Norbert Boos · Max Aebi (Editors) Spinal Disorders Fundamentals Of

Norbert Boos · Max Aebi (Editors) Spinal Disorders Fundamentals of Diagnosis and Treatment Norbert Boos · Max Aebi (Editors) Spinal Disorders Fundamentals of Diagnosis and Treatment

With 274 Figures in 1290 Parts and 190 Tables Prof. Dr. Norbert Boos Zentrum für Wirbelsäulen- und Rückenmarkchirurgie Universität Zürich Universitätsklinik Balgrist Forchstraße 340, 8008 Zürich Switzerland Prof. Dr. Max Aebi Institut für Evaluative Forschung in Orthopädischer Chirurgie MEM Forschungszentrum, Universität Bern Stauffacherstraße 78, 3014 Bern Switzerland

ISBN 978-3-540-40511-5 Springer-Verlag Berlin Heidelberg New York

Library of Congress Control Number: 2006927571 ˇ 2008 Springer-Verlag Berlin Heidelberg This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable to prosecution under the German Copyright Law. Printed in Germany The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from therelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar, Spain Illustrations: Alain Blank, Zürich, Switzerland Printed on acid-free paper 987654321 springer.com Dedication

ToChrista, Anna, Lisa and Sarah N.B. ToChristine, Eva and Samuel M.A. For their love, understanding, encouragement and tolerance, without which this book would not have been possible VII Foreword

Form Follows Function Congratulations to the editors and authors on a truly outstanding book. Most books recapitulate what many already know, and leave one seeking more. This book is unique in its content and format. “Form follows function”, popularized by the great American architect Frank Lloyd Wright, is a principle associated with modern architecture and industrial design in the 20th century. Simply stated, the shape of a building or object should be predicated by or based upon its intended function or purpose. Like this phrase there is often a history that is important to recognize and understand if we are to truly understand its meaning. The origin of the phrase “Form follows function” can be traced back to the American sculptor Horatio Greenough, but it was American architectural giant Louis Sullivan who adopted it and made it famous. Sullivan actually said, “form ever follows function”, but the simpler (and less emphatic) phrase is the one usually remembered. Sullivan’s student and assistant Frank Lloyd Wright adopted this principle in slightly different form – perhaps because shaking off the old styles gave them more freedom and latitude. Drs. Boos and Aebi have adopted a particular form, in this book, in order to give the reader a thorough grounding in the basic knowledge and general principles of spinal disorders. The didactic concept (form) of all the chapters is based on a consistent style and layout, and follows three basic principles of sustainable learning (functions), i.e.: (1) less is more, (2) repetition enhances sustained learning, and (3) case studies are an efficient and complementary means of learning. The book utilizes learning aids to highlight and repeat core messages throughout all chapters, and visual aids facilitate a repetition-based learning approach, starting with the core messages, leading to an in-depth reading of each chapter. Marginal notes allow for effective repetition of material to facilitate the learning process, and outstanding graphics with pictorial and anecdotal learning methods are used to complement the many detailed case studies to exemplify the core messages. Finally, the use of important references and landmark articles makes this a prized book for everyone’s shelf. Congratulations to Norbert and Max on a fantastic contribution. This book will help those most in need, our patients. “Form and function” are the most important outcomes of this work, especially for those of us who work everyday to care for people with these various spinal disorders. Thank you. James N. Weinstein Director, The Dartmouth Institute for Health Policy and Clinical Practice Professor & Chairman, The Department of Orthopaedics Editor-in-Chief – Spine Dartmouth College and Medical School Dartmouth Hitchcock Medical Center Lebanon, New Hampshire, USA IX Foreword

Dinosaur or State of the Art? Long ago, medical observations, advances, innovations and reviews were first presented at meetings and published in books. With the introduction of scientific medical journals, two things happened. First publication time was cut down dra- maticallycomparedtobooksanddisseminationofknowledgebecamefaster. Secondly a new approach to scientific publication was introduced in the form of peer review. This again lengthened publication time, yet benefited quality. Some argued that scientific journals would herald the slow death of books. History proved them wrong. The advent of the internet again mixed up all the cards. Would scientific journals survive the internet? Initially the peer review aspect was lost and the quality of available knowledge suffered. Yet, sites like Wikipedia introduced the very concept of peer review online. So, would the internet kill peer review journals let alone books? Well, here again history demonstrates that both journals and books remain alive and well. This book on spinal disorders edited by Norbert Boos and Max Aebi is a typical example of the kind of textbook anybody involved with matters regarding the spine wants on her or his desk. Moreover, this work is unique because it is not a classic multi-author textbook. The editors have approached chapter authors with whom they personally collaborated and share a common philosophy on the diagnosis and treatment approach to spinal disorders. By an intensive editing process, the different chapters have been woven into a homogeneous book combin- ing personal experience with evidence based knowledge. Editors of scientific journals know that so-called “review articles” are very popular, more referenced than other articles and thus excellent for boosting a journal’s Impact Factor. Well, this book consists of a succession of reviews bring- ing us a real “state of the art” regarding the spine but put into perspective through personal experience. This work is truly pluri-disciplinary and reflects the complex and difficult nature of the human spine. Among the authors we find clini- ciansaswellasscientists. The editors tackle every aspect of the spine in a well balanced way. No topic is superfluous or perceived as more important than another and the book reads as one continuous flow, one topic logically leading to the next. This book can be recommended to anyone involved in clinical or research aspects of the spine. It simply has to lie on the desk of doctors, scientists, physiotherapists and chiropractors, psychologists and health-care specialists interested in the spine. Robert Gunzburg President 2007–2008 EuroSpine, the Spine Society of Europe Cavell Spine Center Brussels, Belgium XI Preface

Spinal disorders are among the most common medical conditions, having a significant impact on health-related quality of life, use of health care resources and socioeconomic costs. As a therapeutic measure, spinal surgery is still one of the most rapidly growing areas in clinical medicine, and is a major contributor to the continuously increasing costs of modern-day medicine. Similarly, the increas- ingly aging population will have a greater need for the treatment of degenerative spinal disorders, particularly secondary spinal deformities and stenosis. How- ever, at the same time limited health care resources will mean difficult choices in the allocation of treatment modalities. Therefore, a basic knowledge of the state of the art of the diagnosis and treatment of spinal disorders is required, not only for spine specialists but also for general orthopedic surgeons, rheumatologists, neurologists, rehabilitation doctors, psychiatrists, chiropractors, physiotherapists, basic scientists and health care executives, to enable them to choose and/or evaluate appropriate diagnostic and therapeutic approaches. Owing to the rapid development of knowledge of spinal disorders over the past 20 years, a comprehensive new textbook which incorporates all the latest knowledge has become necessary, and we have become aware again and again of innumerable residents, fellows and colleagues searching for a comprehensive introductory learning tool for the study of spinal disorders. Although excellent textbooks on specific issues of the spine and specifically spinal surgery are already available, none fulfills the criterion of being an easily readable teaching tool that focuses systematically on the fundamentals and basic principles in a standardized manner. Strongly encouraged by our residents and fellows, we have designed a textbook on spinal disorders which is an integration of the evidence- based knowledge in the up-to-date literature and our decade-long personal experience at the source of research and treatment of spinal disorders. With Springer, we found a dedicated publisher willing to give our book project strong support, and with carefully selected chapter authors we have hopefully succeeded in creating a consistent message throughout the book. Unlike many other spinal textbooks, the editors did not want simply to collect and edit chapters from many different authors, which often leads to an inhomogeneous book with overlapping, redundant and incoherent chapters. We rather aimed to provide a homogeneous syllabus with a consistent didactic strategy to teach the fundamentals and general principles. Althoughwehavebasedtheinformationinthisbookonanextensivesurvey of the peer-reviewed literature, we have moderated this information in a synthe- sis with research and clinical experience. We have, however, refrained specifically from an in-depth description of sophisticated surgical procedures. For this field of expertise, there are already a number of excellent manuals and textbooks available. Althoughwerecognizethedifficultyandchallengeofourtask,wefeelthatwe have fulfilled our goal by choosing authors with whom we have collaborated for a long time and who concur with our own philosophy. The didactic concept is XII Preface

presented in every single chapter in a consistent manner and is based on three principles: 1. Less is more when concisely written 2. Repetition enhances sustained learning 3. Case studies are an invaluable means of exemplifying important principles We hope that we have met our objective in providing a modern, up-to-date and easy to read textbook on spinal disorders with an appealing layout, and that the book will inspire and stimulate the reader in the study of spinal disorders. It is our hope that this book may become the standard basic textbook for spinal disorders if you, the reader, decides to make this happen. We would like to thank all the contributing authors for their major commit- ment and hard work. We would also like to thank our students, fellows and colleagues for critically proof-reading the chapters and their constructive and encouraging feedback. We owe many thanks to Doris Stettler and Grit Gagel- mann for their support and help with the editing process. We further thank Wil- liam Shufflebotham in the UK for copy-editing the book. We also want to acknowledge the Medical Pictorial Documentation team of the University Hospi- tal Balgrist (Heidi Wylenmann, Helene Uhlmann and Christian Streng) for their invaluable help with the editorial preparation of the medical images and figures. We are particularly indebted to Alain Blank, who created the unique illustrations with his meticulous and careful attention to the anatomical and surgical details. The major book sections are separated by the paintings of Arnaldo Ricci- ardi, who perfectly understood how to transform his inspirations of spinal disorders into works of art. We also thank Springer, the publisher, and specifically Gabriele Schröder for making this book happen.

Zürich and Bern, March 2008 Norbert Boos Max Aebi Centre for Spinal Surgery MEM Research Centre for University Hospital Balgrist Orthopaedic Surgery University of Zürich University of Bern XIII Contents

1 History of Spinal Disorders Basic Science Philipp Gruber, Thomas Boeni CoreMessages...... 1 2 Biomechanics of the Spine ABriefEtymology ...... 1 Stephen Ferguson HistoricalCaseIntroduction...... 2 CoreMessages...... 41 SpinalAnatomyandPhysiology...... 4 TheHumanSpine...... 41 AnesthesiaandSupportiveTechniques...... 6 TheMotionSegment ...... 42 LaughingGas,ChloroformandCocaine..... 6 AnteriorStructures...... 42 AntisepsisandAntibiotics...... 6 PosteriorElements...... 46 DiagnosticImaging ...... 8 LigamentsoftheSpine...... 47 Scoliosis...... 8 MotionSegmentStiffness ...... 48 Pathogenesis...... 9 Muscles...... 48 Assessment ...... 9 Spinal Stability Through Muscular Activity . . 52 Non-operativeTreatment...... 11 Muscle Activity During Flexion and Extension 54 ScoliosisSurgery...... 13 Muscle Activity During Lateral Flexion and JuvenileKyphosis...... 13 Rotation...... 54 Spondylolisthesis ...... 14 SpineKinematics...... 54 AnObstetricalProblem...... 14 RangeofMotion...... 55 Surgery...... 14 Mechanical Response of the Spinal Motion BackPainandSciatica...... 15 Segment...... 55 AWrongMixtureofFluids...... 15 Clinical Instability ...... 57 DiscHerniation...... 17 Kinetics(SpinalLoading) ...... 58 HistoricalCaseStudy...... 19 StaticLoading...... 58 TheFacetSyndrome...... 21 LoadsDuringLifting...... 59 SpinalStenosis ...... 21 DynamicLoading...... 60 SpinalInfections...... 22 Recapitulation...... 61 EgyptianMummiesandSirPercivalPott .... 22 KeyArticles...... 62 Treatment...... 24 References...... 63 AnkylosingSpondylitis ...... 24 DiscoveryofaNewDisease...... 25 3 Spinal Instrumentation SpinalInjuries...... 27 Daniel Haschtmann, Stephen J. Ferguson FirstReports...... 27 CoreMessages...... 67 Spinal Injuries as a Socioeconomic Problem .. 28 GoalsofSpinalInstrumentation...... 67 TractionTableandLaminectomy...... 29 Basic Biomechanics of Spinal Instrumentation .. 69 TheAdventofInternalSpinalFixation ...... 29 Loading and Load Sharing Characteristics . . . 69 Recapitulation...... 30 PosteriorStabilizationPrinciples...... 71 Appendix:Historyofspinaldisorders...... 31 AnteriorStabilizationPrinciples...... 74 KeyArticles...... 33 AnteriorTensionBandTechnique ...... 78 References...... 34 Biomechanicsofthe“AdjacentSegment” ...... 79 Non-FusionPrinciples...... 80 DiscArthroplasty...... 80 Nucleoplasty...... 82 Posterior Dynamic Stabilization Technique . . 82 XIV Contents

Interspinous Process Distraction Technique 83 Disinhibition...... 137 Recapitulation...... 84 Endogenous and Environmental Influences KeyArticles...... 85 onPainPerception...... 137 References...... 86 ClinicalAssessmentofPain...... 138 Differentiating Inflammatory and Neuropathic 4 Age-Related Changes of the Spine Pain ...... 138 Atul Sukthankar, Andreas G. Nerlich, GeneralConceptsofPainTreatment ...... 141 Günther Paesold PharmacologicalTreatment...... 141 CoreMessages...... 91 Non-pharmacological Treatment of Spinal Epidemiology ...... 91 Pain...... 143 CaseIntroduction...... 92 BiopsychosocialInterventions ...... 143 GeneralAge-RelatedChanges...... 92 SurgicalTreatment...... 144 FunctionalSpineUnit...... 93 Recapitulation...... 144 The Intervertebral Disc and Cartilage Endplate 95 KeyArticles...... 145 IntervertebralDisc...... 95 References...... 146 TheCartilageEndplate...... 107 TheFacetJoints...... 109 6 Epidemiology and Risk Factors of Spinal NormalAnatomy ...... 109 Disorders Age-Related Changes ...... 109 Achim Elfering, Anne F. Mannion VertebralBodies...... 110 CoreMessages...... 153 NormalAnatomyandComposition...... 110 GeneralScope...... 153 Age-Related Changes ...... 110 ObjectivesinSpinalDisorders ...... 154 SpinalLigaments...... 111 ClassificationofSpinalDisorders...... 155 NormalAnatomyandComposition...... 111 Etiology...... 155 Age-Related Changes ...... 111 TimeCourse ...... 155 SpinalMuscles...... 112 LowBackPain...... 156 NormalAnatomyandStructure...... 112 NeckPain...... 157 Age-Related Changes ...... 112 Pain,ImpairmentandDisability...... 157 Recapitulation...... 114 BurdenofSpinalDisorders...... 159 KeyArticles...... 115 EconomicCosts...... 159 References...... 116 RiskFactors...... 161 IndividualRiskFactors ...... 161 5 Pathways of Spinal Pain MorphologicalRiskFactors...... 162 HeikeE.Künzel,NorbertBoos PsychosocialFactors...... 162 CoreMessages...... 123 OccupationalPhysicalRiskFactors...... 163 HistoricalBackground...... 123 OccupationalPsychologicalRiskFactors.... 163 PrecartesianTheories...... 123 Absence of Evidence for Certain Risk Factors 164 CartesianTheory ...... 124 GeographicalVariation ...... 164 GateControlTheory...... 124 FlagSystemfortheRiskFactors...... 165 ModernPainTheories...... 124 RedFlags...... 165 EpidemiologyofChronicPain ...... 125 YellowFlags...... 166 Definition and Classification ...... 125 BlueFlags...... 166 TemporalCourse...... 126 BlackFlags...... 166 ContemporaryPainClassification...... 126 Direction for Future Epidemiological Research 167 PathwaysofPain...... 128 Recapitulation...... 167 Transduction...... 129 KeyArticles...... 168 Conduction...... 130 References...... 169 TransmissionandModulation ...... 130 PainProjection...... 133 7 Predictors of Surgical Outcome PainPerception...... 134 Anne F. Mannion, Achim Elfering Neuroplasticity...... 135 CoreMessages...... 175 PeripheralSensitization...... 135 Epidemiology ...... 175 TranscriptionalDRGChanges...... 136 OutcomeMeasures...... 179 CentralSensitization ...... 136 What Constitutes a “Successful Outcome” . . . 180 Contents XV

The Outcome of Common Spine Surgical AcuteTrauma ...... 249 Procedures...... 182 ChronicLowBackPain ...... 251 PredictorsofOutcomeofSpinalSurgery...... 183 PostoperativeImaging...... 251 MedicalFactors...... 184 Whiplash-AssociatedDisorders...... 252 BiologicalandDemographicVariables ..... 186 PainRelatingtotheSacroiliacJoint...... 253 HealthBehavioralandLifestyleFactors..... 187 DiseaseoftheSpinalCord...... 255 PsychologicalFactors...... 187 Recapitulation...... 255 SociologicalFactors...... 189 KeyArticles...... 256 Work-RelatedFactors...... 189 References...... 257 Risk Factor Assessment in Clinical Practice . . . 190 Recapitulation...... 192 10 Spinal Injections KeyArticles...... 193 Massimo Leonardi, Christian W. Pfirrmann References...... 194 CoreMessages...... 261 RationaleforSpinalInjections...... 261 Patient Assessment LumbarandCervicalNerveRootBlocks...... 262 Indications...... 262 8 History and Physical Examination Technique...... 263 Cl´ement M.L. Werner, Norbert Boos Complications...... 265 CoreMessages...... 201 DiagnosticandTherapeuticEfficacy...... 265 Epidemiology ...... 201 EpiduralandCaudalBlocks...... 267 CaseIntroduction...... 202 Indications...... 267 History...... 203 Technique...... 268 Pain...... 204 Complications...... 268 Function...... 210 TherapeuticEfficacy...... 268 SpinalDeformity...... 210 ProvocativeDiscography...... 271 PhysicalExamination...... 211 Indications...... 271 Walking...... 211 Technique...... 272 Standing...... 211 Complications...... 273 Sitting...... 216 DiagnosticEfficacy...... 273 LyingSupine...... 220 FacetJointBlocks...... 275 LyingonLeft/RightSide ...... 220 Indications...... 275 LyingProne...... 221 Technique...... 276 AbnormalIllnessBehavior ...... 221 Complications...... 277 Reproducibility...... 221 DiagnosticandTherapeuticEfficacy...... 278 Differential Diagnosis of Spinal Pain Syndromes 222 SacroiliacJointBlocks ...... 280 Recapitulation...... 222 Indications...... 280 KeyArticles...... 223 Technique...... 280 References...... 224 Complications...... 280 DiagnosticEfficacy...... 281 9 Imaging Studies ContraindicationsforSpinalInjections...... 281 Marius R. Schmid, Jürg Hodler AlgorithmforSpinalInjections...... 282 CoreMessages...... 227 Recapitulation...... 283 ImagingMethods ...... 227 KeyArticles...... 284 StandardRadiographs...... 227 References...... 285 MagneticResonanceImaging...... 229 ComputedTomography...... 241 11 Neurological Assessment in Spinal Disorders AdditionalImagingMethods ...... 244 Uta Kliesch, Armin Curt Indications for Spinal Imaging ...... 247 CoreMessages...... 291 Acute Low Back Pain Without Radicular Epidemiology ...... 291 Symptoms,WithoutTrauma...... 247 CaseIntroduction...... 292 Acute Low Back Pain With Radicular AnatomyandSomatotopicBackground...... 294 Symptoms...... 248 Classification...... 295 Spinal Cord and Cauda Compression NeurologicalAssessment...... 298 Syndromes...... 249 Pain...... 298 XVI Contents

SensoryDeficits ...... 298 Anterior Medial Approach to Cervical Spine . . . 337 MotorDeficits...... 299 Indications...... 338 ReflexDeficits...... 299 Patient Positioning ...... 338 GaitDisorders...... 301 SurgicalExposure...... 339 BowelandBladderDysfunction...... 303 PitfallsandComplications...... 341 DisordersoftheAutonomicSystem...... 303 PosteriorApproachtotheCervicalSpine..... 342 SpinalCordInjury ...... 304 Indications...... 342 SpinalCordSyndrome...... 304 Patient Positioning ...... 342 DifferentialDiagnosis...... 306 SurgicalExposure...... 343 Differentiation of Central and Peripheral PitfallsandComplications...... 345 Paresis ...... 306 Right-SidedThoracotomy...... 345 Differentiation of Radicular and Peripheral Indications...... 346 NerveLesions...... 306 Patient Positioning ...... 346 Differential Diagnosis of Spinal Cord SurgicalExposure...... 346 CompressionSyndromes...... 311 PitfallsandComplications...... 349 MiscellaneousDifferentialDiagnoses ...... 311 Left-SidedThoraco-Phrenico-Lumbotomy.... 350 Recapitulation...... 312 Indications...... 350 KeyArticles...... 313 Patient Positioning ...... 350 References...... 314 SurgicalExposure...... 350 PitfallsandComplications...... 353 12 Neurophysiological Investigations Anterior-Lateral Retroperitoneal Approach Armin Curt, Uta Kliesch toL2–L5...... 353 CoreMessages...... 319 Indications...... 353 HistoricalBackground...... 319 Patient Positioning ...... 353 Neuroanatomy...... 320 SurgicalExposure...... 353 NeurophysiologicalModalities...... 321 PitfallsandComplications...... 355 Electromyography ...... 321 Anterior Lumbar Retroperitoneal Approach . . . 355 NerveConductionStudies...... 322 Indications...... 355 F-WaveRecordings...... 324 Patient Positioning ...... 355 H-Reflex...... 325 SurgicalExposure...... 356 SomatosensoryEvokedPotentials ...... 326 PitfallsandComplications...... 358 Motor Evoked Potentials (Transcranial Posterior Approach to the Thoracolumbar Spine 358 MagneticStimulation)...... 328 Indications...... 358 IntraoperativeNeuromonitoring ...... 329 Patient Positioning ...... 358 Role of Neurophysiology in Specific Disorders .. 330 SurgicalExposure...... 359 SpinalCordInjury ...... 330 PitfallsandComplications...... 361 Cervical/LumbarRadiculopathy...... 330 LandmarksforScrewInsertion...... 361 CervicalMyelopathy...... 331 Cervico-occipitalSpine...... 361 LumbarSpinalCanalStenosis...... 331 Recapitulation...... 368 NeurophysiologyinDifferentialDiagnosis.... 332 KeyArticles...... 369 Peripheral Nerve Lesion Versus Radiculopathy 332 References...... 369 Neuropathy Versus Spinal Canal Stenosis . . . 332 MyopathyandMyotonicDisorders...... 333 Peri- and Postoperative Management Hereditary and Neurodegenerative Disease . 333 Recapitulation...... 334 14 Preoperative Assessment KeyArticles...... 334 Stephan Blumenthal, Youri Reiland, References...... 335 Alain Borgeat CoreMessages...... 373 AimofPreanestheticEvaluation...... 373 13 Surgical Approaches InformationandInstructions...... 374 Norbert Boos, Claudio Affolter, PatientAssessment...... 374 Martin Merkle, Frank J. Ruehli History...... 374 CoreMessages...... 337 PhysicalExamination...... 375 Surgery and Planning ...... 337 LaboratoryStudies...... 375 Contents XVII

Organ-SpecificAssessment...... 376 16 Postoperative Care and Pain Management AirwayAssessment...... 376 Stephan Blumenthal, Alain Borgeat RespiratorySystem...... 376 CoreMessages...... 417 CardiovascularAssessment...... 378 PostoperativeCare ...... 417 NeurologicalAssessment...... 379 PostoperativeVentilationorExtubation.... 418 PerioperativeDrugTherapy ...... 379 HemodynamicAssessment...... 419 WhattoStop,toContinueandtoAdd?..... 379 NeurologicalAssessment...... 419 Premedication...... 380 GastrointestinalFunction...... 420 ThromboembolicProphylaxis...... 380 ThromboembolicProphylaxis...... 420 Special Conditions Requiring Spinal Surgery . . 382 PostoperativePainManagement...... 420 SpinalDeformity...... 382 ConsequencesofPain...... 420 NeuromuscularDisease...... 383 Non-narcotics...... 421 CerebralPalsy...... 383 Non-steroidalDrugs...... 421 Malignancy...... 384 Opioids...... 421 SpinalCordInjury ...... 384 LocalAnesthetics...... 422 Recapitulation...... 385 N-Methyl-D-aspartateAntagonists...... 422 KeyArticles...... 386 Recapitulation...... 423 References...... 387 KeyArticles...... 423 References...... 424 15 Intraoperative Anesthesia Management Juan Francisco Asenjo Degenerative Disorders CoreMessages...... 389 HistoricalBackground...... 389 17 Degenerative Disorders of the Cervical Spine GoalsofAnesthesiainSpinalSurgery...... 389 Massimo Leonardi, Norbert Boos PreoperativePatientAssessment...... 390 CoreMessages...... 429 InductionofAnesthesia...... 390 CaseIntroduction...... 430 Airway Control and Endotracheal Intubation 391 Epidemiology ...... 430 AntibioticProphylaxis...... 393 Pathogenesis...... 432 Patient Positioning ...... 394 NeckPain...... 432 MaintenanceofAnesthesia...... 396 CervicalDiscHerniation...... 432 IntraoperativeMonitoringTechniques...... 397 CervicalSpondyloticRadiculopathy ...... 433 AdvancedMonitoringofVitalFunctions.... 397 CervicalSpondyloticMyelopathy...... 433 Monitoring Depth of Anesthesia ClinicalPresentation...... 435 (Consciousness)...... 400 History...... 436 Intraoperative Blood Preserving Techniques . . . 400 PhysicalFindings...... 437 ControlledHypotensiveAnesthesia...... 401 FunctionalAssessment...... 439 IntrathecalOpiates...... 402 DiagnosticWork-up...... 439 Blood Predeposit and Erythropoietin ImagingStudies ...... 439 Injection...... 402 NeurophysiologicalAssessment...... 444 CellSalvage...... 402 DifferentialDiagnosis ...... 444 PharmacologicalMeasures ...... 403 Non-operativeTreatment...... 444 Blood Transfusion and Coagulation Factor NaturalHistory...... 445 Substitution...... 403 ConservativeTreatmentModalities...... 446 IntraoperativeSpinalCordMonitoring...... 405 OperativeTreatment...... 448 AnestheticEffectsonSSEPs...... 406 GeneralPrinciples ...... 448 AnestheticEffectsonMEPs...... 407 SurgicalTechniques...... 449 NerveRootMonitoring...... 408 CaseStudy1 ...... 451 Wake-upTest...... 408 CaseStudy2 ...... 454 EndofAnesthesia...... 409 CaseStudy3 ...... 456 PostoperativePainManagement...... 409 SurgicalDecision-Making...... 459 Recapitulation...... 411 Complications...... 463 KeyArticles...... 411 Recapitulation...... 464 References...... 412 KeyArticles...... 466 References...... 468 XVIII Contents

18 Disc Herniation and Radiculopathy CaseStudy1 ...... 527 Massimo Leonardi, Norbert Boos CaseStudy2 ...... 529 CoreMessages...... 481 OperativeRisksandComplications...... 530 Epidemiology ...... 481 Recapitulation...... 531 CaseIntroduction...... 482 KeyArticles...... 532 Pathogenesis...... 483 References...... 533 RiskFactors...... 483 Radiculopathy...... 484 20 Degenerative Lumbar Spondylosis ClinicalPresentation...... 486 Martin Merkle, Beat Wälchli, History...... 486 Norbert Boos PhysicalFindings...... 487 CoreMessages...... 539 DiagnosticWork-up...... 488 Epidemiology ...... 539 ImagingStudies ...... 488 CaseIntroduction...... 540 NeurophysiologicAssessment...... 490 Pathogenesis...... 541 UrologicAssessment ...... 490 Disc Degeneration and Discogenic Back Pain 542 DifferentialDiagnosis ...... 491 FacetJointOsteoarthritis...... 543 Classification...... 491 SegmentalInstability...... 544 Non-operativeTreatment...... 493 ClinicalPresentation...... 545 NaturalHistory...... 494 History...... 546 ConservativeMeasures...... 494 CaseStudy1 ...... 547 OperativeTreatment...... 496 PhysicalFindings...... 548 GeneralPrinciples ...... 496 DiagnosticWork-up...... 548 CaseStudy1 ...... 497 ImagingStudies ...... 549 SurgicalTechniques...... 497 CaseStudy2 ...... 550 CaseStudy2 ...... 499 InjectionStudies...... 551 Conservative Versus Operative Treatment . . . 503 TemporaryStabilization...... 552 Complications...... 504 PatientSelectionforTreatment...... 552 Recapitulation...... 505 Non-operativeTreatment...... 553 KeyArticles...... 506 OperativeTreatment...... 554 References...... 507 GeneralPrinciples ...... 554 BiologyofSpinalFusion ...... 555 19 Lumbar Spinal Stenosis SurgicalTechniques...... 558 Patrick O. Zingg, Norbert Boos ComparisonofTreatmentModalities...... 568 CoreMessages...... 513 Complications...... 569 Epidemiology ...... 513 Recapitulation...... 570 CaseIntroduction...... 514 KeyArticles...... 571 Pathogenesis...... 515 References...... 573 Anatomy...... 515 Pathogenesis...... 515 21 Non-specific Low Back Pain SpinalClaudicationSyndrome...... 517 Florian Brunner, Sherri Weiser, Classification...... 517 Annina Schmid, Margareta Nordin ClinicalPresentation...... 519 CoreMessages...... 585 History...... 519 Epidemiology ...... 585 PhysicalFindings...... 520 CaseIntroduction...... 586 DiagnosticWork-up...... 520 ClassificationofBackPain...... 587 ImagingStudies ...... 520 PathogenesisofNSLBP...... 587 NeurophysiologicStudies ...... 523 Patient Assessment and Triage for Non-operative DifferentialDiagnosis ...... 524 Treatment...... 588 Non-operativeTreatment...... 524 ManagementofNSLBP...... 590 NaturalHistory...... 525 Management of Acute NSLBP (<4 weeks) . . . 590 Non-operativeOptions...... 525 Management of Subacute NSLBP (4–12 weeks) 592 OperativeTreatment...... 526 Management of Chronic Non-specific LBP GeneralPrinciples ...... 526 (>12weeks)...... 595 SurgicalTechniques...... 526 Recapitulation...... 596 Contents XIX

KeyArticles...... 596 OperativeTreatment...... 641 References...... 598 IndicationsforSurgery ...... 641 GeneralPrinciples ...... 642 22 Postoperative Rehabilitation CaseStudy1 ...... 646 Florian Brunner, Shira Schecter-Weiner, SurgicalDecisionMaking...... 647 Annina Schmid, Rudolf Kissling CaseStudy2 ...... 651 CoreMessages...... 603 Complications...... 651 Epidemiology ...... 603 Recapitulation...... 652 ConceptionalBackground...... 604 KeyArticles...... 653 TheoreticalConsiderations...... 604 References...... 654 AnatomicalandSurgicalConsiderations.... 605 IndividualandSocietalConsiderations..... 606 24 Neuromuscular Scoliosis Indications for Postoperative Spinal Jean A. Ouellet, Vincent Arlet Rehabilitation...... 606 CoreMessages...... 663 GeneralGoals...... 607 Epidemiology ...... 663 SpecificGoals ...... 607 CaseIntroduction...... 664 PrinciplesofPostoperativeRehabilitation..... 607 DiseaseSpecificSpinalDeformity ...... 666 PreoperativeAssessment...... 607 Pathogenesis...... 667 PostoperativeRehabilitation...... 608 Classification...... 667 ObstaclesforRehabilitation...... 616 ClinicalPresentation...... 669 Morphological Obstacles and General Medical History...... 669 Obstacles...... 616 PhysicalExamination...... 670 PsychosocialObstacles...... 617 CaseStudy1 ...... 671 Work-RelatedObstacles...... 617 DiagnosticWork-up...... 673 Recapitulation...... 617 MedicalAssessment...... 673 KeyArticles...... 618 CaseStudy2 ...... 674 References...... 619 ImagingStudies ...... 675 Non-operativeTreatment...... 677 Spinal Deformities and Malformations NaturalHistory...... 677 Non-operativeTreatmentOptions...... 678 23 Idiopathic Scoliosis OperativeTreatment...... 678 Mathias Haefeli, Kan Min SurgicalIndications...... 678 CoreMessages...... 623 GeneralPrinciples ...... 679 Epidemiology ...... 623 SurgicalTechniques...... 680 CaseIntroduction...... 624 CaseStudy3 ...... 680 Pathogenesis...... 625 CaseStudy4 ...... 686 GeneticFactors...... 625 Recapitulation...... 689 Connective Tissue and Skeletal Muscle KeyArticles...... 690 Abnormalities...... 625 References...... 691 Thrombocyte Abnormalities, Calmodulin andMelatonin...... 626 25 Congenital Scoliosis Classification...... 626 Francis H. Shen, Vincent Arlet Age-RelatedClassification...... 626 CoreMessages...... 693 RadiologicalClassification ...... 627 Epidemiology ...... 693 ClinicalPresentation...... 627 CaseIntroduction...... 694 History...... 627 Pathogenesis...... 694 PhysicalExamination...... 629 Classification...... 695 DiagnosticWork-up...... 632 ClinicalPresentation...... 696 ImagingStudies ...... 632 History...... 696 NeurophysiologicEvaluation...... 637 PhysicalFindings ...... 697 Treatment...... 637 DiagnosticWork-up...... 698 GeneralConsiderations...... 637 ImagingStudies ...... 698 NaturalHistory...... 637 SpecificInvestigations...... 700 Non-operativeOptions...... 639 Non-operativeTreatment...... 700 XX Contents

NaturalHistoryandProgression ...... 700 ConservativeTreatmentOptions ...... 745 OperativeTreatment...... 701 OperativeTreatment...... 747 GeneralPrinciples ...... 701 GeneralPrinciples ...... 747 SurgicalTechniques...... 702 SurgicalTechniques...... 748 CorrectiveSurgeryProcedures...... 702 CaseStudy2 ...... 751 CaseStudy1 ...... 703 Complications...... 756 CaseStudy2 ...... 704 Recapitulation...... 757 MiscellaneousSurgicalTechniques...... 707 KeyArticles...... 758 Recapitulation...... 708 References...... 759 KeyArticles...... 709 References...... 710 28 Juvenile Kyphosis (Scheuermann’s Disease) Dietrich Schlenzka, Vincent Arlet 26 Degenerative Scoliosis CoreMessages...... 765 Max Aebi Epidemiology ...... 765 CoreMessages...... 713 CaseIntroduction...... 766 Epidemiology ...... 713 Pathogenesis...... 767 CaseIntroduction...... 714 NormalSagittalProfile...... 768 Pathogenesis...... 715 Definition and Classification ...... 771 Classification...... 716 ClinicalPresentation...... 773 ClinicalPresentation...... 717 History...... 773 History...... 717 PhysicalFindings...... 774 PhysicalFindings...... 719 DiagnosticWork-up...... 775 DiagnosticWorkup...... 720 ImagingStudies ...... 775 ImagingStudies ...... 720 NeurophysiologicalTests...... 777 InterventionalRadiologicalProcedure ..... 721 LungFunctionTest...... 777 AdditionalDiagnosticTools...... 722 DifferentialDiagnosis ...... 777 Non-operativeTreatment...... 722 Non-operativeTreatment...... 779 OperativeTreatment...... 723 NaturalHistory...... 779 DecompressionProcedure...... 724 BracingandCasting...... 780 CorrectionProcedures...... 724 CaseStudy1 ...... 780 SurgicalTechniques...... 725 OperativeTreatment...... 782 CaseStudy1 ...... 728 PreoperativeAssessment...... 782 CaseStudy2 ...... 729 GeneralPrinciples ...... 783 Recapitulation...... 729 OperativeTechnique...... 784 KeyArticles...... 730 CaseStudy2 ...... 786 References...... 731 ResultsofOperativeTreatment...... 788 Complications...... 790 27 Spondylolisthesis Recapitulation...... 791 ClaytonN.Kraft,RüdigerKrauspe KeyArticles...... 792 CoreMessages...... 733 References...... 793 Epidemiology ...... 733 CaseIntroduction...... 734 29 Malformations of the Spinal Cord Pathogenesis...... 735 Dilek Könü-Leblebicioglu, Yasuhiro Classification...... 735 Yonek awa ClinicalPresentation...... 736 CoreMessages...... 797 History...... 736 Epidemiology ...... 797 PhysicalFindings...... 738 CaseIntroduction...... 798 DifferentialDiagnosis ...... 738 Pathogenesis...... 799 DiagnosticWork-up...... 739 EmbryologicalAspects...... 799 Imaging...... 739 RelevantEmbryogeneticSteps ...... 800 CaseStudy1 ...... 742 RiskFactors...... 801 InvasiveImagingStudies...... 743 Pathophysiology of Tethered Cord Syndrome 802 Non-operativeTreatment...... 745 TerminologyandClassification...... 802 NaturalHistory...... 745 ClassificationofSpinalMalformation...... 803 Contents XXI

CaseStudy1 ...... 805 Classification and Treatment of Subaxial Injuries 863 ClassificationofTetheredSpinalCord...... 811 Classification...... 864 ClinicalPresentation...... 812 Treatment...... 866 History...... 812 CaseStudy3 ...... 870 PhysicalFindings...... 813 Complications...... 871 DiagnosticWork-up...... 814 Recapitulation...... 871 PrenatalDiagnosis...... 814 KeyArticles...... 873 PostnatalDiagnosticTests...... 815 References...... 874 Treatment...... 815 InUteroTreatment...... 816 31 Thoracolumbar Spinal Injuries PostnatalSurgery...... 816 Michael Heinzelmann, Guido A. Wanner Recapitulation...... 818 CoreMessages...... 883 KeyArticles...... 819 Epidemiology ...... 883 References...... 819 CaseIntroduction...... 884 Pathomechanisms...... 885 Fractures AxialCompression...... 885 Flexion/Distraction...... 886 30 Cervical Spine Injuries Hyperextension...... 886 Michael Heinzelmann, Karim Eid, RotationalInjuries...... 886 Norbert Boos Shear...... 887 CoreMessages...... 825 Classification...... 887 CaseIntroduction...... 826 DenisClassification...... 888 Epidemiology ...... 827 AOClassification ...... 888 Pathomechanisms...... 828 ClinicalPresentation...... 892 NormalAnatomy ...... 828 SpinalInjuries...... 892 BiomechanicsofCervicalSpineTrauma.... 830 NeurologicalDeficit...... 892 SpinalCordInjury ...... 832 ConcomitantNon-spinalInjuries...... 893 Pathomechanism of Whiplash-Associated History...... 893 Disorders...... 833 PhysicalFindings...... 894 ClinicalPresentation...... 834 DiagnosticWork-up...... 895 History...... 834 ImagingStudies ...... 895 PhysicalFindings...... 835 Non-operativeTreatment...... 898 Classification of Whiplash-Associated SteroidTreatmentofSpinalCordInjury.... 899 Disorders...... 836 Non-operativeTreatmentModalities...... 899 DiagnosticWork-up...... 836 CaseStudy1 ...... 900 ImagingStudies ...... 836 OperativeTreatment...... 903 Neurophysiology...... 842 GeneralPrinciples ...... 903 VascularAssessment...... 842 SurgicalTechniques...... 905 Synopsis of Assessment Recommendations .. 842 CaseStudy2 ...... 906 GeneralTreatmentPrinciples...... 844 CaseStudy3 ...... 911 Whiplash-AssociatedDisorders...... 844 Outcome of Operative Versus Non-operative Non-operativeTreatmentModalities...... 845 Treatment...... 914 SpinalCordInjuries...... 848 Recapitulation...... 918 Specific Treatment of Upper Cervical Spine KeyArticles...... 919 Injuries...... 850 References...... 920 FracturesoftheOccipitalCondyle...... 850 Atlanto-occipitalDislocation...... 851 32 Osteoporotic Spine Fractures FracturesoftheAtlas...... 852 Paul F. Heini, Albrecht Popp AtlantoaxialInstabilities ...... 853 CoreMessages...... 925 DensFractures ...... 854 Epidemiology ...... 925 CaseStudy1 ...... 858 CaseIntroduction...... 926 TraumaticSpondylolisthesisoftheAxis .... 860 Pathogenesis and Definition ...... 926 CaseStudy2 ...... 862 Classification of Vertebral Body Compression CombinedAtlas/AxisFractures ...... 863 Fractures ...... 929 XXII Contents

ClinicalPresentation...... 930 34 Spinal Metastasis History...... 930 Dante G. Marchesi PhysicalFindings...... 933 CoreMessages...... 977 DiagnosticWork-up...... 933 Epidemiology ...... 977 ImagingStudies ...... 933 CaseIntroduction...... 978 RadionuclideStudies...... 934 Pathogenesis...... 978 Densitometry ...... 934 ClinicalPresentation...... 980 BoneBiopsy...... 935 History...... 980 LaboratoryInvestigations...... 935 PhysicalFindings...... 980 Non-operativeTreatment...... 936 DiagnosticWork-up...... 981 ConservativeFractureManagement...... 936 ImagingStudies ...... 981 MedicalTreatment...... 936 Biopsy...... 983 OperativeTreatment...... 937 LaboratoryInvestigation...... 983 GeneralPrinciples ...... 937 Classification...... 984 SurgicalPrinciples...... 937 Non-operativeTreatment...... 985 Recapitulation...... 942 Steroids ...... 985 KeyArticles...... 943 Radiotherapy...... 985 References...... 944 OperativeTreatment...... 986 GeneralPrinciples ...... 986 Tumors and Inflammation GeneralSurgicalTechniques...... 987 SpecificSurgicalTechniques...... 988 33 Primary Tumors of the Spine CaseStudy1 ...... 989 Bruno Fuchs, Norbert Boos CaseStudy2 ...... 992 CoreMessages...... 951 CaseStudy3 ...... 993 Epidemiology ...... 951 PostoperativePatientManagement ...... 993 CaseIntroduction...... 952 Recapitulation...... 994 TumorBiology...... 953 KeyArticles...... 995 MolecularTumorBiology ...... 953 References...... 995 PathwaysofMetastasis...... 954 HistologyandBiologyofSpinalTumors.... 956 35 Intradural Tumors ClinicalPresentation...... 957 Yashuhiro Yonekawa, Richard Marugg History...... 957 CoreMessages...... 997 PhysicalFindings...... 957 Epidemiology ...... 997 DiagnosticWork-up...... 958 CaseIntroduction...... 998 ImagingStudies ...... 958 EtiologyandPathogenesis...... 998 CaseStudy1 ...... 960 ClassificationofIntraduralTumors...... 999 CaseStudy2 ...... 961 Intradural-ExtramedullaryTumors...... 999 Biopsy...... 964 DifferentialDiagnosis ...... 1000 LaboratoryInvestigations...... 964 CaseStudy1 ...... 1001 TumorStaging...... 964 Intradural-IntramedullaryTumors...... 1002 BenignTumors...... 965 CaseStudy2 ...... 1004 MalignantTumors ...... 966 ClinicalPresentation...... 1005 Non-operativeTreatment...... 967 History...... 1005 Non-steroidal Anti-inflammatory Drugs . . . 967 PhysicalFindings...... 1006 AdjuvantTherapy...... 967 DiagnosticWork-up...... 1006 OperativeTreatment...... 968 ImagingStudies ...... 1007 GeneralPrinciples ...... 968 LumbarPuncture...... 1008 SurgicalTechniques...... 969 Treatment...... 1009 CaseStudy3 ...... 971 Non-surgicalTreatment...... 1009 Recapitulation...... 973 SurgicalTreatment...... 1009 KeyArticles...... 974 SurgicalTechniques...... 1010 References...... 974 Intrinsic Spinal Cord Tumor Resection . . . . 1012 CaseStudy3 ...... 1013 Recapitulation...... 1016 Contents XXIII

KeyArticles...... 1017 38 Ankylosing Spondylitis References...... 1018 Thomas Liebscher, Kan Min, Norbert Boos CoreMessages...... 1057 36 Infections of the Spine Epidemiology ...... 1057 Norbert Boos CaseIntroduction...... 1058 CoreMessages...... 1021 Pathogenesis...... 1060 Epidemiology ...... 1021 ClinicalPresentation...... 1061 CaseIntroduction...... 1022 History...... 1061 Pathogenesis...... 1023 PhysicalFindings...... 1062 Classification...... 1023 DiagnosticWork-up...... 1063 ClinicalPresentation...... 1024 LaboratoryInvestigations...... 1063 History...... 1024 ImagingStudies ...... 1063 PhysicalFindings...... 1025 DiagnosticCriteria...... 1066 DiagnosticWork-up...... 1025 Non-operativeTreatment...... 1067 LabaratoryInvestigations ...... 1025 NaturalHistory...... 1067 ImagingStudies ...... 1026 Non-operativeManagement...... 1068 Biopsy...... 1028 Physiotherapy...... 1069 NonoperativeTreatment ...... 1029 TreatmentRecommendations...... 1069 CaseStudy1 ...... 1030 OperativeTreatment...... 1070 OperativeTreatment...... 1031 GeneralPrinciples ...... 1070 GeneralPrinciples ...... 1031 Planning of Osteotomies ...... 1071 SurgicalTechniques...... 1031 SurgicalTechniques...... 1072 CaseStudy2 ...... 1035 CaseStudy1 ...... 1076 Recapitulation...... 1036 CaseStudy2 ...... 1078 KeyArticles...... 1037 Complications...... 1080 References...... 1037 Recapitulation...... 1080 KeyArticles...... 1081 37 Rheumatoid Arthritis References...... 1082 Dieter Grob CoreMessages...... 1041 Epidemiology ...... 1041 39 Treatment of Postoperative Pathogenesis...... 1041 Complications CaseIntroduction...... 1042 Martin Krismer, Norbert Boos Classification...... 1044 CoreMessages...... 1087 ClinicalPresentation...... 1045 FrequencyofComplications...... 1087 History...... 1045 CervicalSpineSurgery...... 1087 PhysicalFindings...... 1045 CaseIntroduction...... 1088 DiagnosticWork-up...... 1045 AnteriorSpinalSurgery...... 1089 ImagingStudies ...... 1045 Disc Herniation and Spinal Stenosis ...... 1089 CaseStudy1 ...... 1047 LumbarSpinalFusion ...... 1090 InjectionStudies...... 1048 ComparisonofComplications ...... 1090 NeurophysiologicalInvestigations...... 1048 PreventiveMeasures...... 1090 Non-operativeTreatment...... 1048 ScreeningofRiskFactors...... 1091 OperativeTreatment...... 1048 Preoperative Planning ...... 1093 GeneralPrinciples ...... 1048 ProfoundKnowledgeofAnatomy...... 1094 Indications...... 1049 Patient Positioning ...... 1094 SurgicalTechniques...... 1050 Neuromonitoring...... 1095 CaseStudy2 ...... 1053 Approach-RelatedComplications...... 1095 Recapitulation...... 1054 AnteromedialCervicalApproach...... 1096 KeyArticles...... 1054 CaseStudy1 ...... 1097 References...... 1055 Anterior Approach to the Cervicothoracic Junction...... 1098 Thoracotomy...... 1098 ThoracolumbarApproach...... 1100 XXIV Contents

Anterior Lumbar and Lumbosacral 40 Outcome Assessment in Spinal Approach...... 1100 Surgery Posterior Approach to the Cervical Spine . . 1103 Mathias Haefeli, Norbert Boos Posterior Approaches to the Thoracic and CoreMessages...... 1123 LumbarSpine ...... 1104 General Concepts of Outcome Assessment . . . 1123 ProcedureRelatedComplications...... 1104 Pain...... 1125 Decompressive Cervical and Lumbar GeneralAspects ...... 1125 Surgery...... 1104 Instruments...... 1126 DeformityCorrection...... 1106 Disability...... 1128 Reduction of High-Grade Spondylolisthesis 1108 GeneralAspects ...... 1128 Corpectomy/Osteotomy...... 1108 Instruments...... 1128 PostoperativeComplications...... 1109 QualityofLife...... 1130 Homeostasis Related Complications ...... 1109 GeneralAspects ...... 1130 NeurologicalComplications ...... 1110 Instruments...... 1130 PostoperativeWoundProblems ...... 1110 Psychosocial Aspects, Work Situation and Fear CerebrospinalFluidFistula...... 1112 AvoidanceBeliefs ...... 1133 VascularComplications...... 1112 GeneralAspects ...... 1133 PulmonaryProblems...... 1113 Instruments...... 1133 GastrointestinalProblems...... 1113 ClinicalFeasibilityandPracticability...... 1134 UrogenitalComplications...... 1114 Recapitulation...... 1135 RetrogradeEjaculation ...... 1114 References...... 1136 Recapitulation...... 1115 KeyArticles...... 1116 Subject Index ...... 1143 References...... 1117 The Editors ...... 1163 The Medical Illustrator ...... 1164 The Artist ...... 1165 XXV List of Contributors

Max Aebi Institut für Evaluative Forschung in Orthopädischer Chirurgie, MEM Forschungszentrum, Universität Bern, Stauffacherstr. 78, 3014 Bern, Schweiz e-mail: [email protected] Claudio Affolter Anatomisches Institut, Universität Zürich, Winterthurerstr. 190, 8057 Zürich, Schweiz Vincent Arlet Division of Scoliosis and Spine Surgery, Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908-0159, USA e-mail: [email protected] Juan Francisco Asenjo Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Room D8.132, Montreal (Quebec), H3G 1A4, Canada e-mail: [email protected] Stephan Blumenthal Anästhesie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Thomas Boeni Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz Medizinhistorisches Museum, Universität Zürich, Rämistrasse 69, 8091 Zürich, Schweiz e-mail: [email protected] Norbert Boos Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Alain Borgeat Anästhesie, Universitätsklinik Balgrist, Forchstr. 340, 808 Zürich, Schweiz e-mail: [email protected] Florian Brunner Rheumatologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] XXVI List of Contributors

Armin Curt Spinal Cord Rehabilitation, ICORD, University of British Columbia, 2469–6270 University Blvd., V6T 1Z1, Vancouver, Canada e-mail: [email protected] Karim Eid Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Achim Elfering Psychologisches Institut, Universität Bern, Muesmattstr. 43, 3000 Bern 9, Schweiz e-mail: [email protected] Stephen Ferguson Institut für chirurgische Technologien und Biomechanik, MEM Forschungszentrum, Universität Bern, Stauffacherstr. 78, 3014 Bern, Schweiz e-mail: [email protected] Bruno Fuchs Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Dieter Grob Wirbelsäulenzentrum, Schulthessklinik, Lengghalde 2, 8008 Zürich, Schweiz e-mail: dieter.grob@kws Philipp Gruber Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz Medizinhistorisches Museum, Universität Zürich, Rämistrasse 69, 8091 Zürich, Schweiz e-mail: [email protected] Mathias Haefeli Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Daniel Haschtmann Institut für chirurgische Technologien und Biomechanik, MEM Forschungszentrum, Universität Bern, Stauffacherstr. 78, 3014 Bern, Schweiz e-mail: [email protected] Paul Heini Orthopädische Universitätsklinik, Inselspital Bern, 3010 Bern, Schweiz e-mail: [email protected] Michael Heinzelmann Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Klinik für Unfallchirurgie, Universitätsspital Zürich, Rämistr. 100, 8091 Zürich, Schweiz e-mail: [email protected] Jürg Hodler Radiologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] List of Contributors XXVII

Rudolf Kissling Rheumatologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Uta Kliesch Paraplegikerzentrum, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Dilek Könü-Leblebicioglu Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Neurochirurgische Klinik, Universitätsspital Zürich, Frauenklinikstr. 10, 8091 Zürich, Schweiz e-mail: [email protected] Clayton Kraft Orthopädie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Deutschland e-mail: [email protected] Rüdiger Krauspe Orthopädie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Deutschland e-mail: [email protected] Martin Krismer Universitätsklinik für Orthopädie, Anichstr. 35, 6020 Innsbruck, Österreich e-mail: [email protected] Heike Künzel Zentrum für Psychiatrie, Krumenauerstr. 25, 85049 Ingolstadt, Deutschland e-mail: [email protected] Massimo Leonardi Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Thomas Liebscher Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz Anne Mannion Wirbelsäulenzentrum, Schulthessklinik, Lengghalde 2, 808 Zürich, Schweiz e-mail: [email protected] Dante Marchesi Clinique Bois-Cerfs, Avenue d’Ouchy 31, 1006 Lausanne, Schweiz e-mail: [email protected] Richard Marugg Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Neurochirurgische Klinik, Universitätsspital Zürich, Frauenklinikstr. 10, 8091 Zürich, Schweiz e-mail: [email protected] Martin Merkle Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Deutschland XXVIII List of Contributors

Kan Min Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Universitätsklinik Balgrist, Forchstr. 340, 808 Zürich, Schweiz e-mail: [email protected] Andreas Nerlich Pathologisches Institut, Krankenhaus München-Bogenhausen, Englschalkinger Strasse 77, 81925 München, Deutschland e-mail: [email protected] Margareta Nordin Department of Orthopaedic and Environmental Medicine, School of Medicine, New York University, OIOC, Hospital for Joint Diseases, Mount Sinai NYU, 63 Downing Street, New York, USA e-mail: [email protected] Jean Ouellet Department of Orthopedics, Montreal Children’s Hospital, 2300 Tupper, C521 Montreal, H3H 1P3, Canada e-mail: [email protected] Günther Paesold Universitätsklinik Balgrist, Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Christian Pfirrmann Radiologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Albrecht Popp Poliklinik für Osteoporose, Inselspital, Universität Bern, 3010 Bern, Schweiz Youri Reiland Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 808 Zürich, Schweiz e-mail: [email protected] Frank Ruehli Anatomisches Institut, Universität Zürich, Winterthurerstr. 190, 8057 Zürich, Schweiz e-mail: [email protected] Shira Schecter-Weiner Occupational and Industrial Orthopaedic Center, Hospital for Joint Diseases, New York University Medical Center, 63 Downing Street, New York, NY 20014, USA e-mail: [email protected] Dietrich Schlenzka Orton Orthopaedic Hospital, Invalid Foundation, Tenholantie 10, 00280 Helsinki, Finland e-mail: [email protected] Annina Schmid Physiotherapie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Marius Schmid Radiologie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] List of Contributors XXIX

Francis H. Shen Department of Orthopaedic Surgery, Division of Spine Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908, USA e-mail: [email protected] Atul Sukthankar Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Beat Wälchli Spital Zollikerberg, Aerztezentrum Prisma, Trichtenhauserstr. 12, 8125 Zollikerberg, Schweiz e-mail: [email protected] Guido Wanner Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Klinik für Unfallchirurgie, Universitätsspital Zürich, Rämistr. 100, 8091 Zürich, Schweiz e-mail: [email protected] Sherri Weiser Department of Orthopaedic and Environmental Medicine, School of Medicine, New York University, OIOC, Hospital for Joint Diseases, Mount Sinai NYU, 63 Downing Street, New York, NY 10014, USA e-mail: [email protected] Cl´ement Werner Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] Yasuhiro Yonekawa Zentrum für Wirbelsäulen- und Rückenmarkchirurgie, Universität Zürich, Neurochirurgische Klinik, Universitätsspital Zürich, Frauenklinikstr. 10, 8091 Zürich, Schweiz e-mail: [email protected] Patrick Zingg Orthopädie, Universitätsklinik Balgrist, Forchstr. 340, 8008 Zürich, Schweiz e-mail: [email protected] XXXI Guided Tour

The aim of this textbook is not to provide the most comprehensive overview of spinal disorders, but rather to give a thorough grounding in the basic knowledge and general principles of the subject. The didactic concept of all the chapters of the book is therefore based on a consistent style and layout, and follows three basic principles of sustained learning, i.e.: ) lessismore ) repetition enhances sustained learning ) case study learning This didactic concept is enhanced by many learning aids to highlight and repeat core messages throughout all chapters. The ample use of visual aids mediates the core messages and allows for a gradual and repetition-based learning approach starting with the core messages and going on to an in-depth reading of each chapter. Marginal notes and a short recapitulation facilitate the learning by repetition. A pictorial and anecdotal learning method is enabled by the many case studies, which exemplify the core messages.

Fractures Section 883 884 Section Fractures Thoracolumbar Spinal Injuries

31 Michael Heinzelmann, Guido A. Wanner

a bc d Core messages Core Messages ✔ Spinal fractures are frequently located at the ✔ Primary goals of treatment are prevention and thoracolumbar junction for biomechanical rea- limitation of neurological injury as well as res- sons toration of spinal stability, regardless of highlight the most ✔ The AO classification has gained widespread whether operative or non-operative therapy is acceptance in Europe for the grading of thora- chosen columbar fractures: Type A: vertebral compres- ✔ Secondary goals consist of correction of defor- ef gh sion fractures; Type B: anterior and posterior mities, minimizing the loss of motion, and facili- important learning column injuries with distraction; Type C: ante- tating rapid rehabilitation rior and posterior element injury with rotation ✔ Early stabilization and fusion is generally ✔ The initial focus of the physical examination of accepted for patients with unstable fractures objectives and guide the a patient with a spinal injury is on the vital and and neurological deficits neurological functions, because effective resus- ✔ The optimal treatment for patients with less citation is critical to the management of poly- instability, moderate deformity and absence of traumatized patients and patients with spinal neurological compromise is not based on reader through the chapter. cord injury scientific evidence and remains a matter of ijkl ✔ The imaging modalities of choice are standard debate. radiographs and CT scans. A CT scan should ✔ Good clinical outcome can be achieved with routinely be made to visualize bony injury. MRI non-operative as well as operative treatment Case Introduction is helpful to diagnose discoligamentous injuries This 23-year-old female sustained a motor vehicle accident as an unrestrained passenger. Clinically, she presented with and to identify a possible cord lesion an incomplete paraplegia (ASIA C) and an incomplete conus-cauda syndrome. The initial CT (a–d) scan demonstrates an unstable complete burst fracture of L1 (Type A3.3). The 3D reconstruction (a, b)givesagoodoverviewofthedegreeof comminution and the deformity; the posterior fragment is best visualized in the lateral 2D reconstruction (c)andthe axial view (d). In an emergency procedure, the myelon was decompressed by laminectomy and the fracture was reduced andstabilizedwithaninternalfixator(e–h). Interestingly, the prone position alone (e) reduced the fracture to a certain Epidemiology degree when compared to the CT scan taken with the patient in a supine position. With the internal fixator (RecoFix), the anatomical height and physiological alignment was restored (f) and the posterior fragment was partially reduced (g, h). This indirect reduction of bony fragments, called ligamentotaxis, is possible if the posterior ligaments and the attach- Systematic epidemiologic data on traumatic thoracolumbar fractures are rare and ment to the anulus fibrosus are intact. We performed a complete clearance of the spinal canal by an anterior approach differ depending on the area studied and on the treating center. The studies avail- 5dayslater(i–l). In this minimally invasive technique, the spine is approached by a small thoracotomy from the left, the able from western countries reveal typical and comparable data on incidence, local- ruptured disc and bony fragments are removed, and an expandable cage is inserted. One of the first steps in this tech- ization, and mechanisms of injury. Thoracolumbar fractures are more frequent in nique is the positioning of a K-wire in the upper disc space of the fractured vertebra (i). In this figure, the four retractors men (2/3) than in women (1/3) and peak between the ages of 20 and 40 years [30, 47, of the Synframe and the endoscopic light source are seen. The final result after 9 months (j–l) demonstrates the cage (Synex), the physiological alignment without signs of implant failure or kyphosis, a good clearance of the spinal canal 65, 81, 94]. Approximately, 160000 patients/year sustain an injury of the spinal col- from anterior and the laminectomy from posterior (k), and a bony healing of the local bone transplant of the lateral side umn in the United States. The majority of these injuries comprise cervical and lum- of the cage (l). Fortunately, the patient completely recovered from her neurological deficit (ASIA E). bar (L3–L5) spine fractures. However, between 15% and 20% of traumatic fractures Fractures most frequently occur at the thoracolumbar junction (T11–L2), whereas 9–16% occur in the tho- affect the thoracolumbar racic spine (T1–T10) [36, 46]. Hu and coworkers [56] studied the total population of junction 50–60% of thoracolumbar fractures affect the transition T11–L2, 25–40% the a Canadian province over a period of 3 years. The incidence of spine injuries was 64/ thoracic spine and 10–14% the lower lumbar spine and sacrum [80, 86]. 100000 inhabitants per year, predominantly younger men and older women. A total In a study by Magerl and Engelhardt [81] on 1446 thoracolumbar fractures, of 2063 patients were registered and 944 patients were treated in hospital: 182 most injuries concerned the first lumbar vertebra, i.e., 28% (n=402), followed by patients (20%) with a cervical spine injury, 286 patients (30%) with a thoracic spine T12 (17%, n=246)andL2(14%, n=208). The epidemiologic multicenter study injury and 403 patients (50%) with an injury of the lumbosacral spine. Traumatic on fractures of the thoracolumbar transition (T10–L2) by the German Trauma cross-section spinal cord injury occurred in 40 out of 1 million inhabitants. About Society studied 682 patients and revealed 50% (n=336) L1 fractures, 25%

Introductory cases introduce the topic by reporting typical cases representative of the specific pathology. These cases are intended to serve as a stand-alone tool in mediating core messages of each chapter. XXXII Guided Tour

Thoracolumbar Spinal Injuries Chapter 31 897 908 Section Fractures

a bc

Figures illustrate and Figure 5. CT fracture assessment The axial CT scan reveals: a significant spinal canal compromise by a retropulsed bony fragment. Note the double contour of the vertebral body indicating a “burst” component. b Sagittal 2D image ab exemplify essential reformation demonstrating fracture subluxation. Note the bony fragment behind the vertebral body which may cause neural compression when the fracture is reduced. c Severe luxation fracture of the spine. d The 3D CT reformation nicely demonstrates knowledge and stimulate a the rotation component indicating a Type C lesion pictorial learning.

radiographs in high-risk trauma patients who require screening. In their prospective series of 222 patients with 63 thoracic and lumbar injuries, the results of conventional X-ray compared to initial CT scan were as follows: sensitivity 58% cd vs. 97%, specificity 93% vs. 99%, positive predictive value 64% vs. 97%, negative predictive value 92% vs. 99%, respectively. Figure 8. Surgical technique of two-level fracture reduction and stabilization The axial view allows an accurate assessment of the comminution of the frac- CT is the imaging study The technique demonstrates the use of the Fracture Module of Universal Spine System (Synthes) but the general princi- ture and dislocation of fragments into the spinal canal (Fig. 5a). Sagittal and of choice to demonstrate ples similarly apply to other fracture systems. a Schanz screws are inserted in the pedicles of the vertebral bodies superior coronal 2D or 3D reconstructions are helpful for determining the fracture pat- bony injuries and inferior to the fracture. b Screw clamps connected with the rods are mounted and fixed (arrow). c Thefracturecanbe tern (Fig. 5b–d). The canal at the injured segment should be measured in the reduced by lordosing both screwdrivers. However, it is often better to first tighten the two lower screws and reduce the fracture simultaneously by lordosing the cranial screw bilaterally with the help of the screwdriver. d If this reduction anteroposterior and transverse planes and compared with the cephalad and cau- maneuver does not suffice to restore vertebral height, a temporary C-clamp can be mounted and the fracture distracted dal segments. after loosening the upper screws. Care must be taken not to overdistract the fracture because of the inherent neurological risks. Finally, the Schanz screws are cut with a special screwcutter (not shown). Dependent on canal clearance and anterior vertebral column restoration, an additional anterior approach can be added (preferably in a second stage) Magnetic Resonance Imaging In the presence of neurological deficits, MRI is recommended to identify a possi- MRI is helpful in ruling out ble cord lesion or a cord compression that may be due to disc or fracture frag- discoligamentous lesions mentsortoanepiduralhematoma(Fig. 6a). In the absence of neurological defi- breakage or loosening. These results indicate the need for an adequate anterior cits, MRI of the thoracolumbar area is usually not necessary in the acute phase. column support and an optimal anterior-posterior column load sharing environ- However, MRI can be helpful in determining the integrity of the posterior ligament. mentous structures and thereby differentiate between a Type A and an unstable Transpedicular cancellous If no anterior stabilization is planned, a posterolateral fusion [78, 88] is man- Type B lesion. For this purpose a fluid sensitive sequence (e.g., STIR) is fre- bone grafting is insufficient datory. In addition, transpedicular bone grafting in the disrupted disc space has quently used to determine edema (Fig. 6b). to stabilize the anterior been a treatment option [26, 78, 90]. However, transpedicular bone grafting column could not prevent kyphosis after dorsal removal on implants [1, 68, 108]. Knop et al. [68] studied 56 patients after implant removal and concluded that, because Marginal notes summarize important facts and allow for a rapid repetition of learning Figures provide a schematic objectives. illustration of surgical procedures.

892 Section Fractures Thoracolumbar Spinal Injuries Chapter 31 915

Table 4. Frequency of neurological deficits Table 9. Operative vs. non-operative treatment Tables summarize Types and groups Number of injuries Neurological deficit (%) Authors Cases Study Fracture Type of Neuro- Follow-up Outcome Conclusion design type treatment logical (months) Type A 890 14 (numbers) deficit A1 501 2 A2 45 4 Burke 115 retro- flexion/rota- 89 non-opera- 62% N/A conservative: the indication for early important facts such as and (140) spec- tion (80) tive (postural secondary spinal fusion surgery might be still A3 344 32 Murray tive compression reduction) n=3 further restricted. Type B 145 32 (1976) fractures 26 operative severe chronic pain: 2 B1 61 30 [17] (27) (posterior neurological improve- B2 82 33 pure liga- stabilization ment 35% classifications, treatment B3 2 50 mentous ± laminec- operative: Type C 177 55 injuries (3) tomy) severe chronic pain n=8 C1 99 53 hyperexten- Neurological improve- sion (2) ment 38% objectives and indications C2 62 60 other (3) C3 16 50 Recht- 235 chart unstable 117 operative N/A comparable rates of both treatment modali- Total 1212 22 ine review thoracolum- 118 non-opera- decubitus, deep ties are viable alter- Based on an analysis of 1212 cases (Magerl et al. [80]) et al. for bar fractures tive 6 weeks venous thrombosis, natives for non-operative and (1999) compli- bed rest) pulmonary emboli, [93] cations and mortality between both groups Clinical Presentation 8% deep wound infections after operative surgical treatment. treatment The clinical assessment of patients with a putative trauma to the spine has three shorter hospital stay major objectives, i.e., to identify: after operative treatment ) the spinal injury Shen 80 pro- single-level 47 non-opera- none 288 lesspaininthesurgical posterior fixation pro- ) neurological deficits et al. spec- burst frac- tive: group after 3 and vides partial kyphosis ) (2001) tive tures T11– using a hyper- months. Complica- correction and earlier concomitant non-spinal injuries [105] L2, no frac- extension tions after surgery: pain relief. Functional ture disloca- brace 1 superficial infection outcome at 2 years is tions or ped- 33 operative: and 2 broken screws similar Spinal Injuries icle fractures posterior fixa- hospital charges were tion 4 times higher in the About 30% of It is obvious that the management and the priorities differ between a life-threat- operative group polytraumatized patients ening polytrauma that includes a spinal injury and a monotrauma of the spine. In Wood 47 pro- single thora- 24 operative: none 44 no difference between no long-term advan- have a spinal injury the case of a polytrauma, about one-fourth to one-third of patients have a spinal et al. spec- columbar posterior or groups was found in tage for operative treat- injury [120]. In our institution, we found spinal injuries in 22% of polytrauma- (2003) tive, burst anterior terms of pain, and return ment of burst fractures [121] ran- fractures instru- to work. Non-operatively compared with non- tized patients. In a series of 147 consecutive patients with multiple trauma, Dai et domi- (T10–L2) mented treated patients operative treatment al. [24] found a delayed diagnosis of thoracolumbar fractures in 19%, confirming zed fusion reported less disability 23 non-opera- an earlier study by Anderson et al. [5], in which 23% of patients with major tho- tive: racolumbar fractures were diagnosed after the patient had left the emergency body cast or department. A delay in the diagnosis of thoracolumbar fractures is frequently orthosis associated with an unstable patient condition that necessitates higher-priority procedures than thoracolumbar spine radiographs in the emergency department. However, with the routine use of multi-slice computed tomography (CT) in retention in a cast according to Böhler’s principles was performed. A reposition- Polytraumatized patients polytraumatized patients, the diagnostic work-up is usually adequate [57, 106] ing was possible in 90%; however, only 50% could be maintained over the treat- should be screened and delayed diagnosis of spine fractures should become rare. Multiple burst frac- ment period, 20% returned to the initial kyphotic level and 5% had a worse forspinalfracturebyCT tures occur in approximately 10–34% [10, 11, 53]. result. Reinhold et al. [95] reviewed 43 patients 16.3 years after thoracolumbar fracture and non-operative therapy. On average, patients showed a radiologic Neurological Deficit increase in the kyphosis angle of 5.2° compared to the time of injury. No differ- Sacral sparing indicates An accurate and well-documented neurological examination is of great impor- ence was noted between early functional therapy and treatment with closed an incomplete lesion tance. With an inaccurate or incomplete examination and a subsequent variation of reduction and immobilization by cast. Results of validated psychometric ques- with a better prognosis the patient’s neurological deficit, it will be unclear if the situation has changed or if tionnaires such as SF-36 and VAS showed the characteristic pattern of a popula- the initial assessment was simply inappropriate. In the case of a progressive neuro- tion with chronic back pain. The authors conclude that a radiologic increase in logical deficit, this may hinder urgent further management, i.e., the need for a sur- the traumatic kyphotic deformity in patients with a non-operative treatment gical intervention with spinal decompression. Neurological assessment is usually protocol has to be expected and that measurable negative physical and social done according to the guidelines of the American Spinal Injury Association (see long-term consequences can be anticipated after sustaining a Type A fracture of Chapter 11 ). Importantly, the examination has to include the “search for a sacral thoracolumbar vertebral bodies. However, no correlation between radiologic sparing” which will determine the completeness of the deficit and the prognosis. and functional results was observed. Cross references facilitate Tables also provide a topical state- a quick orientation of-the-art review of the literature and throughout the textbook. stimulate evidence based learning Guided Tour XXXIII

Thoracolumbar Spinal Injuries Chapter 31 911 918 Section Fractures

Recapitulation

Epidemiology. About 60% of thoracic and lumbar lyzed by CT scan. CT is the imaging study of choice spine fractures are located at the transition T11–L2, to demonstrate bony destruction. MRI is recom- 30% in the thoracic spine and 10% in the lower mended to identify a possible cord lesion or a cord lumbar spine. Spinal cord injury occurs in about compression in patients with neurological deficits. 10–30% of traumatic spinal fractures. MRI can be helpful in determining the integrity of the posterior ligamentous structures and thereby in dif- Pathogenesis. The most relevant forces that pro- ferentiating between a Type A and a Type B lesion. duce structural damage to the spine are axial com- ab cd pression, flexion/distraction, hyperextension, rota- Non-operative treatment. Management of thora- tion, and shear. Axial load mayresultinaburstfrac- columbar and sacral spinal fractures remains a con- ture; the posterior elements are usually intact. In troversial area in modern spinal surgery. The litera- flexion/distraction injuries, the posterior ligamen- ture demonstrates a wide range of conflicting re- tous and osseous elements fail in tension; a wedge sults and recommendations. Unfortunately, the compression fracture of the vertebral body is often vast majority of clinical studies can be criticized be- associated. Hyperextension may result in rupture cause of their retrospective design, heteroge- of the anterior ligament and the disc as well as in neous patient populations and treatment strate- compression injuries of the posterior elements, i.e., gies, limited follow-up, and poorly defined out- Case studies aim to fracture of the facets, the laminae, or the spinous come measures. processes. Rotational injuries combine compres- The main advantage of non-operative treatment ef gh sive forces and flexion/distraction mechanisms and of thoracolumbar fracture is the avoidance of sur- mediate the fundamentals are highly unstable injuries. Shear forces produce gery-related complications. According to Böhler, Case Study 3 severe ligamentous disruption and usually result in the time of immobilization in a cast is usually complete spinal cord injury. 3–5 months depending on the fracture type. Im- This 48-year-old female fell from a horse and presented with an incomplete burst fracture of L2 (Type A3.1) without neurological deficits (ASIA E). The MRI scan (a, b) was performed to evaluate the integrity of the dorsal elements. The portantly, skillful physical therapy is paramount to and basic principles of the coronal view (a) shows the T1 sequence and demonstrates a cranial fracture of L2 and a rupture of the disc L1/L2. The Clinical presentation. Inthecaseofapolytrauma, achieve good results. Because thoracolumbar frac- STIR sequence (b), which is very sensitive to edema, confirms the fracture of the vertebral body but does not show any about 30% of the patients have a spinal injury. The tures are bound to return to the initial deformity, evidence of a posterior injury. This allows the distinction between a Type A injury and an unstable Type B injury and neurological examination has to include the functional bracing without repositioning is an alter- helped us to choose the operative approach. We performed a monosegmental anterior stabilization with an expand- “search for a sacral sparing” which determines the native to Böhler’s concept of repositioning and sta- chapters and enhance able cage (Stryker) and an angular stable implant (MACS), which was especially designed for the thoracoscopic technique (c, d). After a small diaphragmatic split, one of the first steps is the positioning of a K-wire just above the endplate completeness of the deficit and the prognosis. bilization with a cast if the initial deformity is ac- of L2 (c); in this figure, the retractor (left), the suctioning device (middle)andtheaimingdevicefortheK-wire(right)can About one-third of all spinal injuries have concomi- ceptable. Many studies were not able to prove a be distinguished. The polyaxial screws are inserted under fluoroscopic control, the ruptured disc and the cranial part of tant injuries; the most frequent are: head injuries, substantial difference in functional outcome be- the fractured vertebral body are removed, and the cage is inserted (d). The postoperative control radiographs (e–g) chest injuries and long bone injuries. The history tween the operative and non-operative treatment, recollection by the principle demonstrate a correct positioning of the screws in the anteroposterior view (e) and lateral view (f); in addition, the local should include the type of trauma (high vs. low en- regardless of the neurological injury. bone transplant on the right side of the cage is seen in e. The conventional X-rays (g, h) demonstrate a physiologic alignment and a correct positioning of the implants. ergy injuries) and the time course of a possible neurological deficit. The initial focus of the physical ex- Operative treatment. There is a general trend to- of case study learning. amination is on the assessment of vital functions wards operative treatment of unstable fractures and neurological deficits. Because the spinal cord mostly because surgical stabilizing procedures re- Thoracoscopic spinal surgery is another technique that reduces the morbidity of Minimally invasive anterior usually terminates at the level of L1, injuries to the sult in early mobilization, diminished pain, facilitat- extensive surgical approaches while it still achieves the primary goals of spinal access technologies offer thoracolumbar junction may result in various neu- ed nursing care, earlier return to work, and avoid- decompression, reconstruction, and stabilization. Since the development of spe- perioperative advantages rological symptoms: e.g., complete/incomplete ance of late neurological complications. In experi- cially designed instruments and implants, the “pure” thoracoscopic operation paraplegia (distal spinal cord), malfunction of the mental animal models, persistent compression of techniquehasbecomepossibleandfeasible.Throughthetransdiaphragmatic vegetative system (conus medullaris), or cauda the spinal cord is potentially reversible from a sec- approach it was also possible to open up the thoracolumbar junction, including equina syndrome. ondary injury by early decompression. Most investi- the retroperitoneal segments of the spine, to the endoscopic technique. In an gators recommend a surgical decompression in early series, Bühren et al. [19] analyzed 38 patients. The authors conclude that, Diagnostic work-up. Static imaging studies are the setting of major neurological deficit, progres- compared to the open method, minimally invasive surgery had the benefit of “snapshots in time” and do not reveal the real de- sive neurological loss, and substantial compromise reducing postoperative pain, shortening hospitalization, leading to early recov- gree of spinal canal compromise that may have of the spinal canal. Currently, there are no gold ery of function and reducing the morbidity of the operative approach. These happened during the injury. A posterior cortical dis- standards regarding the role and timing of de- findings have been confirmed in later reports [8, 9, 62]. The rate of severe compli- ruption seen in the lateral view or an interpedicular compression in acute spinal cord injury. Posterior cations was low (1.3%), with one case each of aortic injury, splenic contusion, widening seen in the anteroposterior view sug- bisegmental reduction and stabilization is the neurological deterioration, cerebrospinal fluid leak, and severe wound infection gests a burst fracture that should be further ana- “working horse” of the posterior approach tech- [62]. Overall, the complication rate was not increased when compared to the nique that allows for fracture reduction and stable

Recapitulations summarize the essential teaching objectives and provide a quick overview for the busy reader.

Thoracolumbar Spinal Injuries Chapter 31 919 920 Section Fractures

fixation. Depending on the persistence of spinal the operative approach. A combined posterior and device in patients who had a burst fracture of the thoracolumbar spine and associated canal compromise or comminution of the fractured anterior approach is used to reduce and stabilize neurological deficits yielded good radiographic and functional results. This article estab- vertebral body, an additional anterior approach is severely comminuted vertebral body fractures and lished the single stage anterior approach for this fracture type. needed. Transpedicular cancellous bone grafting to decompress the spinal canal. In Type C lesions Knop C, Blauth M, Bühren V, Hax PM, Kinzl L, Mutschler W, Pommer A, Ulrich C, Wag- for interbody fusion after posterior stabilization is often multisegmental instrumentation is needed ner S, Weckbach A, Wentzensen A, Wörsdörfer O (1999)Surgicaltreatmentofinjuriesof not recommended in complete or incomplete burst to reliably stabilize the spine. the thoracolumbar transition. 1: Epidemiology. Unfallchirurg 102:924–35 fractures. Only incomplete Type A burst fractures with intact pedicles and a lower endplate should be The reported complication rate in Knop C, Blauth M, Bühren V, Hax PM, Kinzl L, Mutschler W, Pommer A, Ulrich C, Wag- Complications. ner S, Weckbach A, Wentzensen A, Wörsdörfer O (2000)Surgicaltreatmentofinjuriesof considered for posterior monosegmental reduc- the literature varies largely and ranges from 3.6% to the thoracolumbar transition. 2: Operation and roentgenologic findings. Unfallchirurg tion and stabilization. Compared to the open 10%. Postoperative neurological complications 103:1032–47 method, minimally invasive surgery reduces post- range from 0.1% to 0.7%. Only honest and accurate operative pain, shortens hospitalization, leads to assessment of complications will lead to scientific Knop C, Blauth M, Bühren V, Arand M, Egbers HJ, Hax PM, Nothwang J, Oestern HJ, PizanisA,RothR,WeckbachA,WentzensenA(2001) Surgical treatment of injuries of early recovery of function and reduces morbidity of and clinical progress. the thoracolumbar transition – 3: Follow-up examination. Results of a prospective multi-center study by the “Spinal” Study Group of the German Society of Trauma Surgery. Unfallchirurg 104:583–600 These three reports summarize the experience based on 682 patients included in a prospective multicenter study by the “Spinal” Study Group of the German Society of Trauma Key Articles Key articles Surgery. All treatment methods under study were appropriate for achieving comparable clinical and functional outcome. The internal fixator was found superior in restoration of Böhler L (1951) Die Technik der Knochenbruchbehandlung. Maudrich, Vienna the spinal alignment. Best radiological outcomes were achieved by combined stabiliza- Lorenz Böhler was one of the first to advocate a conservative treatment with fracture tion. Merely by direct reconstruction of the anterior column the postoperative re-kypho- introduce landmark reduction and retention in a cast. sing is prevented and a gain in segmental angle is achieved. However, this benefit was not reflected in the clinical outcome. Roaf R (1960) A study of the mechanics of spinal injuries. J Bone Joint Surg Br 42B:810–23 Fehlings MG, Perrin RG (2005) The role and timing of early decompression for cervical papers which had a In this article Roaf studies the biomechanics of spinal injuries and describes the results of spinal cord injury: Update with a review of recent clinical evidence. Injury S-B13–S-B26 studies of spinal units when subjected to forces of different magnitude and direction, i.e., Evidence-based recommendations regarding spinal cord decompression in patients with compression, flexion, extension, lateral flexion, rotation, and horizontal shear. acute spinal cord injury. substantial impact Denis F (1983) The three column spine and its significance in the classification of acute Beisse R (2006) Endoscopic surgery on the thoracolumbar junction of the spine. Eur thoraco-lumbar spinal injuries. Spine 8:817–31 Spine J 15:687–704 This article is a presentation of the concept of the three-column spine. The concept This article summarizes the technique and results based on a large patient group from a evolved from a retrospective review of 412 thoracolumbar spine injuries and observa- German trauma center: A now standardized operating technique, instruments and on our current tions on spinal instability. The posterior column consists of what Holdsworth described implants specially developed for the endoscopic procedure, from angle stable plate and as the posterior ligamentous complex. The middle column includes the posterior longitu- screw implants to endoscopically implantable vertebral body replacements, have gradu- dinal ligament, posterior anulus fibrosus, and posterior wall of the vertebral body. The ally opened up the entire spectrum of anterior spine surgery to endoscopic techniques. anterior column consists of the anterior vertebral body, anterior anulus fibrosus, and understanding of the anterior longitudinal ligament. 1987 Dick W ( ) The “fixateur interne” as a versatile implant for spine surgery. Spine References 12:882–900 pathology, diagnosis This article introduced a new angle-stable fixation device which first allowed a short segmental reduction and fixation of fractures. 1. Alanay A, Acaroglu E, YaziciM, Oznur A, Surat A (2001) Short-segment pedicle instrumentation of thoracolumbar burst fractures: does transpedicular intracorporeal grafting prevent Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classifica- early failure? Spine 26:213–7 or non-operative and tion of thoracic and lumbar injuries. Eur Spine J 3:184–201 2. Anderson PA, Henley MB, Rivara FP,Maier RV (1991) Flexion distraction and chance injuries This article describes a classification of thoracic and lumbar injuries. As a result of more to the thoracolumbar spine. J Orthop Trauma 5:153–60 3. Anderson PA, Rivara FP, Maier RV, Drake C (1991) The epidemiology of seatbelt-associated than a decade of consideration of the subject matter and a review of 1445 consecutive tho- injuries. J Trauma 31:60–7 racolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is surgical treatment. 4. Anderson PA, Bohlman HH (1992) Anterior decompression and arthrodesis of the cervical proposed. The classification is primarily based on pathomorphological criteria. Three spine: long-term motor improvement. Part II – Improvement in complete traumatic quadri- mechanisms classify the injury pattern according to the AO classification: axial compres- plegia. J Bone Joint Surg Am 74:683–92 sion (Type A), flexion distraction (Type B) and rotational/shear injuries (Type C). 5. Anderson S, Biros MH, Reardon RF (1996) Delayed diagnosis of thoracolumbar fractures in 1997 multiple-trauma patients. Acad Emerg Med 3:832–9 Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh S, Fujiya M ( )Anteriordecom- 6. Bagley LJ (2006) Imaging of spinal trauma. Radiol Clin North Am 44:1–12, vii pression and stabilization with the Kaneda device for thoracolumbar burst fractures 7. Been HD, Bouma GJ (1999) Comparison of two types of surgery for thoraco-lumbar burst 79 69–83 associated with neurological deficits. J Bone Joint Surg Am : fractures: combined anterior and posterior stabilisation vs. posterior instrumentation only. One hundred and fifty consecutive patients who had a burst fracture of the thoracolum- Acta Neurochir (Wien) 141:349–57 bar spine and associated neurological deficits were managed with a single-stage anterior 8. Beisse R, Muckley T, Schmidt MH, Hauschild M, Buhren V (2005) Surgical technique and spinal decompression, strut-grafting, and Kaneda spinal instrumentation. The authors results of endoscopic anterior spinal canal decompression. J Neurosurg Spine 2:128–36 conclude that anterior decompression, strut-grafting, and fixation with the Kaneda 9. Beisse R (2006) Endoscopic surgery on the thoracolumbar junction of the spine. Eur Spine J 15:687–704 References provide an in-depth library for further reading.