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Chapter 41 - Other Disordes of Spine

Douglas A. Linville
Spinal Stenosis
Before the development of roentgenograms, there were scattered reports of paralysis caused by narrowing
of the spinal canal. The first verifiable report of lumbar spinal stenosis relieved by two-level laminectomy
was that of Sachs and Fraenkel in 1900. Bailey and Casamajor in 1911 and Elsberg in 1913 wrote similar
descriptions of the symptoms, pathological findings, and relief after surgery. The syndrome was not
widely diagnosed until Verbiest in 1954 described the classic findings of middle-aged and older adults
with back and lower extremity pain precipitated by standing and walking and aggravated by
hyperextension. He delineated congenital narrowing of the spinal canal as a contributing factor in many
and the secondary development of degenerative changes that further narrowed the lumbar canal and
precipitated symptoms. Myelographic block in the midlumbar region with the characteristic degenerative
hypertrophic changes about the discs, facets, and ligamentous structures was described in detail. A
subsequent article by Verbiest on lumbar spondylosis documented detailed measurements of the spinal
canal obtained during surgery. Since that time the syndrome has been well recognized, and numerous
well-documented series have been reported. An excellent four-part review of the entire topic was
published by Ehni et al. in 1969.
Dunlop, Adams, and Hutton in a cadaver study found a significant increase in pressure on the facet joints
with disc space narrowing and increasing angles of extension. Degenerative spinal stenosis has been
attributed to simple hypertrophic overgrowth of the superior articular facets that is the result of a
progressive degeneration of the disc with resultant instability or hypermobility in the facet joints. As joint
destruction progresses, the hypertrophic process finally results in local ankylosis. Calcification and
hypertrophy of the ligamentum flavum and venous hypertension resulting in generalized bone overgrowth
also may be contributing factors. Mild trauma and occupational activity do not appear to significantly
affect the development of this disease, but they may exacerbate a preexisting condition.
ANATOMY

Spinal stenosis can be categorized according to the anatomical area of the spine affected, the region of
each vertebral segment affected, and the specific pathological entity involved ( Table 41-1 ). Stenosis can
be generalized or localized to specific anatomical areas of the cervical, thoracic, or lumbar spine. It is
most common in the lumbar region, but cervical stenosis also occurs frequently. It has been reported
rarely in the thoracic spine. Spinal stenosis can be localized or diffuse, affecting multiple levels as in
congenital stenosis. Degeneration of the disc occurs with disc narrowing and subsequent ligamentous
redundancy, which compromises the spinal canal area. Instability may ensue, aggravating symptoms by
the formation of facet overgrowth and ligamentous hypertrophy. The ligamentum flavum may be
markedly thickened into the lateral recess where it attaches to the facet capsule, causing nerve root
compression. These phenomena occur alone or in combination to create the symptomatic complex
characteristic of spinal stenosis.
A description of spinal stenosis requires an understanding of the anatomy affected and the use of
consistent terminology ( Fig. 41-1 ). Central spinal stenosis denotes involvement of the area between the
facet joints, which is occupied by the dura and its contents. Stenosis in this region usually is caused by
protrusion of a disc, annulus, or osteophytes or by buckled or thickened ligamentum flavum.
Symptomatic central spinal stenosis results in neurogenic claudication. Lateral to the dura is the lateral
canal, which contains the nerve roots; compression in this region results in radiculopathy. The lateral
recess, also known as Lee's entrance zone, begins at the lateral border of the dura and extends to the
medial border of the pedicle. This is where the nerve root exits the dura and courses distally and laterally
under the superior articular facet ( Fig. 41-2, A ). The borders of the lateral recess are the pedicle laterally,
the superior articular facet dorsally, the disc and posterior ligamentous complex (PLC) ventrally, and the
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central canal medially. Ciric et al. reported that facet arthritis most frequently causes stenosis in this zone,
along with vertebral body spurring and disc or annulus pathology. Lee's mid-zone describes the
foraminal region, which lies ventral to the pars. Its borders are the lateral recess medially, the posterior
vertebral body and disc ventrally, the pars distally, and the lateral border of the pedicle laterally. The
dorsal root ganglion and ventral motor root occupy up to 30% of this space. This also is the point where
the dura becomes confluent with the nerve root as epineurium. Causes of stenosis in this area are pars
fracture with proliferative fibrocartilage or a lateral disc herniation ( Fig. 41-2, B ). Thickening of the
ligamentum flavum sometimes persists into the foramen and can be associated with a spur from the
undersurface of the pars, especially if foraminal height is less than 15 mm and posterior vertebral body
height is less than 4 mm. The exit zone is identified as the area lateral to the facet
TABLE 41-1 -- Classification of Spinal Stenosis
Anatomical Area

Anatomical Region (Local Segment)

ANATOMICAL
Cervical

Central
Foraminal

Thoracic

Central

Lumbar

Central
Lateral recess
Foraminal
Extraforaminal (far-out)

PATHOLOGICAL
Congenital
Achondroplastic (dwarfism)
Congenital forms of spondylolisthesis
Scoliosis
Kyphosis
Idiopathic
Degenerative and Inflammatory
Osteoarthritis
Inflammatory arthritis
Diffuse idiopathic skeletal hyperostosis (DISH)
Scoliosis
Kyphosis
Degenerative forms of spondylolisthesis
Metabolic
Paget disease
Fluorosis
joint. The nerve root is present in this location and can be compressed by a far-lateral disc,
spondylolisthesis and associated subluxation, or facet arthritis.
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The most common type of spinal stenosis is caused by degenerative arthritis of the spine, including
Forestier syndrome, and is characterized by hyperostosis and spinal rigidity in elderly patients. Congenital
forms caused by disorders such as achondroplasia and dysplastic spondylolisthesis are much less
frequent. Finally, other processes such as Paget disease, fluorosis, kyphosis, scoliosis, and fracture with
canal narrowing

Figure 41-1 Zones of lateral canal as described by Lee. Entrance zone (1) is cephalad and medial aspects of lateral recess that
begins at lateral aspect of thecal sac and runs obliquely down and laterally toward intervertebral foramen. Mid-zone (2) is
located beneath pars interarticularis and just inferior to pedicle and is bounded anteriorly by posterior aspect of vertebral body
and posteriorly by pars; medial boundary is open to central spinal canal. Exit zone (3) is formed by intervertebral foramen.
(From An HS, Butler JP: Semin Spine Surg 11:184, 1999.)

have been reported to result in spinal stenosis. Hypertrophy and ossification of the posterior longitudinal
ligament in the cervical spine (diffuse idiopathic skeletal hyperostosis [DISH] syndrome) also may result
in an acquired form of spinal stenosis. This disease usually is confined to the cervical spine.
Differentiation between the pathological processes causing spinal stenosis is relatively simple. Congenital
spinal stenosis usually is central and evident on imaging studies. In achondroplasia the canal is narrowed
in both the anteroposterior plane due to shortened pedicles and in lateral diameter because of diminished
interpedicular distance. These findings occur in addition to the other characteristic features of
achondroplasia. Idiopathic congenital narrowing usually involves one dimension of canal measurement,
and the patient otherwise is normal.
Acquired forms of spinal stenosis usually are degenerative ( Box 41-1 ) and are localized to the facet
joints and ligamentum flavum, with additional arthritic changes in the joints visible on roentgenographic
studies. Frequently these abnormalities are symmetrical. The L4-5 level is the most commonly involved,
followed by L5-S1 and L3-4. Disc herniation and spondylolisthesis may further exacerbate the narrowing.
Spondylolisthesis and spondylolysis rarely cause spinal stenosis in young patients. The combination of
degenerative change, aging, and spondylolisthesis or spondylolysis in patients 50 years or older
frequently results in lateral recess or foraminal stenosis. Paget disease and fluorosis have been reported to
result in central or lateral spinal stenosis. Paget disease is one form of spinal stenosis that responds well to
medical treatment with calcitonin.
NATURAL HISTORY

The natural course of all forms of spinal stenosis is the insidious development of symptoms occasionally
exacerbated by trauma or heavy activity. Many patients have significant roentgenographic findings with
minimal complaints or physical findings. Johnsson, Rosn, and Udn reported that 19 (70%) of 27
patients with moderate, untreated spinal stenosis (11 mm or more anteroposterior canal diameter)
remained unchanged after 4 years of observation; 4 (15%) improved, and 4 deteriorated without serious
sequelae. In a separate study, Johnsson et al. found that 11 of 19 (58%) untreated patients were unchanged
at 31-month follow-up, 6 were improved, and only 2 were worse.
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Figure 41-2 A, Entrance zone stenosis. Hypertrophy of superior articular process narrows lateral recess and compresses nerve
root. B, Mid-zone stenosis. Fibrocartilaginous mass associated with spondylolysis may impinge on nerve root at distal level
and medial to pedicle level. (From An HS, Butler JP: Semin Spine Surg 11:184, 1999.)

Box 41-1. Classification of Spinal Stenosis


CONGENITAL
Idiopathic
Achondroplastic
ACQUIRED
Degenerative
Central canal
Lateral recess, foramen
Degenerative spondylolisthesis
Degenerative scoliosis
Combination of congenital and degenerative stenosis
Iatrogenic
Postlaminectomy
Postfusion
Postchemonucleolysis
Spondylolytic
Posttraumatic
Miscellaneous
Paget disease
Fluorosis
Diffuse idiopathic skeletal hyperostosis syndrome
Hyperostotic lumbar spinal stenosis
Oxalosis
Pseudogout

In a prospective, randomized study by Amundsen et al. of 100 patients with symptomatic spinal stenosis,
19 patients with severe symptoms were treated operatively, 50 patients with moderate symptoms were
treated conservatively, and 31 patients were randomized to receive operative (13) or conservative (18)
treatment. Pain relief was noted after 3 months in most patients regardless of treatment but took as long as
12 months in a few patients. However, results in conservatively treated patients deteriorated over time,
and at 4 years were excellent or fair in 50% of patients treated nonoperatively; 80% of those treated
operatively still had good results. Results were not worse if surgery was done 3 years after failed
conservative treatment, and significant deterioration did not occur during the 6 years of follow-up in any
of the three groups of patients. Predictors of poor outcomes could not be identified. These authors
concluded that conservative treatment is appropriate for patients with moderate pain, 50% of whom will
have pain relief in less than 3 months, but operative treatment probably is indicated for patients with
severe pain and those in whom conservative treatment fails.
Reported studies suggest that for most patients with spinal stenosis a stable course can predicted, with
15% to 50% showing some improvement with nonoperative treatment. Worsening of symptoms despite
adequate conservative treatment is an indication for operative treatment.
CLINICAL EVALUATION

In a group of 100 patients, Amundsen et al. found back pain and sciatica present in 95% and claudication
present in 91%. Sensory disturbance in the legs was present in 70%, with motor weakness in 33%, and
voiding disturbance present in only 12% of patients. Despite the coexistent symptoms, back pain had been
present for a median duration of 14 years and sciatica for a median duration of 2 years before
presentation. Bilateral leg complaints were present in 42%, and unilateral leg symptoms were present in
the other 58%. Distribution of symptoms was L5 in 91%, S1 in 63%, L1-4 in 28%, and S2-5 in 5%.
Forty-seven patients (47%) had symptoms specific for two nerve roots, and 35% had monoradiculopathy.
Three- and four-level radicular complaints were recorded in 17% and 1%, respectively. In patients with
central spinal stenosis, symptoms usually are bilateral and involve the buttocks and posterior thighs in a
nondermatomal distribution. With lateral recess stenosis, symptoms usually are dermatomal because they
are related to a specific nerve being compressed. Patients with lateral recess stenosis may have more pain
during rest and at night but more walking tolerance than patients with central stenosis.
Differentiation of symptoms of vascular claudication from those of neurogenic claudication is important
( Table 41-2 ). Vascular symptoms typically are felt in the upper calf, are relieved after a short rest (5
minutes) while still standing, do not require sitting or bending, and worsen despite walking uphill or
riding a stationary bicycle. Neurogenic claudication improves with trunk flexion, stooping, or lying but
may require up to 20 minutes to improve. Patients often report better endurance walking uphill or up steps
and tolerate riding a bicycle better than walking on a treadmill because of the flexed posture that occurs.
Pushing a grocery cart also allows spinal flexion, which enhances endurance in most patients with
neurogenic claudication.
Generally, physical findings with all forms of spinal stenosis are inconsistent. Distal pulses should be felt
and confirmed to be strong, and internal and external rotation of the hips in extension should be full,
symmetrical, and painless. Straight leg raising and sciatic tension tests usually are normal. The
neurological examination usually is normal, but some abnormality may be detected if the patient is
allowed to walk to the limit of pain and is then reexamined. The gait and posture after walking may reveal
a positive stoop test. This test is done by asking the patient to walk briskly. As the pain intensifies, the
patient may complain of sensory symptoms followed by motor symptoms. If the patient is asked to
continue to walk, he may assume a stooped posture, and the symptoms may be eased; or, if he sits in a
chair bent forward, the same resolution of symptoms will occur.

TABLE 41-2 -- Differentiation of Symptoms of Vascular Claudication from Those of Neurogenic


Claudication
Evaluation

Vascular

Neurogenic

Walking distance

Fixed

Variable

Palliative factors

Standing

Sitting/bending

Provocative factors

Walking

Walking/standing

Walking uphill

Painful

Painless

Bicycle test

Positive (painful)

Negative

Pulses

Absent

Present

Skin

Loss of hair; shiny

Normal

Weakness

Rarely

Occasionally

Back pain

Occasionally

Commonly

Back motion

Normal

Limited

Pain character

Crampingdistal to proximal

Numbness, achingproximal to
distal

Atrophy

Uncommon

Occasional

DIAGNOSTIC IMAGING
Roentgenography

Although plain roentgenography cannot confirm spinal stenosis, findings such as short pedicles on the
lateral view, narrowing between the pedicles on the anteroposterior view, ligament ossification, narrowing
of the foramen, and hypertrophy of the posterior articular facets can be helpful hints. Leroux et al.
outlined hypertrophic roentgenographic changes associated with hyperostosis on plain and computed
tomography (CT) ( Box 41-2 ).
The roentgenographic identification and confirmation of lumbar spinal stenosis have improved with the
development of new imaging techniques. Initially only central spinal stenosis was recognized, with canal
narrowing to 10 mm considered absolute stenosis. This could be measured using roentgenograms or
preferably myelography. In 1985 Schnstrm, Bolender, and Spengler compared the identification of
central spinal stenosis with anteroposterior canal measurement by CT to identification by measurement of
the dural sac with myelography in patients undergoing surgery for spinal stenosis. They found no
correlation between the transverse area of the bony canal in normal patients and patients with spinal
stenosis. A dural sac transverse area of 100 mm2 or less did correlate with symptomatic spinal stenosis.
This method allows the inclusion of soft tissue in the determination of spinal stenosis. The analysis of this
area can be calculated relatively easily using standard CT scanning software.
Currently, axial imaging has supplanted standard roentgenograms in the diagnosis of spinal stenosis,
although roentgenograms are important in the initial evaluation of patients with persistent pain of more
than 6 weeks' duration or of those with red flags of other disease, including recent trauma, history of
cancer, immunosuppression, age more than 50 or less than 20 years, neurological deficit, or previous
surgery. Flexion and extension views are useful to identify preexisting instability before laminectomy and
may be useful in determining the need for subsequent fusion. Translation of more than 4 to 5 mm or
rotation of more than 10 degrees to 15 degrees is indicative of instability. A reversal of the normal
trapezoidal disc geometry with widening posteriorly and narrowing anteriorly also may indicate
instability.
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Box 41-2. Hypertrophic Roentgenographic Changes Associated with Hyperostosis *


PLAIN ROENTGENOGRAPHS
Dorsal level
Intervertebral osseous bridge
Lobster claw
Cervical level
Exuberant osteophytosis
Narrow cervical canal
Lumbar level
Marginal somatic osseous proliferation
Candle flame
Lobster claw
Intervertebral osseous bridge
Discarthrosis
Acquired vertebral block
Hypertrophy of the posterior articular processes
Bulb appearance of the posterior articular hypertrophy
Anterior subluxation
Posterior subluxation
LUMBAR CT SCAN
Herniated disc
Disc protrusion
Vacuum disc sign
Hypertrophy of the posterior articular processes
Osteoarthritis of apophyseal joints
Osseous proliferations of the nonarticular aspects of the superior apophyseal joint
Osseous proliferations of the nonarticular aspects of the inferior apophyseal joint
Calcification and/or ossification (C/O) of the posterior logitudinal ligament (PLL)
C/O of the yellow ligament (YL)
C/O of the supra-spinal ligament (SL)
Anterior C/O of the posterior articular capsule
Posterior C/O of the posterior articular capsule
Anteroposterior diameter of the spinal canal
Transverse diameters of the spinal canal

*Modified from Leroux JL, Legeron P, Moulinier L, et al: Spine 17:1214, 1992.
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MRI

Boden et al. noted abnormal findings in 67% of asymptomatic patients evaluated by MRI. In patients
older than 60 years, 57% of MRI scans were abnormal, including 36% of patients with herniated nucleus
pulposus and 21% with spinal stenosis. MRI is helpful in identifying other disease processes, such as
tumors and infections, and is a good noninvasive study for patients with persistent lower extremity
complaints after roentgenographic screening evaluation. MRI should be confirmatory in patients with a
consistent history of neurogenic claudication or radiculopathy, but it should not be used as a screening
examination because of the high rate of asymptomatic disease. Sagittal T2-weighted images are a good
starting point because they give a myelogram-like image. Sagittal T1-weighted images are evaluated with
particular attention focused on the foramen. An absence of normal fat around the root is indicative of
foraminal stenosis. Axial images provide a good view of the central spinal canal and its contents on T1and T2-weighted images. Far-lateral disc protrusions are identified on axial T1-weighted images by
obliteration of the normal interval of fat between disc and root ( Fig. 41-3 ). The foraminal zone is better
evaluated with sagittal T1-weighted sequences, which confirm the presence of fat around the nerve root.
Absolute anatomical measures also can be used, as previously discussed ( p. 2065 ). Schnebel et al. noted
a 96.6% agreement in pathological anatomy defined by postmyelogram CT and MRI. They noted the
greatest disagreement in the MRI L5-S1 axial cuts because of the inability of the cut to be aligned parallel
to the disc space. This can be a problem with spinal deformity, including scoliosis and significant
spondylolisthesis, because true axial images are difficult to obtain. A disadvantage of MRI is the cost;
nonetheless, MRI has become a useful, noninvasive diagnostic tool for the evaluation of patients with
extremity complaints.
CT and Myelography

Despite the prevalence of MRI, myelography followed by CT scanning is still accepted and widely used
for operative planning in patients with spinal stenosis; it has a diagnostic accuracy of 91%. The addition
of CT scanning after a myelogram allows detection of as many as 30% more abnormalities than with
myelography alone. Because of the dynamic nature of the study, stenosis not visible on MRI with the
patient recumbent may be identified on standing flexion and extension lateral views. CT scanning after
myelography characterizes the bony anatomy better than MRI, which helps the surgeon plan
decompression surgery. However, imaging of the nerve roots in the foraminal region lateral to the pedicle
is not possible because of the confluence of the dura with the epineurium at this point. Thus myelography
followed by CT scanning is best suited for dynamic stenosis, postoperative leg pain, severe scoliosis or
spondylolisthesis, around metallic implants, or in patients with lower extremity symptoms in the absence
of findings on MRI.
Wiesel et al. evaluated 52 patients without low back symptoms or spinal disease and discovered that 50%
over 40 years old had abnormal CT scans. They identified herniated nucleus pulposus in 29.2%, facet
degeneration in 81.5%, and spinal stenosis in 48.1%. It must be reiterated that abnormal findings occur in
as many as 24% to 34% of asymptomatic individuals evaluated with CT and myelography, just as with
MRI, so clinical correlation is a must.
Ciric et al. and others used CT to further define lateral recess stenosis and foraminal stenosis. These types
of stenosis rarely are identified with myelography. The lateral recess is anatomically the area bordered
laterally by the pedicle, posteriorly by the superior articular facet, and anteriorly by the posterolateral
surface of the vertebral body and the adjacent intervertebral disc. The superior border of the
corresponding pedicle is the narrowest portion of the lateral recess. Measurement of the recess in this area
using the tomographic cross section usually is 5 mm or greater in normal patients, but in symptomatic
patients the diagnosis is confirmed if the height is 2 mm or less ( Fig. 41-4 ). The foramen is the area of
the spine bordered by the inferior edge of the pedicle cephalad, the pars interarticularis with the
associated inferior articular facet and the superior articular facet from the lower segment posteriorly, the
superior edge of the pedicle of the next lower vertebra caudally, and the vertebral body and disc
anteriorly. This area rarely can be seen with myelography. A standard CT scan in the cross-sectional mode
suggests narrowing if the foraminal space immediately after the pedicle cut is present for only one or two
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more cuts (provided the cuts are close together). The best way to appreciate foraminal narrowing is to
reformat the lumbar scan, which can create sagittal views through the pedicles and structures situated
laterally. Riew et al. reported that myelography influenced operative decision making more than MRI.
When requested by the treating physician, CT myelography altered the operative plan in 74% of patients.
Even when CT myelography was considered unnecessary, it altered the treatment plan in 49% of patients.

Figure 41-3 T1-weighted MRI showing far lateral disc protrusion. Note obliteration of normal interval of fat between disc and
root.

Figure 41-4 Three-dimensional illustration of segmental stenoses. A, Anatomical; B, segmental; C, pathological. (Redrawn
from Ciric I, Mikhael MA, Tarkington JA, Vic NA: J Neurosurg 53:433, 1980.)

Figure 41-5 A, Coronal view of CT scan showing impingement of transverse process of L5 on sacrum. B, Coronal section
showing right transverse process. C, Drawing of coronal section. (From Wiltse LL, Guyer RD, Spencer CW, et al: Spine 9:31,
1984.)

Wiltse et al. described a far-out compression of the root that occurs predominantly in spondylolisthesis
when the root is compressed by a large L5 transverse process subluxed below the root and pressing the
root against the ala of the sacrum. This diagnosis is best confirmed with a reformatted CT scan with
coronal cuts ( Fig. 41-5 ).
Some studies have attempted to correlate clinical outcomes with pathological findings on myelography
and CT. In a retrospective review of 251 patients who underwent surgery for lumbar spinal stenosis,
operative outcomes, as determined by Oswestry questionnaires, were evaluated and correlated with
myelographic results. Patients who had a block on myelogram had a better chance of obtaining a good
outcome. A prospective study by Herno et al. confirmed postoperative stenosis in 64% of 191 patients at
4-year follow-up. Slight differences between those with and without stenosis were noted on the Oswestry
questionnaire, but not in walking distances; instability was present in 21% without demonstrable clinical
effect. In fact, the degree of decompression on CT myelography did not correlate at all with outcomes.
Herno et al. reported similar results whether all stenotic levels were decompressed, only one level was
decompressed leaving adjacent stenotic levels alone, or incomplete decompression of stenotic levels was
done. Other studies by Paine and Surin et al. contradicted this, reporting worse results in patients with
severe postoperative stenosis. Nonetheless, decompression of all symptomatic levels with evidence of
compression is recommended to enhance neural circulation and function and to avoid reoperation for
recurrent spinal stenosis.
Other Diagnostic Studies

Electrodiagnostic studies should be used if the diagnosis of neuropathy is uncertain, especially in patients
with diabetes mellitus. The diagnostic use of such studies, including somatosensory evoked potentials, is
limited by the lack of prospective studies to determine sensitivity or specificity. Vascular Doppler
examinations are useful in identification of inflow problems into the lower extremities and should be
accompanied by a vascular surgery consultation when indicated.
Differential diagnosis also can be aided by the use of exercise testing. Tenhula et al. described a bicycletreadmill test that stresses the patient in an upright position on an exercise treadmill and subsequently in a
seated position on an exercise bicycle that allows spinal flexion. This study showed significant
postoperative improvement in treadmill walking duration, lower visual analog pain scores, and a later
onset of pain. Of the 32 patients evaluated preoperatively, 88% had symptoms during treadmill testing,
and 41% had symptoms during bicycle testing. After decompression with or without fusion, only 9% had
positive exercise treadmill findings, and 17% developed symptoms on the bicycle. Fritz et al. reported
similar results with a two-stage exercise treadmill test. Earlier onset of leg symptoms with level walking
and delayed onset of symptoms with inclined treadmill walking were significantly associated with
stenosis. Exercise treadmill testing also is useful to help determine baseline function for quantitative
evaluation of functional status after surgery.
NONOPERATIVE TREATMENT

Symptoms of spinal stenosis usually respond favorably to nonoperative management. Despite symptoms
of back pain, radiculopathy, or neurogenic claudication, conservative management is successful in most
patients. Conservative measures should include rest not exceeding 2 days, pain management with
antiinflammatory medications or acetaminophen, and participation in a trunk-stabilization exercise
program, along with good aerobic fitness. Other methods should be reserved for patients who are limited
by pain and should be used to maximize participation in the exercise program. Traction has no proven
benefit in the adult lumbar spine. For a patient with unremitting symptoms of radiculopathy or neurogenic
claudication, epidural steroid injections may be useful in alleviating symptoms to allow better
participation in physical therapy. Epidural steroids can give significant symptomatic relief, although no
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scientific study has documented long-term efficacy. If spinal stenosis is present with coexistent
degenerative arthritis in the hips or knees, some permanent limitation in activity may be necessary
regardless of treatment.
Simotas et al. treated 49 patients with an aggressive nonoperative protocol of therapeutic exercise,
analgesics, and epidural steroid injection. All had spinal stenosis documented by CT or MRI and
symptoms of disabling back, buttock, or leg pain. Except for a few patients with acute neurological
changes who initially were prescribed 1 to 2 weeks of bed rest, patients were given one course of oral
corticosteroids on a 7-day tapered schedule. An epidural steroid injection was given if symptoms
persisted, with a repeat injection given if necessary by the transforaminal route at the point of most severe
constriction. A third injection was administered only at the treating physician's discretion, usually for
flare-ups during follow-up. For less severe symptoms, nonsteroidal antiinflammatory medications were
used for 4 to 6 weeks, and this occasionally was repeated. All patients participated in physical therapy that
included postural exercises, gentle lumbopelvic mobilization exercises, and a daily flexion lumbar
stabilization program. At 3-year follow-up, only 9 patients (18%) had required surgery after this treatment
regimen. At final follow-up, 42% rated overall pain as none or mild, and 56% rated leg pain as none or
mild. Sustained improvement was reported in 24% and mild improvement in 28%, with 13% definitely
worse. Regarding walking, 40% reported improvement, 35% reported no change, and 25% reported
worsening at final follow-up. This study documented the effectiveness of a structured nonoperative
treatment regimen in patients with spinal stenosis, reporting satisfactory results in 69% at 3 years.
Epidural Steroid Injection

Although epidural steroid injections have been used in the treatment of spinal stenosis for a number of
years, reports in the literature have not substantiated a positive effect, and most prospective reports show
no statistically significant benefit. The technique of placementcaudal, translaminar, or transforaminal
also is debated, as is whether fluoroscopy should be used. Using anatomical landmarks for caudal
injections, Stitz et al. reported accurate placement in 65% to 74% of patients, with intravascular
placement in 4%. Accurate placement of translaminar injections appears to be equally difficult, with
successful placement reported in 70%. Complications are infrequent but can occur and include
hypercorticism, epidural hematoma, temporary paralysis, retinal hemorrhage, epidural abscess, chemical
meningitis, and intracranial air. A 5% incidence of dural puncture has been reported, and, if it occurs,
subarachnoid injection of steroids or local anesthetic should be avoided to prevent mechanical or
chemical nerve root irritation. Headaches occur in 1% to 5% of patients and are related to dural puncture
or the use of the caudal injection route. In patients with headaches associated with caudal injections, the
cause has not been determined because dural puncture should not occur at this level, since the dural
sleeve has terminated at midsacrum.
No scientifically validated long-term outcomes have been reported to substantiate the use of epidural
steroid injections. A meta-analysis showed that epidural steroids have little short-term advantage over
placebo for the treatment of leg pain. Unfortunately, studies are divided on the long-term results and the
avoidance of surgery. The ideal candidate for epidural steroid injection appears to be a patient who has
acute radicular symptoms or neurogenic claudication unresponsive to traditional analgesics and rest, with
significant impairment in activities of daily living. We have used this technique successfully in our
treatment algorithm for neurogenic claudication and radiculopathy.
OPERATIVE TREATMENT

The primary indication for surgery in patients with spinal stenosis is increasing pain that is resistant to
conservative measures. Since the primary complaint is back pain and some leg pain, pain relief after
surgery may not be complete. Most series report a 64% to 91% rate of improvement, 42% in patients with
diabetes, but most patients still have some minor complaints, usually referable to the preexisting
degenerative arthritis of the spine. Neurological findings, if present, improve inconsistently after surgery.
In a series reported by Guigui et al., only 30% had complete improvement in motor symptoms after
laminectomy, with 58% regaining grade 4 strength or better at a mean follow-up of 3 years. Reoperation
rates vary from 6% to 23%. Prognostic factors include better results with a disc herniation, stenosis at a
single level, weakness of less than 6 weeks' duration, age less than 65 years, and monoradiculopathy.
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Reversal of neurological consequences of spinal stenosis seems to be a relative indication for surgery
unless the symptoms are acute.
Roentgenographic findings alone are never an indication for surgery, as clearly indicated in the studies by
Wiesel et al. and Boden et al. Localized lesions without general involvement respond best. Ganz reported
86% good results in his series of 33 patients treated by decompressive surgery. In patients whose
preoperative symptoms were relieved by postural change, the success rate was 96%, compared with only
50% in those not relieved by postural change. Factors predicting outcome are variable, and correlation of
imaging with symptoms seems to be the best guarantee of improvement after surgery.
A patient's inability to tolerate the restricted lifestyle necessitated by the disease and the failure of a good
conservative treatment regimen should be the primary determining factors for surgery in a well-informed
patient. The patient should understand the potential for the operation to fail to relieve pain or to actually
worsen it, especially back pain. In addition to the general risks of spinal surgery, the severity of symptoms
and lifestyle modifications should be considered. Lumbar spinal stenosis does not result in paralysis, only
decreased ambulatory capacity, and conservative management is warranted indefinitely in a patient with
good function and manageable symptoms. Cervical and thoracic spinal stenoses, on the other hand, are
associated with painless paralysis in the form of cervical and thoracic myelopathy and require closer
attention and follow-up.
Principles of Spinal Stenosis Surgery

Decompression by laminectomy or a fenestration procedure is the treatment of choice for lumbar spinal
stenosis ( Fig. 41-6 ). Fusion is required if excessive bony resection compromises stability or if isthmic or
degenerative spondylolisthesis, scoliosis, or kyphosis is present. Other important indications for fusion
include adjacent segment degeneration after prior fusion and recurrent stenosis or herniated disc after
decompression. Laminectomy may be preferable in older patients with severe, multilevel stenosis,
whereas fenestration procedures, consisting of bilateral laminotomies and partial facetectomies that
preserve the midline structures, are an alternative in younger patients with intact discs. Whenever
possible, the source of pain should be localized with root blocks preoperatively to allow a more focal
decompression. At surgery, specific attention should be directed to the symptomatic area, which may
result in more extensive decompression than would normally be done with the pain source unconfirmed.
If radical decompression of only one root is necessary, additional stabilization by fusion with or without
instrumentation is unnecessary. The removal of more than one complete facet joint usually requires
instrumented fusion unless the patient is elderly or has a narrow disc at that level. It is advisable to
prepare the patient for fusion in case the findings at surgery require a more radical approach than
anticipated. Positioning the patient with the abdomen hanging free minimizes bleeding. If fusion is likely,
the hips should remain extended to prevent positional kyphosis. As in disc surgery, a microscope or
magnifying loupes and a head lamp are helpful. When proceeding with the decompression, care should be
taken to watch for adhesions that can result in dural tears, even if no previous surgery has been done.
Frequently the narrowing in the lateral recess and foramen is so great that a Kerrison rongeur cannot be
used without damaging the root. Dissection in the lateral recess and foramen usually requires a small,
sharp osteotome or a high-speed burr, which allows the surgeon to thin the bone sufficiently to allow
removal with angled curets. Unlike disc surgery, for decompression the lateral recess is best seen from the
opposite side of the table. The operating surgeon may find it necessary to switch sides during the
operation to better view the pathology and nerve roots. Blunt probes with increasing diameters also are
useful for determining adequate foraminal enlargement. McLaren and Bailey reported that five of six
patients with postoperative cauda equina syndrome had a disc removed from a stenotic spine without
adequate decompression of the stenosis. Spinal stenosis should be treated at the same time as the disc
herniation. A good approach is to start the decompression at a point of lesser stenosis and work toward the
area of most severe stenosis. This often frees the neural structures enough to make the final
decompression simpler and decreases the risk of damage to dura or nerve roots.
Adjacent Segment Degeneration

Adjacent disc degeneration and stenosis, or the transition syndrome, deserves special mention. It is known
that disc degeneration occurs adjacent to a fusion in 35% to 45% of patients because of the ensuing
12

hypermobility of the unfused joint. Lehmann et al. reported a 45% prevalence (15 of 33) of adjacent
segment instability, defined as more than 3 mm of translation, and a 42% occurrence of spinal stenosis
(14 of 33), usually above the fusion mass. Adjacent segment stenosis below the fusion mass, although less
frequent, always occurred along with stenosis above the fusion.
Adjacent segment breakdown may cause symptoms that require surgery in 30% of patients. Pathology,
including spinal stenosis, herniated nucleus pulposus, and instability, may require treatment years after
successful surgery. Breakdown is possible one or two levels above lumbosacral fusions and above or
below thoracolumbar and floating lumbar fusions. Schlegel et al. reported 58 patients who developed
spinal stenosis, disc herniation, or instability at a segment adjacent to a previously asymptomatic fusion
that was done an average of 13.1 years earlier. They found that floating lumbar fusions had

Figure 41-6 Algorithm for treatment of spinal stenosis. (From Hadjipavlou AG, Simmons JW, Pope MH: Semin Spine Surg
10:193, 1998.)

a much shorter symptom-free interval (6.3 years) than did other fusions (range, 13 to 16.6 years). Of 37
patients followed for more than 2 years after identification of adjacent segment breakdown and
subsequent surgery, 26 (70%) had good or excellent results, and 7 (19%) required additional operative
procedures. Some contribution of postoperative loss of lordosis after index surgery was suggested but was
not statistically significant in their data. These clinical findings have been substantiated by subsequent
biomechanical studies that confirmed kinematic changes in segments adjacent to spinal fusions. Simple
malalignment that occurs during patient positioning when the hips are not extended may result in
hypolordosis and increase the load across implants, as well as increase posterior shear and laminar strain
at adjacent levels. These changes may help to explain the cause of adjacent segment breakdown. Posterior
lumbar interbody fusion (PLIF) also resulted in adjacent segment changes in all patients, but this did not
affect results at 5 years in the series of Miyakoshi et al.
13

Rigidity of instrumentation has been hypothesized to correlate with motion at adjacent segments. A study
by Even-Sapir et al. using single photon emission computed tomography (SPECT) revealed increased
uptake in adjacent motion segments 4 years after surgery in 46% of patients with posterolateral fusions
and in 67% of patients with circumferential fusions. However, Doeer et al. found little difference in
adjacent segment motion between circumferential fusion and posterior fusion in a calf spine model.
Motion at the adjacent segment increased by 29% after posterior fusion and by 21% after circumferential
fusion. Thus it is undetermined whether more rigid fusion increases the likelihood of adjacent segment
changes.
Fusion is more difficult as the number of levels fused increases, with L4-5 being the most frequent site of
pseudarthrosis. Addition of a second level of fusion should be avoided if possible, and fusing a
degenerative disc as a prophylactic measure does not seem to be supported by the data available. The
actual source of transition syndromes cannot be determined from published studies; however,
postoperative hypolordosis and rigidity of the fused segment probably both contribute to the problem.
Surgery should attempt to maintain normal segmental lordosis and global sagittal balance, in addition to
fusing the fewest segments possible.
Complications are relatively infrequent after decompression for spinal stenosis and occur more often in
patients who are older than 80 years or age or who have diabetes. Complications are three times more
likely after the age of 75 than before age 40 and are twice as likely in those older than 80 years as in
patients younger than 70 years. The mortality rate is 2.3% after spinal stenosis in patients older than 80
years compared with 0.8% in those younger than 75 years. Comorbidities also contribute to poorer patient
satisfaction and increased operative complications. Deep venous thrombosis also must be considered in
patients after decompression. The incidence of this complication varies but is likely higher than reported.
Pulmonary emboli, however, are exceedingly rare. Prophylaxis is best limited to pneumatic compression
devices of the foot or calf and early ambulation, since the risk of epidural hematoma from
pharmacological agents is greater than the risk of a significant pulmonary event or deep venous
thrombosis. Reoperation is necessary in 9% to 23% of patients with spinal stenosis.
Decompression

There are no universal indicators of outcome after decompression. Outcome studies of lumbar
decompression for spinal stenosis by Herron and Mangelsdorf and McCullen et al. identified subgroups
associated with decreased rates of improvement. The factors they associated with poorer outcomes
included questionable roentgenographic confirmation of stenosis, female sex, litigation, previous failed
surgery, and the presence of spondylolisthesis. Katz et al. stated that for patients treated with laminectomy
with or without fusion, the patient's self-assessment of health was the best predictor of satisfaction, with
cardiac comorbidity also being predictive.
A 5-year follow-up study by Jnsson et al. described the ideal patient as one who has a pronounced
constriction of the spinal canal, insignificant lower back pain, no concomitant disease affecting walking
ability, and a symptom duration of less than 4 years. In their study, successful results were present in 63%
to 67% of patients, deteriorating to 52% at 5 years, with reoperations necessary in 18%. Specifically,
patients with 6 mm or less anteroposterior canal diameter preoperatively had better results. Similar results
were reported by Airaksinen et al., with 62% good or excellent results at 4.3 years after surgery in 438
patients who had undergone decompression only. Results were worse in patients with hip arthritis,
diabetes mellitus, previous surgery, vertebral fracture, or a postoperative complication. At an average 8.1year follow-up, Katz et al. reported that 75% of patients were satisfied with the results of decompression
despite severe back pain in 33% and inability to walk two blocks in 53%.
Prospective analysis of the Maine Lumbar Spine Group (Atlas et al.) identified a cohort of 67 patients
with spinal stenosis studied 4 years after surgery and compared with a less severely affected group of 52
patients treated conservatively. Better outcomes were noted in the operatively treated group despite their
being more severely affected and worse functionally before surgery: 70% of the operatively treated group
and 52% of the conservatively managed group reported improvement in back or leg pain. Some loss in
functional improvement was noted in the operatively treated group over time, with no worsening in the
conservative group. This also was confirmed in a later study by the same group. Of 148 patients with
14

lumbar spinal stenosis followed for 4 years after treatment, 81 had been treated with surgery and 67 were
treated without surgery. Those treated with surgery had more severe symptoms and worse function
preoperatively but had better outcomes at 4-year follow-up. Back and leg pain were much improved or
completely gone in 70% of the operatively treated group compared with 52% of those treated
nonoperatively. Of those having surgery, 63% were satisfied with their current status, compared with 47%
of those treated nonoperatively. Maximal benefit was noted 3 months after surgery. A modest decline in
outcomes over the 4-year follow-up was noted in the operatively treated group, with no significant
changes, either positive or negative, in those treated nonoperatively.
Progressive instability after decompression does not predict poor results. Poor ambulation has been
correlated with roentgenographic signs of instability; however, Frazier et al. found that normal walking,
sensory deficits, and ability to perform activities of daily living improved despite instability. Some further
anterolisthesis is tolerated well after decompression, and it is appropriate to observe these patients for
further symptoms before recommending fusion because as many as 30% of patients develop
anterolisthesis after decompression.
Midline Decompression (Neural Arch Resection)

TECHNIQUE 41-1
Perform the procedure with the patient under general endotracheal anesthesia. Position the patient prone
using the frame of choice. Make the incision in the midline centered over the level of stenosis. Localizing
roentgenograms should be taken if the level of dissection is uncertain. Carry the incision in the midline to
the fascia. Strip the fascia and muscle subperiosteally from the spinous processes and laminae to the facet
joints to expose the pars interarticularis. Take care to avoid damaging facet joints that are not involved in
the bony dissection. Identify and remove the spinous processes of the levels to be decompressed. Then
clear the soft tissue with a sharp curet. Dissect the lower edge of ligamentum flavum from the lamina with
a curet and remove the lamina with a Kerrison rongeur. If the lamina is extremely thick, a high-speed drill
with a diamond or side-cutting burr can be used to thin the outer cortex to allow easier removal of the
inner portion with a Kerrison rongeur. Take special care in removal of the lamina and ligamentum flavum.
The neural structures will be found compressed, and the usual space for instrument insertion may not be

Figure 41-7 Typical midline decompression for spinal stenosis. Note medial facetectomy and foraminotomy with preservation
of the pars. Decompression is from inferior border of L3 pedicle to superior border of L5 pedicle, exposing both lateral borders
of dura in lateral recess. (Redrawn from Whiffen JR, Neuwirth MG: Spinal stenosis. In Bridwell KH, DeWald RL, eds: The
textbook of spinal surgery, ed 2, Philadelphia, 1997, Lippincott-Raven.)

available. Remove the lamina until the pedicles can be felt. Using the pedicle as a guide, identify the
15

nerve root and trace it out to the foramen. With a chisel or rongeur, carefully remove the medial portion of
the superior facet that forms the upper portion of the lateral recess ( Fig. 41-7 ). Check the foramen for
patency with an angled dural elevator or graduated probes. If there is further restriction, carry the
dissection laterally and open the foramen, taking care not to remove more than half of the pars.
Undercutting into the foramen is especially helpful in this regard. Inspect the disc and remove gross
herniations unilaterally but try to avoid bilateral annulotomy because this compromises stability. Usually
the disc is bulging, and the annulus is firm. Remove the annulus and bony ridge ventrally if it is kinking
the nerve. This procedure involves some risk of nerve injury and requires a bloodless field. If safety is a
concern, a complete facetectomy may be better. Complete the dissection at all symptomatic levels.
Decompression should be from the caudal aspect of the most proximal pedicle to the cephalad aspect of
the most distal pedicle, allowing observation of the lateral margins of the dura in the lateral recesses. This
can be done with preservation of the proximal portion of the lamina and the intervening ligamentum
flavum at the level above and below. Many failed decompressions are the result of inadequate
decompression of the foraminal region, so probing the foramen is mandatory to determine if the
decompression is adequate. If no obstructions are noted and all areas have been decompressed adequately,
close the incision. If desired, take a large fat graft from the incision or buttock and place it over the
laminectomy defect and then close the incision.

Less-Invasive Decompression.

The consequences of bone and ligament removal must be considered when performing decompression for
spinal stenosis. Removal of the spinous processes, laminae, variable portions of the facets and pars,
supraspinous and interspinous ligaments, ligamentum flavum, and portions of facet capsules is routine
during these operative procedures. Denervation of the paraspinal musculature occurs with wide
exposures, which results in altered muscle function. A minimally invasive technique allows
decompression of the significant compressing anatomy while preserving paraspinal muscles, the spinous
processes, and intervening supraspinous and interspinous ligaments.
Spinous Process Osteotomy (Weiner et al.)

TECHNIQUE 41-2 ( Fig. 41-8 )


Patient positioning and localization of spinal levels are as described in the previous technique. Make a
midline incision to expose the dorsolumbar fascia. Make a paramedian incision in the fascia,
preserving the supraspinous and interspinous ligaments with subperiosteal dissection of the paraspinal
muscles from the spinous process and laminae. Take care to avoid lifting the multifidus muscles
beyond the medial aspect of the facet joint to preserve their innervation. With a curved osteotome, free
each spinous process from the lamina at its base. Release only the levels shown to be affected on
preoperative imaging. Once the spinous process is freed, retract it to one side with the paraspinal
muscles beneath the retractor and the other blade of the retractor beneath the multifidus muscles to
expose the midline ( Fig. 41-8, A ). Resect approximately half of the cephalad lamina and one fourth
of the caudal lamina along with the underlying ligamentum flavum. Using a loupe or microscope for
magnification, undercut the lateral recess and open the foraminal zone ( Fig. 41-8, B ). Complete
laminectomy is recommended for severe stenosis or congenital stenosis involving all anatomical zones
(central, lateral recess, and foraminal zones). Close the incision in routine fashion, allowing the
spinous process to return to its normal position with suture of the fascia ( Fig. 41-8, C ).
Weiner et al. reported a 47% improvement in the Low Back Outcome Score and a 66% improvement in
average pain level in 46 of 50 patients evaluated 9 months after surgery. Spinous process osteotomy was
done at one to four levels; the only complications were dural tears in four patients. Although 3 patients
died of unrelated causes, 38 of the 46 remaining patients were satisfied or very satisfied with their
operative results. On reexploration or postoperative CT scans, spinous processes usually united with the
remaining lamina in patients with short decompressions, although nonunion did not correlate with poor
results. Complete laminectomy may be necessary if adequate decompression is not possible through the
limited laminotomy in patients with severe involvement.
16

Figure 41-8 Spinous process osteotomy. A, Muscle is taken down on only one side and only to medial facet border. B,
Decompression is performed under microscopic magnification. C, After closure, spine returns to normal position. (Redrawn
from Weiner BK, Brower RS, McCulloch JA: Semin Spine Surg 11:253, 1999.)
Microdecompression

Microdecompression can be done in patients without disc herniations or instability including degenerative
spondylolisthesis. This is a technically demanding procedure and is not recommended for patients with
severe stenosis or congenital stenosis, which require complete laminectomy. McCulloch reported that
decompressions were done at one to five levels without intraoperative complications in 30 patients treated
for neurogenic claudication unresponsive to nonoperative measures. One superficial wound infection
occurred. Of the 30 patients, 26 were very satisfied or fairly satisfied with their results; all but one stated
that they would recommend the procedure to a friend with a similar problem.
TECHNIQUE 41-3 (McCulloch) ( Fig. 41-9 )
Place the patient in a kneeling position to increase interlaminar distance and identify the operative level
on standard roentgenograms. Make a midline incision centered over the affected levels documented on
preoperative imaging studies. Make a paramedian fascial incision on the most symptomatic side 1 cm
from the midline. Elevate the multifidus muscles subperiosteally from the spinous process and laminae
but do not retract them beyond the medial aspect of the facet joint. Obtain unilateral interlaminar
exposure and maintain it with a discectomy retractor. Under microscopic magnification, perform
laminotomy cephalad until the origin of the ligamentum flavum is encountered. Use undercutting to
preserve as much dorsal bone as possible; angle the microscope to accomplish this. In a similar fashion,
resect the proximal one fourth of the caudal lamina, thus completing removal of the ligamentum flavum
from origin to insertion. Again, angling of the microscope into the lateral recess allows further
decompression of the cephalad and caudad nerve roots and lateral dura. Once decompression is
completed on one side, angle the microscope toward the midline for contralateral decompression ( Fig.
41-9, A ). Rotation of the operative table allows better viewing of the contralateral structures ( Fig. 419, B ). Use a no. 4 Penfield elevator or similar instrument to release adhesions between the dura and
opposite ligamentum flavum, which is then resected in a similar fashion. Remove the bone at the base
of the spinous processes of the cephalad and caudal levels to provide adequate vision of the opposite
side ( Fig. 41-9, C ). Some removal of the deepest portions of the interspinous ligament also will be
necessary to adequately view the structures across the midline.
AFTERTREATMENT.

Special considerations are not necessary after a simple decompression. The patient should be examined
carefully for the first few days for new neurological changes that may indicate the formation of an
epidural hematoma. The patient is encouraged to walk on the first day.

17

Figure 41-9 Microdecompression. A, Muscle is taken down on only one side and ipsilateral decompressive hemilaminotomy is
done (gray area); then contralateral side is accessed under midline structures. B, Sac and root are gently retracted for
contralateral decompression. C, End result is complete decompression with preservation of paraspinal musculature and
interspinous and supraspinous ligaments, limited dead space, and excellent cosmetic result. (Redrawn from Weiner BK, Brower
RS, McCulloch JA: Semin Spine Surg 11:253, 1999.)

Sutures are removed at 14 days if nonabsorbable sutures have been used. The same limitations as after
disc surgery ( Chapter 39 ) apply to decompressions without fusion. For patients engaged in heavy
manual labor, a permanent job change may be required. Return to work also is similar to return after disc
surgery.
Decompression with Spinal Fusion.

The indications for spinal fusion with decompression for spinal stenosis are becoming more clearly
defined. The prevalence of postoperative problems related to instability is highly variable, possibly
because of the great variations in the extent of the operative decompression. Shenkin and Hash noted a
6% occurrence of postoperative spondylolisthesis in patients with bilateral facetectomy and a 15%
occurrence when three or more facets were removed. White and Wiltse noted subluxation after
decompression in 66% of patients with degenerative spondylolisthesis. They suggested that a fusion be
done in conjunction with decompression in (1) patients younger than 60 years of age with instability
caused by the loss of an articular process on one side, (2) patients younger than 55 years of age with a
midline decompression for degenerative spondylolisthesis that preserves the facets, and (3) patients
younger than 50 years of age with isthmic spondylolisthesis. Others have suggested that patients with
spinal stenosis and concomitant scoliosis should be treated with fusion because of the potential for
instability and progression of deformity. The complete removal of one facet, or more than 50% resection
of both facets, may result in instability. In addition, generalized spinal stenosis that requires extensive
decompression with the loss of multiple articular processes may require fusion. When complete bilateral
facetectomies are necessary, the addition of a lateral fusion may be difficult, and the bone graft may
impinge on the exposed nerve roots. In this instance, an anterior interbody fusion is warranted to prevent
postoperative instability. New posterior segmental fixation instrumentation for posterior spinal fusion has
decreased the high incidence of pseudarthrosis after these long lumbar fusions.
The complications of this procedure are similar to those of disc surgery; however, the risk of nerve root
damage and dural laceration is greater. The rates of infection, thrombophlebitis, and pulmonary embolism
also are slightly higher. When a facet has been partially resected, later facet or pars fracture may account
for a recurrence of symptoms. However, Getty et al. found that in their series the most important cause of
failure to relieve symptoms was inadequate decompression. Postacchini and Cinotti noted bone regrowth
at an average follow-up of 8.6 years in 88% of 40 patients who had total laminectomy for spinal stenosis.
Bone regrowth was noted in all patients with associated spondylolisthesis.

18

Degenerative Spondylolisthesis and Scoliosis


Junghanns first described degenerative spondylolisthesis in 1930, separating the pathology from isthmic
spondylolisthesis. He described this entity as pseudospondylolisthesis, which was later renamed by
Newman as degenerative spondylolisthesis because of the associated arthritic changes noted on
roentgenograms. Degenerative spondylolisthesis often is accompanied by spinal stenosis, which usually is
the cause of aggravation of symptoms and must be considered in patients with degenerative
spondylolisthesis.
Unstable stenosis, as described by Hanley, exists in two forms: unisegmental, which is manifested by
degenerative spondylolisthesis, and multisegmental, which is represented by degenerative scoliosis. Thus
treatment of either of these entities is really a continuum, and therefore they are considered together.
INCIDENCE

Degenerative spondylolisthesis occurs in patients older than 40 years and rarely is identified before that
time. It is characterized by a posterior slip of one vertebra on another of less than 33%, with deformity
occurring at L4-5 six times more often than at other lumbar levels and four times more often above a
sacralized L5. Other levels may be similarly affected, with L3-4 affected more often than L5-S1. This
disorder was found in approximately 4% of autopsy specimens and was identified in 10% of women older
than 60 years. Women are affected by this condition four to six times more often than men, probably
because of ligamentous laxity and abnormal facet morphology. Diabetes has been present in a
disproportionate number of study patients, and Imada et al. found that oophorectomized patients had a
three times greater rate of degenerative spondylolisthesis than did non-oophorectomized patients.
Degenerative scoliosis develops in patients with previously straight spines after the age of 40 years,
typically affecting the lumbar spine with an associated lumbar hypolordosis, lateral olisthesis, and spinal
stenosis. Men and women are affected more equally than patients with idiopathic curves, with about 60%
to 70% of those affected being women. Degenerative scoliosis also affects fewer segments (2 to 5
segments) than does adult idiopathic scoliosis (7 to 11 segments), with an equal distribution of right and
left lumbar curves. Symptoms of spinal stenosis occur most often in degenerative curves that have defects
in both the convexity and concavity, possibly because significant degenerative changes preceded the
development of the scoliosis. As a result, treatment for degenerative scoliosis often is necessary to relieve
spinal stenosis by decompression, with instrumented fusion to prevent instability and further progression
of deformity.
ANATOMY AND BIOMECHANICS

Degenerative spondylolisthesis is differentiated from isthmic spondylolisthesis by the presence of an


intact pars. Because the arch is intact and moves forward with the L4 vertebral body, progressive spinal
stenosis occurs in addition to facet degenerative changes. The true deformity of degenerative
spondylolisthesis does not appear to be pure translation but rather a rotary deformity that may distort the
dura and its contents and exaggerate the appearance of spinal stenosis. Existing theories to explain the
development of degenerative spondylolisthesis include the primary occurrence of sagittal facets and disc
degeneration, with secondary facet changes accounting for anterolisthesis. The sagittal facet theory
suggests a predilection for slippage because of facet orientation that does not resist anterior translation
forces and, over time, results in degenerative spondylolisthesis. The disc degenerative theory proposes
that the disc narrows first, and subsequent overloading of the facets results in accelerated arthritic
changes, secondary remodeling, and anterolisthesis.
It appears that facet arthritic changes are more severe than disc space narrowing, with the most advanced
anterolisthesis present when disc narrowing is more pronounced. Thus a continuum seems to exist as
degeneration progresses. In addition, facets that are aligned in a more sagittal orientation provide less
stability at the involved level, but whether these changes result from chronic instability or from a primary
anatomical variant is debatable. Boden et al. showed that sagittal facet angles of more than 45 degrees at
L4-5 predicted a 25 times greater likelihood of degenerative spondylolisthesis. Despite the increased
frequency of degenerative spondylolisthesis in women, there appears to be no gender-specific difference
19

in facet orientation, which calls into question the theory that sagittal facet joints are a primary cause of
degenerative spondylolisthesis. Sagittal facet orientation has been correlated with disc space narrowing,
suggesting that disc narrowing increases loading of the facet, resulting in secondary facet changes.
Regardless of the exact nature of the first inciting event, this instability causes facet arthritis, disc
degeneration, and ligamentous hypertrophy, which all contribute to produce symptoms. Facet orientation
therefore may be part of the consideration of potential instability when evaluating a patient for surgery,
especially decompression alone.
In degenerative scoliosis, severe degenerative changes result in significant back pain. Mechanical
insufficiency of the lumbar spine with a decrease in lordosis is caused by the degenerative changes.
Curves usually are less than 60 degrees, with 81% developing a lateral olisthesis. Spinal stenosis occurs
most commonly at the apex of the primary curvature (either concave or convex), with variable amounts of
structural rotary deformity, although as many as 33% of patients develop symptoms because of stenosis
within the distal compensatory curve. Characteristically, patients with neurogenic claudication and
degenerative scoliosis do not obtain relief simply by bending forward or sitting. These patients require
support of the torso by the upper extremities to obtain relief of their neurogenic claudication. Finally,
osteoporosis is a significant consideration in the treatment of these patients. Although there is no causeeffect relationship between bone density and degenerative scoliosis, these patients usually are older and
more predisposed to senile osteoporosis, and compression fractures may complicate the treatment.
NATURAL HISTORY

Most of the literature describing natural history concerns spinal stenosis rather than degenerative
spondylolisthesis. Matsunaga, Ijiri, and Hayashi reported that in 145 patients examined annually for a
minimum of 10 years progressive spondylolisthesis occurred in 34%, and further disc space narrowing
continued in those without further slip. There was no correlation between roentgenographic findings and a
patient's clinical picture. In fact, low back pain actually improved in those with continued disc space
narrowing, which may imply autostabilization. Of the 145 patients, 76% remained without neurological
deficits; however, 83% of patients with neurological symptoms, including claudication and vesicorectal
disorder, deteriorated and had a poor prognosis. This is in agreement with an earlier study by Matsunaga
et al, which showed that, over 60 to 176 months, progressive slipping occurred in 30% of patients without
significant effect on clinical outcome.
Degenerative scoliosis occurs in 6% to 30% of the aged population, with most curves being minor. Rotary
subluxation is variable and appears to be worse after decompression surgery without fusion. Men and
women appear nearly equally affected, although a propensity for women has been noted. Curves can be
progressive, but the natural history has not been elucidated conclusively. Grubb et al. reported progression
of 1 to 6 degrees a year in 8 patients, but the small number of patients limits generalizations.
It appears from the literature that observation and nonoperative treatment are warranted initially in these
patients. For those who develop neurological symptoms or who fail to improve despite nonoperative
treatment, operative intervention should be considered.
CLINICAL EVALUATION

Symptoms of degenerative spondylolisthesis include back pain, neurogenic claudication, radiculopathy,


and rarely bowel and bladder dysfunction. Although symptoms of spinal stenosis are more common, with
leg pain and claudication in 68%, 32% have axial back pain only. Radiculopathy occurs in 32%, and
cauda equina is rarely noted (3%). Overlap of symptoms of neurogenic claudication and vascular
claudication requires a careful evaluation. Peripheral neuropathy also must be considered in the
differential diagnosis.
Symptoms of neurogenic claudication are present in 71% to 90% of patients with degenerative scoliosis
and usually cause patients to seek medical attention, with deformity incidentally noted. These symptoms
usually do not improve with forward bending, and to obtain relief patients support the trunk with the arms
or assume a supine position. This is in contrast to the usual patient with spinal stenosis and neurogenic
claudication. Radiculopathy from facet overgrowth, foraminal stenosis within the concavity of curvature,
20

or nerve root tension along the curve convexity can occur, although neurological deficits are rare and
back pain is ubiquitous. Thus primary treatment is directed at decompression of spinal stenosis, with
fusion or instrumentation indicated based on the potential for instability.
Physical findings are nonspecific in most patients. Motion usually is preserved, but patients guard against
hyperextension. Symptoms may be reproduced by this maneuver in the presence of spinal stenosis.
Neurological examination rarely identifies significant motor, sensory, or reflex deficits; however, any
abnormal findings should be documented. Evaluation of distal pulses is necessary to help rule out
peripheral vascular disease and vascular claudication. Bilateral absence of tendo calcaneus reflexes may
be an indicator of peripheral neuropathy. Flattening of the lumbar spine is representative of degenerative
change, and a lumbar prominence on forward bending accentuates the convexity of a coronal deformity,
which is absent in those with degenerative spondylolisthesis. Sagittal and coronal balance should be
estimated clinically.
DIAGNOSTIC IMAGING
Roentgenography

Roentgenographic imaging is straightforward in the diagnosis of degenerative spondylolisthesis and


scoliosis. Anterolisthesis typically is seen at L4-5 without an associated pars defect. Standing
roentgenograms are imperative because 15% of deformities spontaneously reduce on supine imaging.
Variable disc space narrowing is indicative of degenerative changes. Flexion-extension lateral views may
reveal instability, which is considered to be present when 4 to 5 mm of translation or more than 10 to 15
degrees of sagittal rotation is identified. Degenerative scoliosis is evident, with a solitary lumbar curve
and associated degenerative disc changes. Flattening of the normal lumbar lordosis is present, and rotary
subluxation may be evident in some patients, with lateral olisthesis of varying degrees.
Bending films add information for operative decision making. Flexion-extension views should be
obtained with any spondylolisthesis or kyphosis, and lateral bending films should be obtained for coronal
deformities. These studies are useful in determining whether supplemental anterior surgery is necessary or
if all decompression and stabilization can be done from a posterior approach alone.
The Ferguson anteroposterior view shows any significant degenerative changes in the lumbosacral joint
and allows better visualization of the transverse processes of L5. Hypoplastic transverse processes also
should prompt the consideration of interbody fusion because of the paucity of bony substrate for fusion,
especially for lumbosacral fusions.
CT Myelography and MRI

CT myelography and MRI are used as indicated for the evaluation of spinal stenosis ( p. 2065 ) and may
show facet overgrowth, hypertrophy of the ligamentum flavum, and rarely disc herniation. Because of the
arthritic component affecting the facet joints, synovial cysts also have been documented. When identified,
synovial cysts may alter the treatment plan, necessitating more extensive decompression into the
foraminal zone.
Deformity, specifically scoliosis, is still a common indication for the use of CT scanning after
myelography. Because of the difficulty of obtaining MR images parallel to the disc spaces in patients with
scoliosis or spondylolisthesis and leg pain or claudication, myelography is better for evaluating the spinal
canal and nerve roots. Flexion and extension myelography studies should be obtained with the patient
standing and should be followed by CT scanning. Dynamic images may reveal nerve compression not
apparent on supine images. The axial images show the bony deformities clearly, including the facet
subluxations and bony spurring that often cause lower extremity complaints, lateral recess stenosis from
ligamentum flavum hypertrophy, and pedicular kinking of the concave nerve roots. Pathology lateral to
the dorsal root ganglion cannot be seen, however, because of the absence of subarachnoid space. MRI
may supplement the information obtained by CT myelography, especially regarding the soft tissues, and
often is helpful in decision making.
21

Although axial images are limited in larger deformities, with attention to the neural foramen and farlateral regions, MRI can be very useful in preoperative evaluation. Disc hydration is a useful piece of
information provided by T2-weighted sequences and may influence whether surgery stops at or includes a
lower degenerative segment. Desiccation of the L5-S1 disc should prompt extra consideration to end at
the adjacent disc above or include the degenerative segment. Adjacent segment pathology is common, and
in older patients it may be prudent to include such diseased discs. Discography also may be warranted in
such cases.
Discography

Kostuik advocated the use of discography to decide if instrumentation must include the lumbosacral disc
or other discs not anticipated to be included in the fusion for adult idiopathic scoliosis. Although no
prospective randomized study has proved the usefulness of discography for this purpose, Kostuik reported
satisfying results with this testing protocol. Grubb and Lipscomb also used this protocol for determining
fusion levels and reported good results, although they did not find discography necessary in patients with
degenerative scoliosis. In fact, in their study, discography was abandoned for the evaluation and treatment
of patients with degenerative scoliosis because fusion with instrumentation to the L5 or S1 levels was
done in most patients, and all degenerative levels evident on plain roentgenograms were included in the
fusion. Results were only slightly less satisfactory in patients with degenerative scoliosis than those in
patients with idiopathic scoliosis.
Other Studies

EMG and nerve conduction velocity studies are useful in differentiating peripheral neuropathy from other
abnormalities, especially in patients with diabetes mellitus. Nerve conduction studies should be used if
the diagnosis is uncertain because the results of surgery are less predictable in patients with neuropathy.
In addition, arterial Doppler studies, angiography, or vascular surgery consultation may be necessary in
some patients. A noninvasive functional study using the bicycle-treadmill test ( p. 2068 ) also may help to
differentiate neurogenic from vascular claudication.
NONOPERATIVE TREATMENT

Conservative treatment is warranted for patients with neurogenic claudication from spinal stenosis caused
by degenerative scoliosis and spondylolisthesis. Standard interventions should include short periods of
rest, antiinflammatory medications, and, rarely, bracing. The use of specific exercise programs has not
been evaluated; however, trunk-stabilization exercises and low-impact aerobic exercises seem to benefit
this patient group.
Epidural Steroid Injection

Epidural steroid injections have been advocated, but randomized or placebo-controlled trials are lacking
to determine their effectiveness in the treatment of spinal stenosis. The antiinflammatory effect of
corticosteroids is the basis for their use. Long-term effects also may be a result of the local anesthetic
agent administered with the steroid. Epidural steroid injections appear to be most beneficial in patients
with radiculopathy; fluoroscopic guidance is helpful because a dorsal medium septum may be present,
which can restrict injectate diffusion. No literature exists to support the use of a series of three epidural
steroid injections unless symptoms improve partially after the first injection. If the first injection is done
without fluoroscopy and is ineffective, a second injection can be done with fluoroscopy to ensure proper
placement and diffusion. Further injections are not warranted if there is not a favorable response after a
single well-placed injection. If epidural steroid injection is successful, physical therapy should be
instituted.
OPERATIVE TREATMENT

For patients with unremitting back and leg pain after adequate nonoperative treatment, operative
intervention is indicated. Only 10% to 15% of patients with degenerative spondylolisthesis require
surgery. Caution should be exercised in proceeding with surgery for back pain alone because adjacent
level pathology may account for symptoms.
22

Decompression
Degenerative Spondylolisthesis.

Similar criteria for decompression alone are used for degenerative and isthmic spondylolisthesis. For
patients with significant disc collapse and no pathological motion on dynamic roentgenograms and for
young patients with multiple level congenital stenosis, decompression alone is indicated. Epstein reported
the results of decompression in 290 patients. Laminectomy was done in 249 patients over an average of
3.4 levels, and limited decompression by fenestration, hemilaminectomy, or coronal hemilaminectomy
was done over an average of 1.7 levels. Progressive slips required fusion in only 5 patients (1.7%), and
secondary decompressions were necessary in 7 (2.8%). Roentgenographic findings did not correlate with
clinical results, which were good or excellent in 82%. Several studies reported successful 5-year results in
90% of patients after fenestration procedures and in 71% to 81% after laminectomy.
Subsequent fusions were required in only 0.8% to 4%. Epstein reported a higher rate of reoperation for
instability in patients with decompression and simultaneous disc excision. Of the eight patients
undergoing reoperation for instability, five had discectomy at the time of the index decompression. The
violation of the disc may have contributed to instability, which has been documented biomechanically in
ligament-sectioning studies.
In the meta-analysis of Mardjetko, Connolly, and Shott, a review of 11 papers representing 216 patients
showed that decompression without fusion was satisfactory in 69%, with progressive slips in 31%
postoperatively. This occurrence is similar to the natural history of degenerative spondylolisthesis and did
not compromise the operative results in most reports.
Degenerative Scoliosis.

Decompression is a viable option for a patient with symptomatic spinal stenosis and minimal kyphosis, a
neutral sagittal vertical axis, and no instability on dynamic imaging. Attempts should be made to avoid
destabilizing the spine during decompression, and fusion should be done if more than 50% of both facets
or an entire facet is resected. Degenerative scoliosis should be considered the coronal variant of
spondylolisthesis; if the ligamentous structures are violated, facet and disc resection is necessary and
fusion should be considered.
Decompression and Fusion
Degenerative Spondylolisthesis.

Patients with preserved disc height are prone to instability after decompression, and fusion should be
considered. Other indications for the addition of fusion include osteoporosis (which predisposes to pars
fracture), absence of osteophytes on roentgenograms, and minor nonpathological motion on
roentgenograms. After the report of Herkowitz and Kurz, the addition of fusion to decompression has
become the standard in the treatment of degenerative spondylolisthesis and concomitant spinal stenosis.
Outcomes are improved with the addition of in situ fusion regardless of whether there is a solid
roentgenographic fusion. Most studies report that fusion rates are better with instrumentation, but clinical
results are not different from those after uninstrumented fusion. Bridwell et al., however, reported better
functional results, correction of sagittal alignment, and a fusion rate of 87% in patients with instrumented
fusions compared with a 30% fusion rate in those with uninstrumented fusion. Similar findings were
documented by Mardjetko et al. in their meta-analysis, with 90% satisfactory outcomes in instrumented
fusions compared with 69% satisfactory results with decompression alone at 12- to 84-month follow-up.
Booth et al. reported 6.5-year follow-up of 36 patients who had decompression, autogenous iliac crest
bone grafting, intertransverse fusion, and pedicle screw instrumentation for degenerative
spondylolisthesis. Stenosis at the level of previous decompression did not recur, but five patients
developed symptomatic adjacent level transition syndromes, with another seven having asymptomatic
adjacent level degenerative changes. Sagittal alignment was maintained at the fused segments in all
patients. Eighty-three percent were satisfied with their results, 86% reported that back and leg pain was
better than before surgery, and 77% stated that they would have the surgery again. Dissatisfaction was
associated with more than four medical comorbidities. Major complications were rare (2%) and involved
23

screw breakage without symptoms. In Nork et al.'s report of 30 patients evaluated after decompression
and instrumented posterior fusion, 93% were satisfied with their outcomes, based on SF-36
questionnaires, and showed improvement in abilities to perform heavy and light activities, participate in
social activities, sit, and sleep. Pain, depression, and medication use also were decreased in this group.
The fusion rate was 93% at an average of 128 days. Complications were rare, and poorer outcome was
associated with more severe preoperative stenosis or the occurrence of a complication.
Pedicle screw implants appear to be better for maintaining anatomical alignment than distraction
constructs and Luque rods or rectangles, which are reported to worsen anterolisthesis. Fusion rates with
pedicle screws also are higher (86%) than with rod constructs (69%). Although fusion is not a necessity
for successful results, it does appear to improve results when added to adequate decompression. Longterm results, however, are necessary to determine if adjacent segment transition syndromes are more
likely in patients with more rigid instrumented fusions than in those with posterolateral in situ fusions.
Therefore decompression and fusion, with or without instrumentation, are recommended for patients with
degenerative spondylolisthesis and spinal stenosis in the absence of multiple medical comorbidities.
Degenerative Scoliosis.

In a patient with a flexible spine and mild to moderate scoliosis, symptomatic spinal stenosis is treated
with traditional decompression. Occasionally, facetectomy or partial pedicle resection is necessary to
decompress symptomatic nerve roots. In this situation, posterior intertransverse fusion is recommended. If
laxity is present, instrumentation should extend from neutral and stable vertebrae at each end of the
construct. Ending the instrumented fusion at a level of kyphosis potentiates adjacent segment changes and
may result in an adjacent compression fracture. This occurs at the thoracolumbar junction in as many as
15% of patients, which may be an indication for prophylactic polymethylmethacrylate augmentation.
Rotary subluxation also can occur after decompression alone in the presence of unstable degenerative
scoliosis. The fusion should end at a neutrally rotated, level, and stable end vertebra and should restore
sagittal and coronal balance. Simmons and Simmons advocated avoiding fusion into the thoracic spine.
Care should be taken to avoid stopping instrumentation and fusion at any apical segments or at the apex
of a kyphosis or scoliosis because this creates deformity later.
Posterior Lumbar Interbody Fusion (PLIF) and Transforaminal Lumbar Interbody Fusion (TLIF)

Recent advances in instrumentation and techniques have resulted in an increased use of the PLIF
technique with threaded interbody fusion cages. These cages may be allograft bone dowels or metal
cylinders filled with bone graft. Biomechanically, bone dowels or metal cages appear equivalent.
The use of these as stand-alone implants inserted through a posterior approach for grade I degenerative
spondylolisthesis has provided only moderate stability in in vitro studies. Both implants appear to be
susceptible to loosening with cyclic fatigue when used alone. This likely is a result of the posterior
decompression and the resection of the disc for implant placement. It appears that significant disruption
of the disc results in increased motion when loaded. If these implants are used posteriorly, further
stabilization is necessary and is best provided by pedicle screw implants ( Fig. 41-10 ). No reports have
yet compared the outcomes of PLIF with traditional intertransverse fusion, with or without
instrumentation, for degenerative spondylolisthesis. Ideal indications for interbody fusion in a patient
with degenerative spondylolisthesis include discographically concordant single-level axial back pain with
radiculopathy, minimal disc degenerative changes, and preserved disc height; it also is indicated for
revision surgery with an inadequate posterior fusion mass. PLIF or TLIF also is appropriate for small or
absent transverse processes at the levels to be fused, which would make intertransverse fusion
impractical. The technique for PLIF is described on p. 2094 .

24

Figure 41-10 Posterior lumbar interbody fusion using titanium mesh cage and transpedicular fixation. (From Jenis LG, An HS:
Semin Spine Surg 11:57, 1999.)
Anterior Spinal Fusion

Anterior spinal fusion can be used for the treatment of degenerative spondylolisthesis if some indirect
spinal decompression is provided by eradication of the disc, restoration of disc height, and ligamentotaxis
by placement of structural bone graft or cage after distraction of the disc space and tensioning of the
posterior ligamentous structures. Mardjetko et al. reported that the fusion rate with anterior procedures in
pooled studies was 94%, with an 86% satisfaction rate, suggesting that there may be a place for anterior
lumbar interbody fusion in this patient population because the results are similar to those obtained with
decompression and instrumented fusion.
Decompression and Combined Fusion (360-Degree Fusion)

Any adult spinal deformity that requires fusion of L5-S1 also requires anterior fusion of the L5-S1 disc.
This can be accomplished by an anterior procedure or a posterior interbody procedure. In patients with
degenerative scoliosis, kyphosis, and a positive sagittal vertical axis, anterior interbody fusion usually is
necessary to restore the height of L5-S1 and restore

Figure 41-11 Geometry of threaded interbody cylinder devices (B) does not allow replication of lordotic contour of
intervertebral disc, as mesh cage does (A).
25

the normal segmental lordosis at this level. Because of the disproportionate amount of lumbar lordosis at
this and the adjacent L4-5 level, the kyphosis that ensues often can be corrected with restoration of
anterior disc height and without osteotomy. Posterior interbody procedures often do not allow safe
excision of a contracted annulus and anterior longitudinal ligament for height restoration. Flexion and
extension roentgenograms help with this aspect of the decision-making process by showing a narrow,
immobile disc space.
For sagittally neutral or lordotic spines and an intact disc, posterior interbody fusion techniques can be
considered. If disc height is maintained, it is easier to maintain normal lordotic disc anatomy during
interbody fusion.
Regardless of the technique, restoration of normal segmental anatomy is of paramount importance at the
L4-5 and L5-S1 levels. The objective of interbody grafts at these levels is to recreate the segmental
lordosis of 20 to 28 degrees. This can be done with mesh cages, femoral ring allografts, iliac crest
tricortical autograft wedges, fibular rings, or carbon fiber trapezoidal cages. Threaded interbody cylinder
devices should be used cautiously in these applications, especially at the L4-5 and L5-S1 levels. Because
of the geometry of the cylinder, the lordotic contour of the intervertebral disc cannot be replicated with
this device ( Fig. 41-11 ).
Adult Idiopathic Scoliosis
Treatment of adult scoliosis, both idiopathic and degenerative, requires a different approach from that
used for typical adolescent idiopathic scoliosis. By definition, adult idiopathic curves are curves that are
diagnosed in a patient older than 20 years of age. These curves have been present since adolescence but,
for any number of reasons, the diagnosis was delayed. The prevalence of adult scoliosis is from 4% to
6%, with a similar female-to-male ratio as idiopathic adolescent scoliosis ( Chapter 38 ).
In contrast, approximately 60% of patients with late-onset degenerative scoliosis are female.
Degenerative curves are short segment, usually lumbar, and less severe than those in idiopathic scoliosis.
Symptoms of spinal stenosis are more common than in patients with degenerative scoliosis, and
myelographic defects, if present, are within the primary curve. The goal of treatment of degenerative
scoliosis is to relieve back pain and the symptoms of spinal stenosis, whereas the treatment goals for adult
scoliosis usually are pain control and deformity correction.
SAGITTAL BALANCE

In the treatment of adult spinal deformities, it is important to understand the normal sagittal relationships.
In a normal spine, the primary curvature is kyphosis of the thoracic spine, which develops first in infants.
Subsequent to upright posture, the secondary lordotic curvatures in the cervical and lumbar spine develop
between the ages of 5 and 15 years. Curves in males and females are similar at the cessation of growth,
although the curves develop more quickly in females.
Sagittal balance is the alignment that is necessary to center the head over the pelvis or hips in both the
sagittal and coronal planes. A plumb line dropped from the center of the C7 vertebral body is referred to
as the sagittal vertical axis (SVA). On the lateral long-cassette view, the plumb line normally falls through
or behind the sacrum. Normal values for the SVA are 3.2 3.2 cm for adult populations, with negative
values indicating a position behind the sacral promontory. The coronal vertical axis (CVA) is represented
in a similar fashion with a plumb line on the posteroanterior roentgenogram, with a normal balance
through the center of the sacrum. Any translation of the coronal vertical axis to either side of the midline
is considered decompensation.
Sagittal and coronal vertical axes are used to evaluate and estimate global balance. Global balance is the
result of segmental alignment of the functional spinal unit, and regional alignment of the cervical,
thoracic, and lumbar segments. Bernhardt and Bridwell measured 102 roentgenograms of normal spines
to determine normal sagittal plane alignment ( Fig. 41-12 ). By convention, kyphosis is represented as a
positive measurement, and lordosis as a negative value. In a normal adult spine, there is a small amount of
26

kyphosis segmentally at each end of the thoracic kyphosis, reaching a maximum at the apical region (T67) of about +5 degrees. Apical discs or vertebrae are identified in the sagittal plane as those that are
parallel to the floor. Considered independently, the thoracolumbar junction is a transition zone of force
transmission and alignment. In this region a shift occurs from the thoracic kyphosis to lumbar lordosis.
The first lordotic disc is typically at L1-2, and normal thoracolumbar alignment as measured from the
cephalad T12 endplate to the caudal L2 endplate is 0 to 10 degrees. The lumbar spine is a region of
lordosis, reaching a maximal segmental lordosis at L4-5 and L5-S1. The sagittal apex of the lumbar spine
usually is L3. It is important to note that over 60% of lumbar lordosis is created by the discs at L4-5 and
L5-S1, which contribute 20 degrees and 28 degrees, respectively, to the regional lordotic measurement.
Because most lordosis is present in the distal lumbar spine, it is important to maintain normal segmental
and regional

Figure 41-12 Segmental sagittal measures of thoracic and lumbar spine. Note contribution of L4-5 and L5-S1 discs to overall
lumbar lordosis (67%). (From Bernhardt M, Bridwell KH: Spine 14:717, 1989.)

interrelationships so that global balance is preserved. As a rule of thumb, on a lateral roentgenogram


taken with the patient facing the surgeon's right, there is a sagittal clock, as described by Bridwell. In a
normal, standing patient, the apical L3 disc or endplate points at the 3-o'clock position, L4 points at the 4o'clock position, and L5 points at the 5-o'clock position. If this regional alignment is maintained, then the
likelihood of a postoperative flatback deformity is minimized.
Static normal values of kyphosis and lordosis probably are not useful in the treatment of spinal
deformities. Because of the dynamic nature of the curves, normal is balanced. Hardacker et al. confirmed
the dynamic nature of the spine in their study of cervical lordosis. They concluded that 75% of cervical
lordosis occurs at C1-2, with only 10 degrees occurring in the rest of the subaxial cervical spine.
Dynamic interrelationships also were confirmed. Increased cervical or lumbar lordosis correlated with
increased thoracic kyphosis. Their study documented the dynamic nature of the spine and showed how
compensatory changes occur to maintain global balance. Therefore normal kyphosis should be balanced
by lordosis in the lumbar and cervical spines so that the plumb line falls through or behind the sacrum. A
good rule of thumb is that lumbar lordosis should measure approximately 20 to 30 degrees more than the
thoracic curve.
27

INCIDENCE

Adult idiopathic scoliosis is defined as a coronal deformity of more than 10 degrees with associated
structural changes in a patient older than 20 years at time of diagnosis, most commonly in patients in their
late thirties. Women are affected much more frequently than men, similar to the incidence of adolescent
scoliosis. Studies have shown a prevalence of 2% to 4% for curves of more than 10 degrees. It is
estimated that as many as 500,000 adults have coronal curves of more than 30 degrees. As noted by
Weinstein and Ponseti in their classic description of the natural history of adult scoliosis, some of these
curves are progressive. According to their report, thoracic curves of more than 50 degrees progress
approximately 1 degree per year up to 75 degrees, when progression slows to about 0.3 degrees per year,
finally stopping at about 90 degrees. Lumbar curves progress at a rate of 0.4 degrees per year after
reaching only 30 degrees; thus a more aggressive approach is warranted for lumbar curves, especially
after progression is documented. Predictors of lumbar curve progression include L5 above the intercristal
line, apical rotation of more than 30%, an unbalanced or decompensated curve, a thoracic curve of more
than 50 degrees, and a thoracolumbar or lumbar curve of more than 30 degrees. As many as 68% of adult
curves progress more than 5 degrees over time.
Patients with idiopathic scoliosis rarely develop significant pulmonary complications, even with curves
exceeding 100 degrees. Pehrsson et al. showed that over a 20-year period, diminished lung function in
scoliosis patients paralleled that of the general aging population. In the absence of overt thoracic lordosis,
surgery generally is not warranted to maintain or improve pulmonary function in adults.
CLINICAL EVALUATION

Back pain occurs in 60% to 80% of patients with scoliosis, which is similar to the occurrence in the
general population. Despite this, 25% to 80% of patients with adult idiopathic curvatures present with the
chief complaint of pain. Pain symptoms include mechanical back pain, buttock pain, and occasionally
radiculopathy or neurogenic claudication. Neurogenic claudication occurs in 13% as a result of
degenerative changes within or, more commonly, distal to the lumbar curve. Radiculopathy occurs in only
4%, with entrapment of nerve roots within the foramina of the concavity. In contrast to degenerative
scoliosis, most adult patients with idiopathic scoliosis have more mechanical symptoms than neurological
complaints. Patients may relate symptoms of curve progression: a progressive lean or list to one side,
changes in waistline symmetry, hip prominence, protuberant or flaccid abdomen, hemline changes, or a
loss in height in the absence of fracture. Neurological symptoms may include radiculopathy or neurogenic
claudication, which usually is a result of degenerative changes in the distal fractional curve. Diminished
pulmonary function in patients with curves of more than 60 degrees or cor pulmonale in patients with
curves of more than 100 degrees occasionally is caused by the scoliosis and should be evaluated carefully
to rule out other causes. Predictors of pain include curves of more than 45 degrees, lumbar curves, and
thoracolumbar and lumbar curves of more than 45 degrees with apical rotation and coronal
decompensation.
Physical examination findings usually are negative except for the spinal deformity. The skin should be
examined for evidence of pathological lesions and hair patches that suggest underlying intraspinal
anomalies. If spinal cord anomalies exist, atrophy may be evident in the lower extremities, or intrinsic
atrophy of the foot may be present with pes cavus and clawing of the toes. Reflexes should be
documented, as should the results of a comprehensive neurological examination.
The deformity should be evaluated by looking for structural features of the rib and lumbar paraspinal
prominence on forward bending while also recording flexibility. This test also helps to determine which
curve is primary, since more rotation and subsequent prominence is found in the more structural primary
curve. If rib prominence exceeds 3 cm, thoracoplasty should be considered if surgery is performed. Trunk
shift is identified by dropping an imaginary line perpendicular to the floor from the lateral ribs. These
should symmetrically intersect the pelvis. Plumb lines should be dropped to evaluate for coronal
decompensation and also to help in estimating sagittal balance. Special attention should be paid to the left
shoulder because instrumentation of a curve with a structural upper thoracic curve must include this
segment to avoid a high left shoulder postoperatively. Waistline asymmetry should be noted, and any limb
28

length inequality must be considered. Equalizing limb length with -inch blocks sometimes is helpful if
limb length discrepancy is more than 1 inch.
ANATOMY AND BIOMECHANICS

Adult scoliosis shares most of the anatomical features of idiopathic adolescent scoliosis. There is a more
structural and rigid primary curve and a compensatory secondary curve, and there also can be a structural
upper thoracic curve similar to the King type V ( see Fig. 38-29 ) or types 2 and 4 curves using the
classification scheme of Lenke et al. ( see Fig. 38-30 ). Unique to adult scoliosis patients are the
diminished elasticity of the ligamentous structures and the narrowing of disc spaces, which combine to
stiffen primary and secondary or compensatory curves. Osteopenia also must be considered in older
patients, especially in those with risk factors for osteoporosis, such as glucocorticoid use and a significant
family history.
The biomechanics of the bone-implant interface must be considered if long instrumentation constructs are
used, especially when extended to the sacrum. Because of the long lever arm produced, the poor fixation
obtained in the sacrum, even when bicortical screws are used, will fail if not protected. Of the different
constructs used for instrumenting and fusing the lumbosacral joint, the most rigid fixation appears to be
obtained with a modified Galveston technique and the use of iliac screws in addition to sacral bicortical
screws. Fixation can be augmented with a structural interbody fusion device, but the most significant
biomechanical increase in strength is with the addition of the iliac screws. Other techniques that have
been used include the Jackson intrasacral rod and a transiliac rod used to anchor the distal instrumentation
as described by Kostuik. With the exception of the intrasacral rods, however, these techniques limit the
amount of bone graft available for harvest. The superiority of any of these techniques has not been
established, and the surgeon's experience and preference determine the choice.
DIAGNOSTIC IMAGING
Roentgenography

Standard roentgenograms on 36-inch cassettes must be obtained and scrutinized for coronal and, more
important, sagittal balance. Depending on the level of proposed instrumentation, a Ferguson
anteroposterior view ( see p. 2089 ) may be helpful in determining the presence of significant
degenerative changes at L5-S1, which would prompt its inclusion in the proposed fusion. Bending
roentgenograms over a foam fulcrum are ideal for assessing flexibility, although standard maximal effort
bending films often will suffice. For sagittal deformities, appropriate fulcrum bending films should be
obtained to determine flexibility. Push prone views, as described by Kleinmann et al. and Vedantam et al.,
are useful in determining the response of the lowest instrumented vertebra to instrumentation.
Discography

Special imaging studies, including MRI and myelography supplemented with CT scanning, are discussed
on p. 2076 . Discography, although not yet validated by prospective data, may have a place in the
evaluation of spinal deformity in adults. Grubb and Lipscomb reported that in patients with degenerative
scoliosis, discographic findings were similar to those in other patients with spinal stenosis and added little
to the diagnostic picture. However, in patients with idiopathic scoliosis and mechanical complaints,
discography consistently identified abnormal, painful discs with reproduction of pain. These abnormal
discs were most commonly, but not exclusively, in a compensatory lumbar or lumbosacral curve. Painful
disc abnormalities frequently were identified in areas that would not have been included in the fusion
area, according to accepted rules for fusion of idiopathic adolescent scoliosis. Therefore for operative
decision making it is important to distinguish idiopathic scoliosis from degenerative scoliosis and to use
discography as indicated clinically.
NONOPERATIVE TREATMENT

Traditional methods of nonoperative treatment of back and leg pain ( p. 2068 ) are appropriate in patients
with adult idiopathic scoliosis. Orthotics may be helpful for the relief of axial degenerative symptoms.
29

Intermittent use of a soft thoracolumbosacral orthosis (TLSO) ( Fig. 41-13 ) is better tolerated than a rigid
TLSO by older, often endomorphic, patients. The orthosis

Figure 41-13 Soft TLSO is better tolerated than rigid orthosis, especially by older patients. (Courtesy Boston Brace
International, Avon, Mass.)

should be worn during symptomatic periods and kept to a minimum otherwise. Correction of deformity or
prevention of progression of these curves is not possible, and an orthosis is used only for the management
of symptoms; the patient should be aware of the treatment goals. Physical therapy should be continued in
addition to bracing, with the ultimate goal of paraspinal strengthening and subsequent stabilization that
allow the brace to be discarded.
OPERATIVE TREATMENT

Once adequate nonoperative treatment has failed in a patient with unremitting symptoms or
roentgenographic progression, surgery should be considered. Curves of more than 50 degrees with
documented progression, loss of pulmonary function believed to be caused by the scoliosis when curves
exceed 60 degrees, progressive neurological changes, and significant coronal or sagittal decompensation
are relative indications for surgery. Cosmetic considerations are a genuine concern for patients as well and
may play a part in operative decision making.
A spinal implant should be used that allows segmental placement of hooks or screws and also allows iliac
fixation. If fusion of the lumbosacral joint is anticipated, interbody fusion must be obtained with either
allograft or fusion cages that are cut to maintain the normal segmental lordotic disc alignment.
Autologous blood donation is encouraged, and a cell saver is useful in preserving blood lost
intraoperatively. Spinal cord monitoring should include somatosensory and motor evoked potentials
(SSEP and MEP). If useful data are obtained and maintained with SSEP and MEP, wake-up testing is
unnecessary until the conclusion of the surgery. If pedicle screws are used below T8, pedicle screw
stimulation also is useful to confirm proper placement. Fluoroscopy or computer-aided navigation
enhances the use of anatomical landmarks and is helpful for some surgeons. Regardless, this surgery is
complex and has an extended recuperation period, with a significant risk of complications, which the
patient must understand when operative treatment is chosen.
Posterior Instrumentation and Fusion

Patients with flexible curves of less than 70 degrees and no significant kyphosis or decompensation are
candidates for posterior instrumentation and fusion alone. This can be done with a number of
instrumentation systems and techniques ( Chapter 38 ). The ideal candidate for a posterior procedure has a
smaller, flexible curve, hypokyphosis, and a flexible compensatory lumbar curve. Posterior procedures
also are an appropriate choice for a King type V or Lenke subclass 2 or 4 structural upper thoracic curve.
Standard posterior approaches are used ( Chapter 34 ), and instrumentation may include hooks, wires, or
screws for curve correction. The current trend involves the use of all pedicle screw constructs for
deformity correction because of the segmental fixation that is obtained and the three-column control that
is provided by a pedicle screw placed into the vertebral body. With this fixation, derotation may be
possible to some extent during the correction maneuver. Another benefit of the use of pedicle screws is
30

the extraspinal placement of implants, which avoids the space-occupying phenomenon created by hooks
or wires placed within the spinal canal. Finally, the cortical fixation of a screw through the pedicle is
superior biomechanically to hook fixation, which makes this technique appealing for an osteoporotic
adult spine. These benefits are not without risks, however, and the primary concern is pedicle screw
malposition that affects either the great vessels or the spinal cord, dura, or nerve roots. Thus far, when
done by surgeons with proper training, pedicle screw placement has been safe and effective for the
treatment of adult scoliosis; however, it is wise to discuss procedures in detail with patients before surgery
and to explain the FDA status of devices used.
Selection of fusion levels is similar to that in adolescent scoliosis patients. The goal of surgery is a
balanced spine with the head centered over the pelvis in the sagittal and coronal planes. Fusion should be
from stable vertebra to stable vertebra unless pedicle screw instrumentation is used and fusion can safely
be stopped short of the stable vertebra. For curves with features similar to King types II and V curves
without severe kyphosis, pedicle screw fixation appears ideal. This technique allows fusion of the curve
from end vertebra to end vertebra, which can save one to three fusion levels distally in some patients
compared with typical hook constructs. In adults, flexibility of the compensatory curve must be
considered more than in adolescents with scoliosis because overcorrection of the thoracic curve in a spine
with a relatively inflexible lumbar curve results in decompensation and an unsatisfactory result. Therefore
it is prudent to apply only a conservative amount of correction that can be accommodated by the
compensatory curve so that normal balance is restored and further progression is halted. The amount of
correction that can be obtained is estimated from preoperative bending films.
Avoiding a flatback deformity during posterior distraction is mandatory because this deformity is much
easier to prevent than to treat. Nonetheless, because of pseudarthrosis, implant failure, transition
syndromes, adjacent level fracture, patient positioning, and other technical reasons, flatback deformity
can occur in some patients under the best of circumstances. Concave distraction of the lumbar spine,
especially beyond L2, should be avoided because this maneuver is kyphogenic. Segmental
instrumentation allows differential correction along the same rod, which is helpful in preventing flatback
deformity and shoulder decompensation. Avoiding distraction, or even applying some convex
compression, along with precontouring the rods into lordosis helps to maintain normal lumbar alignment.
Anterior Spinal Instrumentation and Fusion

Deformity correction through an anterior approach is described in Chapter 38 but deserves mention here
because anterior instrumentation and fusion with third-generation implants have given excellent
deformity correction in adults and have not caused significant problems with kyphosis as did the early
Zielke and Dwyer implants. With single or double rod implant systems and structural grafts, anterior
deformity correction is an excellent alternative for lumbar and thoracolumbar curves because it allows
short segment correction of flexible curves. Primary thoracic curves with flexible and compensatory
lumbar curves in adults also can be treated effectively with anterior fusion. However, correction must be
appropriate for the ability of the lumbar curve to compensate; overcorrection in adults results in more
decompensation than in the flexible spines of children with scoliosis. Also, as in pediatric deformities,
strict attention must be paid to the upper thoracic spinal segment from T1 or T2 to T6 to prevent shoulder
asymmetry due to a structural upper thoracic curve. An upper thoracic curve is a relative contraindication
for anterior spinal instrumentation and fusion unless measures are taken to allow persistent tilt of the
cephalad end vertebra, which will allow the upper thoracic curve to remain balanced.
Postoperative Management

Patients are monitored routinely in the intensive care unit with frequent neurological evaluations and
observation to prevent complications associated with fluid shifts, which occur after such long procedures.
Sitting is encouraged the day after surgery, and formal physical therapy is initiated. Walking as tolerated
is encouraged with assistance until independent ambulation is achieved. A rigid TLSO is used in patients
with osteoporosis but is not necessary except when patients are getting up from a supine position and
ambulating. The Foley catheter is removed once the patient is able to get to a bedside commode with
minimal assistance. Antibiotics are discontinued once drains are pulled, and oral narcotic analgesics
usually are well tolerated by the third day after surgery. Pneumatic foot pulsation devices are used as
31

prophylaxis against deep venous thrombosis because of the possible risk of epidural hematoma associated
with pharmacological agents. These are discontinued once the patient is fully independently ambulatory.
Nonsteroidal antiinflammatory medications are avoided for 3 months postoperatively because of their
inhibitory effect on fusion. The TLSO is discontinued at 4 to 6 months after surgery in most patients.
Combined Anterior and Posterior Fusions

For a rigid curve of more than 70 degrees or a curve that is decompensated either sagittally or coronally,
or for instrumentation that crosses the lumbosacral joint, a combined approach is necessary. For severe
rigid thoracic deformities of more than 100 degrees, which often are associated with translation of the
trunk of more than 4 to 6 cm anterior or lateral to the pelvis, Boachie-Adjei and Bradford showed that
vertebrectomy, as a combined or staged procedure, was effective in achieving spinal balance. It is
preferable to complete combined procedures, if possible, under a single anesthesia because this results in
fewer complications and a shorter hospitalization; however, if any portion of the procedure is
unexpectedly long, blood loss is excessive, or a patient is not able to tolerate continuation of the
procedure, then it is prudent to postpone the second stage of the procedure. Parenteral nutrition between
stages is recommended because patients often develop a postoperative ileus and do not tolerate enteral
nutrition.
When a combined procedure is used, the first stage usually includes anterior release, discectomy, and
fusion of the primary curve. If instrumentation is extended to the lumbosacral joint, anterior interbody
fusion is necessary at L4-5 and L5-S1, with structural grafting of these discs to maintain lordosis,
improve fusion rates, and decrease stresses on the posterior implants. Morselized bone graft is placed in
the thoracic disc spaces and usually consists of the rib excised for the exposure. Supplemental bone graft
can be obtained from the inner table of the anterior iliac crest if the rib is small or osteoporotic.
Instrumentation may or may not be necessary during the anterior portion of the procedure and is placed at
the surgeon's discretion.
After anterior release and fusion, posterior instrumentation and fusion are done, with segmental fixation
from stable vertebra to stable vertebra. Care is taken to avoid ending an instrumentation construct at the
apex of a curve in either the coronal or sagittal plane because of the risk of later decompensation. It also is
prudent to include any disc level with severe degenerative changes, especially in degenerative
deformities.
TECHNIQUE 41-4 (Boachie-Adjei and Bradford)
Approach the convex side of the curve. The specific exposure is dictated by the levels to be fused ( p.
2083 ). Ligate the segmental vessels and elevate the outer cortex of the vertebral body as an
osteoperiosteal flap. Resect the remaining vertebrae down to the dura at one or at multiple levels. For
more severe deformities, resect multiple vertebrae. Excise the intervertebral discs completely to the
posterior longitudinal ligament at all levels encompassing the curve. Place the spongy cancellous bone
removed from the resected vertebral bodies loosely over the dura, which is protected by fat or Gelfoam.
Loosely reattach the outer cortex of the osteoperiosteal flap back over the spinal column. Remove the
pedicles on the concave and the convex sides over the resected segments. The concave pedicle resection
requires care and meticulous technique to resect the segment to its base. If this is not possible because of
dural tube transposition, then most of it should be resected; whatever portion remains is removed during
the second stage of the posterior procedure ( Fig. 41-14 ).
The second stage of the procedure, done 1 to 2 weeks later, consists of concave rib osteotomies
throughout the curvature and a thoracoplasty on the convex side. Remove the pedicles, laminae, and facets
over the area and resect anteriorly. Examine the spinal cord over the entire resected area and continually
monitor the dura to be certain that pulsation continues throughout the procedure. Perform segmental
spinal instrumentation with L-rods or segmental instrumentation ( Chapter 38 ). Insert iliac fixation in
addition to sacral pedicle screws ( Chapter 38 ) for fusion to the sacrum. Cut the ribs into match sticks and
place over the fusion area lateral to the implants, taking care that no loose fragments lie against the spinal
cord. Use fat or Gelfoam to protect the dura. Attempt to balance the spine in both the anteroposterior and
32

sagittal planes. Total correction is not essential and therefore should not be attempted. Monitor
somatosensory evoked potentials throughout the procedure. In addition, perform a wake-up test on all
patients who do not have dependable somatosensory and motor evoked potentials.

Figure 41-14 Vertebral column resection and arthrodesis for complex deformities. (From Boachie-Adjei O, Dendrinos GK,
Ogilvie JW, Bradford DS: J Spinal Disord 4:131, 1991.)

33

Figure 41-15 A and B, Severe structural deformity with marked scoliosis, as well as kyphosis and sagittal plane imbalance.
Correction was possible only by vertebral resection carried out over apical portion of curvature. Although Cotrel-Dubousset
instrumentation was used, rods were placed so that correction without distraction was possible. Rods were positioned to allow
cantilevered bending and coronal realignment without distraction, which would have run risk of producing paralysis. C and D,
Postoperative appearance. (From Bradford DS: Adult scoliosis. In Lonstein JE, Bradford DS, Winter RB, Ogilvie JW, eds:
Moe's textbook of scoliosis and other spinal deformities, ed 3, Philadelphia, 1995, WB Saunders.)
AFTERTREATMENT.

An underarm polypropylene body jacket is applied, and the patient is allowed to ambulate at will. The
body jacket is worn for 4 to 6 months, depending on the quality of fusion mass ( Fig. 41-15 ).
New Techniques

The newest generation of implants can be used to treat most deformities, allowing instrumentation of all
thoracic levels down to the sacrum and pelvis. Approaches and techniques generally have remained the
same, however. Pedicle screw instrumentation has been used in all levels in the treatment of spinal
deformities, with excellent clinical and roentgenographic results. For lumbar curves, pedicle screw
instrumentation is applied to the convexity and compressed to create lordosis; for typical thoracic curves,
the pedicle screws are applied to the concavity of the deformity and distracted to restore kyphosis. Any
compensatory curves must be treated appropriately with compression where lordosis is required and
distraction where kyphosis is desired. Upper thoracic curves are controlled by compression of the
convexity, since most of these curves also are kyphotic. Suk et al. achieved excellent correction and
balance, while saving distal fusion levels, with the use of all-pedicle-screw constructs in the treatment of
adolescent idiopathic scoliosis.
Computer navigation devices allow the placement of fiducials, or reference points, intraoperatively. Once
computer reconstructions are calculated, video referencing creates a best-fit overlay over the known
anatomy. This allows interpolation or animation of the placement and trajectories of proposed implants on
preoperatively obtained images. This technique initially was used with CT and MRI studies but more
34

recently has been used with fluoroscopy. Fluoroscopy has the advantage of real-time images that are
not dependent on patient position and are not subject to as much error from motion as are CT and MRI.
These technologies can confirm anatomical relationships and, although expensive, are being used more
frequently.
Video-assisted thoracoscopic surgery (VATS) also has been gaining more widespread use. For skilled
endoscopic spinal surgeons, VATS provides excellent visualization through relatively small incisions with
the potential to decrease blood loss, postoperative pain, periscapular winging, and pulmonary
dysfunction. However, the learning curve is very steep, with initial procedures taking a good deal longer
than the typical thoracotomy. This technique requires double lumen intubation and places increased
demands on the anesthesia staff. Although VATS continues to develop, the options for its use in anterior
instrumentation are still limited. In adult patients with spinal deformity, in whom osteoporosis and
osteopenia are prevalent, structural grafts may be more difficult to place endoscopically, thus limiting the
application of VATS.
Adult Isthmic Spondylolisthesis
Spondylolisthesis is most commonly an acquired condition. Most progressive deformities occur in
childhood, and deformities in adults usually are static and low grade. Two types of spondylolisthesis
occur in adult patients: isthmic and degenerative. Each has its own characteristic etiology and
pathoanatomy, and treatment varies slightly for each. Degenerative spondylolisthesis is discussed on p.
2074 .
INCIDENCE

Isthmic spondylolisthesis is absent in newborns but occurs in juveniles and reaches the adult prevalence
of 5% to 8% by the age of 18 years. Upright walking and its associated weight-bearing appear to be
prerequisites for its development, since this disorder has not been reported in nonambulatory patients.
Males are affected twice as often as females, and risk factors for isthmic spondylolisthesis include
gymnastics, football, and pole-vaulting. Other at-risk avocations include weight-lifting, dancing, and
volleyball, among other activities that cause

Figure 41-16 Defect in isthmic spondylolysis, type IIA. (Redrawn from Wiltse LL, Rothman SLG: Semin Spine Surg 5:264,
1993.)

excessive lordosis or hyperflexion of the lumbar spine. People with active vocations, especially military
recruits, may have a higher incidence of symptomatic or asymptomatic pars fractures (reported to occur in
9.7% of 1598 soldiers). Genetic transmission appears to occur and may be contributory.
35

ANATOMY

Generally, adult isthmic spondylolisthesis is nonprogressive, although symptoms of back pain and
radiculopathy are common. Isthmic spondylolisthesis affects L5 in 89% of patients, L4 in 11%, and L3 in
3%. In adults, the slip usually is less than 50% and usually causes accelerated degeneration of the disc at
the level of the pars defect. The slip occurs as the result of a defect in the pars interarticularis that
interferes with the bony hook of the affected spinal motion segment ( Fig. 41-16 ). The bony hook
consists of the pedicle, pars, and inferior articular facet of the cephalad segment and the superior articular
facet of the caudal segment. This structural linkage is weakened as a result of spondylolisthesis and can
no longer resist translational instability. The posterior elements subsequently separate through the pars
fracture, leaving the facet joints located, and the entire trunk translates anteriorly over the sacrum or
caudal vertebral body. Severe slips can severely affect global sagittal balance because of the forward shift
of the body's center of gravity.High-grade spondylolisthesis, however, is rare in adults.
Progression is rare in adult patients with L5 isthmic spondylolisthesis unless a previous decompression
has been done to destabilize the posterior elements. The restraints to progression include the strong
iliolumbar ligaments, large L5 transverse processes, disc, and annulus; further protection is provided by
deep seating of L5 below the intercristal line. A stress riser necessarily exists at the level of the L4-5
disc at its junction with the immobile pelvis and stabilized L5, and this explains the increased progression
and instability at the L4-5 level. Clinically, multiple factors likely contribute to stability and the resistance
to spondylolisthesis. Increased instability should be suspected in the rare adult patient with isthmic
spondylolisthesis at L4-5, and some degree of slip progression may occur.
In the presence of a pars fracture, shear stresses are placed across the disc, with 100% of the body weight
creating an anteriorly directed force, compared with approximately 80% of the body weight when the
intact facets share the load. This increased stress exacerbates disc space degeneration in adults and also
may contribute to the formation of foraminal stenosis and subsequent radiculopathy. As callus formation
occurs at the pars, a hook protrudes anteriorly from the bone itself and may be present simultaneously
with superior articular facet overgrowth, both of which narrow the neural foramen. Fibrocartilaginous
tissue also is present in the area of the pars fracture from failed attempts to heal the stress fracture. This
pathoanatomy usually affects the L5 nerve root in patients with L5-S1 spondylolisthesis. Once the nerve
is tethered within the neural foramen, further slipping mechanically stretches the nerve over the sacrum,
contributing to radiculopathy.
Abnormal anatomy, such as dysplasia, also may predispose to progressive spondylolisthesis. Spina bifida
occulta and dysplastic facet joints are defects in the bony hook that decrease the stability of the
spondylolisthetic spinal segment, diminishing the normal resistance to shear forces and translation and
allowing olisthesis. According to the classification of Marchetti and Bartolozzi, dysplasia can be divided
into high and low dysplasia. Untreated high dysplasia is rare in adults and has a high incidence of
progression. Low dysplasia is more common, with features consistent with spina bifida occulta, does not
tend to progress, and is more commonly noted incidentally in adult patients.
BIOMECHANICS

Although pars fractures have been simulated in the laboratory, recreating spondylolisthesis has not been
as straightforward. For instance, division of the pars in vitro resulted in significant motion in the axial and
coronal planes, but translational instability did not occur. Biomechanical data also suggest that rotation
and not a pure extension force may be the cause of pars fracture. In addition, the inability to recreate
spondylolisthesis in biomechanical studies suggests that pars fracture is not the sole cause of translational
instability. Further sectioning of the iliolumbar ligaments by Grobler et al. did not create any translation.
In comparisons with a normal spine, Grobler et al. showed 12% more rotation, 33% more shear
translation, and 43% more axial translation after creation of pars defects at L4-5 than after creation of
pars defects at L5-S1. This difference was not attributable to the iliolumbar ligament because transection
of the ligament alone did not result in a statistically significant increase in motion at the lumbosacral
level. Thus it appears that instability is greater after pars fracture at the L4-5 level than at the L5-S1 level.
The iliolumbar ligaments may contribute some stability to the L5 level, but other mechanical or
anatomical factors also must contribute to resistance of translational instability.
36

NATURAL HISTORY

Although not as likely as in adolescent patients, progression to a lesser degree may occur in adults,
causing worsening of symptoms and progressive loss of function. Slips of 50% or more are rare in adults.
Thus most adult patients are treated after pain develops and not prophylactically, as are children and
adolescents. Postoperative progression of spondylolisthesis must be considered and prevented in patients
with pars fractures who have decompressive procedures because of the possible disruption of the
posterior ligamentous complex, facet capsules, or annulus. In a study by Haraldsson and Willner
comparing adolescents and adults with spondylolisthesis, only 2 of 20 adults had progression of slips after
age 25; both were after laminectomies. In contrast, 10 of 25 of those younger than 25 years of age had
progressive slips. Thus laminectomy or combined bilateral resection of more than one facet must be
considered a relative indication for fusion to prevent translational instability in the presence of a pars
fracture.
Progressive disc degeneration occurs in most patients with isthmic spondylolisthesis and may be a
contributing factor in the development of back pain. Floman documented progression of the slip from 9%
to 30% (average, 14.6%) in 18 adult patients (32 to 55 years of age) with incapacitating lumbar back pain
over a mean of 6.8 years. Progression began after the third decade and coincided with marked disc
degeneration. A study of elite child and adolescent athletes by Muschik et al. and a study of 139 adults by
Osterman et al. confirmed that in 80% to 90% most of the slipping had already occurred at the time of
initial diagnostic studies and that competitive sports did not affect the progression of spondylolisthesis.
The degree of slipping has been associated with same-level disc degeneration, but this was not associated
with increased back symptoms. Excellent function can be maintained despite the presence of
spondylolisthesis and disc degeneration and, accordingly, treatment should be directed at alleviating
symptoms and not at preventing progression, since this rarely occurs.
CLINICAL EVALUATION

Patients often report distal lumbar pain; 11% of patients with distal back pain reported by Wiltse were
found to have pars defects. Other authors have reported back pain of varying degrees in up to 91% of
patients, occurring daily in about half and reported as severe and disabling in approximately 10% to 15%.
However, spondylolysis and spondylolisthesis do not seem to predispose patients to more disability or
pain than in the general population. However, pars fractures, with or without slipping, appear to be more
common in symptomatic than asymptomatic patients. Antecedent trauma may be minimal, and the pars
fracture may be an incidental finding. Disc

Figure 41-17 Standing anteroposterior (A) and lateral (B) roentgenograms of patient with isthmic spondylolisthesis.

degeneration, facet arthritis, and pars fracture all may contribute to the back pain syndrome. Risk factors
for back pain include grade II slip, increased wedging of L5 (low lumbar index), early disc degeneration,
and spondylolisthesis at L4-5. L4-5 slips may be more symptomatic and more pronounced, probably
because of increased biomechanical stresses and more inherent instability than at L5-S1.
Nerve compression may cause symptoms of radiculopathy or neurogenic claudication. Tension signs have
been reported to be present in 19%, hamstring contractures in 27%, and a palpable step-off in 42% of
37

patients. Sciatica is found more frequently in adults than in adolescents, is caused by foraminal stenosis,
and usually affects the L5 root. Symptoms of neurogenic claudication caused by central spinal stenosis
are not common in patients with isthmic spondylolisthesis because of the relative decompression of the
spinal canal by the pars fractures. Symptoms of neurogenic claudication should prompt further evaluation
of the spinal canal to identify the source of neural compression.
History and physical examination are important in determining the severity of symptoms and dysfunction.
Special attention should be paid to aggravating and alleviating factors and the location of the pain. Pain in
the distal lumbar spine that is worse with extension is characteristic of facet or pars pathology. Pain with
flexion or sitting often is associated with discogenic causes. Radiculopathy may be aggravated with either
maneuver. Pain that improves with walking uphill, resting on a grocery cart, or pushing a lawnmower
indicates posterior element pathology. Tension signs may or may not be present but may be helpful in
determining whether leg and buttock pain is radicular, referred, or muscular. Hamstring spasm, paraspinal
muscle spasms that cause flattening of the back, and a spinous process step-off also can be identified.
Claudication symptoms may signal the development of lateral recess stenosis, foraminal stenosis, or farout compression of the L5 root by pressure between a large L5 transverse process and the sacrum. Bowel
or bladder dysfunction is rare; however, if suspected, it can be identified with urological studies.
DIAGNOSTIC IMAGING
Roentgenography

Standing anteroposterior and lateral roentgenograms are diagnostic in most patients ( Fig. 41-17 ).
Standing films may show some slips that spontaneously reduce when the patient is supine. Supine films
may be helpful in the evaluation of spinal tumors, for which better bone detail is necessary. Inspection of
the pars region on the anteroposterior view usually identifies a lucency suggesting fracture, reactive
sclerosis often contralateral to a spondylolysisthe Napoleon's hat signor other indications of posterior
element insufficiency, such as laminectomy or spina bifida occulta. The standing lateral view allows
loading of the disc to translate any spondylolisthesis, making it and the pars fractures more visible. Lowe
et al. showed that in 13 of 50 patients with spondylolisthesis translation was visible only on standing
films. Occasionally, oblique views that show the traditional Scotty dog profile are necessary; oblique
views identify as many as 19% of pars fractures that would be missed otherwise. A Ferguson
anteroposterior view, which is a modified pelvic outlet view, may be useful as a preoperative study to
evaluate the transverse processes of L5, the disc space between L5 and S1 for degeneration, and the
posterior elements at L5 and S1. This image is acquired by focusing the roentgen beam on the L5-S1 disc
with the beam parallel to the disc space (approximately a 30-degree cephalad tilt). Flexion-extension
lateral images are useful for preoperative planning and for identifying hypermobility. In a patient with
severe lumbosacral kyphosis, hyperlordosis, or sagittal decompensation, scoliosis films are warranted to
assess global sagittal balance.
MRI

MRI is useful as a noninvasive screening tool for detection of compression on the neural elements and for
early identification of disc desiccation. Sagittal images clearly delineate the discs and spinal canal, and
parasagittal sequences give excellent detail of the neural foramen on T1-weighted images unless the
patient has a concomitant scoliosis. Occasionally, horizontalization of the facet and diminished perineural
fat obscure the nerve root, with an area of low signal intensity. This low-signal material identified on MRI
has been found at surgery to correlate with fibrocartilaginous tissue and hypertrophic ligament within the
neural foramen. T2-weighted images show disc hydration and edematous vertebral endplate changes, as
described by Modic. A typical adult disc is white on T2-weighted images, with a slight cleft of decreased
intensity. Asymmetry in disc attenuation is an indicator of desiccation and degeneration. In patients with
adult isthmic spondylolisthesis, disc degeneration is present at the level of pars fracture. Of 40 patients
studied with MRI by Szypryt et al., only 4 of 20 patients younger than 25 years had degeneration of the
disc below the pars fracture; in contrast, 14 of 20 discs were degenerative in patients aged 25 to 45 years.
At the adjacent level disc above the pars fracture, 4 of the 20 younger patients had disc desiccation,
whereas half of those 25 to 45 years of age had degenerative changes. Osterman et al. confirmed disc
degeneration in all 27 of their patients treated operatively. MRI also is helpful for the identification of
38

fusion levels when surgery is planned and for guiding invasive diagnostic procedures such as discogram
and myelogram. However caution must be exercised because of the large number of asymptomatic
abnormalities on diagnostic studies even in young patients.
Bone Scintigraphy

Technetium bone scanning occasionally is helpful in adults to identify other causes of axial lumbar pain.
Sacroiliac arthritis can mimic pars and facet pain syndromes because of sclerotomal referred pain. Facet
arthritis, acute fractures, impending pars fractures, benign or malignant tumors, infection, pseudarthrosis,
and metabolic bone diseases all may be identified by bone scanning. Bone scanning is more useful in
younger patients to identify acute fractures of the pars, which may have healing potential, and to identify
occult fractures of the pars. In a study by Lowe at al., 25% of a group of military recruits had increased
uptake in the presence of a pars fracture documented on roentgenograms. Similarly, Van Den Oever et al.
found that 74% of their patients with spondylolysis had normal bone scans. Both studies noted that
increased activity was more common when symptoms were present for less than a year. Although bone
scanning generally is not required for the diagnosis of adult isthmic spondylolisthesis, it may be helpful in
excluding other conditions that can cause similar symptoms.
CT Myelography

Myelography followed by CT scanning is a dynamic study that allows observation of spinal fluid flow
along the nerve roots and the conus medullaris. Because of its invasive nature, it should be used only as a
preoperative study or if MRI is indeterminate or technically not feasible. Myelography is indicated for
preoperative correlation with MRI studies in patients with (1) radicular complaints and multiple foci of
pathology on the MRI, (2) continued radiculopathy in the absence of MRI findings, (3) radiculopathy and
significant spinal deformity that precludes the use of MRI, and (4) contraindications to MRI. Standard
myelogram images should be obtained, including anteroposterior, lateral, and oblique views, with the
addition of flexion and extension lateral views in the upright position. Flexion and extension lateral
images provide a dynamic picture of the bony structures and their relationship with the dural sac and
neural elements and may identify nerve root compression that is missed by the static positioning of MRI
or CT alone. After the myelogram, CT images are obtained to complete the study. For optimal
reconstructions, 1.0- to 1.5-mm cuts should be obtained through the area in question. Alternatively, for
helical CT scanners, 3.0-mm cuts can be used, with 1.0- to 1.5-mm reformatted images giving a similar
high resolution.
Discography

Discography is a provocative procedure that seeks to elicit and reproduce exactly a patient's primary pain
pattern. This can be done before surgery in a patient with adjacent level disc degeneration or multiple
level degenerative disease that has been documented on MRI to determine if an adjacent level should be
included in a fusion. Care must be taken in the interpretation of discograms because abnormal
discographic findings may be present in as many as 17% of normal subjects. Discography may be useful
in identifying symptomatic adjacent level degenerative disease, which was noted Henson, McCall, and
O'Brien to be present in 27 (51%) of 52 patients with back pain and spondylolisthesis at L5-S1.
Spondylolisthesis at L4-5 was noted in 14 of 27 patients with discographically confirmed disc
degeneration; however, the extent of disc degeneration did not correlate with the amount of slippage. No
prospective randomized trial has correlated operative outcome with preoperative discographic findings.
In clinical practice, discography may still be considered in the preoperative evaluation of patients with
spondylolisthesis. In patients with multiple degenerated segments, if pain is elicited at all levels, elective
fusion might be reconsidered because all levels may be affected or a significant psychosocial component
may be present. Under these circumstances, a long fusion to the sacrum would likely be debilitating to the
patient. If pain is identified at a single segment, or at most two segments, fusion can be done with more
reassurance of improvement. At least one normal level should be identified and injected as a control, and,
if possible, the patient should be lightly sedated and able to respond to questioning during the procedure.
Concordance of pain response seems to be more important than morphology of the disc. Correlation
between MRI and discography has been found to be high, and some authors reported equivalent results
39

using MRI alone. Discography has yet to be proved as a diagnostic and predictive study, and its use must
be carefully considered. Anecdotal reports have shown its usefulness in determining fusion levels if
uncertainty exists after conventional imaging has been done.
NONOPERATIVE TREATMENT

Nonoperative management of isthmic spondylolisthesis is effective in most adult patients. Initial


treatment includes a short period of rest and the use of acetaminophen or nonsteroidal antiinflammatories
for pain control. The use of muscle relaxants and narcotics is minimized because of potential dependence
and the lack of data to support their efficacy above over-the-counter medications. Manipulation and
modalities, such as heat, cold, ultrasound, and transcutaneous electrical nerve stimulation, are short-term
remedies and may be effective; however, a more preventive approach should be considered. Physical
therapy should be initiated early for symptoms that do not improve. Trunk-stabilization exercises,
avoiding hyperextension, are useful in improving posture and extensor muscle strength and may prevent
later flare-ups. Proper instruction in isometric trunk stabilization has been reported by O'Sullivan et al. to
result in sustained reduction of pain and disability compared with controls as confirmed by visual analog
pain scores and the Oswestry functional disability scores at 30-month follow-up. At 3-year follow-up of
an extension exercise program, pain described as moderate or severe was present in 62%, with 61%
unable to work or limited in their vocation. In a demographically similar group of patients with
spondylolisthesis treated with an abdominal flexion program and evaluated at 3 years, only 19% had
moderate or severe pain, and only 24% were unable to work or were limited in their vocation. Thus it
appears that pure extension exercise programs are not as effective as isometric stabilization programs or
flexion programs. Aerobic fitness also has been shown to be effective in the treatment of back pain and
should be considered early. Inactivity should be minimized because this produces debilitation and
depression, both of which may contribute to the development of a chronic pain syndrome.
Bracing is an option for pain management in some patients, but without a thigh cuff no orthosis is
particularly effective in immobilizing the lumbar spine below L3. Because pars fractures in adults do not
heal, bracing provides only symptomatic treatment. An orthosis may have an indirect positive effect by
limiting activity, but this restriction also may result in atrophy of the trunk muscles and more pain when
unsupported, which leads to a patient's dependency on the orthosis. If bracing is used, it should be
continued only until symptoms abate, and then trunk-stabilization exercises should be started as long as
the patient remains pain free during extension maneuvers. If symptoms allow, isometric exercises while
wearing the brace can be done until the brace is discontinued.
Epidural Steroid Injections

A corticosteroid and anesthetic solution can be used for pars injections, transforaminal, translaminar, or
caudal epidural steroid injections, and facet injections, but no literature exists to guide the surgeon in the
use of injections for spondylolisthesis. Radicular symptoms seem to respond better to steroid injection
than does axial pain.
Nonoperative treatment can be effective for back pain and radiculopathy. In adult patients the actual
diagnosis may be new to the patient, but the pathology likely has been present without symptoms for
decades. Therefore every attempt should be made to control symptoms nonoperatively if possible.
OPERATIVE TREATMENT

For patients in whom nonoperative treatment is unsuccessful, who have a favorable psychological profile,
and who are compliant and aware of surgical shortcomings, operative intervention should be considered.
Patient selection is extremely important when decompression or fusion is done in adults with
spondylolisthesis. Hanley and Levy noted that satisfactory results were significantly fewer in
compensation cases, in patients with radicular symptoms, and in smokers. Franklin et al. reported that in
compensation cases, back pain persisted in 66.7% of patients, and the quality of life was the same or
worse in 55.8%. They also noted that the use of instrumentation increased the rate of failure in this
population. Pseudarthrosis correlated with poor results. An educational level of less than the twelfth grade
also was related to a poor prognosis for pain relief and return to work.
40

Back pain or radicular symptoms that have not improved with conservative treatment are the most
common indications for surgery in adults with isthmic spondylolisthesis. Information obtained from a
thorough history and physical examination and appropriate diagnostic imaging studies determines which
operative procedure is best for an individual patient.
Decompression

Lumbar decompression without fusion may be indicated in patients with symptoms of radiculopathy or
neurogenic claudication. Although not recommended in children because of the risk of progressive
spondylolisthesis, the Gill laminectomy has provided satisfactory long-term results in 75% to 90% of
patients, regardless of postoperative slipping. In Gill's report, a maximum of 14% slip progression
occurred in a group of 52 patients followed for an average of 71 months. Progression of spondylolisthesis
may occur less frequently after Gill laminectomy if there is antecedent stabilizing disc degeneration. This
procedure simply is a resection of all bone and fibrous tissue from the pars defect distally, including the
lower portion of the pars interarticularis, lamina, spinous process, inferior articular facet, and all
intervening ligamentous structures. Radiculopathy is relieved in most patients; however, significant back
pain should be considered as an indication for fusion.
TECHNIQUE 41-5 (Gill et al.)
Place the patient prone on the operating table and through a midline incision expose subperiosteally the
spinous processes of the fourth and fifth lumbar and the first sacral vertebrae ( Fig. 41-18, A ).
Demonstrate the mobility of the fifth lumbar neural arch and with a rongeur resect the spinous processes
of all three vertebrae ( Fig. 41-18, B ). Also with a rongeur resect the middle part of the loose fifth lumbar
neural arch ( Fig. 41-18, C ). Then bite away the inferior aspect of the laminae of the fourth lumbar
vertebra until the ligamentum flavum has been freed. By sharp dissection excise the ligamentum flavum
from between the fourth and fifth vertebrae. Again by sharp dissection excise on one side the lateral part
of the loose fifth lumbar arch, freeing it from its articulation with the sacrum and from the tissues in the
defect in the pars interarticularis ( Fig. 41-18, D ); dissect close to bone to avoid damaging the fifth
lumbar nerve root ( Fig. 41-18, E ). Next retract this root superiorly and medially. Carefully dissect it from
the fibrocartilaginous tissue and free it laterally until it passes through the intervertebral foramen ( Fig. 4118, F and G ). Resect bone from the pedicle as necessary to free the root. Then examine the exposed
fourth and fifth lumbar discs and, if indicated, excise one or both. Carry out the same procedure on the
opposite side.

41

Figure 41-18 Operation of Gill, Manning, and White for spondylolisthesis (see text). (From Gill GG, Manning JG, White HL:
J Bone Joint Surg 37A:493, 1955.)

42

AFTERTREATMENT.

Postoperative care involves routine use of epidural or parenteral narcotics. Physical therapy is employed
in the initial mobilization of the patient, which is started on the day after surgery. No anticoagulation is
used if epidural anesthesia has been given. Pneumatic compression devices should be worn until the
patient is ambulatory. A bladder catheter is retained until the patient can get to a bedside commode or to
the bathroom with assistance, usually at 1 or 2 days. The epidural catheter is removed on the basis of
patient analgesic requirements or by the third day after surgery. Diet is advanced as tolerated, walking is
encouraged, and the patient is discharged when independent ambulation is possible and only oral pain
medication is required.
Posterolateral in Situ Fusion

Presently, standard treatment for adult patients with isthmic spondylolisthesis is in situ fusion from L5 to
S1, with or without instrumentation, using autogenous cancellous bone graft. Fusion appears superior to
decompression alone for resolution of symptoms. Single-level fusion is required in approximately 85% of
patients, and good results are obtained in 89%. Although 30% of patients had progression of their slips
after laminectomy and in situ fusion, Bosworth et al. found no difference in symptoms among these
patients compared with those with in situ fusion alone. If slip progression does occur after posterolateral
in situ fusion, observation is warranted.
TECHNIQUE 41-6 (Wiltse, Modified)
Induce anesthesia and insert an endotracheal tube, Foley catheter, and arterial intravenous line as indicated
by the clinical status of the patient. Place the patient on a spinal frame that allows the abdomen to hang
free. Make a midline skin incision extending one spinous process above and one below the levels to be
fused. Elevate the subcutaneous tissue off the fascia for a distance of three or four fingerbreadths
bilaterally; include exposure of the posterosuperior iliac crest on the side to be used for the bone graft
donor site. Make a fascial incision two fingerbreadths lateral to the midline, extending over the area to be
fused. Bluntly dissect the paraspinal muscles down to the facet joint capsules. Carry the dissection down
to the transverse processes to be fused. Clean the muscle subperiosteally to expose the transverse process
and intertransverse ligament. Denude the facet joints by removing the fascia over them and then stripping
them clean by subperiosteal dissection. Carry the dissection around the pars interarticularis. Prepare the
opposite side in a similar manner. Do not denude the superior facets of the most cephalad level to be
fused.
Obtain the bone graft from the donor site before denuding the recipient site. Incise the fascia over the iliac
crest with sharp or electrocautery dissection. Carry the dissection from the posterosuperior iliac spine to
about 3 to 4 cm lateral on the iliac crest. Strip the gluteal musculature from the crest laterally. Remove a
corticocancellous bone graft from the exposed portions of the crest down to the inner table. Close the
wound over closed suction drainage.
Prepare the recipient site for grafting by first placing corticocancellous strips beneath the transverse
processes, bridging the transverse ligament. Place the grafts with the cortical side toward the ligament.
Remove all cartilage from the facets to be fused. Place cancellous bone grafts in the facet defects. Denude
all areas of exposed bone, including the ala of the sacrum, the transverse processes, and the exposed pars
interarticularis. Carefully pack the remaining bone in the gutters bilaterally from the pars interarticularis
to the tips of the transverse processes. Close the wound in layers. Place closed suction drains in the
subcutaneous tissue bilaterally.

AFTERTREATMENT.

The patient is allowed to be up the next day, wearing a rigid lumbosacral brace, but is strongly advised to
refrain from smoking until the fusion is solid. Aspirin and nonsteroidal medication are discontinued, and
bracing is continued until the fusion is solid.
43

Modifications of Bilateral Lateral Fusion

Spinal decompression can be done through a midline exposure of the spine over the areas to be
decompressed. This incision is closed before the lateral approach is made. Decompression should always
accompany a reduction attempt to help minimize the risk of injury to the cauda equina. This not only
prevents impingement of nerve roots on bony or ligamentous structures during the reduction maneuver,
but also allows the surgeon to assess tension directly by palpation. Reduction is indicated based on the
pathology present and the patient's symptoms. For predominant symptoms of radiculopathy in a patient
with spondylolisthesis, decompression should accompany posterolateral fusion. Pedicle screw
instrumentation to improve the fusion rate is becoming increasingly popular. A prospective, randomized
study of 77 patients treated with posterolateral fusion either with pedicle screw fixation (37) or without
instrumentation (40) found no significant

Figure 41-19 Unilateral posterior lumbar interbody fusion (uPLIF or transforaminal lumbar interbody fusion). A, Decorticated
vertebral body and preparation of osteotomy site. B, Bone chips and stacked dowels in place. (Redrawn from Blume HG: Clin
Orthop 193:75, 1985.)

differences in level of pain, disability, or fusion rates between the two groups of patients. As in children
and adolescents, fusion alone may relieve symptoms in adults with low-grade spondylolisthesis. In a
retrospective study, Nooraie et al. compared 19 patients undergoing stabilization and fusion to 26 patients
treated with decompression, stabilization, and fusion. Results showed no significant differences between
the two groups. Instrumentation should be considered for high-risk groups (e.g., smokers).
Instrumentation is especially important if a reduction has been done, even if unintentional. The pedicles
usually are identified after the primary exposure is complete. They can be identified at the point formed
by the intersection of an imaginary line bisecting the transverse process and another line bisecting the
superior facet. This area is denuded, and the pedicle is probed with special instruments or guide wires.
The pedicles can be tapped to receive the screws after the position of the probes or guide wires has been
confirmed by roentgenograms, fluoroscopy, or computer-assisted navigation. Direct EMG stimulation of
pedicle screws also is helpful to determine if pedicle cortical bone has been violated, especially medial
and inferiorly. The placement of the screws and plates or rods varies with the type of instrumentation
used.
Posterior Lumbar Interbody Fusion

A technique for PLIF described by Cloward in 1943 has been used extensively by him and others for the
treatment of spondylolisthesis. It is best suited for grade I or II displacement but is generally unsuited for
displacements of grade III or higher unless reduction is done by posterior Harrington or similar
instrumentation, as advocated by Vidal et al. Bohlman and Cook combined posterior interbody fusion
with a posterolateral fusion, and Takeda combined it with a Bosworth H-graft fusion. Retraction of nerve
roots and the dural sac is necessary to insert the grafts, and cauda equina deficits have been reported.
Cloward reported a 4% incidence of footdrop in his series, all of which improved. This technique
frequently requires internal fixation to prevent displacement of the graft and further slip. Cloward used
spinous process wiring. Steffee and Sitkowski and others suggested the use of pedicle screws and plates
for this type of fixation. Cloward achieved fusion in 97% and complete resolution of pain in 83% of
patients. Suk et al. reported the results of PLIF combined with pedicle screw instrumentation for patients
44

with combinations of back pain, radiculopathy, and neurogenic claudication. In their retrospective review
of 76 patients, claudication symptoms resolved in 96%, motor symptoms improved in 71%, and sensory
changes were better in 55%. Success rates were equal in the PLF and PLIF groups, although the PLIF
group had significantly more excellent results (75% compared with 45%). Reduction of approximately
50% was obtained in both groups; however, only 28% reduction was maintained with PLF with pedicle
screws compared with 42% reduction maintained in the PLIF group.
A variation of PLIF is unilateral PLIF (uPLIF) or transforaminal lumbar interbody fusion (TLIF).
Originally described by Blume, uPLIF produced successful results in 80% of patients treated for lumbar
disc pathology. Unique to this procedure is the preservation of the ligamentum flavum by approaching the
disc in the foraminal region after unilateral facetectomy ( Fig. 41-19 ). This theoretically avoids epidural
scarring and excessive postoperative instability because the spinal canal is not opened and the
interspinous-supraspinous ligament complex, lamina, and contralateral facet are left intact. Harms et al.
reported successful arthrodesis with TLIF in 97% of patients. Complications have been few, and in
carefully selected patients this procedure has definite advantages over traditional PLIF.
TECHNIQUE 41-7 (PLIF)
Make a posterior approach to the spine to expose the transverse processes of L5 bilaterally as well as the
sacral ala. Pedicle screws can be placed before laminectomy so that distraction can be applied through the
screws to assist in providing tension. Once the posterior structures are on tension, removal of the loose
posterior element of L5 is easier. Perform a Gill decompression ( p. 2091 ) to expose the nerve roots and
create a pedicle-to-pedicle working window. Carefully retract the S1 nerve root medially to expose the
disc space, with periodic rest periods to allow blood flow to the root. Perform annulotomy sharply from
each side of the dura and remove the disc with curets and pituitary rongeurs. A bone chisel also is helpful
in removing the posterior endplate to a level flush with the central concavity of the endplate. This
maneuver decorticates the endplate and also allows a better fit of the graft material. Further decorticate the
anterior third of the disc under lateral fluoroscopy using an angled bone chisel or an angled curet under
direct observation. Place cancellous autograft in the anterior third of the disc space and use tamps to
compact it against the annulus and anterior longitudinal ligament (ALL). Place mesh or trapezoidal carbon
fiber cages, allograft struts, or tricortical autograft into the disc space while distraction is maintained, first
from one then the other side of the dura. After the structural graft or implant is placed, pack and tamp
more cancellous autograft behind it. Take care not to overfill the disc space so that the graft is not
retropulsed into the spinal canal.
This technique allows restoration of the normal lordotic disc configuration after the posterior
instrumentation is compressed. Use of threaded cylindrical interbody fusion cages results in parallel
endplates of adjacent discs and may contribute to loss of normal segmental lordosis, which is most
important at L5-S1. If these implants are used, take care to maintain this normal alignment. Close the
incision over drains and use an epidural catheter or parenteral narcotics for postoperative analgesia.
AFTERTREATMENT.

Aftertreatment is similar to that after other fusion techniques, but the use of an orthosis is optional. The
epidural catheter, if used, is removed the morning of the third postoperative day, and the patient usually is
discharged 5 days after surgery.
Anterior Lumbar Interbody Fusion

Anterior lumbar interbody fusion (ALIF) can be used alone or as part of a combined procedure. For lowgrade slips, ALIF alone allows removal of the disc, which is degenerative in most adult patients. This,
theoretically, should alleviate discogenic pain. Removal of the disc and placement of a graft also can
restore disc height significantly. The bone graft is under constant compression, which should improve
fusion, paraspinal muscles are not disturbed, and in revisions the difficulty of reexploration can be
avoided. For severe slips, in situ L5-S1 fibular peg grafting can be done with relative ease but requires
posterior stabilization.
45

Disadvantages of ALIF are well known: retrograde ejaculation, vascular injury, visceral injury, and deep
venous thrombosis. Herniated disc fragments are not visible from the anterior approach, nor are the nerve
roots or pars fractures, to aid in determining whether decompression is adequate.
Satisfactory results after ALIF appear to be independent of the fusion rate and comparable to the results of
decompression and PLF. Of 20 patients treated with ALIF for adult isthmic spondylolisthesis, Cheng et al.
reported satisfactory results in 19, with definite fusions in 15 at an average of 10.5 years after surgery.
Symptoms of back pain predominated and responded well to ALIF. Of the 9 patients in this study with
sciatica, 6 had resolution of symptoms, 2 had occasional sciatica, and 1 had constant pain. The
improvement in nerve root symptoms seems to be related to disc height restoration, ligamentotaxis, and
increased volume of the neuroforamen. Using threaded interbody fusion cages in a human cadaver model,
Chen et al. showed a 29% increase in neuroforaminal area at L4-5 and a 34% increase at L5-S1. Posterior
disc height also increased 37% and correlated well with the neuroforaminal area increases. Thus by
removing and fusing the degenerative disc, restoring disc height, and increasing neuroforaminal area,
ALIF can be successful in the treatment of adult isthmic spondylolisthesis. The fusion rate, despite
satisfactory results, has remained low in comparison to PLF.
Spondylolisthesis Reduction

High-grade spondylolisthesis is rare in adults, and when it occurs, the slip usually is quite rigid. If a slip
of more than 50% is identified in an adult patient, reduction should be considered. The goal should be
reduction of the slip angle to neutral, or lordosis if possible, and the slip should be reduced to 50% or less
but not necessarily to an anatomical position. Complete reduction of slips carries great morbidity in
children and is likely more dangerous in adults, except in low-grade slips. For stiff, high-grade slips in
adults, resection of L5 anteriorly followed by reduction of L4 onto the sacrum probably is the best option
if in situ fusion will not suffice.
The technique described by Speed generally is used for high-grade slips after posterior instrumentation,
fusion, and decompression.
TECHNIQUE 41-8 (Speed)
Make a midline incision from the umbilicus to the pubis and fully expose the sacral promontory. Then
raise the foot of the table and pack the intestines out of the way. Palpate the relations of the fifth lumbar
vertebra with the sacrum and confirm the roentgenographic findings. If the bifurcation of the aorta is low,
retract it along with the left common iliac vein. Just to the right of the midline and avoiding the midsacral
nerve and artery and the sympathetic ganglia, incise the peritoneum from the fourth lumbar interspace to
the sacrum. Then determine the proper angle and depth for a drill to be inserted to pass obliquely through
the body of the fifth lumbar vertebra and into the sacrum; with the patient supine, the direction is almost
perpendicular to the floor. Then pass a large drill through the fifth lumbar vertebra and into the sacrum; as
the drill passes from the body of the fifth lumbar vertebra and into the intervertebral space, advancing the
drill is easier until the body of the sacrum is reached, when it becomes more difficult. From the tibia take
a cortical graft and insert it into the hole, transfixing the fifth lumbar vertebra to the sacrum ( Fig. 41-20 ).

46

Figure 41-20 Kellogg-Speed anterior fusion for spondylolisthesis. (Redrawn from Speed K: Arch Surg 37:715, 1983.)
AFTERTREATMENT.

In patients with high-grade slips, a rigid TLSO with a hip spica cast is fitted, and the patient is nonweight-bearing for 6 weeks. Weight-bearing then is initiated, and the brace is discontinued at 3 months or
once fusion is evident.
Paramedian Retroperitoneal Approach

The retroperitoneal approach is useful for exposure of the lumbosacral joint and lumbar spine distal to the
renal vessels. This approach is made with the patient supine, which allows a direct anterior approach to
the discs. A left-sided longitudinal incision or a bikini incision can be used to allow access to the
confluence of the fascia over the rectus abdominis muscle and the oblique abdominal muscles. The fascia
is divided to expose the pre-peritoneal fat, and blunt dissection is used to expose the peritoneal contents,
which are ligated anteriorly. The segmental vessels are ligated with special attention to ligating the
presacral vessels and the iliolumbar vein at L5. This mobilizes the iliac vessels and allows exposure of the
entire L5-S1 disc. Care must be taken to avoid the use of electrocautery near the superior hypogastric
plexus because damage to this structure, which lies on the left iliac artery, can cause sexual dysfunction in
women or retrograde ejaculation in men. Multiple ALIFs can be done using this approach, although
thorough dissection of L5-S1 may be difficult if spondylolisthesis is significant.
TECHNIQUE 41-9 (Lehmer)
This procedure consists of two stages. The determination of when the second stage should be done
depends on the stability after completion of the first stage. In the first stage, approach the anterior
lumbosacral spine transperitoneally or retroperitoneally. Remove the body of L5 along with the
L4-5 and L5-S1 discs to the bases of the pedicles. In the second stage, excise the loose neural arch
and the pedicles of L5 through a midline posterior approach. Prepare the opposing L4 and S1
endplates for fusion. Reduce the body of L4 onto S1 (with or without an interbody fusion).
Stabilize the L4 and S1 reduction and fusion with transpedicular instrumentation. Perform a
routine bilateral posterolateral fusion.
AFTERTREATMENT.

A lumbosacral orthosis is worn for 6 to 12 weeks. Ambulation is begun on the second postoperative day
after the second stage.
47

Rheumatoid Arthritis of Spine


Rheumatoid arthritis is a systemic inflammatory disorder caused by lymphoproliferative disease within
synovium, which results in cartilaginous destruction, periarticular erosions, and attenuation of ligaments
and tendons. Pannus formation in the spine also may cause spinal cord compression. This entity occurs
twice as often in young women, with the age at diagnosis typically between 30 to 50 years. Cervical
instability is the most serious and potentially lethal manifestation of rheumatoid arthritis, with
roentgenographic changes or instability present in 19% to 88% of patients. Lumbar or thoracic pathology
rarely is present in patients with rheumatoid arthritis. Spinal disease is more common in patients severely
affected by erosive peripheral disease and in patients with a longer disease history. Three basic types of
cervical instability are present in this disease: atlantoaxial instability is most common, affecting 19% to
70% of patients, basilar impression or atlantoaxial impaction occurs in up to 38%, and subaxial
subluxation occurs in 7% to 29%.
CLINICAL EVALUATION

Pain, neurological sequelae, or instability often are the presenting symptoms. Approximately 61% of
individuals undergoing total joint replacement were reported to have instability in the cervical spine; 50%
of these patients had no symptoms attributable to the neck preoperatively. From 40% to 88% of patients
with rheumatoid arthritis of the spine have neck pain, and 7% to 58% have neurological findings. Axial
neck pain usually is occipital and may be associated with headaches. Myelopathic symptoms include
early weakness and gait disturbance, with frequent tripping or clumsiness. Hand function may be
impaired, with coordination disturbances that cause difficulty differentiating coins or buttoning clothing.
Sensory changes and bowel and bladder incontinence are late myelopathic symptoms. In patients with
atlantoaxial instability, vertebrobasilar insufficiency due to kinking of the vertebral arteries can cause
vertigo, tinnitus, or visual disturbances that lead to loss of equilibrium. Neurological evaluation often is
difficult because of the peripheral disease. Tendon ruptures, severe joint disturbances, and previous
surgery also make neurological examination difficult. Any findings consistent with myelopathy should
stimulate further investigation.
DIAGNOSTIC IMAGING
Roentgenography

Roentgenograms should include anteroposterior, lateral, odontoid, and lateral flexion and extension
views. Instability and potential for neurological sequelae are correlated best with the posterior atlantodens
interval (PADI), which is determined by measuring the distance between the ventral surface of the lamina
of C1 and the dorsal aspect of the odontoid; the interval should be more than 14 mm. This measurement is
97% sensitive for the presence of paralysis. In patients with preoperative paralysis caused by atlantoaxial
subluxation, recovery is not expected if the spinal canal diameter is less than 10 mm. If basilar impression
is coexistent, then significant recovery occurs only if the space available for the cord is at least 13 mm. If
the space for the cord is 14 mm or less, decompression must be considered because of the risk of paralysis
in patients with atlantoaxial instability. The PADI, however, does not represent the space available for the
cord because the soft tissues are not included in the measurement. The atlantodens interval (ADI) is
determined by measuring the distance between the posterior edge of the ring of C1 and the anterior edge
of the odontoid and normally should be 3.5 mm or less in an adult. An ADI of more than 10 to 12 mm is
clinically significant and suggests transverse ligament disruption; however, this measurement is not useful
in predicting neurological sequelae caused by instability, possibly because of the natural history of
atlantoaxial instability. As atlantoaxial instability progresses, subsequent vertical instability develops. As
this superior migration occurs, the ADI actually decreases. Despite significant progression of instability
and potential neurological deficit, the ADI will not increase further. Posterior subluxation is best
determined by acute angulation of the cord and upper cervical spine as identified by sagittal reformatted
CT scanning, lateral air contrast tomography, or preferably MRI. Lateral subluxation implies some
rotation of the atlas and is present when the lateral masses of C1 lie 2 mm or more laterally than those of
C2.

48

Figure 41-21 Drawing of base of skull and upper spine showing McGregor's line, McRae's line, and Chamberlain's line. (From
Hensinger RN: Section 23, Cervical Spine: pediatric. In American Academy of Orthopaedic Surgeons: Orthopaedic knowledge
update I: Home study syllabus, 1984.)

Atlantoaxial impaction is measured using the McGregor line ( Fig. 41-21 ). This line is constructed from
the base of the hard palate to the outer cortical table of the occiput. The tip of the odontoid is then
measured perpendicular to this line. Superior migration is considered present in men if the tip of the
odontoid is 4.5 mm above this line. Ranawat et al. described a method of determining the degree of
settling on the lateral roentgenogram using the minimal distance between a line drawn from the center of
the anterior arch to the center of the posterior arch of the atlas, and a vertical line drawn along the
posterior aspect of the odontoid from the center of the pedicles of C2. They reported that the normal value
was 15 mm for women and 17 mm for men, with less than 13 mm considered abnormal ( Fig. 41-22 ). To
determine vertebral settling, Redlund-Johnell and Pettersson used the minimal distance between the
McGregor line and the midpoint of the inferior margin of the body of the axis on the lateral
roentgenogram in the neutral position ( Fig. 41-23 ). They noted the normal value for men to be 34 mm or
more and 29 mm or more for women (100 patients each). Kawaida, Sakou, and Morizono compared the
predictive power of these screening methods and reported that they found the Redlund-Johnell method
better for diagnosing basilar impression.
Subaxial subluxations produce a cascading, or staircase, appearance of the spine. Any slippage of 4 mm
or more, or 20% of the adjacent vertebral body, is considered significant. Measurement of sagittal spinal
canal diameter is most useful and should be more than 13 mm. The risk of spinal cord compression and
injury is higher in patients with smaller canal diameters.
CT Myelography and MRI

Three-dimensional imaging is useful in patients who have a neurological deficit or roentgenographic


evidence of instability. MRI or CT myelography helps delineate the true space available for the cord. MRI
is excellent for viewing soft tissues and the neural elements, but myelography followed by CT scanning
gives similar information. In addition to bony compression, pannus further decreases the space available
for the cord by 3 mm or more in approximately 66% of patients. Determining the cervicomedullary angle
is helpful in identifying vertical instability. A line drawn along the dorsal surface of the odontoid will
intersect a line drawn ventral and parallel to the medulla. This angle normally should be 135 to 175
degrees, with angles less than 135 suggesting atlantoaxial impaction and correlating with the presence of
myelopathy. Kawaida et al. noted that MRI was 100% accurate in identifying vertical settling, and it is
currently the most definitive, least invasive test for cord compression. Flexion and extension MRI
scanning also has been used to determine dynamic compression of the spinal cord. Data from anatomical
studies indicate that the space available for the cord should be 14 mm at the foramen magnum, 13 mm at
the atlantoaxial articulation, and 12 mm in the subaxial cervical spine.

49

Figure 41-22 Measurement of superior migration in rheumatoid arthritis. A, Diameter of ring of first cervical vertebra and
distance from center of pedicle of second cervical vertebra to this diameter are measured. B and C, Measurement of superior
migration is not changed in flexion or extension of spine. (Modified from Ranawat CS, O'Leary P, Pellicci P, et al: J Bone
Joint Surg 61A:1003, 1979.)

Figure 41-23 Determination of vertebral settling in rheumatoid arthritis. Distance is measured between McGregor line (McG)
and midpoint of base of C2. (From Redlund-Johnell I, Pettersson H: Acta Radiol [Diagn] 25:23, 1984.)
CERVICAL INSTABILITY

Cervical disease has an early onset and is correlated with appendicular disease activity. Other factors that
predict more severe spinal involvement include longer duration of disease, positive rheumatoid factor, use
of corticosteroids, and male sex. Once cervical myelopathy is established, mortality is common if this
condition remains untreated. In fact, 100% of 21 patients refusing surgery for cervical instability died
within 7 years of the onset of myelopathy. The incidence of sudden death from the combination of basilar
impression and atlantoaxial instability is about 10%. Patients with rheumatoid arthritis have a shorter life
expectancy than the normal population. Pellicci et al. reported a mortality rate significantly higher than
50

the normal rate for comparable ages in patients with rheumatoid arthritis, even though none died as a
result of cervical disease.
Atlantoaxial subluxation (AAS) is the most common instability, with a reported incidence of 11% to 46%
of cases at necropsy. Atlantoaxial subluxation can be anterior, posterior, or lateral, with anterior instability
predominating. Posterior instability may occur in 20% and lateral instability in 7% of patients. This
instability results from erosive synovitis of the atlantoaxial, atlantoodontoid, and atlantooccipital joints.
Basilar impression, vertical settling, or atlantoaxial impaction (AAI) is the settling of the skull onto the
atlas and the atlas onto the axis as a result of erosive arthritis and bone loss. This settling can result in
vertebral arterial thrombosis. According to Ranawat et al., atlantoaxial instability is present in as many as
38% of patients with rheumatoid arthritis; however, its frequency increases with disease severity. In the
report of Oda et al., patients with mild disease did not develop this instability, but 52% of patients with
moderate erosive disease developed vertical instability, as did 88% of those with severe erosive disease.
Subaxial subluxations (SAS) are more subtle and frequently multiple, affecting 10% to 20% of patients
with rheumatoid arthritis. They are believed to result from synovitis of the facet joints and uncovertebral
joints, accompanied by erosion of the ventral endplates. They may result in root compression from
foraminal narrowing. Myelography, postmyelography reformatted CT scans, and MRI all show root cut
off and partial or complete block. Postmyelography reformatted CT scans and MRI are clearly superior in
identifying soft tissue obstructions and cord compression. Absolute subluxation distances of clinical
significance are not known for this problem.
The signs and symptoms of these instability patterns include pain, stiffness, pyramidal tract involvement,
vertebrobasilar insufficiency, root findings, and symptoms similar to the Lhermitte sign in multiple
sclerosis. Early clinical manifestations include the Hoffman and Babinski signs and hyperreflexia.
Nonoperative Treatment

Goals of nonoperative treatment include preventing neurological injury, avoiding sudden death,
minimizing pain, and maximizing function. Many patients, despite roentgenographic abnormalities,
remain asymptomatic, and supportive treatment is all that is necessary. Medical management during
disease flares is important for patient comfort and should be coordinated with a rheumatologist. A cervical
orthosis is helpful in some patients if pain persists. Isometric exercises help stabilize the neck without
excessive motion and also may help alleviate mechanical symptoms. Yearly follow-up with five-view
roentgenograms is indicated to detect instability so that stabilization can be done before neurological
deficits develop.
Operative Treatment

The indications for operative treatment are neurological impairment, instability, and pain. Boden et al.
recommended arthrodesis for patients, with or without neurological deficits, who have atlantoaxial
subluxation and a posterior atlantoodontoid interval of 14 mm or less, atlantoaxial subluxation with at
least 5 mm of basilar invagination, or subaxial subluxation with a sagittal spinal canal diameter of 14 mm
or less. Axial imaging that shows compression of the spinal cord to a diameter of less than 6 mm also is
an indication for surgery.
Atlantoaxial subluxation is best treated by posterior C1 and C2 fusion. This is accomplished with a
posterior wiring technique using interlaminar autogenous iliac crest; transarticular screws can be added
from C2 into C1, which obviates the need for a halo and allows the use of a Philadelphia collar or other
similar postoperative orthosis. Preoperative planning must include axial CT scans with sagittal
reconstructions to determine whether ample lateral mass is present for fixation and also to confirm that
anomalies of the vertebral arteries do not put these structures at risk. Stabilization alone will result in
some decrease of pannus, and odontoid excision is unnecessary unless anterior compression persists after
fusion or if compression is purely bony.
In patients with basilar impression a trial of halo or tong traction for reduction is an option, if tolerated. If
reduction is accomplished, a posterior occipitocervical fusion is done. If reduction is not possible,
51

posterior fusion is done after anterior transoral decompression or posterior decompression that includes
decompression of the foramen magnum. Posterior stabilization can be obtained with wiring and
corticocancellous struts, Luque rods, lateral mass plates, Y-plates, and newer rod-screw or rod-hook
systems. The prognosis is guarded in patients with preoperative neurological deficits, and basilar
impression is associated with poorer recovery of function. As a result, aggressive treatment is indicated to
prevent neurological deficits once progressive atlantoaxial impaction is identified.
Symptomatic subaxial subluxation probably is best treated by posterior fusion. Halo traction can be used
to reduce subluxations preoperatively, especially in patients with myelopathy or paraplegia. Ranawat et
al. reported that the results of anterior cervical decompression and fusion for subaxial subluxation were
not satisfactory. Decompression occasionally is necessary if reduction is not possible and if narrowing of
the space available for the cord is clinically significant. After reduction of the subluxation, posterior
fusion is done using wires, plates, or rods and autogenous bone graft. If plates or rods are used, fixation is
either into the lateral masses or transpedicular, with the latter more suited for C2 and C7 or T1, where the
lateral masses are thin. Stability can be increased by the placement of polymethylmethacrylate around the
wires. A bone graft is placed laterally to provide long-term stability. The mortality associated with surgery
for these problems is 8% to 20%. The complication rate also is high, including a nonunion rate of 20% to
33%. Boden and Clark developed a treatment algorithm for atlantoaxial subluxation ( Fig. 41-24 ).
The techniques for occipitocervical, atlantoaxial, and subaxial posterior cervical fusion are described in
Chapter 36 .
Pain is decreased after surgery in 90% to 97% of patients. Peppelman et al. reported that neurological
function improved in 95% of their patients with atlantoaxial subluxations, in 76% of those with combined
atlantoaxial subluxation and atlantoaxial impaction, and in 94% of those with subaxial subluxations.
Atlantoaxial subluxations have a poor prognosis for neurological recovery, with several studies reporting
improvement of function of one Ranawat class in only 40% to 50% of patients. The severity of the
preoperative neurological deficit also influenced results. Casey et al. reported that, of 134 patients with
Ranawat class III neurological deficits, 58% of ambulatory patients (IIIA) improved but only 20% of
nonambulatory patients (IIIB) did so.
Ankylosing Spondylitis
Ankylosing spondylitis is one of a variety of inflammatory spondyloarthropathies that affect the spine,
sacroiliac joints, peripheral joints, and entheses, as well as possibly cause conjunctivitis and uveitis.
Enteropathic spondyloarthropathies are associated with Crohn disease and ulcerative colitis, and reactive
arthritis or Reiter syndrome also may affect the spine. Of these disorders, ankylosing spondylitis has a
significantly more severe course once the spine is involved. There is a known association with the HLAB27 antigen, which is present in 88% to 96% of patients who have ankylosing spondylitis.
Initially, morning stiffness is the primary symptom. Men are affected four times more frequently than
women, usually in the second and third decades, with disease prevalence in white men estimated at 0.5 to
1 per 1000. As the disease progresses, ankylosis can cause various disfiguring and disabling spinal
deformities. Ankylosis usually progresses from caudal to cephalad. After ankylosis, however, pain
symptoms often improve. Other symptoms may be related to hip arthritis, which occasionally progresses
to spontaneous arthrodesis. Pulmonary cavitary lesions with fibrosis occur, as do aortic insufficiency and
conduction defects. Amyloid deposition can cause renal failure. Uveitis requires special ophthalmological
care and follow-up to prevent permanent vision changes. Breathing may be restricted because of fusion of
the costochondral and costovertebral articulations.

52

Figure 41-24 Algorithm for evaluation and management of rheumatoid arthritis of cervical spine. AAS, Atlantoaxial
subluxation; VMO, vertical migration of odontoid; SAS, subaxial subluxation; PADI, posterior atlantodental interval; SAC,
space available for cord; CMA, cervicomedullary angle. (From Boden SD, Clark CR: Rheumatoid arthritis of the cervical
spine. In The Cervical Spine Research Society, Editorial Committee: The cervical spine, ed 3, Philadelphia, 1998, LippincottRaven.)

Roentgenograms initially show fusion of the sacroiliac joints, which characteristically occurs bilaterally.
In the vertebral bodies, inflammatory resorption of bone at the enthesis causes periarticular osteopenia.
This resorption initially is seen as a squaring off of the corners of the vertebral bodies. Subsequent
ossification occurs in the annulus fibrosis, sparing the anterior longitudinal ligament and disc and giving
the bamboo spine appearance on roentgenograms. The posterior elements are similarly affected, with
ossification of the facet joints, interspinous and supraspinous ligaments, and ligamentum flavum.
Atlantoaxial instability must be identified, especially in any patient having surgery for conditions
associated with ankylosing spondylitis. Because of the stiff subaxial spine, instability occurs in 25% to
90% of patients with ankylosing spondylitis.
Treatment is directed at maintaining flexibility with stretching of the hip flexors and hamstrings and
maintaining spinal alignment with exercises. Antiinflammatory medications are useful in symptomatic
management. All nonoperative measures essentially are supportive.
Spinal fractures in patients with ankylosing spondylitis are always serious and frequently are lifethreatening injuries. Detwiler et al., Wade et al., Broom and Raycroft, and Graham and Van Peteghem
noted that these fractures usually occur in the lower cervical spine, frequently are unstable, and usually
are discovered late. Persistent pain may be the only finding until late neurological loss occurs. In patients
with established kyphosis the deformity may suddenly improve. Unfortunately, the patient's previous
deformity may not be known to those providing emergency care. Any perceived change in spinal
alignment, even if the result of trivial trauma, should be considered a fracture in a patient with ankylosing
spondylitis. The standard procedure is to immobilize the patient in the position in which he is found, since
extension may result in sudden neurological loss. A widened anterior disc space, which may be the only
obvious roentgenographic finding, creates a very unstable configuration that is prone to translation, late
53

neurological loss, and very slow healing. Imaging with MRI or CT with sagittal reconstructions is helpful
in making the diagnosis.
Graham and Van Peteghem, Rowed, and Broom and Raycroft advocated conservative treatment with
traction and halo immobilization unless displacement and neurological compromise are present. They
noted fewer complications with this approach. Detwiler et al. and Trent et al. advised early surgical
stabilization by posterior fusion with posterior rods. Ho et al. recommended an anterior approach for
stabilization. Surgical stabilization should be undertaken only with great care. Combined anterior and
posterior stabilization with instrumentation may be required. It is important to note that the morbidity and
mortality for these procedures in patients with ankylosing spondylitis are very high.
Traction should be carefully designed to reestablish the patient's previous deformity. This may require
placing the patient in a kyphotic position that protects the spine but creates skin and mobility problems.
Halo immobilization also can be difficult to institute and maintain without displacement.
Each patient with ankylosing spondylitis who has a fracture should be evaluated carefully to determine
the best therapy for the specific injury. Nonoperative therapy appears to be more successful than surgery.
Pseudarthrosis is a frequent complication of a fracture in patients with ankylosing spondylitis. Wu et al.
and Peh et al. noted late roentgenographic findings of disc space widening and discovertebral disruption.
Collie et al. noted that the bone scan frequently is hot in these occult fractures, whereas the rest of the
spine is no longer active on bone scan because of the disease process. Iplikcioglu et al. noted that MRI is
superior to other imaging methods if the diagnosis is questionable.
OSTEOTOMY OF LUMBAR SPINE

Smith-Petersen, Larson, and Aufranc in 1945 described an osteotomy of the spine to correct the flexion
deformity that often develops in ankylosing spondylitis and sometimes in rheumatoid arthritis. Since then,
LaChapelle, Herbert, Wilson, Law, Simmons, and others have reported similar procedures. The technique
described by Smith-Petersen et al. is carried out in one stage. Others have described surgery done in two
stages, one consisting of division of the anterior longitudinal ligament under direct vision instead of
allowing it to rupture when the deformity is corrected by gentle manipulation, as in the method of SmithPetersen et al.
If the flexion deformity is severe, the patient's field of vision is limited to a small area near the feet, and
walking is extremely difficult. This is evident by looking at the chin-brow to vertical angle ( Fig. 41-25 ).
Respiration becomes almost completely diaphragmatic, and gastrointestinal symptoms resulting from
pressure of the costal margin on the contents of the upper abdomen are common; dysphagia or choking
may occur. In addition to improvement in function, the improvement in appearance made by correcting
the deformity is of great importance to the patient. If extreme, the deformity should be corrected in two or
more stages because of contracture of soft tissues and the danger of damaging the aorta, the inferior vena
cava, and the major nerves to the lower extremities. Lichtblau and Wilson reported one patient with
transverse rupture of the aorta caused by manipulation of the spine for ankylosing spondylitis with severe
flexion deformity. The patient had previously received 2000 units of roentgen therapy. These authors
suggested that the roentgen therapy once used for this type of arthritis, not the arthritis itself, causes the
aorta to adhere to the anterior longitudinal ligament and makes it subject to rupture during manipulation
or osteotomy. They advocated a procedure in two stages in which the aorta is freed from the anterior
longitudinal ligament in the first and the osteotomy is made in the second. They pointed out that in all
their patients, regardless of the number of levels at which osteotomies were made, all correction took
place at only one level. Law reported a series of 114 patients and Herbert one of 50 in which the patients
were treated by osteotomy; in each series the mortality was about 10%, but in both reports most of the
deaths occurred early in the series, and both surgeons predicted that the rate would be lower with more
experience. Goel later reported a series of 15 patients in whom no deaths or serious complications
occurred. According to Law, 25 to 45 degrees of correction usually can be obtained, resulting in marked
improvement both functionally and cosmetically.
54

Figure 41-25 Chin-brow to vertical angle is measured from brow to chin to vertical while patient stands with hips and knees
extended and neck in its fixed or neutral position. (From Kostuik JP: Ankylosing spondylitis: surgical treatment. In Frymoyer
JW: The adult spine: principles and practice, ed 2, Philadelphia, 1997, Lippincott-Raven.)

Adams suggested that the operation be carried out with the patient lying on his side. This lateral position
has several advantages: (1) it is easier to place the grossly deformed patient on the table; (2) the danger of
injuring the ankylosed cervical spine by pressure of the forehead against the table is eliminated; (3) the
anesthesia is easier to manage because maintaining a clear airway and free respiratory exchange are less
difficult; and (4) the operation is easier because any blood will flow out from the depth of the wound
rather than into it. We agree that this is the safest and most efficient position for this procedure. Adams
described hyperextending the spine with an ingenious three-point pressure apparatus, and Simmons
described surgery with the patient on his side and under local anesthesia. When the osteotomy is
complete, the patient is turned prone, carefully fracturing the anterior longitudinal ligament with the
patient briefly under nitrous oxide and fentanyl anesthesia.
Osteotomy usually is made at the upper lumbar level because the spinal canal here is large and the
osteotomy is distal to the end of the cord. A lumbar lordosis is created to compensate for the thoracic
kyphosis; motion of the spine is not increased. Osteotomy methods include resection of the spinous
processes from the laminae to the pedicles, simple wedge resection of the spinous processes into the
neural foramina ( Fig. 41-26,A and B ), chevron excision of the laminae and spinous processes ( Fig. 4126, C and D ), and combined anterior opening wedge osteotomy following posterior resection of the
spinous processes and laminae ( Fig. 41-26, E and F ).
Styblo, Bossers, and Slot in 1985 reported an average correction from 80 degrees to 44 degrees after
upper lumbar osteotomy; correction was maintained by internal fixation. Manual osteoclasis worked best
in patients with calcified ligaments. They noted seven different types of spinal disruption caused by the
manual osteoclasis. Complications from this procedure included hypertension, gastrointestinal problems,
neurological defects, urinary tract infections, psychological problems, dural tears with leakage, and
retrograde ejaculation. One rupture of the aorta was reported by Lichtblau and Wilson.
Spinal osteotomy is a demanding procedure for which proper training and experience are mandatory. The
surgeon should be familiar with the several options available.

55

Figure 41-26 Methods of high lumbar spinal osteotomy. A and B, Simple wedge resection of spinous processes into neural
foramina. C and D, Chevron excision of laminae and spinous processes. E, Total laminectomy. F, Rather than osteotomy with
opening of disc in front (middle), Thomasen used resection of posterior wedge and resection of pedicles (right). (A, B, E, and
F redrawn from Thomasen E: Clin Orthop 194:142, 1984; C and D redrawn from Smith-Petersen MN, Larson CB, Aufranc
OE: J Bone Joint Surg 27:1, 1945.)

56

Figure 41-27 Patient's position on operating table before (A) and after (B) reduction of osteotomy. Osteotomy gap is closed
when table is brought from flexed to straight position. (From Thiranont N, Netrawichien P: Spine 18:2517, 1993.)
Smith-Peterson Osteotomy

The Smith-Peterson osteotomy is an excellent option for correction of smaller degrees of spinal
deformity. Bone is removed through the pars and facet joints ( Fig. 41-26, C and D ). If a previous fusion
has been done, care should be taken to thin the fusion mass gradually until the ligamentum flavum or dura
is exposed. Symmetrical resection is necessary to prevent creating a coronal deformity. Removal of the
underlying ligament also is helpful in preventing buckling of the dura or iatrogenic spinal stenosis.
Approximately 10 degrees of correction can be obtained with each 10 mm of resection. Excessive
resection should be avoided because it may result in foraminal stenosis. In patients with degenerative
discs, decreased flexibility may limit the amount of correction that can be obtained. The osteotomy is
closed with compression or with in situ rod contouring and bone graft is applied.

Figure 41-28 Eggshell procedure. After posterior elements have been removed and pedicles have been collapsed outward,
long, sharp curet is used to collapse eggshell. (From Heinig CF: Eggshell procedure. In Luque ER, ed: Segmental spinal
instrumentation, Thorofare, NJ, 1984, SLACK.)
57

Pedicle Subtraction Osteotomy (Thomasen)

Pedicle subtraction osteotomy ( Fig. 41-26, A and B ) is best suited for patients who have significant
sagittal imbalance of 4 cm or more and immobile or fused discs. Pedicle subtraction osteotomy is
inherently safer than the Smith-Peterson osteotomy because it avoids multiple osteotomies. Typically, 30
degrees or more of correction can be obtained with a single posterior osteotomy, preferably at the level of
the deformity. If the deformity is at the spinal cord level, pedicle subtraction osteotomy can be used, but
care must be taken to avoid manipulation of the cord. Thomasen, and Thiranont and Netrawichien
described the use of this osteotomy after laminectomy and pedicle resection. In their technique,
compression instrumentation is used, along with simultaneous flexion of the head and foot of the
operating table ( Fig. 41-27 ). Care must be taken to avoid compression of the dura or creation of a
coronal deformity. A wake-up test is done once correction and cancellous bone grafting have been
completed.
Eggshell Osteotomy

The eggshell osteotomy requires both anterior and posterior approaches and usually is reserved for severe
sagittal or coronal imbalance of more than 10 cm from the midline ( Fig. 41-28 ). This is a spinal
shortening procedure with anterior decancellization followed by removal of posterior elements,
instrumentation, deformity correction, and fusion.
OSTEOTOMY OF CERVICAL SPINE

In patients with chin-on-chest deformity, often the mandible is so near the sternum that opening the mouth
and chewing properly are difficult. Law reported a series of 14 patients treated by osteotomy of the
cervical spine for this deformity. He pointed out that cervicodorsal kyphosis usually can be treated
satisfactorily by lumbar osteotomy, which provides a compensatory lumbar lordosis and results in an erect
posture. However, cervical osteotomy may be indicated (1) to elevate the chin from the sternum, thus
improving the appearance, the ability to eat, and the ability to see ahead; (2) to prevent atlantoaxial and

Figure 41-29 Extent of resection of cervical laminae for safe osteotomy. Lateral resections are beveled toward each other so
that opposing surfaces are parallel and in apposition after extension osteotomy. (Redrawn from Simmons EH: Clin Orthop
86:132, 1972.)

cervical subluxations and dislocations, which result from the weight of the head being carried forward by
gravity; (3) to relieve tracheal and esophageal distortion, which causes dyspnea and dysphagia; and (4) to
prevent irritation of the spinal cord tracts or excessive traction on the nerve roots, which causes
neurological disturbances. The appropriate level for osteotomy is determined by the deformity and the
degree of ossification of the anterior longitudinal ligament. Law successfully performed osteotomies at
the levels of C3 and C4, C5 and C6, and C6 and C7. He fixed the spine internally with the plates devised
by Wilson and Straub for use in lumbosacral arthrodesis. However, wiring of the spinal processes
( Chapter 36 ), or use of a halo alone, also should be effective. In the osteotomy technique described by
58

Simmons ( Fig. 41-29 ), decompression is done first and is extended into the neural foramen. After
decompression and resection of the inferior aspect of the pedicles, extension manipulation is done. The
operation is carried out with the patient sitting in a dental chair and inclined forward with the arms resting
on an operating table ( Fig. 41-30 ). Overcorrection of the deformity must be avoided because otherwise
the trachea and esophagus could be overstretched and become obstructed. If halo stabilization alone is
used, postoperative neurological symptoms are treated by lessening correction; if internal fixation is used
for more postoperative stability, reoperation is required for adjustment of correction. The halo is worn for
3 months, and a Philadelphia collar or similar orthosis is worn an additional 6 to 8 weeks.
Freeman reported using skeletal traction to treat a patient with severe cervicodorsal kyphosis who could
not actively lift his chin from the sternum but in whom minimal passive motion of the cervical spine was
demonstrated by skeletal traction. The traction reduced a subluxation of C4 on C5 but failed to restore
acceptable alignment. The Crutchfield tongs were then

Figure 41-30 Position of patient for cervical osteotomy: sitting on stool with head suspended by halo and traction. (Redrawn
from Simmons EH: Clin Orthop 86:132, 1972.)

removed, and a plaster jacket with an attached halo was applied. The neck was extended gradually until
some of the cervical lordosis had been restored. Then, with the halo still in place and the patient under a
local anesthesia, an arthrodesis from the occiput to T3 was carried out successfully.
Tumors of Spine
BENIGN TUMORS

Of all primary benign bone tumors, 8% occur in the spine or sacrum. Although most spinal tumors are
metastases and malignancies, 20% to 40% are primary benign spinal tumors. Benign lesions have a
predilection for younger patients, with 60% of benign lesions identified in the second and third decades
( Box 41-3 ). The exception to this is sacral tumors, which more often are malignant, even in the younger
age groups. However, 70% of spinal tumors are malignant in patients over 21 years of age. Typically,
benign lesions are in the posterior elements, with most anteriorly located lesions malignant (76%).
Kostas et al. reported 22 patients who had back pain and deformity caused by benign tumors or tumorlike
lesions of the spine (15 lumbar, 7 thoracic); the duration of pain ranged from 1 to 6 years. Management
included tumor excision and thorough debridement; spinal fusion with instrumentation was used to
correct deformity and provide stability in five patients. Of five patients who had preoperative incomplete
59

paraplegia, four recovered completely and one (who had a spinal cord hemangioma) improved two
Frankel grades. They noted that because these lesions are rare in the thoracolumbar and lumbar spine,
they are easily misdiagnosed in patients with persistent back pain.
During operative treatment of tumors, certain fundamentals must be followed to maintain function and
anatomy and to minimize the risk of recurrence or instability. These principles are most important in the
region of the spinal cord. For cervical and thoracic lesions, the spinal cord must be preserved. Roots vary
in importance depending on anatomical location and can be resected if long-term benefit is to be gained.
Some paired vascular structures, including the vertebral arteries, also can be singly resected. Adequate
collateral circulation is identified by temporary occlusion during angiography if resection of the vertebral
artery is anticipated.
In the thoracic spine, laminectomy alone does not provide safe access to the anterior column. The risk of
paralysis is significant, and alternative approaches must be used. For patients who are unable to tolerate a
thoracotomy, a costotransversectomy is a reasonable and safe approach to the anterior column.
Unfortunately, with aggressive lesions, the spinal canal may be contaminated. Nerve roots serve only the
intercostal muscles, so sacrifice of some of the thoracic roots does not severely affect function unless
numerous roots are taken. As more thoracic roots are sacrificed, there is some effect on chest cage
function and respiration due to interference with intercostal innervation.
Sacral tumors requiring wide excision are rare. Combined approaches often are necessary for wide
excision and require complex reconstruction to stabilize the ilia to the distal lumbar spine. Resection of
the sacrum and its associated nerve roots also affects continence. If both S1 nerve roots and a single S2
nerve root are preserved, 50% of patients retain continence. If only a single S3 root is taken, with S1 and
S2 undisturbed, bowel and bladder function are retained. The nature of the tumor to be resected, however,
often dictates the anatomical level of resection.
Stability

Stability considerations after resection are different in adult and pediatric patients. In the cervical and
thoracic regions, laminectomy creates instability in an immature spine, so arthrodesis should be done. The
adult spine seems to tolerate laminectomy better, and some biomechanical considerations are useful when
choosing instrumentation and fusion procedures. Instability created by anterior resection increases as
more vertebral body is resected. As a rule of thumb, fusion should be done when any significant amount
of vertebral body is resected. The exception to this is curettage: if adequate bone graft is placed after
curettage, fusion usually is not necessary. After anterior fusion, with or without instrumentation,
immobilization with a TLSO generally is recommended. Once incorporation of fusion bone is identified,
usually 3 to 6 months postoperatively, the orthosis is discontinued.
Determination of instability after posterior spinal resections is not as straightforward as after anterior
procedures. Important bony and ligamentous structures posteriorly individually contribute to overall
stability in the intact spine. Soft tissue restraints include the supraspinous, interspinous, and posterior
longitudinal ligaments, the ligamentum flavum, and the facet capsules. Bony stability is provided by the
spinous processes, laminae, pars interarticularis, facet joints individually on the left and right, and the
posterior vertebral wall. Point systems have been created to assist in the determination of stability.
Bridwell assigned 25% of posterior vertebral stability for each stabilizing structure, including the midline
osteoligamentous complex (laminae, spinous processes, and intervening ligaments), the two facet joint
complexes (left and right), and the posterior vertebral wall, disc, and annulus. Violation of two of the four
complexes, or disruption of 50% of the stabilizing structures, is an indication for instrumentation and
fusion. Bony involvement of tumors also contributes to impending pathological fracture and instability.
Considerations for impending instability or for determining stability after fracture include more than 50%
collapse of the vertebral body, translation, segmental kyphosis of more than 20 degrees above normal, and
involvement of both anterior and posterior columns.

60

Box 41-3. Radiographic Diagnosis of Spine


Tumors According to Age and Location *
DIAGNOSIS ACCORDING TO AGE
10 to 30 Years of Age
Aneurysmal bone cyst (ABC)
Ewing
Giant cell
Histiocytosis X
Osteoblastoma
Osteoid osteoma
Osteochondroma
Osteosarcoma
30 to 50 Years of Age
Chondrosarcoma
Chordoma
Hodgkins
Hemangioma
50 + Years of Age
Metastatic
Myeloma
DIAGNOSIS ACCORDING TO LOCATION
Vertebral Body
Chordoma
Giant cell
Hemangioma
Histiocytosis X
Metastatic disease
Multiple myeloma
Posterior Elements
ABC
Osteoblastoma
Osteoid osteoma
Osteochondroma
Adjacent Vertebrae
ABC
Chondrosarcoma
Chordoma
Multiple Vertebrae
Histiocytosis X
Metastatic
Myeloma
*From Parks P, Herkowitz HN: Semin Spine Surg
2:3, 1990.

61

Figure 41-31 Enneking staging of benign spinal tumors. Capsule of tumor is indicated by 1, reactive pseudocapsule by 2.
Stage 3 aggressive benign tumors can expand through posterior vertebral wall and compress cord. Pseudocapsule is
vascularized reactive tissue and can adhere to dura. (Redrawn from Boriani S, Biagini R, DeIure F: Semin Spine Surg 7:317,
1995.)
Classification

As with tumors in other locations, the Enneking classification is useful in determining treatment of spinal
tumors ( Fig. 41-31 ). Stage 1 tumors (such as osteoid osteoma, eosinophilic granuloma, osteochondroma,
and hemangioma) are latent and typically require no treatment. If surgery is necessary, often intralesional
excision is all that is necessary, with or without adjuvants like liquid nitrogen, phenol, or PMMA. Stage 2
lesions are active, become symptomatic, and usually require only en bloc excision (i.e., removal of the
tumor as a whole, as opposed to piecemeal). Intralesional excision, again, often suffices for these tumors.
Examples of stage 2 lesions include osteoid osteoma, osteoblastoma, eosinophilic granuloma, more
aggressive hemangiomas, osteochondroma, and aneurysmal bone cysts. Aggressive lesions are
characterized as stage 3. Despite being classified as benign tumors, lesions such as giant cell tumors and
osteoblastomas are locally aggressive and have a tendency to recur. Wide excision is indicated for these
lesions and consists of removal of the tumor with a cuff of normal tissue if possible. A marginal excision
would result in a biopsy specimen that includes the reactive zone around the tumor. The exact type of
excisional biopsy often is dictated by the anatomy of the spine and the location of the tumor.
Posterior Element Tumors
Osteoid Osteoma.

Osteoid osteoma is a lesion of bony origin that was first described by Jaffe in 1935. These lesions are
most common in the spine (42%), affect males more often than females, and are most common in the
second decade. The lumbar spine is the most common location, the cervical next, and the thoracic last,
and the lesion is almost invariably located in the posterior elements. Few osteoid osteomas of vertebral
bodies have been reported. This lesion is not locally aggressive and is defined by a size of less than 2 cm;
larger lesions are classified as osteoblastomas.
Pain is the primary complaint in 83% of patients, is worse at night with awakening in nearly 30%, and is
relieved by aspirin in 27%. Because of the location in the posterior elements, radiculopathy occurs in up
to 28% of patients. A painful scoliosis may result, with the lesion usually present at the apex of the curve
in the concavity. Although various curve types may result, the usual structural features of vertebral
rotation normally present in idiopathic scoliosis are absent. The resultant scoliosis is rigid and rapidly
progressive. Saifuddin et al, in a meta-analysis of spinal osteoid osteoma and osteoblastoma, determined
that (1) 63% of patients had scoliosis, (2) scoliosis was significantly more common with osteoid osteomas
than with osteoblastomas, (3) lesions were more common in the thoracic and lumbar regions than in the
cervical region and more common the lower cervical region than the upper cervical region, and (4) lesions
were more commonly located to one side of the midline. They concluded that these findings support the
concept that in patients with spinal osteoid osteoma or osteoblastoma scoliosis is secondary to
asymmetrical muscle spasm.
62

Diagnosis can be difficult, since early roentgenograms may appear normal. Frequently, a sclerotic lesion
of the pedicle is all that is apparent, and even this may be a subtle asymmetry. Later, the usual
configuration of a central nidus with surrounding sclerosis may be found, but in only half of patients will
it be typical in appearance. Oblique roentgenograms can be helpful when the pedicle, facet, and pars
interarticularis are studied. A radioisotopic bone scan is most helpful in accurate localization, and CT
scanning often shows the nidus.
Treatment should consist of surgical excision of the lesion if symptoms fail to improve or the scoliosis is
progressive. Confirmation of nidus excision can be made by specimen CT. If the spine is considered
unstable because of facet or pedicle removal, a single-level fusion is done simultaneously. Complete
excision should result in improvement in the angular degree of the scoliosis, although resolution is less
likely in patients aged 9 to 13.5 years. Scoliosis persists in 20% to 30% of patients after successful
resection. Curves that persist for more than 18 months after resection may require treatment. Brace
management may be necessary in immature patients, and regular follow-up is advised. Surgery for spinal
deformity usually is deferred until after treatment and resection of the osteoid osteoma and follows the
same principles as for idiopathic scoliosis. Prompt relief of pain is the best postoperative indicator of
successful removal of the tumor.
More recently described treatment methods include high-frequency radio wave ablation (Osti and
Sebben) and percutaneous CT-guided thermocoagulation (Cove et al.). Reports at present are anecdotal,
and the effectiveness and safety of these minimally invasive techniques have yet to be proved.
Osteoblastoma.

Osteoblastoma accounts for 10% of all spinal tumors and, of those reported, 32% appear in the spine.
Like osteoid osteoma, it is most common in the second and third decades, with a male-to-female ratio of
2:1. These lesions almost always involve the pedicle or posterior elements, or both, although contiguous
levels may be affected. The predominant spinal region affected is the cervical region (40%), followed by
the lumbar (23%), thoracic (21%), and sacral regions (17%). Osteoblastoma may be misdiagnosed as an
osteosarcoma, Ewing sarcoma, lymphoma, or aneurysmal bone cyst, which all are high on the list of
differential diagnoses. Differentiation from osteoid osteoma is based on size, as these lesions exceed 2
cm.
Roentgenographic evaluation reveals a destructive, expansile lesion with a thin rim of cortical bone. Lytic
features are predominant and occur in 50%, with purely blastic changes in 20%. Bone scanning always is
positive and is helpful in identification. Although MRI is useful in identifying a soft tissue mass, it may
confuse the picture. A flare reaction may occur, suggesting extracompartmental extension and
confusing the diagnosis of a benign lesion. As with other bony lesions, CT is best for definition of the
extent of the tumor and for identification of the nidus.
Wide excision, if possible, is the treatment of choice. The tumor recurs as late as 9 years after resection in
as many as 10% to 20% of patients with intralesional excision. The best indication of successful removal
is relief of preoperative pain. Ozaki et al. reported open resection of 13 osteoblastomas and 9 osteoid
osteomas; 17 of the 22 patients had scoliosis before surgery, which improved in 16 after tumor resection.
Two patients with osteoid osteomas had recurrences because of incomplete resection. Because of the
possibility of recurrence and malignant transformation, however, long term CT follow-up is mandatory.
Operative treatment is necessary for recurrences because these lesions are not radiosensitive.
Osteochondroma.

Although rarely symptomatic, osteochondroma is the most common benign primary bone tumor. Half of
patients with symptomatic tumors are younger than 20 years of age, which is consistent with the growing
cartilaginous cap. Males are affected three times more often than females, with most lesions protruding
eccentrically from the neural arch. Because the spinal canal is occupied by spinal cord in the thoracic and
cervical spine, lesions here are more frequently symptomatic. As many as 91% of osteochondromas occur
in the cervical and upper thoracic spine, although the lumbar spine and sacrum also are affected. The lack
of symptoms may result in underdiagnosis of lesions in the lumbar and sacral regions.
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Roentgenographic evaluation often is diagnostic, with the lesions found most often in the posterior
elements. Because of the radiolucent cartilaginous cap, however, MRI or myelography may be necessary
to determine if impingement of the neural structures is present. These lesions are slow growing and
require excision only if symptomatic. Malignant transformation occurs in fewer than 1% of tumors and is
suspected when symptoms are rapid in onset with growth of a previously stable osteochondroma. A
cartilaginous cap larger than 1 cm also is suspect. En bloc excision to include all of the cartilaginous cap
is done, with neurological recovery the rule and recurrence the exception.
Aneurysmal Bone Cyst.

Aneurysmal bone cysts are relatively uncommon, accounting for only 1% to 2% of benign bone tumors.
Although predominantly a posterior element lesion, an aneurysmal bone cyst may expand to include the
pedicle and vertebral body. Of all aneurysmal bone cysts, 11% to 30% occur in the spine and are most
frequent in patients younger than 20 years of age. There does not appear to be a gender preference. Back
pain is the predominant symptom in 95% of patients, although muscle spasms causing spinal rigidity or
scoliosis also may be present. The differential diagnosis includes giant cell tumors, tuberculosis, fibrous
dysplasia, eosinophilic granuloma, Ewing sarcoma, and osteoblastoma.
The characteristic roentgenographic finding with aneurysmal bone cysts is an expansile lesion with a
reactive rim of cortical bone outlining the lesion as it expands from the cortex, although this may be
absent in 30%. Another characteristic feature is that these lesions may affect contiguous levels.
Arteriography may show a lesion with multiple septa and blood-filled spaces. MRI with gadolinium
enhancement also shows the fluid levels within the septations.
De Cristofaro et al. reported that embolization was successful in 79% of their patients (19 of 24), although
some required repeated embolizations. Low-dose irradiation has had limited success, with few side effects
when dosages are kept below 30 Gy. Radiation alone, however, is successful in only approximately 50%.
Surgery therefore has remained the standard of care for aneurysmal bone cysts. After embolization to
decrease intraoperative blood loss, curettage and bone grafting are done. Despite intralesional margins,
the recurrence is only 13%. Any instability created must be treated at the time of surgery and often
requires a single-level fusion in skeletally immature patients. Papagelopoulos et al. reported a recurrence
rate of 10% within 10 years of treatment of 52 patients with aneurysmal bone cysts of the spine.
Vertebral Body Tumors

Typical benign lesions found in the vertebral bodies include eosinophilic granuloma, hemangioma, and
giant cell tumors. Historically, lesions such as these were considered surgically inaccessible when in the
vertebrae. The older literature recommended irradiation or chemotherapy. Although this still may be
appropriate in special circumstances, such as in highly radiosensitive malignant tumors, angular
deformity with potential paraplegia may result because of subsequent spinal instability. Benign tumors are
best treated without irradiation to avoid secondary sarcomatous change. Optimal treatment of aggressive
benign or solitary malignant tumors, however, may be anterior resection of the tumor to effect a cure or
for tumor debulking.
Hemangioma.

Hemangioma is a common lesion, present in as many as 10% to 12% of autopsy specimens. Most of these
lesions are clinically silent and are detected only incidentally during evaluation for other problems.
Occurrence may be single or multiple with contiguous levels affected, but the vertebral body is the most
common location for hemangiomas, especially in the lumbar and lower thoracic regions. The posterior
elements are involved in 10% to 15% of patients; however, this is atypical and indicative of an aggressive
lesion. Patients with symptomatic hemangiomas most commonly have pain (60%), neurological
compromise (30%), or symptomatic fracture (10%).
Epidural cavernous hemangiomas are extremely rare. Shin et al. reported five epidural cavernous
hemangiomas (four thoracic and one lumbosacral), all of which showed paravertebral extension and
partially encircled the spinal cord, and Zevgaridis et al. reported three such lesions that produced
64

symptoms of spinal cord syndrome, thoracic radiculopathy, and lumbar radiculopathy. MRI findings
included a homogeneous signal intensity similar to spinal cord and muscle on T1-weighted images and a
high signal intensity, slightly less intense than that of cerebrospinal fluid, on T2-weighted images.
Roentgenograms detect larger lesions, which have vertical striations and coarse, thick trabeculae,
described as a corduroy vertebra. Expansion may be noted in aggressive hemangiomas, with erosion of
the vertebral body. Axial CT scanning shows a classic polka dot appearance. Bone scanning is not
particularly helpful because lesions may be either hot or cold. MRI scanning has become the standard for
diagnosing these lesions. Typical hemangioma is identified by increased intensity on both T1- and T2weighted sequences and can be differentiated from Paget disease because Pagetic bone has more cortical
thickening and affects the entire vertebral body. Aggressive hemangiomas can involve the entire vertebral
body, may be expansile and have a soft tissue component, which is differentiated from typical
hemangioma by hypointensity on T1-weighted images and hyperintensity on T2-weighted images.
Most hemangiomas do not require treatment, and other causes of pain must be excluded. For the rare
symptomatic lesions, radiation is successful in 50% to 80%. Embolization also is useful, especially in
patients with progressive neurological deficits, and may provide temporary relief of pain. Vertebroplasty
has been successfully used for treatment of aggressive hemangiomas by stabilizing pathological bone
with an injection of bone cement into the vertebral body. Recent use of inflatable bone tamps has had
similarly good short-term results. Direct intralesional injection of ethanol has been reported to be
effective in obliterating symptomatic vertebral hemangiomas. CT angiography is required before injection
to identify functional vascular spaces of the hemangioma and to direct needle placement. Doppman,
Oldfield, and Heiss reported complete obliteration of hemangiomas in 11 patients; 5 of 6 patients with
paraplegia recovered completely, and 1 had improved at short-term follow-up. These authors cautioned
that less than 15 ml of ethanol should be used because two patients who received 42 and 50 ml developed
pathological fractures of the involved vertebrae 4 and 16 weeks after treatment. For progressive
neurological deficit, radiation alone may be successful in arresting progression. With neurological deficit
and fracture, however, surgery is necessary to remove an aggressive hemangioma, and embolization
should be done preoperatively to minimize bleeding intraoperatively.
Eosinophilic Granuloma.

Eosinophilic granuloma is most common in patients younger than 10 years of age. It typically is a solitary
lesion of bone, with 7% to 15% occurring in the spine, and has a predilection for the thoracic region.
Symptoms usually include pain, muscular rigidity, and neurological deficits; systemic symptoms may
occur. The classic roentgenographic finding is vertebra plana seen as a complete collapse of the vertebral
body on the lateral view. Bone scans are cold, and MRI often reveals a flare reaction on T2-weighted
images, which can be mistaken for a malignant lesion. Differential diagnosis includes Ewing sarcoma,
aneurysmal bone cyst, infection, tuberculosis, leukemia, and neuroblastoma. Because roentgenographic
findings are not pathognomonic, biopsy is necessary.
Once the diagnosis is made, immobilization and observation alone often are sufficient treatment. These
lesions typically regress spontaneously over time with some, although incomplete, restoration of vertebral
deformity. Raab et al. reported partial to nearly complete reconstitution of vertebral height (72% to 97%)
in 14 patients between the ages of 1 and 11 years with eosinophilic granulomas treated with brace
immobilization. Follow-up is important to detect instability. Operative intervention, including curettage
and grafting, may speed healing. There presently is no role for radiation in the treatment of eosinophilic
granuloma. Recurrence is unusual, and resolution of neurological deficits usually occurs as the tumor
regresses.
Giant Cell Tumor.

Giant cell tumor is the most prevalent benign tumor of the sacrum, rarely affecting other spinal sites, and
is second only to hemangioma as the most common benign spinal neoplasm. Giant cell tumors account
for 4% to 5% of all primary bone tumors, occurring most often between the third and fifth decades.
Females are affected twice as frequently as males, and 1% to 18% of giant cell tumors occur in the spine.
65

Because of its lytic appearance, differential diagnosis includes aneurysmal bone cysts, osteoblastoma, and
metastasis.
Pain is the most common complaint and often is of long duration before diagnosis. Neurological deficits
occur in 20% to 80% of patients with giant cell tumors of the spine. Roentgenograms show the lesions as
lytic, septated, and expansile, often with cortical breakthrough and an associated soft tissue mass. More
than 50% of these lesions involve the vertebral body only. When present in the sacrum, the lesion is in the
proximal aspect and eccentrically located.
Because of the aggressive nature of these lesions, en bloc resection with wide margins is necessary.
Despite aggressive operative treatment, a 10% to 50% recurrence rate has been reported. Preoperative
embolization is recommended, and embolization and radiation are reserved for lesions that cannot be
resected. Kahn et al. reported treatment of six patients with giant cell tumors of the spine treated with
radiation and conservative surgery (biopsy or subtotal tumor resection). At an average follow-up of 13
years, five of the six patients had no evidence of disease, and one had disease that was not clinically
apparent. These authors concluded that radiotherapy is a reasonable treatment alternative for tumors that
cannot be excised completely or in which surgery would result in significant functional morbidity.
Although the dose response in their patients was not clear, their review of the literature suggested that
doses ranging from 3500 to 4500 cGy are safe and effective in controlling giant cell tumor. If intralesional
excision is done, adjuvant cryotherapy should be considered. Metastases occur in 1% to 11% of patients,
with a 10% incidence of sarcomatous change.
PRIMARY MALIGNANT TUMORS

Almost all patients with malignancies of the spine have pain. More than 95% seek medical care for pain,
with radiculopathy occurring in around 20% of these patients.
Classification

The Enneking classification of malignant tumors also is useful for spinal tumors: stage I, low-grade; stage
II, high-grade; and stage III, regional or distant metastases ( Fig. 41-32 ). The site of the tumor is
indicated by A, intracompartmental, or B, extracompartmental. This classification scheme is useful in
determining if marginal or wide excision is best. Radical excision is not possible in the spine.
Osteosarcoma

Primary osteosarcoma of the spine is rare, accounting for only 3% of all osteosarcomas, and frequently is
lethal. Pain is the most common presenting complaint, but neurological symptoms also are present in up
to 70% of patients. These tumors are anterior column tumors, and 95% affect the vertebral body. Men and
women are equally affected. Secondary osteosarcomas, which occur most commonly after irradiation or
develop in patients with Paget disease, affect patients in the seventh decade. Soft tissue extension, or
extracompartmental disease, is the rule at the time of diagnosis, which is evident on MRI scans or at
surgery.
Roentgenograms may show a lytic, blastic, or a mixed picture affecting the vertebral body. Bone scanning
is useful in identifying multicentric or metastatic disease, and axial CT scans are useful in delineating the
bony anatomy. Intensive radiation therapy and chemotherapy are the primary treatments. Radical surgery
has been suggested, including wide resection with adjuvant radiotherapy. In a series of 30 consecutive
patients with primary spinal sarcomas, Talac et al. reported that the risk of local recurrence was five times
greater in patients with positive resection margins than in patients with tumor-free resection margins.
Ozaki et al. also noted that wide or marginal excision of the tumor improved survival and recommended
treatment with chemotherapy and at least marginal excision if possible. In their series, patients with
metastases, large tumors, and sacral tumors had a poor prognosis. Venkateswaran et al., however, found
no association between the affected spinal region and outcome in 33 children and adolescents with
primary Ewing-family tumors of the vertebrae. Total sacrectomy and reconstruction with
polymethylmethacrylate, plate-and-screw devices, and custom-made prostheses have been reported to be
successful in the treatment of sacral osteosarcoma.
66

Figure 41-32 Enneking staging of malignant spinal tumors. Capsule of tumor is indicated by 1, pseudocapsule by 2, island of
tumor within pseudocapsule (satellites) or at distance (skip metastases) by 3. Types I and IIB tumors can compress cord if
expanding posteriorly. Pseudocapsule is more or less infiltrated by neoplastic tissue, which can have direct contact with dural
sac. (Redrawn from Boriani S, Biagini R, DeIure F: Semin Spine Surg 7:317, 1995.)
Ewing Sarcoma

Another anterior column primary bone tumor, Ewing sarcoma, is a permeative lesion that affects the spine
only 3.5% to 8% of the time, with half of these tumors found in the sacrum. Neurological deficits are
present in many patients because of soft tissue extension, and constitutional symptoms are common.
Roentgenographic findings are confusing, with vertebra plana apparent in some patients, which may be
confused with eosinophilic granuloma. Generally, these tumors are lytic, with a soft tissue mass identified
on MRI. Treatment is similar to that for appendicular Ewing sarcoma: chemotherapy and radiation.
Surgical decompression is indicated only for tumors causing neurological compromise and for potential
instability to preserve neurological function. Long-term survival is possible with this tumor; 5-year
survival using chemotherapy and irradiation is between 20% and 44%. The frequency of cerebral and
skeletal metastasis is higher than in appendicular disease, where pulmonary metastasis is most prevalent.
Chordoma

Primarily a tumor of adults, chordoma is an uncommon tumor that affects the sacrum and coccyx. It
originates embryologically from the notochord remnants and, as such, usually is a midline tumor. It is
relatively slow growing, but relentless in progression with high recurrence rates when a wide excision is
not obtained. Symptoms usually are indolent with a palpable mass in the sacrum anteriorly on rectal
examination. Men are affected twice as often as women, and the tumor affects an older population, with
peak incidences during the fifth and seventh decades.
Roentgenograms reveal a lytic lesion in the midline of the sacrum with variable calcification. Bone scans
often are negative because of the indolent biological behavior of these tumors. MRI provides excellent
67

delineation of the anterior soft tissue extension that typically occurs with these tumors. Treatment
involves a wide en bloc excision that may not be possible in the proximal sacrum without sacrifice of the
S2 nerve roots. Recurrence rates approach 28% with sacrectomy, and bowel and bladder continence are
retained only if both the S2 roots and one of the S3 roots are preserved. If for any reason the tumor is
incised during excision, recurrence may be as great as 64%. As a result, great care is necessary in
resection of these tumors, and radiation should be used for tumors with incisional margins. Long-term
survival may approach 50% to 75% if marginal resection or better is achieved.
Multiple Myeloma

Plasmacytoma is the single-lesion variety of multiple myeloma and is rare, accounting for only 3% of
plasma cell dyscrasias. This diagnosis carries a 60% 5-year survival rate. Thereafter, however, gradual
progression to multiple myeloma occurs, although extended survival has been reported. Multiple
myeloma, in contrast, accounts for 1% of newly diagnosed malignancies and is uniformly fatal within 4
years of diagnosis in all patients once spinal disease is diagnosed. Men and women are equally affected
during the sixth to eighth decades. These tumors result from unregulated proliferation of plasma cells,
causing systemic manifestations. Diagnosis is confirmed by the presence of at least 10% abnormal plasma
cells, lytic bone lesions, and monoclonal gammopathy diagnosed on serum protein electrophoresis
(SPEP) or urine protein electrophoresis (UPEP). Anemia and elevation of sedimentation rate also are
characteristic on laboratory studies. Protein electrophoresis may be negative in as many as 3% of patients
with myeloma, which requires a low threshold for bone marrow aspiration in patients at risk. Treatment of
plasmacytoma and multiple myeloma is irradiation, with operative intervention reserved for patients with
neurological deficits or progression despite maximal chemotherapy and irradiation.
METASTATIC TUMORS

Metastatic tumors are the most common malignant lesions found in bone, present 40 times more often
than all other primary malignant bone tumors combined. Tumor types include breast, lung, prostate,
kidney, gastrointestinal, and thyroid. Lymphoma is another tumor that commonly affects the spine and
must be considered. Recent advances in chemotherapy, radiation therapy, and other cancer therapies have
resulted in a significant improvement in survival for many of these types of cancer. With the improved
survival, previously silent spinal metastases are becoming clinically apparent and significantly impairing
quality of life. Metastatic disease involves the spine in 50% to 85% of patients, most often affecting the
vertebral bodies of the lumbar spine, followed by the thoracic, cervical, and sacral regions.
The chief complaint in most patients is pain, although 36% of spinal metastases do not cause symptoms.
Pain usually is progressive and unremitting, and often no relief occurs even with rest or at night. A
previous history of cancer, regardless of how remote, must prompt a search for metastatic disease in
patients with progressive pain. Neurological symptoms or signs may be present but are less frequent,
occurring in 5% to 20% of patients with spinal metastases. For patients with thoracic metastasis, however,
the rate of neurological symptoms increases to 37%, probably because of the more sensitive spinal cord
with less space available at this level compared with compression of the nerve roots in the lumbar spine.
In patients who develop neurological deterioration and paraparesis, only 25% to 35% regain lost motor
function. Patients who are paraplegic or have complete bowel or bladder dysfunction are not likely to
regain function regardless of treatment. Rapid onset of symptoms over a period of less than 24 hours also
indicates a poor prognosis for neurological recovery in contrast to a lesion with a slower onset of
symptoms. Fortunately, with aggressive treatment, 60% of patients who retain the ability to walk before
treatment of spinal metastasis will maintain this function after treatment.
Imaging often is inconclusive and nondiagnostic in these patients. Plain roentgenograms of the spine are
inconclusive in many with metastatic disease. The most sensitive study is bone scanning, which identifies
most lesions larger than 2 mm, although false negatives occur in 5%. Multiple myeloma, breast,
nasopharyngeal, lung, and renal tumors are the most likely neoplasms to appear falsely negative on bone
scans. Use of CT scanning is helpful in delineating soft tissue extension from the bone or into the bone
from extrinsic sources. Also, certain features of the CT scan are useful in determining whether a
compression fracture is a result of osteoporosis or metastasis. Osteoporotic compression fractures reveal
no evidence of cortical destruction, homogeneous involvement of the vertebral body, localized pathology,
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and the absence of a soft tissue mass. MRI is more useful in evaluating soft tissue masses, neural
elements, and vertebral body lesions. Characteristic features of metastatic lesions are hypointensity on
T1-weighted images, with enhancement on T2-weighted images and gadolinium-enhanced T1-weighted
images. Myelography occasionally is necessary for tumors not well defined by other, less-invasive
procedures but should be used cautiously because it can precipitate neurological deterioration in 16% to
24% of patients, necessitating immediate decompression.
The standard methods of treatment for benign tumors involving excision and grafting usually are
insufficient for the early mobilization of patients with symptomatic metastatic disease. Siegal, Tiqva, and
Siegal estimated that 5% of patients with metastatic cancer develop spinal cord compression. Kawabata et
al. noted that 2 of 3880 autopsied patients with the diagnosis of metastatic cancer had previous clinical
evidence of spinal metastasis but that at autopsy the rate of metastasis varied from 21% to 48%. Schaberg
and Gainor analyzed 322 patients with metastatic cancer. The rate of spinal metastases varied from 2.2%
to 31%. Breast and prostate tumors were the most frequent, followed by thyroid, lung, and renal cancer.
Of patients with spinal metastases, 36% did not have back pain. Spinal cord compression was noted in
20% of the patients.
Prostatic tumors were the most common cause of epidural impingement. Hypernephroma was the most
common malignancy to cause neurological impairment as the first sign of malignancy.
Pathoanatomy

The distal lumbar spine is interconnected with an extensive venous plexus that is valveless, allowing
drainage of the brain, thorax, and pelvis. Batson's plexus allows retrograde blood flow within these
systems, which interconnect the vertebral bodies, epidural veins, basivertebral, and paraarticular veins. As
a result, metastases may follow these pathways, resulting in the characteristic pattern of bony spread.
Interconnections of the epidural plexus with both the pelvic and mammary veins lends a relatively
unimpeded pathway for the spread of prostate and breast cancer, which show the most affinity for spread
to spinal sites.
Classification

DeWald et al. suggested a classification of spinal metastases. Class I is destruction without collapse but
with pain. This class is divided further into (a) less than 50% vertebral body destruction, (b) greater than
50% vertebral body destruction, and (c) pedicle destruction. In this class they considered surgery only for
grades Ib and Ic. Class II is the addition of moderate deformity and collapse with immune competence.
This class is considered a good risk for surgery. Class III patients are immunocompromised with moderate
deformity and collapse. This class carries greater risk for surgery. Class IV includes patients with
paralysis, collapse, and deformity with immune competence. This class is considered a relative surgical
emergency. Class V adds immune incompetence to paralysis, collapse, and deformity. This class is not
considered a good operative risk. Further, surgical reconstruction is recommended when more than 50%
vertebral body destruction is identified or in the presence of involvement of one or both pedicles due to
the risk of later fracture and deformity. This classification allows consideration of the tumor, potential
instability, and patient physiology, which is a sensible approach to a difficult problem.
Irradiation

For most metastatic tumors, irradiation is sufficient for the palliation of symptoms of pain and
neurological deficit. Indications for irradiation include pain and mild, slowly progressive neurological
symptoms in the presence of a radiosensitive tumor, spinal canal compromise that results from soft-tissue
compression and not bony retropulsion, and multifocal lesions compressing the spinal canal. Instability is
a relative contraindication for irradiation because of the potential collapse and progression of deformity
that could occur with tissue necrosis. Use of irradiation causes initial necrosis of tumor bone, which later
is converted to lamellar bone and normal bone marrow. This process results in remineralization of the
lesion at 2 months, formation of woven bone at 4 months, and reorganization into mature bone at 6 to 12
months. Initial necrosis after irradiation of large and potentially unstable lesions may result in acute
instability and neurological deterioration.
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Successful treatment has been documented in 62% of patients with pain and in 52% of patients with
neurological impairment. Improvement in neurological symptoms was noted in 25%. Surgery has failed
to show a benefit in survival rates over irradiation; therefore, if symptoms can be controlled, radiation
therapy appears to be the logical choice. Acute neurological deterioration, however, is an indication for
immediate surgical decompression.
Operative Treatment

Indications for surgical decompression include the requirement of tissue for diagnosis, treatment of an
isolated lesion, treatment of a fracture causing instability, pain, or spinal canal compromise, radioresistant
tumors, which usually include gastrointestinal and kidney metastases, recurrent tumor in a previously
irradiated field, neurological symptoms that are progressive despite adjuvant measures, and potential
instability. Operative procedures often are extensive and involve significant blood loss; therefore the
patient must be in a physical state that allows for survival of the proposed procedure. Expected survival of
more than 6 weeks is a relative condition for surgery in the presence of unremitting or progressive
symptoms, although general physical condition also is important in operative decision making. In patients
with a reasonable long-term survival, bone grafting is recommended rather than polymethylmethacrylate
because of the likely failure of such materials. Adjunctive radiotherapy must be planned carefully,
however, to allow for incorporation of grafts when used. This is best accomplished by performing
radiotherapy preoperatively or delaying it until at least 3 weeks postoperatively if at all possible to
improve fusion rates. Because of the hypercoagulable state of malignancy, especially in patients with
paraplegia, the use of a preoperative inferior vena cava filter also should be considered.
Laminectomy has been shown to be of little value in the treatment of progressive paralysis caused by
malignant spinal tumors in the anterior column. Successful results using this approach have been reported
in only 30% to 40% of patients and are inferior to those obtained with radiation alone. Radical
laminectomy for tumor resection is of value, however, and should be considered when compression is
caused by lesions in the posterior elements compressing the dura. Careful evaluation of diagnostic images
is necessary for appropriate preoperative planning of the operative approach and subsequent procedures.
Because of the predominant vertebral body location of malignant tumors, anterior decompression is most
often necessary to remove the pathology responsible for neurological deterioration and pain. Other
indications for anterior surgery include pathological kyphosis with an intact posterior osteoligamentous
complex. Improvement in pain is possible in 80% to 95% of patients, with restoration of neurological
function in 75%. Decompression often creates instability that requires reconstruction with
instrumentation, allografts, and occasionally structural bone cement. Although circumferential
instrumentation is definitely superior in stabilization, anterior instrumentation alone often will suffice if
the posterior osteoligamentous complex is intact and resection is less than a complete spondylectomy.
Additional posterior decompression and stabilization in a combined approach often are necessary if the
spinal canal is compressed both anteriorly and posteriorly or if the posterior column is attenuated. If
exposure of both anterior and posterior columns is necessary, a two-stage approach combined under one
anesthesia or a simultaneous approach can be used. High-grade instability, contiguous vertebral
involvement, destruction of both anterior and posterior columns, and need for en bloc resection are
indications for these approaches. Solid fixation is possible with structural grafting anteriorly, and solid
segmental instrumentation can be applied both anteriorly and posteriorly if necessary to provide the most
rigid surgical constructs.
For patients with anterior column involvement who are unable to tolerate a thoracotomy, or those with
circumferential spinal cord or neural constriction, a costotransversectomy is useful in the thoracic spine,
and a posterolateral approach is useful in the lumbar and cervical spines. Admittedly, excision is
intralesional, but decompression often is acceptable with the ability to restore stability using structural
grafts or devices anteriorly with segmental instrumentation posteriorly. The morbidity of a thoracotomy is
avoided, which is a necessity in some patients, especially those with symptomatic metastasis from lung
cancer. By excising the rib head, intercostal neurovascular bundle, and transverse process on the side of
the lesion, the anterior and middle columns are accessible to about the midline using special curets. If the
pedicle is uninvolved, this medial wall is preserved to avoid contamination of the spinal canal or damage
to the spinal cord. Bilateral approaches occasionally are necessary for extensive posterior vertebral body
70

involvement to allow access to both sides of the middle column. Care must be taken with soft tissue
extension to avoid inadvertent entry into the great vessels anteriorly. These procedures should be followed
by instrumentation and fusion, and structural interbody grafting should be used if significant bony
resection is done anteriorly to decrease tension stresses on the posterior implants.
Scoville et al. in 1967 were the first to use polymethylmethacrylate to fill defects in the vertebral bodies.
Keggi, Southwick, and Keller reported the use of polymethylmethacrylate (PMMA) as an adjunct to
internal fixation in situations in which bone fixation was questionable. There have been numerous reports
on the efficacy of this material as an adjunct to internal fixation and bone grafting. Bone cement functions
well in compression; however, results have been disappointing on the tension side of spinal
reconstructions. Failure has been noted at a mean of 200 days after treatment, and therefore its use has
been recommended for patients with a short life expectancy or in salvage cases. Generally, if life
expectancy is more than 3 to 6 months, bone graft incorporation is possible. Fear of neural injury from the
use of PMMA has been a frequent concern. Wang et al. showed that, although the temperature of the
curing cement may reach 176 to 194 F, the temperature measured beneath an intact lamina and under
Gelfoam covering the dura at a laminar defect was significantly less (45 F). Later examination of the
spinal cord in test animals did not show evidence of neural injury. Clinically we have noted a fall in
amplitude of somatosensory evoked potentials during the curing phase that returns to normal within 20 to
30 minutes of insertion of PMMA. Injury from the use of the material near the spinal cord has not been
reported. PMMA can be used to augment existing internal fixation devices; however, loosening is to be
expected. If long-term survival is expected, then provision for bone grafting and graft incorporation must
be made.
Percutaneous vertebroplasty has been reported to be effective treatment for osteolytic spinal metastases
and multiple myelomas. Cortet et al. reported decreased pain 48 hours after vertebroplasty in 36 (97%) of
37 patients. Beneficial effects were increased or unchanged in all after 1 month, in 89% after 3 months,
and in 75% after 6 months. Although leakage of the cement outside the vertebral body occurred in 29,
only 2 patients developed severe nerve root pain due to leakage into a neural foramen. They cautioned
that vertebroplasty should be done only in centers with experienced neurosurgeons or orthopaedic
surgeons because of the possibility of severe complications.
Anterior Decompression

TECHNIQUE 41-10
Approach the diseased spine using the standard anterior approach for that spinal segment from the side of
the most prominent tumor mass, but choose an approach that allows for more radical or extensive
exposure if necessary. Identify normal bone and disc cranially and caudally. First ligate segmental vessels
to allow discectomy, which is done to the posterior longitudinal ligament. Ligation of the segmental
vessel at the level of vertebral body involvement may be difficult because of encasement by soft tissue
extension. Decompression of the spinal canal or resection of tumor is possible if lesions are anteriorly
situated. If decompression is necessary, create an access portal within the vertebral body anterior to the
tumor and then use curets to pull tumoral tissue anteriorly away from the spinal canal into the void. This
allows decompression without forcing material against the already compressed dura. Piecemeal resection
commonly is done for metastatic lesions; however, for en bloc resection the tumor must not be violated.
In these cases, osteotomize the pedicles after discectomy to allow en bloc resection. Be prepared for a
spinal fluid leak, as adherence of the tumor to the dura is certainly a possibility. If any extension of tumor
is present into the posterior elements, a staged posterior procedure for completion of vertebrectomy is
done.
Once resection of tumor is complete, prepare for fixation. For patients with expected long-term survival
of more than 1 to 2 years, place allograft or autograft for structural support. These grafts include allograft
femur, humerus, fibula, or iliac crest. Autograft fibula or iliac crest are the only options unless a structural
spacer, such as a mesh cage, is applied. Bone cement is a consideration in patients with a poor expected
survival and allows for irradiation and immediate compressive strength when combined with anterior
instrumentation. Cover the exposed dura or anterior longitudinal ligament or both with Gelfoam. Insert
71

the polymethylmethacrylate in a semiliquid or doughy state. Use of a reinforcement device is


recommended; this may include Harrington or other hook-rod implants used as a distraction device,
Steinmann pins, or a mesh titanium cage that engages the vertebral bodies and is totally covered with
polymethylmethacrylate to provide a smooth external surface. Remove excess cement, which is especially
important in the cervical spine, where a large mass of cement can cause dysphagia. Take care to avoid
pushing the cement against the dura and spinal cord. As soon as the cement has been trimmed, begin
continuous irrigation of the wound with normal saline. This theoretically keeps perineural temperatures at
a minimum, although due to CSF convection this may be unnecessary. Anterior instrumentation is added
to provide maximal fixation. Numerous implants that are of low profile and provide at least four fixation
points are available. For optimal fixation, place vertebral body screws in a bicortical fashion. If a later
posterior instrumentation construct is planned, slight modification of screw placement is necessary to
allow for placement of pedicle screws if these are to be used. Under these circumstances, identify the
pedicle and simply keep the vertebral body screws just inferior to these structures. Once fixation is
complete and compression of the interbody construct is maintained, test the construct for stability before
closing. Remove and replace the cement and metal fixation if it is loose. Close the wound in the standard
fashion. If corpectomy of more than a single level is done or if posterior column involvement is present,
then a combined approach with posterior instrumentation is preferred.

AFTERTREATMENT.

Rigid immobilization is preferable after these procedures, especially when the bone quality is in question
due to osteoporosis or other metabolic causes. A TLSO is typically worn when getting out of bed and
while up; however, it is not necessary for the patient to wear this during sleep. Once the graft incorporates
over the next 3 to 6 months, the TLSO is discontinued. Radiation is deferred for 3 weeks if possible.
Great attention is paid to nutrition during the perioperative period and may require parenteral or enteral
supplementation.
Costotransversectomy

TECHNIQUE 41-11
Using a standard posterior incision or a paramedian incision, expose the spinous processes and transverse
processes bilaterally over the levels of anticipated instrumentation ( Chapter 34 ). Once roentgenographic
localization is complete, identify and expose the rib of the level and side of pathology. To perform
corpectomy, it usually is necessary to subperiosteally expose three ribs and disarticulate them at the
costotransverse articulation and also to excise the medial 8 to 10 cm of the ribs. Removal of the
transverse processes aids in vertebral body exposure. Once the ribs are removed, use peanut dissectors to
bluntly elevate the pleura from the vertebral bodies. Create working portals between the intercostal
neurovascular bundles for placement of retractors and instruments. During this step of the procedure,
headlight illumination is mandatory to see into the retropleural space. Laminectomy or facetectomy can
be done if necessary for posterior decompression. Ligation of the segmental vessels is possible, if
necessary, under direct observation. Retention of the intercostal nerves is preferable; however, these can
be sacrificed if they interfere with proper decompression. The tradeoff is chest wall anesthesia, intercostal
paralysis, and potentially upper abdominal muscle paralysis below T7. Perform discectomy above and
below the affected vertebral body in the standard fashion. Remove the tumor with curets and rongeurs to
the level of the posterior longitudinal ligament or dura as necessary. Brisk bleeding as the tumor is
curetted is to be expected but is minimized by preoperative embolization. Intermittent packing of the
tumor also helps to control bleeding, with continuation of the procedure after bleeding subsides. Once the
tumor is excised, hemostasis usually occurs without much difficulty.
For curative resections, it is difficult to obtain en bloc or wide margins using this approach. Osteotomes
can be safely directed to parallel the posterior vertebral body wall; however, obtaining margins beyond
the opposite lateral cortical wall of the vertebral body is not possible because of the risk of injury to the
opposite segmental vessels. Nonetheless, the approach is useful in patients unable to tolerate thoracotomy
72

when anterior pathology is predominant and stabilization is necessary. Instrumentation is necessary for
stabilization and can be used posteriorly at any time during the procedure, although we prefer to place
implants before exposure of the spinal canal to minimize incidental dural tear while placing implants.
Early placement of implants also can be helpful to distract the ligamentous structures and disc during the
decompression. Pedicle fixation avoids the concerns of spinal canal compromise of hooks or wires and
allows fixation of levels after laminectomy. Hook-rod or Luque-type constructs also are applicable, and
the type used is determined by surgeon's experience. Before closure, maintain positive pressure
ventilation momentarily while irrigation is allowed to cover the pleura. This is done to inspect the pleura
for leaks that usually would necessitate placement of a chest tube. After bone grafting, standard closure is
done over drains.

Posterolateral Decompression

TECHNIQUE 41-12
This approach is indicated for patients with tumors that involve the anterior, middle, and posterior
columns simultaneously. This is done without the risks or the extensive exposure required for a
simultaneous approach. If a posterolateral approach is used, make a midline incision to expose the
pathological level. Once identification of the correct level is confirmed, decompression can be done
or posterior instrumentation can be placed. Regardless, because of the potential destabilization that
occurs with laminectomy and pedicle resection, place posterior instrumentation before completion
of the procedure.
Begin decompression as the pedicle that leads into the tumor is sounded, and use sequentially larger
curets to remove bone through this access site. Hemilaminectomy is helpful to expose the medial
border of the pedicle to avoid medial penetration, unless adequate decompression requires
laminectomy, in which case this is done before the transpedicle decompression. Resect the lateral
wall of the pedicle with a Leksell rongeur, which allows medialization of the curets. If the posterior
vertebral body wall is retropulsed, resect the medial pedicle border as well. If compression is
bilateral, a bilateral transpedicle approach is necessary. Once the pedicle is resected, a reverse-angle
curet or even a PLIF tamp can be placed ventral to the dura, against the tumor or retropulsed
posterior vertebral wall so that it is tamped or pushed back into the vertebral body. Decancellation of
the middle column often is necessary before this maneuver to create a space for the bone that is
reduced. Once the retropulsed material is pushed anteriorly, resect it with curets and pituitary
rongeurs. Anterior column grafting depends on the procedure performed. Take care that morselized
graft is not retropulsed into the spinal canal after placement, creating the same problem the
procedure was intended to correct. Perform appropriate bone grafting and instrumentation. If a large
anterior vertebral body was resected, a structural device should be placed in addition to posterior
segmental spinal instrumentation.

AFTERTREATMENT.

Patients are fitted for a TLSO, and immobilization is continued after the procedure for 3 to 6 months.
Ambulation is started on the first postoperative day, unless neurological deficit was preexistent, in which
case bed-to-chair transfers are started. Anticoagulants are not used in spinal surgery patients because of
the inherent risk of epidural hematoma, so lower extremity antiembolism stockings and compression foot
devices are used until the patient is ambulatory. A vena cava filter should be considered for high-risk
patients. Radiation is deferred, if at all possible, for at least 3 weeks when autogenous or allograft bone is
used.

73

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