fixation, in spinal deformation biomechanics, 606–609, 608–609 clinical failures and solutions, 602 complications, 609 fixation zones, 602–606, 602–608 zone I case study, 609, 610, 612 zone II case study, 611, 612–613 zone III case study, 612, 613 historical background, 601 revision surgery, 643–644 surgical anatomy, 601–602 Sacrospinalis See Erector spinae Sacrum dorsal region anatomy, 2, spinal fusion, idiopathic scoliosis patient, 566 surgical anatomy, 2–4, bony fusion and spinal instrumentation, 4–7 L5-S1 facets, 4–6 S1 pedicle screws, 6–7 S2 pedicle, S3 pedicle, fixation applications, L5-S1 surgery, anatomic relationships, 8–9 lateral masses, intrasacral rod fixation, surgical anatomy, 7–8 ventral region anatomy, 2, Sagittal alignment osteotomies, 557, 557–559, 560 patient positioning, 480–481, 481 revision surgery, 650 Sagittal plane spinal deformity, clinical evaluation, 269, 270 spinal implant biomechanics, 157–159, 163–164, 163–164 Same day surgical techniques, combined anterior/posterior surgical approaches, 563, 564–565 Scheuermann’s kyphosis bracing protocols, 758, 780 clinical evaluation, 77 conservative management and physiotherapy, 779–780 etiology, 777 natural history and progression, 778–779 pathological anatomy, 777 849 pediatric spinal patients, back pain evaluation, spinal deformities, 293, 294 plain radiographic assessment, 353, 355 radiographic imaging, 777–778, 778–781 ‘‘ring’’ apophysis growth mechanism, 65 surgical procedures, 781–785, 782–785 Schmid metaphyseal chondrodysplasia, pediatric patients, 714 Schmorl’s nodes neonatal development, 87 Scheuerman’s kyphosis, 778 Sciatica, nonoperative therapy, 399 Sclerotomes, embryogenesis, 104, 105–106 somite formation, 59–60, 61 Scoliosis See Adolescent idiopathic scoliosis (AIS); Idiopathic scoliosis ‘‘Scottie dog’’ deformity, radiographic assessment, 355, 358 Seatbelt fractures, pediatric spinal injury, 734, 734–735 Segmental instability spinal fusion for, 400, 400 surgical fixation, neurologic injury risk, 617–618 Segmental spinal muscles, anatomy, 49 Segmentation defects congenital scoliosis, 686–687, 686–687 patient evaluation, 262 Seizure disorders cerebral palsy patients, 318 neuromuscular scoliosis, preoperative assessment, 719–720 Sensory evaluation, congenital spinal deformation, 259 Sequential surgical strategy, revision surgery protocols, 642 Servohydraulic testing machines, spinal loading measurements, 177, 178 Sexual function, sacral nerve roots, injury and microanatomy, 107, 108–109, 109–110, 111 Sickle-cell disease, hematogenous osteomyelitis, 222 Sillence classification, osteogenesis imperfecta (OI), 764 Simmons-Keystone technique, spinal fusion, anterior procedures, 544 850 Index Single photon emission computed tomography (SPECT) bone imaging with, 373, 373 neoplasms of the spine, pediatric patients, 743 osteoid osteoma, 744 spinal injury, pediatric patients, 731 spondylolisthesis imaging, 790 Skeletal age, idiopathic scoliosis pediatric patients, 673 skeletal maturity, 677–680, 677–680 Skeletal development idiopathic scoliosis, pediatric patients, 670 radiographic assessment, 356, 360 Skeletal dysplasias, pediatric patients, 706, 709, 709–710 Skeletal muscle abnormalities, idiopathic scoliosis etiology, 657–658 Skeletal syndromes and disorders, pediatric patients achondroplasia, 710–712, 711 arthrogyroposis, 706, 708 cleidocranial dysplasia, 714 diastrophic dysplasia, 712, 712–713 Down syndrome, 706, 707 Ehlers-Danlos syndrome, 702–703, 703 familial dysautonomia (Riley-Day syndrome), 706 Jarcho-Levin syndrome, 715 Kneist dysplasia, 713 Larsen’s syndrome, 714–715 Marfan’s syndrome, 701, 702 metaphyseal chondrodysplasia, 714 metatropic dysplasia, 713 Morquio’s syndrome, 715, 715 mucopolysaccharidoses (MPS), 715, 715 neurofibromatosis-1, 704–705, 705 osteogenesis imperfecta, 703–704, 704 Prader-Willi syndrome, 706 pseudoachondroplasia, 714 skeletal dysplasias, 706, 709, 709–710 spondyloepiphyseal dysplasia (SED) congenita, tarda, 713–714, 714 Stickler syndrome, 715 Skin integrity, wheelchairs and adaptive seating and, 387 Skull base, cervical spine, surgical anatomy, 33, 34 Slip angle, spondylolisthesis classification, 790 Slowdown lines, spinal growth and, 65 Smith-Peterson osteotomy (SPO) ankylosing spondylitis, 439, 440 anterior releases/morselized graft, mutiple SPO following, 552, 552 multiple procedures, indications for, 551–552 techniques, 553, 553 vs pedicle subtraction osteotomy, 552–553 Smith-Robinson surgical technique cervical spine surgery decompression, anterior procedures, 522–526 extrapharyngeal approach, 497–498, 500 retropharyngeal approaches, 498–501, 500 upper and lower cervical spine, 501 spinal fusion, anterior procedures, 544 Sodium fluoride, osteoporosis prevention and treatment, 199 Sodium-potassium edenosine triphosphate (ATP)-requiring pump, nerve physiology, 121 Soft lumbar and lumbosacral orthoses, rehabilitation using, 386 Somatomedin axis, idiopathic scoliosis etiology, 662–663 Somatosensory evoked potentials (SEP) electrophysiology, 135–137 136–137 clinical applications, 136–137, 137 intraoperative applications, 137–138 lumbar spinal stenosis, anesthesia management, 533–534, 534 revision surgery neurophysiological monitoring, 642 preoperative assessment, 638 spinal surgery, neurological monitoring anesthesia management, 337–338 neurologic injury risk avoidance and, 623 stimulation and recording sites, 136 Somite formation, embryogenesis, 59–60, 61 Spasticity cerebral palsy, neuromuscular scoliosis, 722, 724 spinal cord injury (SCI), 388–389 Spastic quadriplegia, cerebral palsy, 316–318, 317 Specimen preparation, spinal testing, 177–179, 178–179 Spermatozoa emission, sacral nerve roots, injury and microanatomy, 107, 108–109, 109–110, 111 Spina bifida embryogenesis, ossification defects, 62 scoliosis and kyphosis, clinical evaluation, 278–279, 279 Spinal alignment normal conditions, 578, 578–579 revision surgery, early imbalance, 646–647 Spinal balance fusion biomechanics and, 168 revision surgery early imbalance, 646–647 flatback and sagittal late imbalance, 650 preoperative assessment, 637 principles and protocols, 640 pseudarthroses, 644–645 Spinal canal injury, adult spine, 415, 417–418 myeolgraphic imaging, 366–369, 368–369 postnatal development, 63 spinal neoplasm encroachment, 451, 451 surgical anatomy, 22–23, 23 Spinal cord blood supply, 98, 100–101, 102 congenital/developmental abnormalities diastematomyelia and diplomyelia, 312, 312 syringomyelia, 311, 311 tethered cord, 311, 312 cross-sectional anatomy, 95–98, 97–99 gross anatomy, 94, 95, 95–96 irradiation, spinal neuroarthropathy and, 219 magnetic resonance imaging (MRI), 361–362 pathology, 102 pediatric anatomy, 730 postnatal development, 62 stimulation techniques, 140–141 Spinal cord injury (SCI) clinical definition, 302, 303 epidemiology, 302 neurologic assessment, 304–305 pediatric spine, 735 reflex assessment, 305–306 rehabilitation protocols, 387–389 contractures, 389 Index heterotopic ossification, 389 latex allergy, 389 osteopenic fracture, 389 pressure ulcers, 388 spasticity, 388–389 spinal deformation, 389 rheumatoid arthritis, indications for surgery, 427 sacral nerve roots, injury and microanatomy, 107, 108–109, 109–110, 111 scoliosis and kyphosis clinical evaluation, 281 pathology and management, 320, 321 spinal shock, 303–304 as surgical complication intraoperative injury, 804–805 pathogenesis, 615–616, 616 surgical risk of cervical spine surgical anatomy, 43, 44 thoracic spine surgical anatomy, 31 syndromes, 303 Spinal cord injury without radiologic abnormalities (SCIWORA) syndrome, pediatric patients, 730 absence of radiographic abnormality, 735 imaging studies, 731, 731 vertebral end plate fractures, 735–737, 736–737 Spinal deformation See also specific disorders, e.g Idiopathic scoliosis back pain evaluation adult differential diagnosis, 295–298 imaging studies, 287–290, 288–290 inflammatory markers, 291 laboratory studies, 290–291 patient history, 284–285 pediatric patients, differential diagnosis, 291–295, 292, 294 physical examination, 285–287, 285–287 pulmonary function testing, 291 basic correction principles geometric principles, 578–759 normal spine alignment, 578, 578–579 realignment goals and concepts, 579–580 Charcot-Marie-Tooth disease (CMTD), 313–314 clinical evaluation patient history, 267, 267 physical examination, 267–271, 267–271 congenital spinal deformation, patient evaluation history taking, 258 physical examination, 258–260, 259 pulmonary function evaluation, 263 radiologic and other imaging, 260–263, 261–265 familial dysautonomia (FD) (RileyDay syndrome), 314–315 Freidreich’s ataxia, 313 instrumentation for correction, 580–581 load application, 581–585 cantilever loads, 582–583, 583–585 translation loads, 580–582, 582 transverse plane/torsional loads, 583–585, 586 vertical loads, 579, 581 metabolic disease decision making guidelines, 761, 762 Ehlers-Danlos syndrome, 768 idiopathic juvenile osteoporosis, 767–768 Marfan’s syndrome, 761–763 mucopolysaccharidosis, 765–766 osteogenesis imperfecta, 764–765 Morquio’s syndrome, 766 myopathic disorders, 320, 322–323, 323–324 neuromuscular scoliosis cerebral palsy, 722, 724 Duchenne’s muscular dystrophy, 727 management protocols, 722, 724–727 myelodysplasia, 724–727, 726 neuropathic disorders cerebral palsy, 316–318, 317 hydrosyringomyelia, 320 management issues, 316 myelodysplasia, 318–319, 319 Rett syndrome, 320 spinal cord injury (SCI), 320, 321 osteotomy indications, 551 paralytic poliomyelitis (PPM), 307, 308 radiologic assessment, 356–358, 359–360 Chiari malformations, 364 computed tomography, 358, 360 diastematomyelia, 362, 363 851 magnetic resonance imaging (MRI), 358, 361–362 scoliosis/stenosis, 364, 364–367, 366 syringomyelia, 362–364, 364 tethered cord pathology, 362, 362 respiratory function modification and, 131 respiratory history and examination, 132–133, 133 rigidity of, revision surgery considerations, 640–641 sacropelvic fixation biomechanics, 606–609, 608–609 clinical failures and solutions, 602 complications, 609 fixation zones, 602–606, 602–608 zone I case study, 609, 610, 612 zone II case study, 611, 612–613 zone III case study, 612, 613 historical background, 601 surgical anatomy, 601–602 spinal cord injury (SCI), 389 spinal muscular atrophy (SMA), 308 surgical management neurologic injury as complication, pathogenesis, 616, 616 patient positioning criteria, 484, 485 Spinal development altered development, 54–55 deformation, 55 disruption, 54–55 malformation, 54 bone formation patterns, 55–57 endochondral bone formation, 56, 56–57, 58 membranous bone formation, 55–56 embryogenesis, 57–62 atlas and axis formation, 60 chondrification, 61, 61 mesoderm formation (gastrulation), 57 neural arch formation, 60–61 neural crest differentiation, 58–59 neural tube maturation, 59 neurulation and tube closure, 58, 59 notochord formation/induction, 57–58 ossification, 61–62, 63 paraxial mesoderm formation, 59 somite formation, 59–60, 61 general concepts, 54 growth mechanisms, 64–66 growth cessation, 65–66 852 Index Spinal development (Continued) growth slowdown lines, 65 ‘‘ring’’ apophysis, 65 vertebral growth, 64–65 postnatal development, 62–64 C1 (atlas), 63–64 C2 (axis), 64 canal growth, 63 cord growth, 62 neurocentral synchondroses, 62–63 radiographic imaging, 350–351, 351 vasculature growth, 66 Spinal disorders common medications corticosteroids, 207 COX-2 inhibitors, 207 disease modifying antirheumatic drugs (DMARDs), 207 nonsteroidal anti-inflammatory drugs (NSAIDs), 206 pediatric patients infectious disorders, 696–699 diskitis and vertebral osteomyelitis, 696–697 fungal infections, 699 tuberculosis, 697–699 inflammatory disorders, 694–696 back pain evaluation, spinal deformities, 293 juvenile rheumatoid arthritis, 694 nonorganic back pain, 695–696 spondyloarthropathies, 694, 695 systemic lupus erythematosus, 694–695 Spinal fusion anterior approaches, 544 bed preparation, 119 biological factors in, 540–544 blood supply, 540–543, 541–542 decortication, 543–544 healing mechanisms, 543 biomechanics, 168–172 bone formation, 118 bone grafting, 118–119 allografts, 546–548 autografts, 545–546 biologic factors, 544–545 vascularized rib graft, 548 cervical decompression procedures, 525 cervical spine injuries, 414, 414 congenital scoliosis, surgical management, 688–691, 689–690 degenerative disk disease and spondylolithesis, 399–400, 400 degenerative lumbar stenosis, 393 Down syndrome patients, 706, 707 Duchenne muscular dystrophy (DMD), 323–324 Ehlers-Danlos syndrome, 702–703 electrical stimulation and, 119 Friedreich’s ataxia, 313 idiopathic scoliosis, staging and indications, 566 intraoperative halo femoral traction, 488, 491, 493 lumbar spinal stenosis, surgical indications, 532, 532 Marfan’s syndrome, 701 indications for, 763 neurofibromatosis-1, 705 neuromuscular scoliosis, 719–722, 721–722 anterior instrumentation, 722, 723 anterior spinal release and fusion, 720, 722 intraoperative monitoring, 722 myelodysplasia and, 725 pelvic and sacral fixation, 720, 721 posterior instrumentation, 720 preoperative assessment, 719–720 nicotine and, 119 nonsteroidal anti-inflammatory drugs (NSAIDs), pharmacologic effects, 206 paralytic poliomyelitis, 307 posterior spinal fixation and fusion, cervical spine, 503–504 revision surgery adolescent patients, 644 adult patients, 644–645, 645 principles and protocols, 640 rheumatoid arthritis Brooks fusion technique, 429 occipital-cervical arthrodesis, 431 occipital cervical fusion, 429, 431 posterior cervical fusion, 433 Scheuerman’s kyphosis, 782 spinal muscular atrophy (SMA), 308–309 spinal neuroarthropathy treatment, 219, 220 spondylolisthesis high-grade conditions, adult patients, 795–796 high-grade conditions, pediatric patients, 792–794, 795 low-grade conditions, pediatric patients, 792, 793 thorascopic surgery, 571–572, 572–573 transoral technique, 497 vascularized rib grafts, 548 Spinal injury See also Spinal cord injury (SCI) therapeutic exercise and physical therapy and, 384–385 trauma adult spine classification systems, 408–409, 409–410 clinical/neurologic evaluation, 406–407 fracture classification, 413–421, 414–420 radiographic assessment, 407–408, 407–408 spinal cord injury (SCI), pharmacologic treatment, 409–410 therapeutic injuries, 410–413, 411–413 pediatric spine anatomic differences, 730 cervical spine, 731–732, 732 child abuse fractures, 737–738 clinical presentation, 730–731 management strategies, 739–740 prevention strategies, 740 radiographic imaging, 731, 731 spinal cord injury (SCI), 735 spondylolysis, 738–739, 739 thoracolumbar spine fractures, 732–735 vertebral end plate fractures, 735–737, 736–737 Spinal instability pyogenic spinal infection and, 227–228 skeletal dysplasias, pediatric patients, 709–710 spinal injury, adult spine, 410–413, 411–413 White/Panjabin instability criteria, 416, 419 Spinal instrumentation See Instrumentation Spinal ligaments anterior longitudinal ligament (ALL), anatomy, 46, 47 associated fascia, 47, 48 capsular ligaments, anatomy, 46, 47 interspinous ligaments, anatomy, 47, 4647 intertransverse ligaments, anatomy, 46, 47 ligamentum flavum, anatomy, 46, 47 Index postterior longitudinal ligament (PLL), anatomy, 46, 47 supraspinous ligament, anatomy, 47, 47 Spinal muscular atrophy (SMA) neuromuscular scoliosis, preoperative assessment, 720 pathophysiology, 307–309, 309 spinal deformation pathology and management, 322–323, 324 scoliosis and kyphosis, clinical evaluation, 279, 279–280 Spinal musculature anterior musculature anatomy, 50–52, 51 extrinsic muscles, 52 longus capitis, 51–52 longus colli, 50–51 psoas muscles, 52 quadratus lumborum, 52 posterior musculature anatomy, 48–49, 50–51 erector spinae (sacrospinalis), anatomy, 49, 50 segmental muscles, anatomy, 49 spinotransversalis, anatomy, 49, 50 transversospinalis muscles, anatomy, 49, 51 Spinal neuroarthropathy diagnosis, 219 etiology, 218–219, 219 incidence, 218 pathogenesis, 219 treatment, 219, 220 Spinal rhythm assessment, spinal deformity, clinical evaluation, 269–270 Spinal shock clinical definition and etiology, 303–304 trauma, adult spine, clinical/ neurologic evaluation, 406–407 Spinal stenosis achondroplasia, 711–712 lumbar spine, decompression procedures anesthesia protocols, 533–534 clinical presentation, 528 combined techniques, 536–537, 537 complications, 537–538 fusion and, 532, 532 imaging studies, 528, 529 indications for surgery, 533 laminectomy, 534–535 lateral recess anatomy, 529–530 limited decompression, 535 microscopic laminoplasty, 535–536, 536–537 microsurgical techniques, 535–538 pars interarticularis anatomy, 529, 530 pathophysiology, 531–532 patient positioning, 533, 533 plain X-ray localization, 534, 534 three-floor spine concept, 530– 531, 530–531 treadmill-bicycle functional testing, 529 spinal canal, postnatal development, 63 Spinal structure, biomechanics instantaneous axis of rotation (IAR), 158, 158–159 stresses and forces, 154–159, 155–157 application of proce, 157 force coupling, 157 Spinal testing coordinate system, 173, 176 data acquisition, 184–185 destabilization, 179 fatigue testing, 183–184 ultra high molecular weight polyethylene (UHMWPE) models, 184 fixation procedures, 179 loading, 176–177, 177 specimen preparation, 177–179, 178– 179 stability testing, 180–182 strength testing, 182–183, 183 Spinal tumors See Neoplasms of the spine Spinotransversalis, anatomy, 49, 50 Spinous process surgical anatomy, 21 thoracic spine internal fixation anatomy, 27, 29 surgical anatomy, 25–26 Spirometry, respiratory function testing, 131, 131 Splenic disorders, hemostasis abnormalities, spinal surgery and, 238 Spondyloarthropathies Marfan’s syndrome, 701 pediatric patients, 694, 695 Spondyloepiphyseal dysplasia (SED) congenita, tarda, pathophysiology and management, 713–714, 714 853 Spondylolisthesis bone scan imaging of, 371, 372 classification, 787–788, 788 degenerative lumbar spondylolisthesis, 531–532 Ehlers-Danlos syndrome, 702–703 high-grade spondylolisthesis, adult patients, 796–797, 797 L5-S1 facets, surgical anatomy, 3, low-grade spondylolisthesis adult patients, 794–796 pediatric patients, 792, 793 Marfan’s syndrome, 701 natural history and progression, 788–791, 789–790 nonoperative management, 791 osteogenesis imperfecta (OI), 764 pediatric spinal patients back pain evaluation, spinal deformities, 293 high-grade spondylolisthesis, 792–794, 795 low-grade spondylolisthesis, 792, 793 radiographic imaging, 365, 366 Scheuerman’s kyphosis, 778 spinal fusion for, 399–401, 400, 402– 404 surgical management indications for, 791 patient positioning, 484, 484–485 Spondylolysis bone scan imaging of, 373, 373 classification, 787–788, 788 natural history and progression, 788–791, 789–790 nonoperative therapy, 791 osteogenesis imperfecta (OI), 764 pediatric spine back pain evaluation, spinal deformities, 293 traumatic injury, 738–739, 739 surgical management, patient positioning, 484 surgical procedures indications for, 791 pars repair, 791–792 Spondyloptosis, high-grade spondylolisthesis and, 796–797, 797 Spontaneous electromyography (EMG), protocols for, 143–144, 144 Sprengel’s deformity, congenital scoliosis, 684 Stability testing, protocols for, 180–182 854 Index Stable spinal injuries, adult spine, therapeutic management, 411 Staphylococcus aureus bacteriology, 222 osteomyelitis epidemiology, 222 postoperative wound infection diagnosis, 627 vertebral osteomyelitis epidemiology, 445–446 Staple insertion L5-S1 facets, surgical anatomy, 3, 4–6 thoracic spine, vertebral body anatomy, 31 Stenosis, degenerative lumbar stenosis, surgical management clinical indications for, 392–393 postoperative procedures, 394 principles of, 393 research background, 392 techniques and protocols, 393–394 Sternum-splitting surgical technique, thoracolumbar spine, 507–508 Steroids bone remodeling, 117 metastatic spinal disease, therapy using, 252–253 Steroids, spinal disease management, 207 Stickler syndrome, pediatric patients, 715 Stiffness sacropelvic fixation, maximum stiffness at failure, 606, 607 spinal biomechanics, 154–156, 155–156 derotation control and prevention, 162, 162–163 spinal stability testing, 180–182 Strain gauge, spinal testing modalities, 184–185 Strain measurements spinal biomechanics, 154–159, 155–157 spinal testing modalities, 185 Strength testing, protocols for, 182–183, 183 Stress analysis spinal biomechanics, 154–159, 155–157 spinal testing modalities, 185 Stretch test, cranial traction, GardnerWells tongs, 493–494 Subarachnoid space (SAS), cerebral spinal fluid (CSF) circulation, 149–150 Subaxial cervical injury, pediatric spine, 732, 732 Subaxial subluxation, rheumatoid arthritis (RA), 424 surgical management, 433 Subaxial vertebra, cervical spine internal fixation anatomy, 42–43 surgical anatomy, 35–36, 40–41 Sublaminar decompression lumbar spinal stenosis, 535 neurologic injury risk, 618 Superficial anal reflex, spinal cord injury (SCI), 306 Superior gluteal neurovascular bundle, bone harvesting and risk to, 11, 12 Superior mesenteric artery (SMA) syndrome, as postoperative complication, 630–632, 631 Superior nuchal line, cervical spine, surgical anatomy, occipital condyles and skull base, 33, 34 Super laryngeal nerve, cervical spine surgery and injury to, 497 Supine position, spinal surgery, 481, 483 Supraspinous ligaments, anatomy, 47, 47 Surfactant, respiratory function and, 127, 128 Surgical procedures anesthesia intraoperative monitoring, 331–339 blood replacement techniques, 334–337 acute normovolemic hemodilution (ANH), 334–335 autologous predonation, 336–337 cell salvage, 336 controlled hypotension, 335–336 neurological monitoring, 337–339 patient positioning, 331–334 cervical position, 334 lateral position, 333–334 prone position, 331–333 malignant hyperthermia, 342–343 pediatric patients, 339–341 cardiopulmonary disease, 339–340, 340–341 laboratory assessment, 341–342 patient evaluation, 340–341 postoperative management, 339 preoperative preparations, 328–331 cardiovascular system, 328–330, 330 pulmonary system, 330–331 ankylosing spondylitis cervical osteotomy, 435–437, 436, 438 alternative technique, 437, 438 lumbar osteotomy, 437–439, 440 anterior approaches cervical decompression four-level disease, 525 instrumentation criteria, 525–526 plating procedures, 526 three-level disease, 525 two-level disk disease, 525 cervical spine, 497–501 cervicothoracic approach, 504, 504 combined approaches, 501 extrapharyngeal approach, 497–498, 500 retropharyngeal approaches, 498–501, 502 retrosternocleidomastoid approach, 498 transoral technique, 497, 498–499 complications, 566 intraoperative complications, 801–803 degenerative spondylolisthesis and disk disease, interbody fusion, 401, 402–404 indications for, 562 myelodysplasia management, diskectomy and arthrodesis, 319 neuromuscular scoliosis and kyphosis clinical evaluation for, 273, 275 myelodysplasia, 725 release and fusion, 720, 722, 723 osteotomies anterior releases/morselized graft, mutiple SPO following, 552, 552 posterior osteotomies, anterior structural grafting and, 552 pyogenic spinal infection, surgical management of, 228 revision surgery, 642 Scheuerman’s kyphosis, 782 spinal fusion, 544 biomechanics, 169–171 Index spinal implant biomechanics, 162, 164 spinal injury, adult spine, decompression fusion and instrumentation, 415, 417 spinal neoplasms, 458–460 spondylodesis, 794 thoracolumbar spine retroperitoneal lumbar approach, 509, 510, 511–512 retroscapular approach, 508 standard thoracotomy, 508–509, 509 sternum-spliting technique, 507–508 thoracotomy, upper thoracic spine, 508 thorascopic technique, 571–572, 572–573 vertebral osteomyelitis, 447–449, 448 antibiotic therapy, 188–193 postoperative infection, 189–190 prophylactic antibiotics, 188–189 tuberculous vertebral osteomyelitis, 191–192 vertebral osteomyelitis, 190–191 blood conservation strategies blood product risk management, 240–242, 241–242 coagulation and coagulopathy, 239–240 intraoperative and postoperative strategies, 244–246 pediatric patients, considerations for, 246 preoperative strategies, 242–244, 243 cervical decompression anterior approach four-level disease, 525 instrumentation criteria, 525– 526 plating procedures, 526 three-level disease, 525 two-level disk disease, 525 laminectomy, 517–519, 520 laminoplasty, 519–522, 521–522 posterior foraminotomy, 517, 518–519 coagulation disorders acquired abnormalities, 237–238 congenital abnormalities, 237 intraoperative bleeding, management strategies, 238 normal hemostasis, 237 preoperative evaluation, 238 combined anterior/posterior approaches cervical spine, 501 indications for, 562–563, 564–565 thoracolumbar spine, 514–515, 515 complications (See Intraoperative monitoring, spinal surgery; Postoperative complications) congenital scoliosis, 687–691, 688–690 Ehlers-Danlos syndrome, 768 endoscopic retroperitoneal approaches, 574 hyperalimentation and parenteral nutrition, 566 idiopathic juvenile osteoporosis therapy, 768 intraoperative complications bleeding complications, management strategies, 200–202, 801 cerebrospinal fluid leaks, 805 hypoxia and thoracic pressure, 802 intraoperative halo femoral traction, 488, 491, 493 mechanical complications, 802–803 missing sponges, 806 nerve root injury, 805 neurologic injury, 622–623, 804 neuromuscular scoliosis, bleeding complications, 723 posterior surgery, 803–804 spinal cord injury (SCI), 804–805 sudden hypotension without bleeding, 801–802 surgical injury, 802 tables and positioning, 485–486 wrong-level surgery, 805 intraoperative monitoring, somatosensory evoked potential (SEP) findings, 137–138 laparoscopic approaches, 574 lumbar spinal stenosis, decompression procedures anesthesia protocols, 533–534 clinical presentation, 528 combined techniques, 536–537, 537 complications, 537–538 fusion and, 532, 532 imaging studies, 528, 529 indications for surgery, 533 laminectomy, 534–535 855 lateral recess anatomy, 529–530 limited decompression, 535 microscopic laminoplasty, 535–536, 536–537 microsurgical techniques, 535–538 pars interarticularis anatomy, 529, 530 pathophysiology, 531–532 patient positioning, 533, 533 plain X-ray localization, 534, 534 three-floor spine concept, 530–531, 530–531 treadmill-bicycle functional testing, 529 Marfan’s syndrome, 763 metastatic spinal disease, 253–255 mini-open approaches, 574, 576 mucopolysaccharidoses, 766 neoplasms of the spine, adult patients, 456–461 metastatic tumors, 457–460 primary tumors, 460–461 neurologic injury complications animal studies of instrumentation, 618 avoidance strategies, 617, 622 etology of, 620–621, 621 Harrington distraction instrumentation, 617, 617 Harrington hybrids for segmental fixation, 617–618 historical review, 615 intraoperative monitoring, 622–623 laminotomy, 617–618, 618 management strategies for, 623–624 pathogenesis, 615–616, 616 pedicle screw instrumentation, 621–622 posterior derotation systems, 619–620, 620 preoperative assessment, 616–617 risk factors, 617 safety guidelines, 622 wire contouring and, 619, 619 neuromuscular scoliosis, 719–722, 721–723 osteogenesis imperfecta, 765 osteotomies anterior releases/morselized graft, with multiple Smith-Petersen osteotomy (SPO), 552, 552 combined sagittal/coronal imbalance, 557, 557, 560 complications, 555, 557 856 Index Surgical procedures (Continued) decompensation, 557 deformity classification, 551 fixed kyphosis, 551 indications for, 566 lordosis calculations, 553 multiple Smith-Petersen osteotomy (SPO), 551–552 outcomes, 557 patient recovery, 555 pedicle subtraction vs multiple Smith-Petersen osteotomy (SPO), 552–553 pedicle/vertebral subtraction osteotomy, 553–555, 553–556 posterior osteotomies, anterior structural grafting, 552 Smith-Peterson techniques, 553, 553 pediatric spinal injury, 740 perioperative blood loss, pharmacologic minimization aprotinin, 201 blood volume enhancers, 202–203 epsilon-aminocaproic acid (Amicar), 200–201 research background, 200 topical hemostatic agents, 201–202 posterior approaches cervical decompression, posterior foraminotomy, 517, 518–519 cervical spine, 501, 503–504 C1-C2 transarticular screw fixation, 503 occipitocervical fixation, 503–504 complications, 566 intraoperative monitoring, 803–804 degenerative spondylolisthesis and disk disease, interbody fusion, 401, 402–404 indications for, 562 neurologic injury risk, 619–620, 620 neuromuscular scoliosis and kyphosis clinical evaluation for, 273, 275 instrumentation and fusion, 720, 721 myelodysplasia, 725 osteotomies, anterior structural grafting and, 552 revision surgery, 642 rheumatoid arthritis (RA), cervical fusion, 433 Scheuerman’s kyphosis, 782 spinal fusion biomechanics, 170–171 spinal neoplasms, 458–460 spondylolisthesis, 794 thoracolumbar spine costotransversectomy, 506–507, 507 extended bilateral costotransversectomy, 507 midline procedures, 506 paraspinal muscle splitting, 506 vertebral osteomyelitis, 447, 449 postoperative complications anterior approaches, 566 dental prophylaxis in spinal instrumentation patients, 629 superior mesenteric artery (SMA) syndrome, 630–632 syndrome of inappropriate antidiuretic hormone secretion (SIADH), 629–630 wound infections, 626–629 delayed deep wound infection, 628–629 early infection, incidence and management, 626–628 epidural abscess, 629 resectioning, hemivertebral resection, 558–559, 560 revision surgery adolescents and young adults, 639 complications, 650–651 computed tomography assessment, 637–638 crankshaft phenomenon, 648 decompensation and add-on phenomenon, 647–648 diagnosis, 638–639 early imbalance, 646=657 flatback and sagittal imbalance issues, 650 fusion problems, pseudarthroses, 644–645 indications for, 634 initial assessment, 634–638 instrumentation failure, 647 junctional failure, 648–650 magnetic resonance imaging, 638 management strategies, 639–641 myelographic evaluation, 637 patient history, 634–635 patient selection criteria, 651 pediatric patients, 638–639 physical examination, 635–636 radiographic imaging, 636, 636–637 recurrent back and leg pain, 647 sequential, staged, and simultaneous approaches, 642–644 spinal balance, 637 wound infection, 645–646 rheumatoid arthritis (RA), 427–433 atlantoaxial instability, 427 Brooks fusion, 429 clinical outcomes, 433–434 Gallie-type wiring plus bone graft, 427–429, 428 lateral mass plating, 433, 434 occipital-cervical arthrodesis, 431 occipital cervical fusion, 429, 431 occipitocervial plating, 431–432, 432 odontoid resection, 432–433 posterior cervical fusion, 433 subaxial subluxation, 433 transarticular C1-C2 screws, 429, 430 sacropelvic fixation, in spinal deformation biomechanics, 606–609, 608–609 clinical failures and solutions, 602 complications, 609 fixation zones, 602–606, 602–608 zone I case study, 609, 610, 612 zone II case study, 611, 612–613 zone III case study, 612, 613 historical background, 601 surgical anatomy, 601–602 Scheuerman’s kyphosis, 779–785, 783–785 spinal fusion anterior approaches, 544 bed preparation, 119 biological factors in, 540–544 blood supply, 540–543, 541–542 decortication, 543–544 healing mechanisms, 543 biomechanics, 168–172 bone formation, 118 bone grafting, 118–119 allografts, 546–548 autografts, 545–546 biologic factors, 544–545 vascularized rib graft, 548 cervical decompression procedures, 525 cervical spine injuries, 414, 414 degenerative disk disease and spondylolithesis, 399–400, 400 Index degenerative lumbar stenosis, 393 Duchenne muscular dystrophy (DMD), 323–324 electrical stimulation and, 119 Friedreich’s ataxia, 313 historical perspective, 540 idiopathic scoliosis, 566 intraoperative halo femoral traction, 488, 491, 493 lumbar spinal stenosis, surgical indications, 532, 532 nicotine and, 119 nonsteroidal anti-inflammatory drugs (NSAIDs), pharmacologic effects, 206 paralytic poliomyelitis, 307 posterior spinal fixation and fusion, cervical spine, 503–504 rheumatoid arthritis Brooks fusion technique, 429 occipital-cervical arthrodesis, 431 occipital cervical fusion, 429, 431 posterior cervical fusion, 433 spinal muscular atrophy (SMA), 308–309 spinal neuroarthropathy treatment, 219, 220 transoral technique, 497 vascularized rib grafts, 548 spondylolisthesis, 791–792 spondyloptosis and, 796–797, 797 staging protocols complications, 562–566 revision surgery, 642 tables and positioning Andrews table, 479 complications, 485–486 data on effects of, 480–481, 481– 482 four-poster frame, 479 Jackson table, 480 lateral decubitus position, 482, 483 prone position general principles, 478 genupectoral position, 479–480, 480 knee chest position, 478–480, 479 Relton-Hall frame, 479 sagittal alignment, 480–481, 481 selection criteria for, 483–485 supine position, 481, 483 Wilson frame, 479 thoracoabdominal approach, 511–512, 512 paramedian lumbar approach, 514, 514 transperitoneal approach, 512–513, 513 thoracolumbar spine anterior approaches retroperitoneal lumbar approach, 509, 510, 511–512 retroscapular approach, 508 standard thoracotomy, 508–509, 509 sternum-spliting technique, 507–508 thoracotomy, upper thoracic spine, 508 combined anterior/posterior approaches, 514–515, 515 posterior approaches costotransversectomy, 506–507, 507 extended bilateral costotransversectomy, 507 midline procedures, 506 paraspinal muscle splitting, 506 thoracoplasty, 568–569, 569 thorascopic approaches, 571–574, 572–575 vertebral osteomyelitis, 447–449, 448 wound infection management with, 627–628 Synaptic physiology, nerve cells, 122–123, 123 Syndrome of inappropriate antidiuretic hormone (SIADH) secretion low urine output, 807 as postoperative complication, 629–630 Syphilis, spinal neuroarthropathy and, 218–219 Syringohydromyelia, radiographic imaging, 363–364 Syringomyelia hydrosyringomyelia, pathology and management, 320 pathophysiology, 311, 311 radiographic imaging, 362–364, 364 spinal neuroarthropathy and, 218 Syrinx formation brain stem pathology, 95 idiopathic scoliosis etiology, 662 spinal cord pathology, 102 syringomyelia, 311, 311 Systemic lupus erythematosus, pediatric patients, 694 857 Tabes dorsalis, spinal neuroarthropathy and, 218–219 Tacoma block, sacropelvic fixation, 603, 604 Tacoma plates, sacral anatomy, fixation using, Tanner stages congenital spinal deformation, 260 idiopathic scoliosis, pediatric patients, 672–673, 673–674 Technetium-99 bone scanning back pain evaluation, spinal deformities, 288, 289 clinical applications, 371, 372–373, 373–374 metastatic spinal disease, 250–251, 252 neoplasms of the spine adult patients, 453, 453 pediatric patients, 743 osteoid osteoma, 744, 745 radiographic techniques for, 371, 372–373, 373–374 revision surgery, preoperative assessment, 638 spinal injury pediatric patients, 731 trauma, adult spine, 407–408 Tethered cord deformity, 311, 312 myelodysplasia, 319 radiographic imaging, 362, 362 Thermoelastic stress measurement, spinal testing modalities, 185 ‘‘Third condyle,’’ cervical spine, surgical anatomy, 33, 34 Thoracic nerve roots microanatomy, 104, 108–109 pathology, 111 Thoracic pressure, as intraoperative complication, 802 Thoracic spine See also Thoracolumbar spine curvature plain radiography, 353, 354–355 spinal implant biomechanics, anterior correction and instrumentation, 162, 164 metastatic disease biopsy protocols, 252 surgical management, 254–255 skeletal dysplasia, 709–710 stability testing, 180–181 strength testing, 182 surgical anatomy, 25–32, 26–27 blood vessels, risk assessment, 32 costovertebral joints, 26, 30 858 Index Thoracic spine See also Thoracolumbar spine (Continued) facet joints, 25 internal fixation, 27–31 lamina and spinous processes, 27, 29 pedicles, 29–31, 31 transverse processes, 27 vertebral bodies, 31 lamina and spinous processes, 25–26 nerve roots, risk assessment, 31–32 pedicles, 25, 28–29 spinal cord, risk assessment, 31 transverse processes, 25 vertebral bodies, 25 Thoracoabdominal surgical technique, thoracolumbar spine, 511–513, 512–514 paramedian lumbar approach, 514, 514 transperitoneal approach, 512–513, 513 Thoracolumbar spine achondroplasia, kyphosis, 710–711, 711 fatigue testing, 184 scoliosis, clinical evaluation, 272, 273 skeletal dysplasia, 709–710 spinal cord injury (SCI), 303 spondyloepiphyseal dysplasia (SED) congenita, tarda, 713–714 stability testing, 181 strength testing, 182 surgical approaches anterior surgical techniques, 507–512 retroperitoneal lumbar approach, 509–512, 510–511 retroscapular approach, 508 standard thoracotomy, 508–509, 509 sternum-splitting approach, 507–508 upper thoracic spine thoracotomy, 508 combined anterior/posterior approaches, 514–515, 515 patient positioning, 479, 483–484 posterior surgical techniques, 506–507 costotransversectomy, 506–507, 507 extended bilateral costotransversectomy, 507 midline technique, 506 paraspinous muscle splitting, 506 thoracoabdominal approach, 512–513, 512–514 paramedian lumbar approach, 514, 514 transperitoneal approach, 512–513, 513–514 traumatic injury adult spine, 417–420, 420 pediatric spine, 732–735, 733–734 Thoracolumbosacral orthoses (TLSOs) idiopathic juvenile osteoporosis therapy, 767 idiopathic scoliosis indications and recommendations, 757–758 results, 757 neuromuscular scoliosis, 758 rehabilitation using, 386–387 traumatic injury, adult spine, 420–421 Thoraco-phreno-laparotomy, revision surgery, 642 Thoracoplasty technique external technique, 568 internal technique, 568–569, 569 rib prominence, 568 ‘‘Thoracospinal concept,’’ idiopathic scoliosis etiology, 663–664 Thoracotomy retroperitoneal lumbar surgical technique combined with, 511, 512 thoracolumbar spine, standard approach, 508–509, 509 upper thoracic spine, 508 Thorascopic surgical technique anesthesia, 571 general principles, 571 lung retraction, 571, 572 patient positioning, 571 portal location, 571, 572 Three-floor spine concept, lateral spinal stenosis, surgical assessment, 530–531, 530–532 Thrombocyte abnormalities, idiopathic scoliosis etiology, 658–661, 659–661 Thromboembolic complications, postoperative period, 807 Thrombotic agents, intraoperative bleeding and, 772 Thyroid hormones, bone remodeling, 117 Titanium rods, spinal implant mechanics, moment of inertia, 164–166, 165 ‘‘Toggle testing,’’ thoracic spine, vertebral body anatomy, 31 Topical hemostatic agents, spinal surgery, perioperative bleeding management, 201–202 Torsional loading intervertebral disk biomechanics, 173 spinal deformation, 583–585, 586 Torticollis, spinal injury, adult spine, 414, 415 ‘‘Total en bloc spondylectomy’’ (TES), spinal neoplasms, surgical management of, 460–461 Total lung capacity (TLC) pulmonary function testing, 131 spinal deformity and modification of, 131 Trabeculae bone, microscopic organization, 72 surgical anatomy, 6, Trachea, functional anatomy, 126–127, 127 Traction techniques Gardner-Wells tongs, 493–494, 493–494 gravity traction, 489, 490–492 idiopathic scoliosis, 755 intraoperative halo femoral traction, 491, 493 Mayfield tongs, 494–495, 494–496 Train patterns, spontaneous electromyography (EMG), 144, 145 Tranexamic acid, intraoperative bleeding management, 772 Transarticular C1-C2 screws posterior spinal fixation and fusion, cervical spine, 503 rheumatoid arthritis occipitocervical plating, 431–432, 432 surgical technique, 429, 430, 431 Transcranial electrical stimulation (TES) clinical application, 139 motor evoked potentials (MEP), 138–139 operative applications, 139–140 Transcranial magnetic stimulation (TMS) electrophysiology of, 139 motor evoked potentials (MEP), 138–139 Index Transcranial motor evoked potentials (TcMEPs), spinal surgery, neurological monitoring, neurologic injury risk avoidance and, 623 Transducers, spinal testing modalities, 184 Transforming growth factor-b(TGF-b) bone remodeling, 117 degenerative disk disease, gene therapy, 214 osteoblast formation, 74 osteoclast microanatomy, 75 spinal fusion techniques, autogenous bone graft, 545–546 Transfusions blood conservation strategies for avoidance of anesthesia management, 334–337 acute normovolemic hemodilution (ANH), 334– 335 autologous predonation, 336– 337 cell salvage, 336 controlled hypotension, 335– 336 blood product risk management, 240–242, 241–242 coagulation and coagulopathy, 239–240 intraoperative and postoperative strategies, 244–246 pediatric patients, considerations for, 246 preoperative strategies, 242–244, 243 preoperative planning for, 771 spinal fusion, blood supply assessment, 540–543, 541–542 Translation loads spinal deformation, 580–582, 582 spinal development, membranous bone formation, 55–56 Transoral surgical techniques, cervical spine surgery, 497, 498–499 Transpedicular fixation neurologic injury risk and, 621–622 vertebral anchors, biomechanics, 588–589 Transperitioneal surgical technique, thoracolumbar spine, 512–513, 513 Transverse connectors (cross-links), biomechanics, 589, 590–591 Transverse load idiopathic scoliosis, orthoses biomechanics, 755–756 plane load, spinal deformation, 583–585, 586 Transverse myelitis pathophysiology, 309–310 spinal neuroarthropathy and, 218 Transverse process spinal fusion surgery, blood supply assessment, 540, 541 surgical anatomy, 21–22, 22 thoracic spine internal fixation anatomy, 27 surgical anatomy, 25 Transversospinalis, anatomy, 49, 51 Trauma adult spine classification systems, 408–409, 409–410 clinical/neurologic evaluation, 406–407 fracture classification, 413–421, 414–420 radiographic assessment, 407–408, 407–408 spinal cord injury (SCI), pharmacologic treatment, 409– 410 therapeutic injuries, 410–413, 411– 413 pediatric spine anatomic differences, 730 cervical spine, 731–732, 732 child abuse fractures, 737–738 clinical presentation, 730–731 management strategies, 739–740 prevention strategies, 740 radiographic imaging, 731, 731 spinal cord injury (SCI), 735 spondylolysis, 738–739, 739 thoracolumbar spine fractures, 732–735 vertebral end plate fractures, 735– 737, 736–737 spinal neuroarthropathy and, 218 spondylolisthesis, 787–788 Treadmill-bicycle functional testing, lumbar spinal stenosis, preoperative assessment, 528, 529 Treponema pallidum infection, spinal neuroarthropathy and, 218–219 Triggered electromyographic (EMG) monitoring, 144–146, 146 Trisomy 21 See Down syndrome Tuberculosis 859 pediatric patients, spinal disease, 697–699, 698–699 pyogenic vertebral infection, differential diagnosis, 226 tuberculous vertebral osteomyelitis, antibiotic therapy, 191–192 Tumors See Neoplasms of the spine Turbinates, functional anatomy, 128, 128 Ultimate tensile strength (UTS), spinal biomechanics, 155, 155–156 implant mechanics, 160 Ultra high molecular weight polyethylene (UHMWPE) models longitudinal rods and plates, biomechanics, 589, 592, 592–594 multisegmental posterior spinal reconstruction, 596, 597, 598 spinal testing fatigue testing, 184 strength testing, 182 Ultrasonography back pain evaluation, spinal deformities, 290 congenital spinal deformation, patient evaluation, 263, 264 Underarm braces, idiopathic scoliosis, results, 757 Unicortical screw fixation occiput, internal fixation anatomy, 37–39, 41–42 subaxial spine, 42–43 Unilateral fractures, adult spine, 415–416, 419 Unilateral hemisacralization, radiographic assessment, 355, 359 Unit rod device, neuromuscular scoliosis, fusion procedures, 720, 722 Upper airway functional anatomy, 128, 128 spinal surgery, anesthesia management and, 339 Urethritis/cervicitis, conjunctivitis/ iritis, Reiter’s syndrome and, 217 Urinary tract abnormalities, congenital spinal deformation, ultrasonographic evaluation, 263, 264 Urinary tract infection delayed deep wound infection, as postoperative complication, incidence and prevention, 628–629 preoperative assessment for, 626 860 Index Urine output, postoperative complications with, 807 Valvular heart disease, anesthesia management, spinal surgery, preoperative cardiovascular evaluation, 329–330 Valvular insufficiencies, anesthesia management, spinal surgery, preoperative cardiovascular evaluation, 329–330 Vancomycin, spinal surgery, 188–189 Variable screw placement (VSP), longitudinal rods and plates, biomechanics, 592 Vascularization cerebral spinal fluid (CSF), 149–150 intervertebral disk, microscopic anatomy, 84, 84–85 respiratory system, functional anatomy, 127–128 spinal cord, 98, 100–101, 102 spinal development and, 66 spinal fusion, blood supply assessment, 540–543, 541–542 Vascularized rib grafts, spinal fusion, 548 Vasopressin, syndrome of inappropriate antidiuretic hormone (SIADH) secretion as postoperative complication, 629–630 Ventilation/perfusion (V/Q) balance gas exchange dynamics, 130 respiratory function testing, 131 Ventilatory function gas exchange during, 129–130, 130 postoperative, in spinal deformity surgery, 132–133 Vertebrae congenital scoliosis and abnormalities of, 684 growth mechanisms, 64–65 idiopathic scoliosis etiology, 662–663 postnatal development, neurocentral synchondroses, 62–63 pyogenic infection (See also Vertebral osteomyelitis) bacteriology, 222–223 biopsy, 225 childhood diskitis/osteomyelitis, 228 definitions, 221 diagnosis, 223 differential diagnosis, 226 epidemiology, 222 epidural abscess, 231 imaging studies, 223–225, 224–225 nonoperative management, 226, 227 osteomyelitis/diskitis, 228–231, 229–230 pathophysiology and pathology, 221–222 postoperative infection management, 231–233, 232–233 prevention, 225–226 spinal instability and, 227–228 surgical management, 228 therapeutic management controversies in, 233–234 strategies for, 226–228, 227 spinal biomechanics, instantaneous axis of rotation (IAR), 158–159, 158–159 spinal injury, adult spine, 417–418 Vertebral anchors, instrumentation biomechanics, 588–589 Vertebral artery, surgical injury risk, cervical spine surgical anatomy, 44 Vertebral bodies embryogenesis neural arch formation, 60–61 ossification, 61–62 radiographic imaging, 350–351, 351 somite formation, 60 fracture classification and alignment of, 408–409, 409 growth mechanisms, 64–65 hemangioma pathophysiology, 463, 463–464 neoplasms, clinical evaluation, 451, 451 strength testing, 182, 183 thoracic spine internal fixation anatomy, 31 surgical anatomy, 25 Vertebral body line, spinal deformation analysis, 578–579 Vertebral collapse, spinal neoplasms, 451, 451 surgical management, 456 Vertebral osteomyelitis antibiotic therapy, 190–191, 192 biopsy, 446 clinical presentation, 443, 444 definitions, 443 epidemiology, 445–446 nonoperative management, 446–447 pathophysiology, 443 pediatric patients, 696–697 radiologic imaging, 444–445, 445–446 surgical management, 447–449, 448 tuberculous vertebral osteomyelitis, antibiotic therapy, 191–192 Vertebra plana, eosinophilic granuloma, pediatric spine, 746 Vertebrectomy spinal neoplasms, 461 spinal neuroarthropathy treatment, 219, 220 Vertebroplasty, spinal neoplasms, surgical management, 458–460 Video-assisted thoroscopic surgery (VATS), spinal biomechanics, yield point magnitude, rod insertion, 166 Viscoelasticity intervertebral disk biomechanics, 173–175 spinal biomechanics, 156, 156 spinal testing, stability testing, 180–182 Viscosity, spinal implant biomechanics, 160 Vitamin D bone remodeling, 117 idiopathic juvenile osteoporosis therapy, 767 osteoclast microanatomy, 75 osteoporosis prevention and treatment, 198 Von Willebrand’s disease, spinal surgery with, 237 blood conservation strategies, 239–240 Wake-up test neurologic injury risk avoidance and, 622–623 spinal surgery, anesthesia management, 338–339 ‘‘Washout theory,’’ spinal surgery, coagulation disorders and blood loss, blood product replacement, 238 WBB surgical staging system, spinal neoplasms, 456 primary tumors, 460–461 Werdnig-Hoffmann disease See Spinal muscular atrophy (SMA) Wheelchairs, rehabilitation using, 387 White blood cells (WBC) cerebral spinal fluid (CSF), 149–150 Index idiopathic juvenile osteoporosis, 767 osteomyelitis diagnosis, 223 White matter nerve root microanatomy, 102–103, 103–104 spinal cord cross-sectional anatomy, 96–98, 97–99 White/Panjabin instability criteria, spinal instability, 416, 419 Whitesides surgical technique, cervical spine surgery, upper and lower cervical spine, 501 Wilson frame, patient positioning in, 478, 479, 480 Wiring techniques neurologic injury risk animal studies, 618 avoidance strategies, 618 contouring protocols, 619, 619 rheumatoid arthritis Brooks fusion technique, 429 modified Gallie-type wiring plus bone graft, 427–429, 428 spinal neoplasms, ‘‘total en bloc spondylectomy’’ (TES), 460–461 Wolff’s law, spinal implant mechanics, load sharing/transfer, 166 Wound infection, as postoperative complication, 626–629 antibiotic therapy, 189–190 delayed deep wound infection, 628–629 early infection, incidence and management, 626–628 epidural abscess, 629 osteotomies, 555 revision surgery, 645–646 spinal fusion surgery, 543 spinal infection, 231–233, 232–233 X-ray imaging congenital spinal deformation, patient evaluation, 260, 260 lumbar spinal stenosis, surgical procedures, level localization, 534, 534 metastatic spinal disease, 250, 250–252 neoplasms of the spine, 451–455, 452–456 osteomyelitis diagnosis, 224, 224–225 861 radiation hazards, 351–353, 352 revision surgery, preoperative assessment, 636–637 spinal injury, trauma, adult spine, 407, 408 spondylolisthesis, 790 Yaws, spinal neuroarthropathy and, 219 Yield point spinal biomechanics, 154–155, 155 rod insertion, 166, 166–167 spinal implant biomechanics, plasticity, 159, 159–160 Young’s modulus, spinal biomechanics, 154–155 Zindrick morphometric measurements, pedicle fixation, lumbar spine surgical anatomy, 16–18, 19 Zone of injury concept, spinal cord injury (SCI), 302 Zone of partial preservation (ZPP), spinal cord injury (SCI), 302 Zygapophyseal joints, surgical anatomy, 15–16, 21, 23