Spine Anatomy Manual

CONFIDENTIAL AND PROPRIETARY. DO NOT DISTRIBUTE.
Spine Anatomy—101 1
THIS MATERIAL IS FOR INFORMATIONAL PURPOSES AND IS INTENDED ONLY FOR GLOBUS MEDICAL EMPLOYEES AND REPRESENTATIVES.
Table of Contents
Chapter 1—Introduction to Spinal Anatomy.……….….…………………………………………………….3
Chapter 2—Bone Biology……………….……...……………………………………………………………………….8
Chapter 3—Spinal Vertebrae……………….……………………………………………………………………….15
Chapter 4—Intervertebral Disc…...………………………..………………………………………………………20
Chapter 5—Ligaments...…………...…….....………….…………………………………………………………….23
Chapter 6—Nervous System…….………..…………………….…...………………………………………………26
Chapter 7—Muscles…..……………………….…………………….…………………………………………………..31
Chapter 8—Internal Organs & Circulation….......….…………………….…………………………………..35
Table of Contents
Chapter 9—Region Specific Anatomy.….….……...…….…..….………………………………………………38
Chapter 10—Imaging…...………………………………...………………………….………………….……………..46
Chapter 11—Biomechanics...…………………………..…………….………….………………..…………………54
Chapter 12—Pathology….………………………….………..………….…………………………….……………….62
Chapter 13—Surgical Treatment Options..……….…………....…………………..………………………..78
Chapter 14—Surgical Instruments..…………..…………….………..…….………….…………………………85
Chapter 15—Operating Room Tables..…………………….……….…..……………………………………..100
Glossary….……..….…………………….....………………………..……….…….…………………………….……...102
References…….………...………………………………..……………………………………………………………….110
INTRODUCTION TO SPINAL
ANATOMY
Chapter 1
The Spinal Column
The spine, or spinal column, is made up of 33 This manual is a foundation to help understand
individual vertebrae. The spinal column provides the the structure and function of the spine, as well as
main support for your body: allowing one to stand up- pathologic disorders and surgical treatments. We will
right, bend, and twist, while protecting the spinal cord start at the beginning with basic anatomy. After that,
from injury. A healthy spine provides strength, flexibil- we will review spinal pathology—
ity, and allows movement in multiple planes. Strong the diseases, degenerative process-
bones and muscles, flexible tendons and ligaments, es and injuries that afflict the spine.
and specialized nerves contribute to a healthy spine. Finally, we will examine treatment
Yet, any of these structures can cause pain if affected options, from conservative care to
by strain, injury, or disease. surgical procedures designed to
relieve pain and restore function.
The spine is a major focus of our company. Globus is
driven to utilize superior engineering and technology
to achieve pain-free, active lifestyles for all patients.
Anatomical Planes and Orientation

The body is referred to in three major anatomical planes: coronal, sagittal, and axial. These
planes are referenced by what is termed the anatomical position. Anatomical position is an
erect position, with the body directed forward, the arms are at the side with the palms of
the hands facing forward. The feet are also facing forward with the legs positioned slightly
apart. Using this as a reference point, planes of the body can be used to describe a particu- Anatomical Position
lar view of the anatomy.
Coronal (frontal): The coronal plane is a vertical line that divides the body into
front (anterior) and back (posterior) portions.
Sagittal (vertical, longitudinal): The sagittal
plane is a vertical line that divides the body
into left and right sections.
Axial (transverse, horizontal, cross-sectional):
The axial plane is a horizontal line that divides
Axial
the body into upper and lower parts.
Coronal Sagittal
Para and Mid: The term mid indicates an
equal division of a plane, while para indicates an unequal division of a plane.
Directional Reference
Numerous terms may be used to describe the orientation of the body in space. These terms make it easier to
communicate accurately about specific anatomy and its relationship to another location. The orientation is
based on the anatomical position we referenced on the previous page.
Medial Toward the midline of the body
Lateral Away from the midline of the body
Proximal Closer to the center of the body or reference point
Distal Away from the center or the reference point
Superior Upper, above
Inferior Lower, below
Anterior Toward the front
Posterior Toward the back
Cranial (Cephalad) Toward the head
Caudal Toward the tail, tail end
Dorsal Posterior, back
CLINICAL APPLICATION
 The breastbone or sternum is located to the front or anterior of the body.
 The spine is located to the back or posterior of the body.
 The spine and sternum sit in the body’s midline.
 The ankle is distal to the knee and hip, and the hip is proximal to the knee and ankle.
Overview of the Spine
The spine consists of 33 vertebrae that are stacked atop each other and separated by intervertebral discs. In total,
there are only 23 intervertebral discs in the spinal column. The spine is separated into regions defined chiefly by
their weight-bearing capacity and function.
The Numbers Game

 Seven (7) vertebrae in the cervical spine (neck)
 Twelve (12) vertebrae in the thoracic spine (mid-back)
 Five (5) vertebrae in the lumbar spine (lower back)
 Five (5) fused sacral vertebrae (sacrum)
 The spine ends in the coccyx (tailbone) with four (4) fused vertebrae
The vertebral bodies within each region are identified by combining

the first letter of the region in which they are found with their con-
secutive order. For example, the first cervical vertebra is referred to
as C1, and the seventh vertebra is referred to as C7. Similarly, the
first thoracic vertebra is T1, and the fifth lumbar vertebra is L5.
 Supports weight
 Attaches to muscles and

ligaments
Functions of the Spine  Protects spinal cord
One major function of the spine, is to  Absorbs shock

serve as a stable attachment for muscles,  Facilitates Motion
tendons, ligaments, and other body parts. MOVEMENT
 Stores minerals
For example, the ribs attach to the tho- Flexion—the action of bending
racic spine and help stabilize the chest (thorax). The spine also sup- forward
ports the weight of the head and torso, and protects the spinal cord. Extension—the action of bending
It absorbs shock from traumas and activities of daily living. It facilities backward
the 6 degrees of freedom (motion): flexion, extension, side bending
(left and right), axial rotation (left and right), and any combination of
these movements. The spine also stores some of the body’s minerals in bone and produces red blood cells in bone
marrow.
Curves of the Spine
An adult spine has natural curves that help to support its
function and withstand stress. From the coronal plane, the
spine should typically appear straight, but in the sagittal
plane, it takes on an S-shape.
In the sagittal plane, the cervical and lumbar regions have a
lordotic, or slight concave curve, and the thoracic and sacral
regions have a kyphotic, or mild convex curve. When erect,
the spine is constantly pulled forward by the axial weight of
the body. The spine’s curves work like a coiled spring to sup-
port, absorb shock, maintain balance, and allow flexibility
throughout the spinal column.
 Kyphotic: curve with anterior concavity in the sagittal
plane
 Lordotic: curve with posterior concavity in the sagittal
plane
Normal Spinal Curves:
Cervical spine: lordosis, 20°-40°

Thoracic spine: kyphosis, 20°-40°
Lumbar spine: lordosis, 30°-50°

Sacral spine: kyphosis
At birth, the spine has only one kyphotic curve, known as a

primary curve. As muscles strengthen enough to lift the head,
a lordotic (secondary) curve develops in the cervical region.
When the infant is able to walk upright, a lordotic curve devel-
ops in the lumbar region. The secondary curves result from
axial weight bearing and are necessary to maintain balance in
the sagittal plane. They also reduce the stress placed on the
posterior spinal muscles.
CHAPTER 2
Bone Biology
The Basics of Bone Biology:
The skeleton is a dynamic system that is constantly remodeling naturally and
in response to the body’s needs. In fact, approximately every 10 years you
have a completely new skeleton.
THE MAJOR FUNCTIONS OF THE SKELETON
The skeleton serves multiple functions in the body including 1) protection of
vital organs, 2) fat storage and release, 3) blood cell production in bone mar-
row, 4) serving as a mineral reservoir (specifically calcium-phosphate, AKA hy-
droxyapatite), 5) facilitating movement and 6) providing structural support
(Figure 1).
TWO TYPES OF BONE
Figure 1. Functions of the skeletal system. http://
The skeleton is composed of two types of bone: cortical (compact) and can- library.open.oregonstate.edu/aandp/chapter/6-1-the-
functions-of-the-skeletal-system/
cellous (trabecular) bone (Figure 2).
Cortical (compact) bone is characterized as dense bone. It composes the outside surface of bones, giving
them strength and structure. Cortical bone appears solid and constitutes 80% of total bone mass. The density of
cortical bone makes it a great fixation point for pedicle screws.
KEY CONCEPTS
Cortical (compact bone) is the dense bone that com-
poses the outside surface of bone, providing strength
and structure.
Cancellous (trabecular bone) is less dense and has a
lattice-like structure. It is found inside bone that con-
tains blood cell & stem cell producing bone marrow.
Figure 2. Skeleton is composed of cortical and cancellous (trabecular)
bone. https://teachmeanatomy.info/back/bones/ver tebral-column/
Cancellous (trabecular) bone is characterized by its porous structure. It composes the inside of bone. Due to
its mesh-like structure, cancellous bone has significantly higher surface area compared to cortical bone. Cancel-
lous bone is also highly vascular and contains bone marrow, which produces red blood cells, hematopoietic
stem cells (HSCs), and mesenchymal stem cells (MSCs).
BONE CELLS (Figure 3)

The bone remodeling process to create new bone, whether cortical or cancellous bone, involves the following
bone cells: osteoblasts, osteocytes, and osteoclasts.
Bone cells
 Osteoblasts are derivatives of MSCs, meaning that given the right signals, MSCs can turn into oste-
oblasts. Osteoblasts are the bone cells that create new bone. When osteoblasts mature and become
entrapped in the bone matrix that they have produced, they are known as osteocytes.
 Osteocytes can detect when physical forces are placed upon bone and can send messages to bone
cells to either resorb bone (due to lack of physical forces) or to build new bone (due to increased
forces placed on the bone). This phenomenon of bone remodeling that responds to the presence
or absence of physical force placed on bone is known as Wolff’s law, which will be discussed later.
 Osteoclasts are cells derived from the HSC lineage that resorb old bone and also secrete bone-
resorbing enzymes at their ruffled edges.
Figure 3
KEY CONCEPTS
Osteoclasts consume old bone.
Osteoblasts build new bone.
Osteocytes ar e matur e osteoblasts.
Hematopoietic stem cells ar e stem cells found in bone
marrow that can differentiate into all types of blood cells (i.e.
red blood cells, white blood cells, platelets) and osteoclasts.
Mesenchymal stem cells (MSCs), such as osteopr ogenitor
cells, are stem cells found in bone marrow that can differenti-
ate into all types of non-blood cells (i.e. muscle, fat, lung) and
osteoblasts.
Collagen (or ganic por tion of bone) is a type of pr otein that
gives bone flexibility.
Hydroxyapatite (inor ganic por tion of bone) is made up of
Figure 4. Bone Matrix. The bone matr ix is composed of collagen that give calcium and phosphate, and is what gives bone strength and
the bone elasticity, and minerals (hydroxyapatite) that give it structure structure.
Bone Composition
Bone composition can be categorized into two main groups: organic and inorganic constituents. The organic
portion is composed of collagen and proteins like growth factors. Collagen contributes to the flexibility of
bone. The inorganic portion is composed of a mineral called hydroxyapatite, which is mainly made up of calci-
um and phosphorus (Figure 4). The hardness and rigidity of bone is due to the presence of hydroxyapatite.
BONE MODELING AND REMODELING or stimuli. This ability to adapt to the body’s needs is
vital to maintaining healthy bones. It is also essential
Wolff’s Law
for the skeleton to properly perform all of its expected
In 1892, Wolff proposed that bone, as a living tissue, functions, such as providing support and protection for
constantly undergoes remodeling (resorbing old bone your body.
and building new bone) in response to the amount of
mechanical forces or loads acting on it – forces such as For example, the bones of an average teenage boy
the stress of gravity or from weight-bearing exercise. would be different in mass than the bones of an astro-
Load can be more simply described as any external naut coming back from space. This is due to the differ-
force. More specifically, bone responds to the lack of ence in loading experienced by each individual’s bones.
load placed on it by resorbing bone and utilizing those The teenage boy’s bones have been experiencing the
nutrients elsewhere, whereas it responds to increased force of gravity on Earth, whereas the astronaut’s
forces placed upon it by building more bone. This prin- bones have not. As a result, the teenage boy will theo-
ciple is known as Wolff’s law. retically have more bone volume than the astronaut.
Due to this, we say that the skeleton is a dynamic sys-

tem that is constantly responding to mechanical forces
Bone Remodeling
The process of bone development, growth, or repair consists of the following steps (Figure 5)
 Resorption: osteoclasts consume old bone, which frees up space for the calcium and phosphate (which
make up hydroxyapatite) necessary to build new bone.
 Formation: Osteoblasts then lay down the organic matrix of bone composed of collagen and proteins.
 Mineralization: Next, osteoblasts deposit the calcium and phosphate ions as hydroxyapatite in the
collagen bone matrix produced in the previous step. The complete mineralization process takes several
months and gives mature bone its strength and rigidity. When bone forms rapidly, as in fracture heal-
ing, it initially begins as immature bone of quite low strength, but gradually gets stronger as mineraliza-
tion continues.
KEY CONCEPTS
Osteoconductive descr ibes a mater ial that ser ves as a scaffold for cells.
Osteoinductive descr ibes a mater ial that signals MSCs to differ entiate
into osteoblasts.
Osteogenic descr ibes a mater ial that contains cells that can differ entiate
into bone-forming cells.
There are 3 steps to bone formation: Resorption, Formation, Mineralization
1. Resorption is the br eaking down of old bone by osteoclasts.
2. Formation is the laying down of the collagen-protein matrix (organic
portion of bone) by osteoblasts.
3. Mineralization is the incor por ation of hydr oxyapatite (inor ganic
portion of bone) into the collagen matrix by osteoblasts.
Figure 5. Bone Remodeling Cycle

https://pgblazer.com/factors-influencing-bone-remodelling/
BONE HEALING AND GRAFTS
The blood supply and mechanical environment at a graft or fracture site primarily determines how it heals. When
a fracture is less than 0.01mm, contact healing can occur naturally. Otherwise, interventional methods such as
biomaterial bone grafts should be utilized in conjunction with access to blood. Blood vessel formation is known
as angiogenesis and supports proper bone healing (Figure 6).
Figure 6.
Bone graft material can be retrieved directly from the patient (autograft) or can be retrieved from a donor
(allograft) (Figure 7). Autograft harvesting sites can include the iliac crest or vertebral body, each of which can
result in years of pain post-operation as well as increased cost, time, and risk of complications. Globus Medical’s
tissue bank, from which the allograft products are received, is Bone Bank Allografts (BBA) (Figure 8).
Figure 8.
Auto- Allograft
Figure 7.
KEY CONCEPTS
A graft is a piece of living tissue, such as bone, that is tr ansplanted sur gically.
Angiogenesis is the for mation of new blood vessels, which is essential to bone healing.
Autograft is a gr aft r etr ieved fr om the patient and used in that patient.
Allograft is a gr aft r etr ieved fr om a donor .
FACTORS THAT AFFECT BONE HEALING
In a clinical setting, bone healing and fusion are primarily evaluated with radiographs. The discussion thus far has
focused on the mechanical and physiological factors that influence bone healing, however, many other factors
also come into play:
 Age: As adults begin to lose bone mass in their early 30s, their bones bones become more brittle and likely to
break as they age.
 Gender: Women are more likely than men to have osteoporosis, which is a progressive decrease in bone mass
(Figure 9).
 Heredity: Children of those with osteoporosis are at higher risk for delevoping the same condition.
Figure 9.
https://www.nature.com/articles/s12276-019-0251-1
 Body Size: Individuals with a smaller frame, such as women in general, are more likely to develop osteopo-
rosis than larger framed individuals.
 Ethnicity: Certain ethnicities are more susceptible to developing osteoporosis later in life.
 Nutrition: Bone requires many nutrients, such as calcium and Vitamin D, to stay healthy and to heal.
 Vascular Health: Bone requires a viable blood supply to heal properly.
 Hormones: Hormones, such as estrogen and testosterone, are responsible for the long-bone growth spurt at
puberty and for the regulation of calcium in the blood. The waning of estrogen levels in postmenopausal
women puts them at a greater risk for osteoporosis.
 Growth Factors: A number of growth factors are also necessary for efficient bone healing. These factors in-
clude among them are BMPs (bone morphogenetic protein), IGFs (insulin-like growth factors), TGFs
(transforming growth factors), PDGFs (platelet-derived growth factors), and FGFs (fibroblast growth factors).
Irregularities in any of these can result in poor bone healing (Figure 10).
 Diseases: A variety of diseases, such as osteoporosis , slow or prevent bone healing (i.e. osteoporosis, diabe-
tes, rheumatoid arthritis, sickle cell disease, and tumors).
 Medications/Medical Treatment: Nexium, steroids, nonsteroidal anti-inflammatory drugs (NSAIDs), antide-
pressants, and antiepileptic drugs can all impede bone healing.
No system in the body works independently of the other systems in the body. The nervous system, cardio-
vascular system, skeletal system, etc. all work together. Therefore, whenever the body is undergoing treat-
ment for a condition, there can be secondary effects on other bodily systems within the body. For instance,
the radiation treatment that comes with chemotherapy can cause a significant amount of damage to bone.
While the chemotherapy may be good for treating lung cancer, the rest of the body is not immune to the ef-
fects of the treatment.
Figure 10. Growth factors that affect bone repair. https://www.google.com/sear ch?
Spinal Vertebrae
Chapter 3
Vertebral Bodies
Intervertebral Disc
As previously mentioned, there are seven cervical, twelve thoracic, five

lumbar, five sacral and four coccygeal vertebrae. Each of the 33 verte- Anterior Vertebra
brae that make up the spinal column consist of two parts: the anterior
portion called “the body” and the posterior portion called “the vertebral Vertebral Body
arch.”
Endplates
Vertebral Arch Posterior Vertebra
The vertebral arch is formed posteriorly by the pedicles and lamina. Two Pedicles Lamina
pedicles extend from the sides of the vertebral body to join the body to Pars Interarticularis
the arch. From each pedicle, a broad plate, a lamina, projects backwards
and medial, to join and form the posterior border of the vertebral fora- Various Processes
men (passageway for the spinal cord). This union completes the triangle
of the vertebral foramen.
Vertebral Body
The vertebral body is a large cylindrical-shaped
structure that consists of cancellous bone sur-
rounded by a shell of cortical bone. The purpose of
the vertebral body is to provide structural support,
and to help transfer axial load throughout the
body. At the superior and inferior ends of the ver-
tebral body there is a thick ring of cortical bone,
known as the apophyseal ring. Due to its strength,
this ring is a good platform for supporting inter-
body bone grafts or fusion devices.
Endplates
The endplates are located on the superior and inferior surfac-
es of each vertebral body. They attach to both the vertebral
body and the outer layer (lamella) of the disc. In the early
stages of life, the endplate functions as a growth plate for the
vertebral body.
There are two layers to the endplate, an inner bony layer and
an outer cartilaginous layer. The outer cartilaginous layer
attaches to the lamellae of the disc.
When surgeons perform an interbody fusion, they scrape
away the cartilaginous layer of the endplate to expose the
bony layer, which is preserved as much as possible to prevent
subsidence (sinking of the implant into the vertebral body
above or below it). Surgeons also score the bone in order to
stimulate blood flow, as blood transports cells and nutrients
that help in the fusion (healing) process.
Laminae
The laminae are shingle-like plates of bone coming from the
pedicles that travel backward, joining at the midline. This
provides protection for the nerves or spinal cord that lie un-
derneath them. Together, the laminae and pedicles form the
vertebral arch, or the roof, of the spinal canal.
Pedicles
The pedicles are short, stem-like projections, lo-
cated on the posterior portion of the vertebral
body. They connect to the laminae and bridge
the gap between the anterior and posterior por-
tions of the vertebra. They form the lateral bor-
ders of the vertebral foramen. The pedicles ap-
pear rounded on the superior and inferior surfac-
es. When vertebrae are stacked one on top of the
other, these notches form openings called the
intervertebral foramen, or neural foramen,
where the nerves exit.
Processes
Spinous Process: The spinous process sits at the midline of the laminae, protruding inferiorly. It serves as an
attachment point for muscles and ligaments. It is the most posterior prominence of the spine.
Transverse Process: Transverse processes extend laterally from the junctions of the pedicles and the laminae
with one on each side. The two processes on each vertebra serve as attachment points for ligaments and muscles.
Articular Process: Each spinal level has four articular processes, two that project superiorly and two that project
inferiorly. These processes start at the junction of the lamina and the pedicle at each spinal level. The inferior ar-
ticular processes from the level above and the superior articular processes below form a facet or zygapophyseal
joint.
Mammillary Process (not pictured): This tubercle is located next
to the superior articular process and assists with attachments for
muscles of the back, particularly the multifidus.
Facets
Two adjacent articular processes form the facet joints. Facet
joints (zygapophyseal joints) are synovial joints, meaning each is
encased by a capsule of connective tissue and produces a fluid to
nourish and lubricate the joint. The joint surfaces are coated with
hyaline cartilage allowing the joints to glide smoothly against
each other. These joints help stabilize the spine while also facili-
tating motion. In a healthy spine, the facet joints carry 20% of the
axial load, while the vertebrae carry 80%. The facets are prone to
Cervical
degeneration and are a common cause of back pain.
Facet Orientation
The orientation of facet joints in the spine
Thoracic
changes according to the vertebral region in
order to accommodate different ranges of
motion.
Cervical: 45° frontal plane; this orientation

gives the cervical spine great mobility in all
Lumbar directions: flexion, extension, lateral flexion,
and rotation
Thoracic: 65° frontal plane; movement is

limited in flexion and extension due to the
ribs but still allows for lateral flexion and
rotation.
Lumbar: 90° sagittal plane; the orientation

of the lumbar allows flexion and extension
Pars Interarticularis (Pars)
The pars is the bony mass that joins the ipsilateral inferior and superior articular pro-
cesses. A defect, or fracture, here is referred to as spondylolysis. When this defect caus-
es slippage, it is called an isthmic spondylolisthesis (we will discuss this further in the
Pathology chapter).
CHAPTER 4
Intervertebral Disc
Each of the 24 movable vertebrae in the spine are separated and cushioned by the intervertebral discs. The discs
act as shock absorbers to enable motion. They are designed to resist axial forces. Each disc forms a fibrocartilagi-
nous joint (a symphysis), to allow slight movement of the vertebrae. They also act as ligaments to hold the verte-
brae together. The outer ring is called the annulus fibrosus and has criss-crossing fibrous bands called lamellae.
The inner layer is the gel-filled center called the nucleus pulposus.
The intervertebral discs make up one-
third of the spinal column’s length. There
is no disc between the Atlas (C1), the Axis
(C2), and the coccyx. Discs are largely
avascular as only the outer one-third has
vascularization. Therefore, the disc de-
pends on the cartilaginous portion of the
endplates to diffuse the necessary nutri-
ents.
Annulus Fibrosus
The annulus is the outer part of the disc and consists of collagen fibers called lamellae. The concentric sheets of
collagen fibers oriented at various angles attach to the vertebral bodies to hold the nucleus under compression.
Injury and strain can cause discs to bulge or herniate, a condition in which the nucleus protrudes through the an-
nulus to compress the nerve roots , which can cause pain. The anterior portion of the annulus is twice as thick as
the posterior portion, making the posterior aspect more susceptible to injury.
NP—Nucleus Pulposus
AF—Annulus Fibrosus
Nucleus Pulposus
The nucleus pulposus is located in the core of the intervertebral disc. The nucleus allows movement and with-
stands forces of compression and torsion. It is composed of a jelly-like material that consists of a proteoglycan-
rich matrix, water, and collagen fibers. Alterations to this structure and/or biomechanical forces result in a dam-
aged (trauma) or degenerated intervertebral disc. A degenerated disc is defined as a loss of hydration and de-
creased ability for fluid reabsorption, which results in the loss of height in the disc space.
Disc Nutrition
As previously stated, the disc is mostly avascular. Therefore, it depends on the process of diffusion
from the blood vessels around the disc margins and in the outer one-third of the disc to supply the
nutrients essential for cellular activity as well as remove metabolic waste. Diffusion is the net move-
ment of particles from an area of high concentration to an area of low concentration. The nutrient
supply may decrease due to changes in blood supply and sclerosis of the cartilaginous portion of the
endplate. These changes may result in degeneration, arthritis, and potential joint instability.
Ligaments
Chapter 5
Ligaments are tough bands of fibrous connective tis- spine. The nuchal ligament (liamentum nuchae) attach-
sue that connect bone to bone and permit normal es to the external occipital protuberance to the spinous
range of motion (ROM). Ligaments are multifunctional, process of C7. From there, the supraspinous ligament
allowing stability and mobility at the same time. When attaches to the spinous process of the C7 and travels to
a joint reaches its maximum ROM, the ligaments be- the sacrum.
come active in order to prevent the joint from hyper- Others are segmental, confined to only one spinal level,
flexion/extension. Following injury, ligaments may take these include the ligamentum flavum, the interspinous
a long time to heal due to limited blood supply. ligament, and intertransverse ligament. Together the
Some spinal ligaments are continuous, running the full continuous and segmental ligaments facilitate coordi-
length of the spine. Continuous ligaments include the nated movement of the entire spine while allowing sim-
anterior longitudinal ligament and posterior longitudi- ultaneous movement by individual or groups of verte-
nal ligament. Two additional ligaments are considered brae.
continuous but do not run the entire length of the
Ligaments of the Vertebral Column and Motion Segment
Anterior Longitudinal Ligament (ALL)
The ALL is a dense and strong fibrous tissue that attaches to the ventral portion of the spine (over the vertebral
bodies and intervertebral discs). It begins at C1 and runs distally to the sacrum. The ALL helps limit flexion and
prevents overextension. It restrains anterior movement of one vertebral body over another in extension ad
helps hold the disc in place anteriorly.
Posterior Longitudinal Ligament (PLL)
The PLL travels vertically along the dorsal aspect of the vertebral bodies and forms the anterior wall of the verte-
bral canal. It travels from C2 inferiorly to the sacrum. It connects to the vertebral bodies and discs. The PLL also
resists flexion and contains the disc posteriorly.
Ligamentum Flavum (Yellow Ligament)
This segmental ligament is present from C2 to the sacrum. It is a
paired, bilateral structure that attaches the lamina to the lamina of
adjacent vertebrae. This ligament permits separation of the laminae
in flexion, works to restore the vertebral column to an erect posi-
tion, and may help protect the discs from injury. Its yellow color is
due to the high percentage of elastin, a springy type of collagen, in
its make-up.
Interspinous Ligament
The interspinous ligament is a thin, fibrous ligament that runs from
the posterior superior aspect of the superior spinous process to the
antero-inferior aspect of the inferior spinous process. This ligament
resists shear and flexion forces.
Facet Capsule
The facet capsule attaches at the adjacent articular processes to limit
the range of motion at the facet joint.
Intertransverse Ligament
The intertransverse ligament runs between the adjacent transverse processes to resist lateral flexion.
Ligamentum Nuchae (Nuchal Ligament)
This ligament attaches from the external occipital protuberance of the occiput runs along the posterior end of
the spinous processes and ends at C7. It is continuous with the supraspinous ligament.
Supraspinous Ligament
The supraspinous ligament runs along the posterior tips of the spinous processes from C7 to the sacrum to limit
hyperextension.
In flexion, the anterior longitudinal ligament is relaxed and the anterior portions of the disc are compressed. At
the limit of the movement (end range of motion), the posterior longitudinal ligament, the ligamentum flavum,
the interspinous ligaments, and the supraspinous ligaments are stretched as well as the posterior fibers of the
intervertebral discs.
Nervous System
Chapter 6
One of the main functions of the spine is to protect the transmits them to the brain. The sensory (dorsal) por-
spinal cord, which together with the brain, constitutes tion is located in the posterior aspect of the spine. The
the Central Nervous System (CNS). The CNS communi- dorsal root ganglion (DRG), a bundle of nerves at each
cates with the Peripheral Nervous System (PNS), which vertebral level, controls the incoming flow of sensory
encompasses all of the nerves outside the brain and spi- information. The motor (efferent) portion of the nerve
nal cord. root sends signals from the brain to the muscles, caus-
ing them to contract. The motor portion can also send
Central Nervous System messages to the glands,
The brain receives and interprets in- which are part of the endo-
formation from twelve pairs of crani- crine system and secrete
al nerves and the nerves of the PNS hormones (chemical media-
that converge in the spinal cord. The tors) that regulate a variety
spinal cord begins at the base of the of body functions. This mo-
skull and ends at the conus medul- tor (ventral) portion is lo-
laris (L1-L2), where the cauda equina cated on the anterior as-
(“horse’s tail”) begins. Cerebrospinal pect of the spinal cord.
fluid (CSF) is a clear, colorless body Proprioceptors are sensory
fluid found in the brain and spine, nerve endings that relay
which acts as a cushion or buffer for information from the
the brain’s cortex, providing basic stretch receptors in mus-
mechanical and immunological pro- cles, and from the inner
tection. ear, about the position of
The spinal cord conveys two types of body parts in relation to
messages from nerves: sensory and one another. They also give
motor. The sensory (afferent) portion one the ability to balance.
of the nerve root conducts messages Nociceptors are sensory
toward the CNS and brain—such as nerve endings in the skin,
touch, pain, and temperature—and joints and muscles that de-
tect harmful stimuli (pain).
Spinal Meninges
The meninges consists of three sheets of connective tissue that
cover the brain and spinal cord.
The dura mater (the outer layer) is a thick, durable membrane,
closest to the skull and vertebrae
The arachnoid mater (the middle layer) is named because of its
spider web-like appearance. It cushions the central nervous
system. This thin, transparent membrane is composed of fi-
brous tissue and, like the pia mater, is covered by flat cells also
thought to be impermeable to fluid. Between the arachnoid
and pia mater is the subarachnoid space, which contains the
CSF.
The pia mater (the inner layer) is a very delicate membrane. It
is the meningeal envelope that firmly adheres to the surface of
the brain and spinal cord, following all of the brain’s contours.
It is a thin membrane composed of fibrous tissue covered on
its outer surface by a sheet of flat cells thought to be imperme-
able to fluid. The pia mater is pierced by blood vessels to the
brain and spinal cord with capillaries that nourish the brain.
Layers of the Meninges
Peripheral Nervous System
The nerves of the PNS connect the CNS to sensory organs (eyes, ears, nose, tongue, skin, etc.), internal organs
(viscera), muscles, blood vessels, and glands. The peripheral nerves include the spinal nerves and roots, and the
autonomic nerves. Autonomic nerves regulate the functions of our internal organs, such as the heart, stomach,
and intestines.
Autonomic Nerves
The autonomic nervous system controls
“automatic” functions that are not under
conscious control. The autonomic system has
two parts.
The sympathetic nervous system (“fight or
flight”) responds to immediate danger by
increasing the heart rate and blood pressure,
dilating the pupils, and releasing adrenaline.
The parasympathetic nervous system (“rest
and digest”) produces relaxation and calm by
controlling pupil constriction, slowing the
heart rate, relaxing blood vessels to increase
circulation, and stimulating the digestive and
genitourinary systems.
Spinal Nerves
Thirty-one pairs of nerve roots exit from the spinal cord through the intervertebral foramina. The nerves branch
to innervate throughout the entire body. Cervical spinal nerves 1-7 (C1-C7) exit above corresponding vertebrae,
spinal nerve C8 exits below vertebra C7 and all other spinal nerves exit below corresponding vertebrae.
• Eight pairs of nerve roots exit the cervical spine, one pair above each vertebra. The C8 nerves pass below the
C7 vertebral body. After this level, all nerves
pass below their corresponding levels. Convention for Naming Levels
• Twelve pairs of nerve roots exit the thoracic
spine
• Five pairs exit the lumbar spine
• Five pairs exit the sacrum
• One pair exits the coccyx
8 cervical nerve roots
12 thoracic nerve roots
5 lumbar nerve roots
5 sacral nerve roots
1 coccygeal nerve root
Cervical Plexus
A plexus is a complex, highly organized system of nerve bundles. The cervical
plexus is a network of nerve fibers that supplies innervation to some of the
structures in the neck and trunk. It is located in the posterior triangle of the
neck, halfway up the sternocleidomastoid muscle, and within the prevertebral
layer of cervical fascia.
Brachial Plexus
The last four cervical spinal nerves combine with the first thoracic spinal nerve to
form the brachial plexus. The brachial plexus, which traverses the neck and armpit
(axillary region), conducts signals to and from the shoulder, arm, and hand.
Lumbar Plexus
The lumbar plexus is in the lumbar region of the body and forms part of the lumbosacral plexus. It is formed by the
ventral divisions of the first four lumbar nerves (L1-L4) and from contributions of the subcostal nerve (T12), which is
the last thoracic nerve. Additionally, the ventral rami of the fourth lumbar nerve pass communicating branches, the
lumbosacral trunk and to the sacral plexus. The nerves of
the lumbar plexus pass in front of the hip joint and mainly
support the anterior part of the thigh.
Sacral Plexus
The sacral plexus is a network of nerve fibers that supplies
the skin and muscles of the pelvis and lower limbs. It is lo-
cated on the surface of the posterior pelvic wall, anterior
to the piriformis muscle. The plexus is formed by the ante-
rior rami (divisions) of the sacral spinal nerves S1, S2, S3
and S4.
Dermatome Shaded areas indicate dermatomes on all surfaces of the body
An area of skin that is mainly innervated by a single

spinal nerve is called a dermatome. The general
pattern of dermatomes is common to everyone,
although precise areas of innervation are quite in-
dividual and adjacent dermatomes often overlap.
Even so, symptoms in certain dermatomes can be
helpful in identifying the site of damage to the
spine. For example, pain that radiates down the leg
to the little toe raises the suspicion of a pinched S1
nerve root.
Myotome
A myotome is a set of muscles innervated by a specific, single
spinal nerve (nerve root).
A myotome may be tested by muscle strength or reflex
testing. A reflex is involuntary and a near instantaneous re-
sponse to a stimulus. During the physical examination, reflexes
and sensations are tested to assess the health of the CNS and
PNS.
Pathology, such as a herniated (bulging) disc, tumors, or in-
jured nerve roots, often manifest as altered sensations, reflex-
es, and muscle strength in body parts far removed from the
spine. Thus, neurologic assessment is an important part of the
physical examination of patients with suspected spinal or
nerve pathology.
MUSCLES
Chapter 7
Muscles of the Spine
Here we will reference a select few muscles you may encounter during surgical procedures or discussions with sur-
geons. Be aware that there are many muscles that make up the spine that will not be reviewed here or in class.
The muscles of the back are categorized into layers by depth— a superficial layer, an intermediate layer, and a
deep layer. The muscles are also placed into categorizes by intrinsic or extrinsic muscles. Intrinsic muscles tend to
originate and insert in the spine, and assist in moving the spine. Conversely, extrinsic muscles attach to the spine,
as well an extremity, and assist in moving the extremity.
Cervical Muscles
Anterior Cervical Muscles

The platysma is a superficial, broad sheet of
muscle fibers arising from the fascia covering
the upper parts of the pectoralis major and
deltoid. Its fibers cross the clavicle and pro-
ceed obliquely upwards and medially in the
side of neck.
We then find the sternocleidomastoid which
passes obliquely down across the side of the
neck and forms a prominent landmark, espe-
cially when contracted. It is thick and narrow
centrally, but broader and thinner at each end.
It helps to tilt the head to the shoulder of the
ipsilateral side of the body and rotates the
head to the contralateral side.
Deepest of the three is the longus colli. It is located

directly on the vertebral bodies, between the atlas and
Longus Colli the third thoracic vertebra. The longus colli functions
to bend the neck forward, flex laterally, and rotate to
the opposite side.
Posterior Cervical Muscles
Muscles of the posterior cervical spine are also found in layers—superficial, intermediate, and deep. Some mus-
cles found in the superficial layer include the trapezius and latissimus dorsi. The intermediate layer includes the
levator scapula and the rhomboids, and the deep layer consists of the serratus anterior and posterior, splenius
capitis, and colli, as well as the prolongations of the erector spinae muscles. The subocciptal muscles connect the
cervical spine to the base of the occiput (skull).
Lumbar Muscles
Anterior Lumbar Muscles

Muscles of importance in the anterior lumbar (or trunk) are pictured below. The
rectus abdominus is a long, flat muscle that extends the whole length of the
front of the abdomen. This is the muscle known as the abdominal muscles or “six-
pack”. It functions to bend, as well as flex, the vertebral column.
The oblique muscles of the abdomen consist of three muscles—the external

Rectus Abdominus oblique, internal oblique, and transversus abdominis. The external oblique is the
largest and most superficial of the three flat mus-
cles. It travels in a downward oblique fashion,
toward the rectus addominus. The internal
oblique is the intermediate of these three and
travels in the opposite direction of the external
muscles, moving upward and away from the rec-
tus abdominus, in an oblique fashion. Located
under the obliques is the transversus abdominis,
named for its direction of muscle fibers. These
muscles wrap around the trunk allowing for pro-
tection and support.
The psoas muscle is a pair of muscles occurring on either side of the spinal column and spans T12-L5, inserting
into the femur. These muscles contribute to flexion of the hips. In the lumbar spine, unilateral contraction
bends the trunk laterally, while bilateral contraction raises the trunk from a supine position. Because of its
frontal attachment on the vertebrae, the psoas stretches as the spine rotates.
Axial T2 MRI displaying the Erector Spinae,

Multifidus, and Psoas Muscles
Posterior Lumbar Muscles

The erector spinae/para spinal/sacrospinalis muscle fibers form a large fleshy mass which splits into three col-
umns from lateral to medial—iliocostalis, longissimus, and spinalis. This muscle group lies in the grooves on the
sides of the vertebral column. It is covered in the thoracic and lumbar spine by the thoracolumbar fascia. One
of the primary functions is to extend the spinal column.
The multifidis is part of the tranversospinalis muscle

group. This muscle group fills the grooves at the sides
of the vertebral bodies from the sacrum to the axis.
While very thin, the multifidus muscle plays an im-
portant role in stabilizing the joints within the spine.
Internal
Internal Organs & Circulation
Organs & Circulation
Chapter 8
Vital Organ Systems
With the exception of the brain, the torso contains all of the body’s vital organs with the exception of the brain.
Any anterior surgical approach to the spine must avoid injuring these organs.
The main organs are grouped according to their functions.
• Circulatory (Vascular) System: blood, heart, blood vessels (arterial and venous)
• Respiratory System: nose, mouth, pharynx, larynx, trachea, bronchi/bronchioles, lungs
• Digestive System: mouth, esophagus, stomach, liver, small and large intestines, rectum, anus, pancreas,
gallbladder
• Endocrine System: hypothalamus, pituitary, thyroid, parathyroid, adrenals, pancreas, ovaries, testes
• Genitourinary System: kidneys, ureters, bladder, urethra
• Nervous System: CNS and PNS
Circulation of the Cervical Region

Vertebral Artery
Vertebral Artery
The vertebral artery is generally the first and largest branch of the subclavian ar-
tery. It enters the transverse foramen (foramen transversarium) at the sixth verte-
brae and ascends through the foramina in each transverse process above this. It
ultimately enters the skull through the foramen magnum.
Carotid Sheath and Contents

The carotid sheath is the anatomical term for the fibrous connective tissue that sur-
rounds the vascular compartment of the neck. The four
major structures contained in the carotid sheath are
the
 common carotid artery (medial),
 the internal jugular vein (lateral),
 the vagus nerve (Cranial Nerve X) (posterior), and
 the deep cervical lymph nodes.
Circulation of the Thoracic and Lumbosacral Region
Arterial Circulation
Blood exits the heart through the aortic arch. The descending aorta passes through the diaphragm at the level of
T12, slightly to the left of the midline, and becomes the abdominal aorta. The abdominal aorta travels along the
posterior wall of the abdomen, immediately anterior to the vertebral column, and follows the curvature of the
lumbar spine to the level of L3. At L4, it bifurcates (divides)
to become the left and right common iliac arteries.
Venous Circulation
The vena cava carries de-oxygenated blood from the lower
body to the right atrium (chamber) of the heart. The vena
cava parallels the abdominal aorta on the right side and bi-
furcates at the level of L5, where it becomes the common
iliac veins.
Circulation of the Vertebral Bodies
Spinal Arterial and Venous Circulation

To provide strength, support, and flexibility, the vertebral column requires an ade-
quate supply of nutrients that are richly supplied by blood vessels.
Blood leaves the vertebral column by two major networks of veins: the internal and
external venous plexuses. They communicate through the intervertebral foramina
and the intervertebral veins.
Paired segmental arteries (intercostals, lumbar arteries) arise from the aorta and
extend dorsolaterally around the middle of each vertebral body, near each trans-
verse process, segmental arteries divide into lateral and dorsal branches.
Normal MRI displaying segmental

structures in the vertebral bodies
CHAPTER 6
Region Specific Anatomy
Cervical Specific Anatomy
The top seven vertebrae make up the cervical spine. The vertebrae of the cervical spine are smaller than those in
the rest of the spine and broader from side to side than from front to back. Several of their functions include con-
taining and protecting the spinal cord, supporting the head (which weighs an average of 10 to 11 lbs.), and enabling
diverse movement.
The cervical spine is relatively mobile in comparison to the thoracic and lumbar spine regions. The cervical spine’s
range of motion (ROM) is approximately 80° to 90° of flexion, 70° of extension, 20° to 45° of lateral flexion, and up
to 80° of rotation to either side.
Atlanto-Occipital Joint Complex

The atlanto-occipital articulation is comprised of a pair of synovial joints that connect the occiput of the skull (C0)
to the first cervical vertebra (atlas/C1).Each joint is comprised of one of the superior articular processes of the atlas
which articulate with the surface of the occipital condyle. The joint is reinforced by supportive fibrous capsules.
This joint allows for 50% of flexion/extension when nodding “yes”. Injuries from motor vehicle accidents are com-
mon at this site.
Altanto-Axial Joint Complex

The upper cervical spine is comprised of the atlas (C1) and
the axis (C2). They differ from other vertebrae in several
ways. First, they have unique bony structures not found in
other vertebrae as outlined below. Second, the unique
structure allows for more rotation (approximately 50% of
the cervical spine) than other areas. Third, there is no in-
tervertebral disc.
Atlas
The atlas (C1), which has neither a body nor a spinous process,
consists of two lateral masses connected by an anterior and pos-
terior arch. Each lateral mass includes upper and lower facets
which articulate with the occipital condyle of the skull and the
axis, respectively. The anterior arch features an anterior tuber-
cle to facilitate attachment to the ALL. A facet is on the posterior
The Atlas (C1)
surface for the odontoid process (dens) of the axis to articulate.
Superior View
The posterior arch has a superior groove for the vertebral artery
and the small C1 nerve on each side, and features a posterior tubercle for attachment of the ligamentum nuchae/
nuchal ligament. The transverse process has an opening (foramen transversarium/transverse foramen) which al-
lows for passage of the vertebral artery that is exclusive to the cervical spine.
Axis
The axis (C2) is characterized by the dens (odontoid process), which projects superiorly from the body and articu-
lates with the posterior aspect of the anterior arch of the atlas. This allows the head to turn from side to side. The
apical and alar ligaments anchor the dens to the occipital bone and the transverse ligament prevents posterior dis-
placement of the odontoid process. The ligaments that bind the atlas to the axis facilitate rotation. There are no
intervertebral disks in between C0-C1 and C1-C2.
The Axis (C2) The Axis (C2)

Anterior View Posterior View
Upper Cervical Ligaments

Three important ligaments to note in the upper cervical spine are the apical, alar, and transverse ligament.
The apical ligament is a small ligament that joins the apex (tip) of the dens of C2 to the anterior margin of the fora-
men magnum. It is weak and does not contribute significantly to
stability.
The alar ligaments connect the sides of the dens (on the axis,
the second cervical vertebra) to tubercles on the medial side of
the occipital condyle. They are short, tough, fibrous cords that
attach on the skull and on the axis, and function to check side-to-
side movements of the head when it is turned.
The transverse ligament of the atlas is a thick, strong band,
which arches across the ring of the atlas, and retains the odon-
toid process in contact with the anterior arch.
Lower Cervical Vertebrae (Subaxial): C3-C7
The lower cervical vertebrae, C3 to C7 are also known as the subaxial spine, as they are situated below the axis.
The bodies are small and oval in shape and the vertebral canal is triangular in shape. As in the atlas and axis, each
transverse process is pierced by a transverse foramen (foramen transversarium) for passage of the vertebral ar-
tery and vein. Bifid (cleft) spinous processes are typically seen from C3-C6. The C7 vertebra has a long, non-bifid
spinous process known as the vertebral prominens.
Axial View
A unique feature of the subaxial cervical spine are the uncinate processes (see image below). The word uncinate
comes from the Latin word “unicinatus”, meaning “hook”. These hook shaped superolateral bony projections arise
from the vertebral bodies. They articulate with indentations in the lateral border of the inferior aspect of the ver-
tebral body above. The uncovertebral joint, or Joint of Luschka, is where these indentations meet. This is an im-
portant landmark during surgery as the vertebral artery is just lateral to this joint.
Coronal View
AP X-ray of the cervical spine circles the Joint of Luschka (uncovertebral joint)
The small arrows show the transverse foramen
Thoracic Specific Anatomy
The twelve thoracic vertebrae form a transitional region
between the cervical and lumbar vertebrae, and constitutes
the most stable part of the spine. The thoracic spine is rela-
tively stiff and has limited ROM.
The vertebral bodies increase in size with the numbers pro-
gressing as they move inferiorly. The thoracic spine’s ROM
is approximately 20-45° of flexion, 25-35° of extension, 20-
40° lateral flexion, and 35-50° of rotation.
The spinous processes are long and point downward, as
opposed to cervical and lumbar spinous processes, which are more horizontal. The vertebral bodies are heart-
shaped and the vertebral canal is round. The long spinous processes, rib attachments, as well as the facet orienta-
tion limit movement in the thoracic spine. Nerve root compression in the thoracic spine is not as common as in the
cervical or lumbar spine since the vertebral foramen are more ample and because the thorax is less mobile and less
prone to injury.
Thoracic vertebrae have unique costal facets to facilitate rib articulation, as seen in the illustration below. The
costo-vertebral facet connects the head of the rib to the body of the vertebrae. The costo-tranverse facet con-
nects the neck of the tubercles with the transverse pro-
cesses.
Ribs 1 to 7 attach anteriorly to the sternum and are classi-
fied as true ribs. Ribs 8, 9 and 10 attach to the sternum in-
directly and are considered false ribs. The 11th and 12th
ribs are known as floating ribs since they do not attach to
the sternum. These floating ribs only articulate with the
vertebral bodies since T11 and T12 lack superior costal fac-
ets.
al
Lumbar Specific Anatomy
The five lumbar vertebrae form the largest seg-
ments of the vertebral column. They are large,
wide from side to side, and a little thicker in front
than in back. The vertebrae are bordered anteri-
orly and laterally by the abdominal organs and
pelvic bones. The two lower segments, L4 and L5,
bear most of the weight and are, therefore, more
prone to injury and degeneration. Occasionally, a
person can have six lumbar vertebrae
(lumbarization of the first sacral segment) or four
lumbar vertebrae (sacralization of the fifth lum-
bar vertebrae). The spinal cord terminates at L1,
therefore, low back problems rarely result in spi-
nal cord damage or paralysis. The lumbar spine’s ROM is approximately 80° of flexion, 35° of extension, and 25° of
lateral bending. Rotation is nominal in the lumbar spine.
The anatomy of a typical lumbar vertebra is seen below. The pedicles are directed backward from the vertebral
body. The laminae are broad, short, and strong. They form the posterior portion of the spinal column (the roof of
the spine). The spinous process is thick, broad, and projects backward. The superior and inferior articular processes
project upward and downward from the junctions of the pedicles and laminae. The transverse processes are long
and slender and are situated in front of the articular processes. In the upper three lumbar vertebrae the articular
processes arise from the junctions of the pedicles and laminae, but in the lower two vertebrae the articular pro-
cesses are set farther forward and arise from the pedicles and posterior parts of the vertebral bodies.
Sacrum and Coccyx
The sacrum consists of five auto-
fused vertebrae whose vestigial
disks are seen in the sagittal
view. The dorsal foramina, the
openings between each fused
sacral vertebra, allow passage of
nerve roots. The sacral ala
(wings) on the lateral superior
sacrum form two articular pro-
cesses, which are the sacral
horns of S1. The median sacral
crest is a spinous process for Anterior View Posterior View
attachment of ligaments. The inferior spinal nerves pass through the sacral canal. The sacral promontory on the
anterior, superior tip of S1 offers the best bone purchase for sacral screw fixation. The spine terminates in the
three to five fused vertebrae of the coccyx.
The Lumbosacral Joint

As the final joint at the base of the spinal column, the lumbosacral joint bears the most weight. It must absorb
and dissipate the stresses transferred through the spine. The forces acting on the lumbosacral joint tend to slide
L5 forward and downward, but are counteracted by its inferior articulating processes being pushed onto the sa-
crum’s superior articulating processes. This puts the pars interarticularis of L5 under enormous stress and may
result in a spondylolisthesis, which is discussed later in the text. Excessive and frequent loading of the joint can
cause serious low back problems.
Sacroiliac Joint
The sacroiliac joint, or SI joint (SIJ), is the joint between the sacrum and the ilium bones of the pelvis, which are
connected by strong ligaments. The joint is a strong, weight transferred joint with irregular elevations and depres-
sions that produce interlocking of the two bones. The human body has two sacroiliac joints, one on the left and one
on the right, which often match each other but are highly variable from person to person. The joint has limited mo-
tion and helps absorb shock and transfer forces.
Pelvis
The pelvis is made up of two hip bones (ilia) joined to the sacrum at the sacroiliac joint. The sacrum and hip bones
form a weight-bearing arch that directs body weight to the femurs, which sit securely in the acetabula of the ilia.
Sacroiliac Joint
IMAGING
Chapter 10
When making a diagnosis or planning surgery, physi- Radiodensity, Magnification and Manipula-
cians rely on images of the bone produced by various tion
types of ionizing radiation or magnetism to supplement
the patient’s history and physical examination. Different tissues absorb different amounts of x-rays
and thus have different radiodensities. Radiopaque
tissues or objects absorb large amounts of x-rays and
appear as light areas.
Radiographs
Radiolucent tissues absorb few x-rays and show up as
X-RAYS dark areas. There are 5 gray-scale intensities from
radiopaque to radiolucent.
In 1895, physicist Wilhelm Roentgen was studying
the response of vacuum tubes to electrical current. Contemporary x-ray machines are calibrated so that
To his surprise, he found that the electricity passing radio densities are standardized from machine to ma-
through a vacuum tube produced an image on a fluo- chine. Radiographs will magnify an image depending
rescent screen. The first image (roentgenogram) tak- on how far the radiation source is from the patient
en with the mysterious rays was of his wife’s hand, and how far the patient is from the “film”. Film is
which appeared dark against a white background. used less frequently now that digital radiographs can
That is because her hand absorbed the X-rays while be manipulated by intensifying contrast and magnify-
the surrounding air did not. ing structures to reveal more information than a
Today’s plain radiographs are produced by the same standard radiograph.
type of ionizing radiation. However, we reverse the
black and white portions of the image to make the
internal structures stand out against a dark back-
ground. Both stationary and mobile x-ray machines
are available.
Radiographs can reveal many details of the bony
anatomy. They are used to detect and evaluate frac-
tures, tumors, arthritis, deformities, osteoporosis,
and infection.
IMAGING VIEWS
Radiographs of the spine from various angles assist in observing different aspects of the anatomy.
AP Anterior/Posterior. These front-to-back views show the spine in the coronal plane and evaluate scoliosis. They
may also assess fractures and degenerative disc disease.
Lateral right or lateral left: Side views evaluate spinal curves (kyphosis and lordosis) in the sagittal plane, and
also assess fractures and degenerative disc disease.
• Confirm the vertebral body alignment forms an uninterrupted curve
AP X-ray View Lateral X-ray View
Oblique:
This view is on a 45° angle and checks the integrity of the pars interarticularis. A pars fracture will show up in the classic
“scotty dog” sign in the oblique view.
• Assess facet joints
• Assess the intervertebral foramen
Oblique x-ray of the cervical spine Oblique x-ray of the lumbar spine visualizing
the “scotty dog” sign to evaluate the pars
Flexion/extension:
This view is used to assess:
 motion segment instability.
 more than 3mm of translation is considered unstable.
Flexion/extension x-rays of the cervical spine
Swimmer’s:
The cervicothoracic junction (C6, C7, and C7-T1) can be examined when one arm is extended overhead and the
other is held by the side, like a swimmer in mid-stroke. The swimmer’s view allows for better visualization of C7,
T1, and T2 vertebrae while the standard lateral projection is obscured by the clavicle and soft tissues of the
shoulder girdle.
Swimmer’s X-ray of the Cervico-thoracic Junction
Open mouth: (AP open mouth):

C1 and C2 are more easily seen in an AP view when the mouth is open and the teeth and jaws are not in the way.
 Traumatic injuries to the upper cervical spine
AP open mouth X-ray of the cervical spine
Fluoroscopy
Conventional fluoroscopy was invented by Thomas Edison in 1896. While fluoroscopy is simple and relatively inex-
pensive, this modality produces a high doses of radiation (higher radiation than X-ray). Fluoroscopy produce real-
time x-ray images and are typically used in operating rooms to confirm placement of needles, guide wires, or im-
plants. C-arm fluoroscopy (mobile fluoroscopic units) have a radiation
source at one end of the arm, capture the image at the other end, and dis-
play it on a monitor. The C-arm is an excellent tool for spine surgical pro-
cedures. The image that is created is the opposite of an x-ray—bone dis-
plays dark, while the surrounding air is white. Fluoroscopy uses more radi-
ation than plain radiographs.
CT Scans
This type of imaging uses either single slice or continuous helical motion technology. CT is a non-invasive imaging
technique that uses x-rays to generate radiographic images in the axial, coro-
nal, or sagittal planes.
This technology was developed by EMI Laboratories, the same company that
produced The Beatles records. Company engineers were looking for a way to
store large amounts of data on something smaller than an LP. The first medi-
cal CT (computed tomography) machines, installed in 1974, could only scan
the head. By 1976, whole-body scanners were available.
CT scans combine many x-ray images to create cross-sectional views of the
anatomy and/or pathology. They provide detailed images of the bones and are helpful in diagnosing small frac-
tures that do not show up on a radiograph (x-ray). CT images can also be taken after contrast medium is injected
into blood vessels (CT angiography) if blockage or constriction is suspected.
CT scans further delineate the fracture pattern and depression of bone fragments. CT scans provide more detail as
they “slice” through the anatomy at pre-determined intervals. This provides the surgeon with “cuts” of the bone in
several different planes allowing them to appreciate the complete injury.
CT scans have several drawbacks. They require rel-
atively high doses of radiation, and metal objects
can create bright white “scatter” artifacts with this
type of imaging.
Sagittal Lumbar CT Sagittal Cervical CT
MRI
A Magnetic Resonance Imaging (MRI) is a form of non- Water movement is typically random within the body
invasive technology that combines radio waves and a and the hydrogen atoms are aligned with use of the
strong magnetic field with hydrogen atoms in the body magnet. Hydrogen nuclei align parallel with the mag-
to produce images of soft tissue structures. MRI uses a netic field during an MRI. When radiofrequency (RF) is
large magnet and radio waves to align hydrogen atoms applied, the hydrogen enters a higher energy state.
in living tissue and then capture digital images of the When the RF is terminated, the atoms give off energy
emitted energy when the magnet is off. The images and return to a lower energy state termed relaxation.
captured can be manipulated to produce coronal, sag- The time between RF pulses is referred to as repetition
ittal or axial views. MRI proves particularly helpful in time (TR). Two independent time constants exist; T1
evaluating soft tissues, such as the brain, spinal cord, and T2.
and discs.
MRI images can be weighted to highlight different types of tissue.

 T1 weighted images accentuate fatty tissues. Longitudinal magnet relaxation time.
 T2 weighted images emphasize water-containing tissues, such as cerebrospinal fluid and blood.
 STIR (short tau inversion recovery). MRI with imaging signal acquisition to enhance images. Excellent for
viewing fractures (fx).
T1 T2
 Water appears gray  Water appears white
 Bone marrow (bright) Cortex (gray)  Bone marrow (gray) Cortex (gray)
 Good to review anatomy  Good to assess pathology
T1 weighted MRI T2 weighted MRI
Imaging Planes
There are several primary imaging planes that are utilized in neuroimaging:
Axial plane: Transverse images representing "slices" of the body, dividing the body into upper
and lower portions.
Sagittal plane: Images taken perpendicular to the axial plane separating the left and right sides
(showing a lateral perspective)
Para-sagittal: An image parallel to the sagittal plane. It divides the body into unequal left and
right halves.
Coronal plane: Images taken perpendicular to the sagittal plane which separate the front from
the back. (frontal view)
Biomechanics
C h a p t e r 11
Biomechanics Biomechanics Terms
Biomechanics is the study of mechanical principles
as referred to in Newtonian physics. In this manual, Force: an external agent that causes a free body to
these principles are applicable to discuss, as they change speed, direction, or shape, or causes a sta-
apply to biological systems. As with any physical tionary object to deform. Gravity, for example, is a
structure, a building or the human body, structure force.
dictates function. The skeleton, for example, bears Tension: the act or action of stretching or the condi-
weight in much the same way that a building’s tion or degree of being stretched to stiffness. Force
beams do. The difference, of course, is that the that elongates the spine. A person doing chin-ups
body not only bears weight but moves. experiences tension on the spine. Note that muscles
can only contract and relax. Thus, they apply tension
on the vertebrae.
The structures of our body form a kinetic chain,
which is subjected to internal and external forces Compression: compression is the application of pow-
(such as gravity) and moves to achieve various pos- er, pressure, or exertion against an object that causes
tures. The joints and muscles of the body work most it to become squeezed, squashed, or compacted;
efficiently when they are physically balanced, and force that flattens the discs and vertebrae. Degenera-
unusual stresses or strains are not operating. Any tive disc disease or falling from a height can result in
imbalance caused by overuse, disease or injury compression fractures of the vertebrae.
affects all of the structures in the kinematic chain. Shear: an action or stress resulting from applied forc-
es that causes or tends to cause two contiguous parts
of the body to slide relatively to each other in the
Being that the spine is prominent in supporting the direction parallel to their plane of contact. Shearing
axial skeleton and in maintaining balance during forces tend to slide vertebrae out of their normal
walking it is subjected to an unusual amount of me- alignment and stress the interior structures and can
chanical wear and tear. Its widespread neural con- tear ligaments, rupture discs, and fracture vertebrae.
nections mean that spine problems frequently man- Torsion: the twisting or wrenching of a body by the
ifest far from the spinal column. Similarly, problems exertion of forces tending to turn one end or part
in the extremities often throw the spine off balance, about a longitudinal axis while the other is held fast
or turned in the opposite direction. Rotational force
resulting in abnormal movement and abhorrent
reacting perpendicular to the spinal axis but not in
wear. the plane of the spine; also known as torque. Tor-
sion, like shear, can tear ligaments, rupture disks and
fracture vertebrae.
Translation: force by which a body shifts from one
point in space to another.
Kinematics: a branch of dynamics that deals with as-
pects of motion apart from considerations of mass
and force.
Kinesiology: the study of the principles of mechanics
and anatomy in relation to human movement. This
discipline, frequently used by elite athletes to guide
their training, has improved our knowledge of how a
healthy body ideally moves.
Biomechanics Terms Continued
Lever: a rigid bar that pivots around a point to move an object at a second point by force applied at a third
point. Levers maximize efficiency by moving large loads with relatively little effort. The skeleton and muscles op-
erate as levers.
 Fulcrum or pivot - the point about which the lever rotates; usually a joint
 Load - the force applied by the lever system; usually applied by gravity or countervailing body parts
 Functional Load - the normal forces the body endures without any increased external force
 Effort - the force applied by the user of the lever system; usually in the form of muscle contractions
In a bicep curl, the elbow is the fulcrum, the load is the weight of the lower arm and hand, and the effort is the
contraction of the bicep muscle.
In the spine the vertebrae is the rigid point that pivots (lever), while the disc and the facets are the fulcrum (or
the points around which the vertebrae moves). Muscles attach to the vertebrae at various points, creating the
effort (force) which allows the vertebrae to move. Ligaments have an opposite application, providing restraints
to the movement and allowing the segment to stay within normal limits of range of motion.
Range of motion (ROM): The degree of movement allowed by structural constraints. ROM varies for each indi-
vidual and is measured using anatomical landmarks. Typically, ROM decreases as a person ages. Disease or inju-
ry may also restrict ROM.
Weight-Bearing
Three columns form the load-bearing structure of the
spine.
 The Anterior Column includes the anterior longitudinal
ligament, the anterior disc and the anterior portions of
the vertebral bodies.
 The Middle Column includes the posterior longitudinal
ligament, the posterior disc and the posterior vertebral
bodies.
 The Posterior Column includes the pedicles, spinal ca-
nal, articular processes, transverse processes, spinous
processes, and their attaching ligaments.
In a healthy spine, the vertebral body carries 80% of the load while the facets carry 20%.
The muscles and ligaments of the back form a posterior tension band, which stabiliz-
es the compressive loads carried by the spinal vertebrae. If the posterior tension
band becomes weak or damaged, the entire spine tends to fall forward (kyphosis).
Restoring the posterior tension band is a major goal of spinal surgery.
Degeneration of the spine, gradually transfers the weight of the body to the facet
joints. This shifts the load-bearing alignment of the spine, also causing the facet joints
to degenerate. The lumbar spine, by virtue of its position in the axial skeleton, bears
more weight than any other segment of the spine. Not surprisingly, it also suffers the
most serious effects of compression and shear.
In addition, the space around the spinal cord may narrow, resulting in lumbar spinal
stenosis. This compression of the nerve rootlets may cause pain, numbness, and
weakness into the legs.
Motion Segment
A motion segment of the spine, or functional spinal unit, is described as the smallest physiological motion unit of
the spine to exhibit biomechanical characteristics.
The motion segment consists of two vertebral bodies, one intervertebral disc, two facet joints, and ligaments.
Within the adult human spine, there are twenty-five motion segments. The exceptions to a motion segment in-
clude the joint between the occiput and C1 (no disc). In the cervical spine, the joint between the occiput and C1,
and the joint between C1 and C2, are not considered motion segments since there are no discs between these lev-
els. Lastly, the joint at L5/S1 is also not considered a motion segment. Although a disc is part of this joint, the sa-
crum is not considered a single vertebra.
Sagittal Balance
Sagittal balance of the spine is important to maintain posture and pre-
vent muscle fatigue. Degenerative disc disease, trauma, congenital
influence, osteoporosis, or neuromuscular conditions can all play a
role in causing imbalance to the spine. When there is an imbalance,
symptoms may include low back pain, difficulty walking, and/or the
inability to look straight ahead when upright. In some cases, this im-
balance can put pressure on spinal nerves, leading to weakness and
pain.
Although the causes may vary, the ultimate goal of surgery is to re-
store overall spinal sagittal balance. Sagittal balance is the most relia-
ble predictor of clinical symptoms in adults with spinal deformity.
Coronal Balance
In a normal AP or coronal image, the ideal spine is straight. A curve greater than 10° is considered scoliosis. Health
care providers measure scoliosis curves in degrees: A mild curve is less than 20°. A moderate curve is between
25° and 40°. A severe curve is more than 50°. The causes of scoliosis may be congenital, early onset, degenerative,
neuromuscular, or idiopathic (unknown).
Symptoms may include low back pain, radicular leg pain, or weakness. In severe cases, cardiopulmonary decline
may occur.
For many, treatment may be observation, physical therapy, and/or bracing. In more severe cases, surgery is re-
quired. The goal would be to restore coronal balance and, in some cases, correct rotation of the spine.
Gait
The interconnected vertebrae of the spine work with the rest of the body to facilitate walking. Visualize stepping
forward with your left foot. Normally, the right shoulder and arm will move forward to counter-balance the action
of the left leg and hip. The trunk, between the left leg and right shoulder, rotates slightly as you take that step.
The rotation occurs primarily in the thoracic spine, which accommodates about 35° of rotation. When the thoracic
spine rotates, the rib cage moves as well. However, the thoracolumbar spine does not flex or extend well, due to
the fixed sternum anteriorly and the long vertebral spinous processes posteriorly that tend to limit those motions.
On the other hand, the lumbar spine is responsible for almost no rotation. The facet joints, located in the sagittal
plane, allow approximately
5° of rotation. Conversely,
it contributes to flexion,
extension, and some lat-
eral flexion (bending side-
to-side). During standing
or walking, the nucleus of
each intervertebral disc
expands in response to
weight bearing. If the an-
nulus is weak, it can no
longer hold the disc in
place, causing a herniation
or protrusion of the disc.
Shear
Shearing occurs when two forces act parallel to each other, but in opposite directions. A spondylolisthesis is one
example, where one vertebrae slides relative to another. This is most common in the lumbar/lumbosacral region
of the spine. These will be explained in more detail in the Pathology chapter.
Tension
Tension pulls apart the structure loaded. Typically, liga-
ments under tension lengthen and narrow. Overstretch-
ing may cause tears resulting in pain. An example would
be a “whiplash” injury.
A force may cause compression on one side of

the spine while causing tension on the opposite.
Hyperextension
This type of injury occurs mostly due to motor vehicle and
diving accidents, in which the head is forced backward after
striking a non-moveable object.
Hyper-flexion
Hyper-flexion injuries in the cervical spine most
frequently result from a motor vehicle accident
(whiplash). This is the most common type of
fracture mechanism in the cervical spine and
can cause ligament tears and vertebral body
fractures.
Biomechanical Loads on the Spine
Axial Compression
This force compresses an object to make it shorter or thicker and is caused by
gravity, muscle contraction, and ligament stress. Most loading is on the anterior
portion of the segment. As compression on the disc increases, there is tension
on the annulus fibers, causing them to change their fiber angles and increase
stability. If severe enough, damage to the disc, and possibly the endplate, can
occur. Injuries may occur from incidents such as falling on your head or
buttocks, or from a motor vehicle accident. Most loading injuries occur in the
cervical and thoracolumbar (T10-L3) region.
Bending
Bending causes tensile and compressive stressors. When bending forward, the disc undergoes compression
on the anterior side and tension on the posterior. Every time a person bends forward, lifts a heavy object, or
sits leaning forward, there is stress placed on the back and spine. Over time, these effects can be damaging.
Torsion
Torsion forces on a structure are caused by rotation in a longi-
tudinal axis; most are a combination of rotation with flexion.
The lumbar and cervical spine are more susceptible to exces-
sive torsion, causing soft tissue and joint damage.
Chapter 12
Pathology
“Pathology” is the cause and effect of disease. Pathology of the spine means there is an abnormality, typically
caused by disease or degeneration, which may result in pain or dysfunction. Pathology of the spine is broken into
five categories—degenerative, deformity, trauma, tumor, and inflammatory. In any of these conditions, stenosis
(narrowing of a passageway) can occur in either the vertebral or the intervertebral canals and potentially compress
the spinal cord and spinal nerve root traveling through the passageway. Causes of stenosis may be degenerative
changes (bulges, herniations, osteophytes, ligament hypertrophy, or various other space-occupying lesions. Surgi-
cal treatment of these conditions involves decompression of the nervous tissue, either directly or indirectly.
The Degenerative Process

In the 1970s, Kirkaldy-Willis first described the "degenerative cascade"
of degenerative disc disease. The degenerative process most commonly begins
with the disc and facets, although degeneration involves every element of the
spine (i.e., the ligaments, facet joints, intervertebral disc, endplates, muscles
and vertebral bodies). There is a sequence of changes at the gross, radiograph-
ic, biomechanical, and biochemical levels.
The smallest functional unit of the spine, or motion segment, consists of an intervertebral disc, two facet joints,
two vertebral bodies and seven ligaments. These elements are interdependent, and must be fully functional to
maintain a healthy spine. When one part is incapable of maintaining its normal function, it places undue stress on
all other elements of the segment and may lead to a cascade of degeneration throughout the motion segment.
Causes of Spinal Aging

From a clinical perspective, disc degeneration is more prevalent and may be more severe within the lumbar spine,
suggesting that the higher mechanical load may be a causative factor. In addition, premature aging of the spine can
be affected by cardiovascular, lifestyle, and genetic factors. Mechanical insults from physically demanding occupa-
tions or sports may contribute to early spinal aging. Smoking and obesity have also been identified as risk factors.
Smoking affects cellular metabolism and proliferation while obesity increases mechanical load. Atherosclerosis is a
major cardiovascular causative factor. Atherosclerosis can affect the lumbar artery, in turn, causing diminished disc
diffusion and may lead to premature disc degeneration. The overall effect is diminished blood flow resulting in de-
creased nutritional supply to the intervertebral disc.
Intervertebral Disc
The disc derives its nutrition through diffusion across vertebral endplates. As the end-
Bulge plates sclerose (or harden), the permeability decreases, diminishing nutrition to the
disc. The concentration of proteoglycans, which are responsible for the hydration of the
disc, tends to decrease as well. This loss of fluid causes a loss of height and begins the
Herniation
degenerative process. As the disc dehydrates, it begins to thin. Loss of disc height re-
duces the disc’s ability to absorb impact, and leads to excessive loading of the facet
joints, resulting in degeneration and relative instability. Concurrently, due to repetitive
stress to the disc and the aforementioned dehydration, the discs may develop small
tears. This weakening of the annulus fibrosis may contribute to the formation of bulging
and/or herniations.
Ruptured
A disc herniation is a condition affecting the spine in which a tear in the outer, fibrous
ring (annulus) allows the soft, central portion (nucleus) to bulge out beyond the dam-
aged outer rings. A herniation is usually due to age-related degeneration of the annu-
Sequestered/ lus, but can also occur due to trauma or lifting injuries. Most minor herniations heal
Fragment within several weeks, with no treatment.
 Disc herniations may occur in several categories:
 Prolapse– bulging of the disc,
 Herniation– the disc pushes on the annulus, pressing it against a nerve or spinal
cord,
 Extrusion (Rupture) - the disc pushes through the annulus fibers and, Sequestration
– where the disc material can break off into the spinal canal. Herniated discs most
commonly occur in the 20 to 50 year old age groups.
Location, Location, Location!

Herniations can occur at various locations around the disc: central, paracentral, and lateral. To understand the
locations look at the image below as though you were viewing the face of a clock.
Central - located at the 6 o’clock position with the disc bulge in the center of the canal. This can create central
stenosis, affecting the spinal cord in the cervical and thoracic regions or the cauda equina in the lumbar spine.
Paracentral/Lateral Recess - located at the 5 and 7 o’clock positions with the disc bulge toward the center right
or center left of the midline, affecting the spinal cord and nerve roots. This can also create central stenosis
affecting the cauda equina or the spinal cord, but also has the possibility of effecting the traversing nerve root.
Foraminal - located at 4 and 8 o’clock positions where nerve roots branch off the spinal cord or from the cauda
equina. This would create foraminal stenosis, possibly affecting the exiting nerve root.
Far Lateral/Extra Foraminal - located at the 3 and 9 o’clock positions and are typically less likely to be sympto-
matic.
Facet Joints
In a healthy spine, the intervertebral disc is the anterior load-bearing structure, and the facet is the posterior load-
bearing structure. Age-related disc degeneration leads to facet pathology because the disc degeneration causes the
load to transfer to the facet joints.
As the load on the facet joint increases, the cartilage is affected Wolff’s Law
and is followed by synovial joint inflammation, joint space nar- Bone in a healthy person or animal will
rowing, and osteophyte (bone spur) formation (Wolff’s Law), adapt to the loads under which it is
which can be demonstrated by bony overgrowth (facet hypertro- placed (bone grows under stress)
phy). This process may eventually result in central or foraminal ste-
nosis and/or spondylolisthesis.
Within the facet joint are nerve endings, which monitor pro-
prioception and nociception. These nerve endings are sensi-
tive to chemical and mechanical stimuli (instability, trauma,
capsular distension) and tend to increase in number and
sensitivity during these degenerative changes. The resulting
inflammation irritates the local nociceptors causing back
pain (facet joint syndrome).
Muscles and Ligaments

Both intrinsic and extrinsic muscles, as well as ligaments, keep the spine at its optimal tension and normal curva-
ture. As muscles age, they lose the ability to maintain postural/supportive tone, and they begin to atrophy. This
destabilization predisposes the spine to premature disc degeneration, compression fractures, and spinal stenosis.
Simultaneously, the ligaments increase in elasticity and decrease in tensile properties, causing them to thicken and
buckle (hypertrophy). If this takes place within the vertebral canal, the thickened ligament may assist in causing
stenosis.
Spinal Stenosis
Spinal stenosis is the narrowing of the vertebral (central) foramen to the point that
it causes pressure on the spinal cord or nerve rootlets. Foraminal stenosis is the nar-
rowing of the openings (intervertebral foramen) where spinal nerves leave the spinal
column. The most common regions affected are the lower cervical and lower lum-
bar regions.
Typically, the ligamentum flavum shortens
and thickens, placing pressure on the ex-
iting nerves. Stenosis also occurs from bulg-
ing of the discs as well as from disc col-
lapse, which narrows the height of the
Cervical Stenosis from C2-C5 (disc bulg-
opening between adjacent vertebral ing and ligamentum flavum buckling)
bodies. Enlargement of the facets
(facet arthropathy) can cause stenosis because, as the joints grow, they
encroach on the normal lumen of the canal. Stenosis may occur in differ-
ent areas of the spinal column: centrally (central stenosis), in the lateral
recess (lateral recess stenosis), and in the foraminal canal (foraminal ste-
nosis). Spinal stenosis occurs when there is narrowing or compression on
the central canal (vertebral foramen), affecting either the spinal cord or
cauda equina. Lateral recess stenosis is when there is compression on
the nerve roots that are exiting the central canal, prior to the interverte-
bral foramen. Foraminal stenosis is a narrowing or compression within
the lateral intervertebral foramen, on the nerve roots that exit from the
body.
Spinal stenosis may be caused by degeneration of the spine due to ag-
ing. Some individuals develop defects or growth in the spine that were
present from birth (congenital defect) or acquired from injury that caus-
es pressure on the nerve roots or the spinal cord. Other factors leading
to stenosis include trauma and spinal tumors of the spine.
Signs and Symptoms of Spinal Stenosis

Previously, we discussed that bulges and herniations can occur in various locations in the spinal canal. If the com-
pression is on the cord in a central presentation within the vertebral foramen, the result may be with myelopathy
or myelopathic symptoms. If the nerve root is compressed within the intervertebral foramen (or after the spinal
cord ends), the result may be radiculopathy or radicular symptoms. If it affects the cauda equina, this is referred to
as cauda equina syndrome, and may be associated with a complex of low back pain (LBP), sciatica, saddle hypoes-
thesia and lower extremity motor weakness and bowel or bladder dys-
function.
A person who has stenosis may experience leg pain while walking and
standing, which is relieved by sitting or lying down. If the cause is nerve
compression, the diagnosis is termed neurogenic claudication. If im-
paired circulation is to blame, this is vascular claudication.
Open canal (left) versus stenotic canal (right). CT or

MRI is the best diagnostic tool to diagnose stenosis
Myelopathy
Cervical and thoracic stenosis is typically a slow progressing condition that can narrow the
openings for the spinal cord and nerves. Myelopathy is compression of the spinal cord and,
therefore, can only occur due to stenosis in the vertebral canal in the cervical and thoracic
spine. It is more common in the cervical spine. Myelopathy is more common in elderly pa-
tients.
Sagittal T2 MRI showing cervical

Signs and Symptoms of Myelopathy
cord compression
Heavy feeling in the legs, difficulty walking (ataxic gait)
Decrease in fine motor skills such as buttoning a shirt
Neck stiffness
Loss of control of bowel or bladder control
Radiculopathy
Radiculopathy, commonly referred to as a pinched nerve, refers to a set of condi-
tions in which one or more nerve roots are affected and do not work properly (a neu-
ropathy). This type of nerve compression happens in the vertebral canal, only after
the spinal cord has ended. Therefore, the nerves of the cauda equina may be im-
pinged. Stenosis in the intervertebral foramen (foraminal canal) in any region may
also result in radiculopathy. This can cause pain that radiates into the extremities.
For example, pain radiating along the sciatic nerve, which runs down one or both
legs from the lower back, is referred to as lumbar radiculopathy or sciatica. Other symptoms may include weak-
ness, numbness, and hyporeflexia (decreased reflex response).
Cauda Equina Syndrome

This is a relatively rare, but serious, condition caused by the compression of nerves
in the lumbar spine and narrowing of the spinal canal. Cauda equina syndrome may
be caused by a herniation in the lumbar spine, infections, tumors, or trauma,
amongst other things.
Symptoms may include:
 Low back pain
 Pain radiating into the lower extremities
• Severe or progressive weakness in the lower extremities, making walking difficult
• Urinary or bowel incontinence
• Saddle Paresthesia (Numb Butt)
In many cases, surgical intervention is necessary. If the condition is left untreated, patients may experience perma-
nent paralysis, impaired bladder or bowel control, difficulty walking, and other physical or neurological problems.
Tumors
A spinal tumor is an abnormal mass of tissue within or
surrounding the spinal cord, nerves, and/
or spinal column. Spinal tumors may be benign (non-
cancerous) or malignant (cancerous).
Intradural-extramedullary:
This tumor develops in the dura, but outside the spinal
cord. Although benign, they can be difficult to remove
and may reoccur. Nerve root tumors are also generally
benign, but some may become malignant over time.
Intramedullary:
These tumors grow inside the spinal cord or individual
nerves, most frequently occurring in the cervical region.
They are often benign, but can be difficult to remove.
Extradural:
These are typically attributed to metastatic cancer derived from the cells covering the nerve roots. Occasionally, an
extradural tumor extends through the intervertebral foramen, lying partially within the vertebral foramen. De-
pending on where they are located, tumors of the spine can cause loss of sensation, muscle weakness, bladder/
bowel issues, gait difficulty and deformity.
Primary vs. Secondary Tumors of the Spine
Many people become confused over the definitions of a pri-
mary vs. secondary or second cancer. Primary cancer is de-
fined as the original site (organ or tissue) where cancer began.
In contrast, a second or secondary cancer may be defined in a
few ways; as either a new primary cancer in another region of
the body or as metastasis (spread) of the original primary can-
cer to another region of the body. The chart below associates
secondary tumors with the primary tumor they are most com-
monly associated with.
Metastatic Cancer of the Lumbar Spine from the Breast—

note the mottling (spotty) appearance in the image above
Trauma
Trauma in the spine is classified by the surgeon through a variety of systems that rely on criteria such as Mecha-
nism of Injury (MOI), injury type, which region of the spine is involved, extent of the injury, and neurological sta-
tus. An early format of this type of system is the Denis Three Column Theory. Trauma classification now incorpo-
rates modern systems including the AO foundation and the Thoracolumbar Injury Classification and Severity
score (TLICS) classifications.
Denis Three Colum nTheory

Denis divided the vertebral column into three vertical columns based on biome-
chanical studies related to stability following traumatic injury. Instability occurs
when injuries affect two or more contiguous columns (i.e. anterior and mid-
dle column or middle and posterior column).
The anterior column consists of the anterior longitudinal ligament, the anterior
of the annulus, and the anterior two-thirds of the vertebral body. The middle
column consists of the posterior third of the vertebral body, posterior annulus,
and posterior longitudinal ligament. The posterior column is made of the poste-
rior ligaments, facets, pedicles, laminae, and spinous process.
McAfee Classification
McAfee classification of acute traumatic spinal injuries is one of a
number of thoracolumbar spinal fracture classification systems and
is based on the three-column concept of the spine (Denis). It re-
quires a CT for an accurate assessment.
Wedge Fracture
A wedge fracture is a subcategory of what is known as a compres-
sion fracture. It constitutes an isolated failure of the anterior column Wedge Fracture
and is identified by its wedge-shaped vertebral body. The mechanism of injury is from a for-
ward flexion. In cases where there is greater than 50% collapse, multiple levels, or a 15° increase in kyphosis, sur-
gical treatment options may be necessary.
Stable Burst Fracture
In this fracture, the anterior and middle columns have failed while sus-
taining the posterior column. It is usually caused by a high energy com-
pressive load, i.e. falls or MVAs. Typically, with a burst fracture, a portion
of the bone may migrate into the spinal canal. If greater than 30% of the
canal is compromised, surgical intervention is utilized.
Stable Burst Fracture
Unstable Burst Fracture
An unstable burst fracture differentiates itself from a stable
burst fracture as while the anterior and middle columns
fail, the posterior column is also disrupted by compression,
lateral flexion, or rotation. This particular fracture may re-
sult in increased kyphosis. Either burst fracture may result
in more neurological compromise over the previously dis-
cussed wedge fracture.
Chance Fracture
A chance fracture is a horizontal avulsion injury that starts from
the posterior elements. During forward flexion, the entire verte-
bra is pulled apart by tensile forces.
X-ray (left) and CT (right) of a Chance fracture
Flexion-Distraction Fracture
This fracture is characterized by the compressive failure of the anterior column
while the middle and posterior columns fail due to tension. The mechanism of in-
jury is a flexion force. The facet capsules are disrupted and most of these are con-
sidered unstable due to the damage to the ligaments.
Translational Fracture
In a translational fracture, all three columns have failed
due to a shear force. There is displacement of the vertebral column that disrupts the ver-
tebral canal. This type of fracture includes slide fractures, rotational fracture-dislocations,
and pure dislocations. They are very unstable and are associated with neurological com-
promise.
Spinal Deformities
Structural Abnormalities of the Spine
In mechanical terms, disease, injury, or overuse may result in structural abnormalities that cause further deterio-
ration if not treated. Structural problems can result from degenerative arthritis, instability, or alteration of normal
anatomy by trauma or tumor growth. Arthritis of the spine (spondylosis) includes degeneration of the disc and/or
facets. In addition to stenosis and disc concerns, individuals may also have alignment pathologies, which include
scoliosis, kyphosis, and lordosis.
Spondylolisthesis
Spondylolisthesis (slippage of the vertebra) results when the fracture gap at the pars
widens and the vertebra slide. Anterior slippage is called spondylolisthesis (also
known as anterolisthesis). Posterior slippage is termed retrolisthesis. Slippage to the
sides is called lateral listhesis. Individuals with pars defects may have lumbar pain or
stiffness and involvement of the posterior thigh. Stress fractures at L5, and some-
times L4, are the most common levels to be affected by a spondylolisthesis. The likeli-
hood of a pars defect is increased with repetitive activities such as gymnastics, Arrow pointing to pars defect
jumping, and football.
Sagittal MRI of an L4-L5 spondylolisthesis Lateral x-ray of a spondylolisthesis at L5/S1
Spondylosis: General term for degenerative

changes
Spondylolysis: Defect or fracture in pars
interarticularis
Spondylolisthesis: Slippage of the vertebra

due to possible defect
Spondyloptosis: Entire vertebra has fallen
off the vertebral body below
Meyerding Classification
According to the Meyerding classification, there are five
grades of spondylolisthesis based on the ratio of slippage to
the vertebral body below, expressed as a percentage.
• Grade I: 1-25% vertebral slippage
• Grade II: 26-50% vertebral slippage
• Grade III: 51-75% vertebral slippage
• Grade IV: 76-100% vertebral slippage

• Grade V: over 100% vertebral slippage (spondyloptosis)
Wiltse Classification
Dysplastic spondylolisthesis occurs because of a malformation in the facet joints.
Isthmic spondylolisthesis is the most common form and can go unnoticed in many patients. The most common
causes are fracture to the pars from a hyperextension injury or pars deformity. There are three types:
 Lytic: fatigue (stress) fracture
 Elongated but intact pars
 Acute: fracture of pars
Degenerative spondylolisthesis is a disease in an older adult that develops as a result of facet arthritis and joint
remodeling. Joint arthritis and ligamentum flavum weakness, may result in slippage of a vertebra.
Traumatic spondylolisthesis is rare and results from acute fractures in the neural arch.
Pathologic spondylolisthesis has been associated
with damage to the posterior elements as a re-
sult of disease process: Paget’s or metastasis.
Scoliosis
Scoliosis is defined as an abnormal (lateral) curvature of the spine in the coronal plane greater than 10 degrees.
On an AP x-ray, the spine of a person with scoliosis looks more like an "S" or a "C" than a straight line. These
curves may cause an individual’s shoulders or hips to be uneven, depending on where the curves are located in
the spine.
Idiopathic scoliosis is by far the most common kind of scoliosis. "Idiopathic" means that the cause is not known,
but it develops most frequently in pre-teens or teenagers. Adolescent Idiopathic Scoliosis (AIS) is 10 times more
common in girls than boys. In most scoliotic patients, a side-to-side (lateral) curvature and a rotation of the ver-
tebrae is present, creating a three-dimensional deformity affecting the coronal, sagittal, and axial planes at mul-
tiple levels. There are different types of scoliosis including congenital, early onset, neuromuscular, degenerative,
and idiopathic. Below we discuss three of the most prevalent types.
Congenital scoliosis refers to a spinal deformity caused by vertebrae that
have not properly formed. Congenital scoliosis occurs within the first six
weeks of embryonic formation. There is no genetic correlation and the
cause is unknown. Although congenital scoliosis is often discovered during
the infant or toddler period, it may not be diagnosed until the adolescent
years. The curves tend to progress only while the child grows, unless adja-
cent (compensatory) curves become significant in size. Progressive curves
require surgical correction and stabilization. As with many other congenital
problems, patients with this type of scoliosis frequently have additional
congenital anomalies.
Neuromuscular scoliosis is an irregular spinal curvature caused by disor-
ders of the brain, spinal cord, and muscular system. Nerves and muscles
are unable to maintain appropriate balance/alignment of the spine and
trunk. In neuromuscular spinal deformities, progression occurs much more
frequently than in idiopathic scoliosis and often continues into adulthood.
The long-term effects of spinal deformity in patients with neuromuscular conditions can be disabling and pulmo-
nary function is markedly affected.
Idiopathic scoliosis is divided into three age categories based upon the initial presentation of the curve. Infan-
tile idiopathic scoliosis presents between the ages of birth and 3 years, juvenile idiopathic scoliosis presents be-
tween the ages of 4 and 10 years, and adolescent idiopathic scoliosis (AIS) presents between the ages of 10 and
18 years. Because infantile and juvenile scoliosis have a higher association with additional spinal abnormalities,
such as tumors, syringomyelia (a large tube or cyst in the spinal cord), and descending of the cerebellum into
the spinal canal (Arnold Chiari malformation), they may require different treatment from adolescent idiopathic
scoliosis. The goals in the surgical treatment of Adolescent Idiopathic Scoliosis are to halt curve progression,
maintain optimal coronal and sagittal balance, and correct the deformity, while fusing the least amount of mo-
tion segments and avoiding complications.
Kyphosis
Kyphosis is a forward rounding of the upper back, commonly referred to as round back, hunchback, or Dower’s
Hump. This deformity is assessed in the sagittal plane. While some kyphosis is normal, an exag-
gerated rounding of more than 50° is considered abnormal. Hyper kyphosis can occur as a result
of developmental problems: degenerative diseases, such as arthritis of the spine, osteoporosis
with compression fractures of the vertebrae, or trauma to the spine. Whereas mild kyphosis may
cause few problems, severe cases can affect the lungs, nerves, and other tissues and organs,
causing pain and other dysfunction.
Treatment for kyphosis depends on age, cause of the curvature, and the effects of the curvature.
Kyphosis symptoms may include:
• Mild back pain
• Spinal stiffness or tenderness
• Fatigue
Types of Kyphosis in Children and Adolescents
Postural kyphosis: The onset of postural kyphosis mainly becomes apparent in adolescence, is generally slow in
progression, and is more common in females. Poor posture or slouching can cause stretching of the spinal ligaments
and abnormal formation of the bones of the spine. Postural kyphosis is often accompanied by an exaggerated in-
ward curve (hyperlordosis) in the lumbar spine, which is the body’s way of compensating for the exaggerated out-
ward curve in the thoracic spine.
Scheuermann’s kyphosis (disease): Like postural kyphosis, Scheuermann’s kypho-
sis typically appears in adolescence, often between ages 10 and 15, while the
bones are still growing and is slightly more common in boys. In Scheuermann’s ky-
phosis, vertebrae may appear wedge-shaped, rather than rectangular, on x-ray.
Schmorl’s nodes, the result of the disc between the vertebrae pushing through
bone at the bottom and top of a vertebra, may be visible on affected vertebrae.
The cause of Scheuermann’s kyphosis is unknown, but it tends to run in families.
Some people with this type of kyphosis also have scoliosis.
Causes of Kyphosis in Adults

• Osteoporosis, a bone-thinning disease that is associated with fractures of the vertebrae, which causes compres-
sion of the spine and contributes to kyphosis
• Degenerative arthritis of the spine, which can cause deterioration of the bones and discs of the spine
• Ankylosing spondylitis, an inflammatory arthritis that affects the spine and nearby joints
• Connective tissue disorders
• Tuberculosis and other infections of the spine, which can result in destruction of joints
• Cancer or benign tumors
Inflammatory Disorders
Inflammatory disorders of the spine can be caused by a wide range of conditions, including arthritis, osteoporosis,
and infection. Inflammation in the spine is rare but can be a significant source of pain and disability. There is a
group of disorders that are caused by a chronic systemic autoimmune disease, while infection is caused by a bacte-
rial or viral invader.
Ankylosing Spondylitis
Ankylosing spondylitis (AS) is an inflammatory autoimmune disease that can cause some of the vertebrae in the
spine to fuse (Bamboo Spine). As it fuses, the spine becomes less flexible and can result in a hunched forward pos-
ture. If the ribs are affected, it may be difficult to breathe deeply. Ankylosing spondylitis affects men more often
than women. Signs and symptoms of ankylosing spondylitis typically begin in early adulthood. Inflammation can
also affect other areas of the body— most commonly, the eyes and
heart. Early signs and symptoms of ankylosing spondylitis may include
pain and stiffness in the low back and hips, especially in the morning
and after periods of inactivity. There is no cure for ankylosing spondyli-
tis, but treatments can decrease pain and general symptomatology.
The areas most commonly affected are:
• The joint between the base of the spine and pelvis
• The vertebrae in the cervical or lumbar spine
• The places where the tendons and ligaments attach to bones, mainly
in the spine
• The cartilage between the breastbone and ribs
• The hip and shoulder joints Bamboo spine on radiographic x-rays
In severe cases of ankylosing spondylitis, new bone forms as part of the
body’s attempt to heal. This new bone gradually bridges the gap between vertebrae and eventually fuses sections
of vertebrae together. These parts of the spine become stiff and inflexible. Fusion can also affect the rib cage, re-
stricting lung capacity and function.
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
DISH, also known as Forestier’s Disease, is considered a form
of degenerative arthritis or osteoarthritis. However, DISH is char-
acterized by unique, flowing calcification along the sides of the
contiguous vertebrae of the spine. Unlike typical degenera-
tive arthritis, it's also commonly associated with inflammation
(tendinitis) and calcification of tendons at their attachments points
to bone. This can lead to the formation of bone spurs, such as heel
spurs. In fact, heel spurs are common among individuals with
DISH. Although it is not known what causes DISH, it is associated
with the metabolic syndrome and is more frequent in people
DISH on Cervical Spine X-ray
with diabetes mellitus.
Symptoms of DISH include intermittent pains in the areas of the bony changes of the spine and inflamed tendons.
Stiffness and dull pain, particularly in the upper and lower back, are common. Sometimes pain in these areas can
be sharp with certain body movements, such as twisting or bending over. DISH is slowly progressive calcifications
between the vertebrae occur over many years. However, calcification can ulimately lead to limitation of motion of
the involved areas of the spine.
Discitis
Discitis is usually a bacterial infection but may be viral. This can occur when a person has had
surgery or trauma, but other medical conditions, such as endocarditis, can also put a person at
risk. Other factors include IV drug use, diabetes, older age, and poor nutrition. This condition
can be quite painful. If bacteria or a virus have infiltrated the disc, and the disc does not have
a good blood supply, the body's immune cells will have great difficulty getting to the infection
since they are transported by the blood stream. Diagnosis is confirmed via biopsy and treat-
ment with a long-term course of antibiotics. Discitis on Sagittal
Lumbar MRI
Osteomyelitis
Osteomyelitis, a rare but serious condition, is an infection of the bone. Bones can become
infected in a number of ways: infection in one part of the body may spread through the
bloodstream into the bone, or an open fracture or surgery may expose the bone to infection.
Treatment is usually surgery to remove portions of bone that have died. This is followed by
strong antibiotics, often by an IV, for at least six weeks.
Osteomyelitis on
Sagittal Lumbar
Osteoporosis
Osteoporosis is the most common type of bone disease, affecting between 15-20 million individuals and resulting
in more than 500,000 compression fractures, annually. Osteoporosis is a decrease in bone mass and tissue with a
marked decrease in minerals and organic components. Although osteoporosis is more commonly seen in post-
menopausal woman over the age of 50, it also affects men over the age of 70. Some of the signs/symptoms in-
clude back pain and wedging of the vertebrae. Osteoporosis is diagnosed by a bone density test, but x-rays MRIs,
and CT scan may also be used to evaluate the disease.
Normal Bone Osteoporotic Bone
Osteoarthritis vs Rheumatoid Arthritis

Osteoarthritis (OA)
Osteoarthritis is the most common cause of arthritis in the spine. It is a result of
degenerative changes due to aging, causing the breakdown of cartilage in the
facet joints and decreasing spacing between the vertebral bodies. As inflamma-
tion of the joints increases, motion and flexibility will decrease. As a result, oste-
ophytes will form as the body attempts to stabilize the affected area by building
more bone (Wolff’s Law). In the cervical spine, the patient may present stiffness
and pain in the neck, shoulders, and arms.
Bone spurs (OA) on X-ray
Rheumatoid Arthritis (RA)
Rheumatoid arthritis (RA) is an autoimmune disease that most commonly affects the
joints of the hands, wrists, elbows, knees, ankles, and feet. Because RA can also affect
organs and body systems, such as the cardiovas-
cular or respiratory systems, it is called a sys-
temic disease. The ligaments can also be dam-
aged, especially at the C1 (atlas) and C2 (axis)
articulation, causing instability. If the damage is
severe, the bony process of C2 (odontoid pro-
cess) can migrate into the spinal canal or foramen magnum, where the spi-
nal cord attaches to the brain (as illustrated in the image). The vertebral
arteries enter the brain at the upper cervical level and deformity here can
cause pressure on the arteries, creating lightheadedness or black outs. Pa-
tients may be referred to a rheumatologist for more extensive treatment.
SURGICAL TREATMENT OPTIONS
CHAPTER 13
Surgical Treatment of the Spine
Most patients with spine pathologies heal with time and/or conservative therapies. For that reason, baring that
there is an acute neurological deficit, non-operative treatment is typically the first option. This includes rest, medi-
cation, physical therapy, chiropractic treatment, and/or epidural or facet injections. If this does not result in im-
provement within six weeks time, or if the patient’s symptoms worsen with
treatment, then surgical intervention may be considered. Surgical options can
range from options like percutaneous discectomy (minimally invasive) to con- Goals of Surgery
ventional surgery (open).  Atraumatic Access
 Relieve Symptoms
The goals of surgery are to gain atraumatic access, relieve symptoms (typically
through decompression), restore alignment, and achieve stability.  Restore Alignment
 Achieve Stability
Decompression
Direct decompression involves physically uncovering the neural element
(nerve root, spinal cord) by removing any material (disc, ligament, or bone) that is directly impinging upon it. A
discectomy is the most common form of decompression.
Indirect decompression enlarges the space around the spinal cord or nerve roots through re-alignment of struc-
tures connecting to the elements that are causing impingement. For example, placing a large graft effectively re-
stores the disc height that has been lost and opens a previously narrow space.
Laminectomy
A laminectomy is mainly used to treat central stenosis. This includes the
removal of the lamina and spinous process to give more room for the spi-
nal cord. A mid-line incision on the posterior aspect of the spine exposes
the structures. Patients post-operatively should see improved function
and better gait. Risks following this procedure may include dural tears,
infection, and increased pain. This procedure can create some instability
so instrumentation may also be utilized.
Hemi-laminectomy
Similar to a laminotomy, a hemi-laminectomy is a procedure in which the surgeon removes only a portion of the
lamina. This removal of bone creates more space in the spinal canal and releases nerve tissue from pressure.
Laminotomy
A laminotomy is a procedure that removes part of a lamina of the vertebral arch in order to decompress the
corresponding spinal cord and/or spinal nerve root.
Laminoplasty
A laminoplasty is the removal of the lamina on one side and the crea-
tion of a hinge on the other. This increases space in the spinal canal
while preserving the posterior structures, to help maintain some stabil-
ity. The opening is maintained with mini plates and in some cases small
bone graft blocks.
The procedural steps are the same as a laminectomy, however, a metal

or plastic spacer bridges the open gap in the lamina. In this procedure,
the spinal canal may not be fully visualized, which may create difficulty
in determining a complete decompression.
Foraminotomy
A foraminotomy is an enlargement of the intervertebral foramen to alleviate localized compression around the
nerve roots. This procedure can include the removal of bone, disc, scar tissue, or excessive ligament.
Discectomy
A discectomy is usually peformed in conjunction with an interbody fusion or corpectomy procedure. The proce-
dure involves removing a portion of an intervertebral disc that is placing direct compression on the spinal cord
and/or nerve root.
Corpectomy
When disease affects the disc as well as the vertebral body, a discectomy alone may not be
enough. In these instances, some, or all of the vertebrae may need to be removed. This proce-
dure is seen more typically with tumor or trauma (fracture) scenarios. The affected area is re-
moved and replaced with a graft (autograft or allograft), a static or an expandable cage. (See
image to the left). When multiple levels are affected, posterior fusion and instrumentation may
also be used. A corpectomy can be performed from an anterior cervical approach, or a number
of thoracolumbar approaches , in any region of the spine.
Fixation/Alignment
The goal of fusion is for bone to grow across the diseased segment. For fusion to occur, the soft tissue is stripped
away from the bone and the cartilage/cortical bone is removed to expose bleeding cancellous marrow. In order to
stimulate healing. Interbody fusion techniques have more recently gained popularity. There are several benefits to
interbody fusion, which include load sharing, larger fusion mass, and improved fusion rates with graft. For more
information on bone grafting (see the Biologics chapter)
Instrumentation
Before the advent of pedicle screws, most fusions performed were “non-instrumented”. This means bone graft
was placed and expected to grow across the segment. Motion was some-
times limited by bracing but, as expected, a number of these patients
suffered non-unions. Instrumentation has improved fusion rates.
Instrumentation can take many forms depending on the approach. Ante-

rior and lateral constructs typically include a plate. These approaches, by
nature, expose the vertebral bodies and a plate is effective as it fixates to
the spine with a low profile. Posterior fixation primarily involves multi-
axial screw and rod constructs. Screws in the posterior lumbar spine are
typically pedicle screws. A subtype are facet screws, which simply affix
the superior and inferior articular processes of neighboring levels.
Patients who are high risk for a non-union include those with osteoporo-
sis, diabetes, smoking history, and overall poor health. In these patients,
surgeons may elect to implement anterior and posterior fixation, as well
as supplement with braces or electronic bone stimulators to improve
healing rates.
Fusion/Stabilization
If movement is a source of back pain, then spinal fusion can be utilized to relieve the pain by restricting motion.
Fusion decreases spinal flexibility but generally treats small enough spinal segments so that gross motion is not
restricted. Bone grafting is standard and accompanies the use of cages and/or internal fixation with plates and
screws. Expandable fusion devices, or spacers, re-establish the height of the vertebral body while the bone is heal-
ing. Fixation restores and maintains anatomical alignment of the spine. One concern about fusion is that stress of
the fused segment will transfer and concentrate on the adjacent vertebrae.
Cervical Surgical Approaches
Anterior Cervical Discectomy and Fusion (ACDF)
Patients may complain of neck pain, pain radiating down the arm and into the hand,
and/or numbness in the fingers. Decompression of the affected nerve removes the
interference (usually a bulging disc or osteophyte). In most cases, the disc is re-
moved and the two vertebrae are fused with a spacer filled with bone graft. A plate
is secured over the affected level(s). The approach may be mid-line, or from the
right or left. Most prefer the left side due to a lower risk of injury to the Recurrent
Laryngeal Nerve, which innervates the muscles that open and close the vocal cords.
Injury may result in a weakened or complete loss of vocal capacity. An ACDF has a
high fusion rate and provides good stability, but the procedure does come with a risk of difficulty swallowing post-
op, potential vascular injury, or esophageal/trachea injury.
Posterior Cervical Fusion

Depending on the site of compression, removal of the lamina, as well as removal of
bone spurs, may be performed where the nerve roots exit the spinal canal. Screws or
hooks and rods are used to hold the spinal column in place while fusion occurs whie
also providing stability. The screws are inserted into the left and right sides of the ver-
tebrae to be fused. A rod connects the screws to stabilize the spine on each side and
caps secure each screw to the rod. Bone graft may be added along the side of the ver-
tebrae to help with fusion. Over time, the vertebrae can grow together through fusion.
Complete fusion varies among patients and can take a few months to a couple of
years.
Cervical Arthroplasty
With a cervical arthroplasty, the defective disc is replaced with an artificial one.
This allows the patient to maintain motion instead of restricting motion through
fusion. By maintaining motion at the affected level this may decrease the potential
for adjacent level degeneration. Patients may also return to work and normal activ-
ities sooner than patients who undergo traditional fusion. Risks for arthroplasty
may include: allergic reaction, neck or arm pain, difficulty swallowing, and nerve
injury.
Lumbar Surgical Approaches
Poster Lumbar Interbody Fusion (PLIF)
Conditions such as spondylolisthesis, degenerative disc disease, or disc herniation
may produce mechanical pain and may be indications for a spinal fusion. A posterior
mid-line incision, discectomy is performed and a spacer (one or two) is inserted into
the disc space, to restore lost height. This procedure will typically require more mus-
cle dissection and a full laminectomy and possible bilateral facetectomy. Pedicle
screws and rods inserted to stabilize the segment. Additional bone graft on either
side of the spinous processes (gutters) may improve fusion. Good fusion rates can be
attained with the PLIF. However, risks may include; failure of fusion, possible adja-
cent level degeneration, and nerve injury.
Transforaminal lumbar Interbody (TLIF)

TLIF follows the same concept as a PLIF; with the exception of it is a unilateral approach, the inferior facet and lat-
eral lamina is removed. This procedure only requires one interbody and allows for minimal muscle dissection and
bone removal. This requires less retraction of the dura and spinal nerves. The TLIF fuses the anterior and posterior
portion of the spine through a single approach. The anterior portion is fused with a bone graft or spacer. The pos-
terior portion is secured with rods and screws. Bone may also be placed alongside the spinous processes bilateral-
ly (the gutters) for additional fusion. The spacer also restores normal intervertebral height that was lost due to
degeneration. Risk are the same as PLIF, but provide more muscle sparring.
As cage insertion became easier through the adoption of tapered, bullet-nose instruments and higher use of pedi-
cle screws, surgeons began to use a unilateral approach called the Transforaminal Lumbar Interbody Fusion (TLIF).
The TLIF involves removing most, or all, of the medial facet and placing the interbody graft obliquely across the
disc space. This avoids having to retract the nerve roots and reduces injury and post-op scarring.
Anterior Lumbar Interbody Fusion (ALIF)
An anterior approach to the lumbar spine allows the surgeon to place a cage wit a large footprint due to uninter-
rupted access to the disc space. The larger footprint is able to span the ring of corticsl bome, known as the
apophyseal ring, which is more stable than the weaker cancellous bone in the middle, especially in osteoporotic
patients. In the lumbar spine, an anterior approach requires
a general or vascular surgeon for access and to avoid poten-
tial complications such as intestinal injury, great vessel inju-
ry, etc. Due to these complications, difficulty scheduling,
and, fee sharing, some surgeons elect not to perform ALIF
procedures. Patients who have had previous posterior lum-
bar surgery, especially a laminectomy at the affected level,
are good candidates for an ALIF. Contraindications for an
ALIF procedure include obesity, those with a steep sacral
slope, childbearing age, or previous bowel surgery. Risks in-
clude vascular injury, hernia, retrograde ejaculation, or Ileus.
Lateral Lumbar Interbody Fusion (LLIF)

The Lateral Lumbar Interbody Fusion (LLIF)/Direct Look approach to the ver-
tebra is effective for thoracic and lumbar cases. The incision is below the rib
cage and above the iliac crest. This technique is retroperitoneal, meaning it
goes behind abdominal organs, but goes through the psoas muscle, which can
put the nerves of the femoral plexus at risk. Some surgeons may prefer to re-
tract the psoas instead of dilating through. Neuromonitoring may be utilized
to ensure safe navigation through the muscles. Advantages of an LLIF include large interbody graft placement, sig-
nificant indirect decompression, and deformity correction, all while maintaining a true minimally invasive, muscle
sparing approach.
Approach by Direction
Surgical Instruments
Chapter 14
Retractors
A retractor is used to hold back tissue so that body parts under the incision may be accessed without fear of
damage. Surgical retractors come in various shapes, sizes and strengths.
Importance of Surgical Retractors
During the dissection/inspection, a surgeon needs an exposure that inflicts the least amount of trauma to the
surrounding tissue. To give the holder a firm grip without tiring, the handles of the retractor may be hook,
notched, or ring shaped to give the holder a firm grip without tiring. The blades of the retractor are at a right
angle to the shaft and can be smooth, raked, or hooked. Several types are depicted below.
Weitlaner Retractor
Gelpi Retractor
Zelpi Retractor with Cerebellar Tip
Deep Gelpi Retractor
Army/Navy Handheld Retractor Richardson Hand Held Retractor
Pedicle Probe
A pedicle probe is used to navigate down the pedicle of the vertebral body to create a pathway for screw place-
ment. Pedicle probes are available with straight and curved tips, as well as in several sizes. Below is an example.
Bone Removal
Instruments used to remove bone. Below are some examples:
Kerrison Rongeur
Leksell Rongeur
Horsley Bone Cutter

Soft Tissue/Disc Removal
Instruments used to remove soft tissue or disc material:
Pituitary Rongeur
Disc Rongeur
Additional Instruments
Cobb—used to separate muscle from bone
Angled Curette—used to remove tissue from bone
Nerve Hook—used for nerve retraction
Dura Elevator—used to retract the dura to avoid injury
Cerebellar Retractor
Hohmann Retractor
Ragnell Retractor
Senn Retractor
Freer Elevator
Periosteal Elevator
Dental Pick
Pointed Reduction Forcep (point-to-point)
Serrated Reduction Forcep (Lobster Claw)
Verbrugge Reduction Forcep
Lohman Reduction Forcep
Osteotome
Operating Room Tables
Chapter 15
This bed has rotational capabilities that facilitate 360˚ spinal fusions
without the need to remove the patient for repositioning.
OR Table with Pedestal

This is a breakable bed allowing for a variety
of positions, which is ideal for many surgeries.
GLOSSARY
Medical Terminology—Prefix
Prefix Definition Prefix Definition

ab from; away from extra outside of; beyond
ad to; toward hemi half
an without or absence of hyper above; excessive
ante before hypo deficient; incomplete
anti against infra under; below
bi two inter between
con together intra within
contra against meso middle
de from; down from; lack of meta after; beyond; change
dia through; complete para beside; beyond; around
dys difficult; labored; painful; abnormal poly many; much
endo within pre before; in front of
epi on; upon, over retro back; behind
ex outside; outward semi half
exo outside; outward sub under; below
trans through; across; beyond supra above
sym together; joined

Medical Terminology—Suffix
Suffix Definition Suffix Definition

agra excessive pain ology study of
algia pain oma tumor; swelling
apheresis removal ostomy creation of an artificial opening
asthenia weakness otomy cutting or incising
clast break paresis slight paralysis
cyte cell penia to lack or have deficient
desis surgical fixation; fusion physis growth

ectomy excision or surgical removal plasty modeling or shaping (surgical)
genesis origin; cause plegia paralysis
itis inflammation sarcoma malignant tumor
lysis destruction sclero hardening
lytic destroy; reduce sepsis infection
megaly enlargement tome instrument used to cut
morph form; shape
Medical Terminology – Root Words
Root Definition Root Definition

acetabul hip socket dextr right
algesi pain esthesi sensation; feeling
andro male etio causation
ankyl crooked; stiff; bent hem (ato) blood
arterio artery kinesis motion or movement
arthro joint leuk white
auto self necro death, dead tissue
carpo wrist
chondro cartilage
cutane skin

Glossary
Allograft—(homograft) a tissue graft between genetically dissimilar members of same species.
Ankylosing Spondylitis—inflammation of the spinal joints (vertebrae) that can lead to severe, chronic
pain and discomfort.
Anterior—The front portion of the body. It is often used to indicate the position of one structure relative
to another.
Anterior Lumbar Interbody Fusion (ALIF)—A surgical approach to the spine from the front of the body to
remove disc or bone material from in between two adjacent lumbar vertebrae.
Anterolateral—Situated in the front and side portion (both anterior and lateral).
Annulus Fibrosus—the tough, outer, fibrous,ring–like portion of an intervertebral disc.
Apical Vertebra—The most laterally deviated vertebra from the patient’s vertical axis.
Arthrodesis—fusion of bones across a joint space, thereby limiting or eliminating movement. It may occur
spontaneously or as a result of a surgical procedure.
Articular—Pertaining to the joint(s).
Autograft (autogenous)— tissue graft originating from the same individual: i.e. an individual’s own bone.
Axial/Transverse (plane)—divides the body into upper and lower halves.

Apophyseal Ring—A tough, fibrous structure around the outer portion of the vertebral body next to the
disc. Repetitive stress can cause the apophyseal ring to pull away from the vertebra. This is the strongest
part of the interbody space and ideal for interbody graft placement.
Avascular—Lacking blood supply.
Axial Skeleton—The bones that form the central axis of the human body, including the skull, spinal col-
umn, ribs, breastbone, and pelvis.
Axon—The slender projection of a nerve cell that carries stimuli away from the cell body.
Biomechanics—The study of mechanical principles applied to biological systems.
Cancellous Bone—A bony latticework at the ends of long bones that contains bone marrow.
Cauda Equina (“Horse’s Tail”)—The collection of nerve rootlets that form after the spinal cord ends,
which extends from L1/L2 to the tailbone (coccyx).
Central Nervous System (CNS)—the part of the nervous system consisting of the brain and spinal cord

Claudication—means pain or cramping, usually due to inadequate blood flow
Collagen—Naturally occurring proteins that are the main components of connective tissue.
Compression—Force that shortens or crushes an object.
Concave—Curved downward or inward (opposite of the apex)
Contralateral—relating to the opposite side

Conus Medullaris—The cone-shaped end of the spinal cord, positioned near L1/L2.
Convex—curving outward toward the apex of the curve.
Coronal (plane)—Refers to a section that divides the body into anterior and posterior portion.
Cortical Bone—dense, hard bone that forms the exterior of long bones.
Dendrite—The slender projection of a nerve cell that carries stimuli toward the cell body.
Dextroscoliosis—curve is to the right.
Diffuse Idiopathic Skeletal hyperostosis (DISH)—A type of arthritis that affects tendons and ligaments,
mainly around your spine. A disease in which bone fills in the anterolateral aspects of at least four adja-
cent vertebrae. Also called Forestier’s disease
Distal—away from the point of reference
Dorsal Root Ganglia—a cluster of neurons (a ganglion) in a dorsal root of a spinal nerve, this is outside
the CNS.
Endplate—The inferior and superior surfaces of a vertebral body.
Etiology—the cause of disease.
Extension—the contraction of a muscle which straightens a limb, increasing the angle between body
parts
Extrinsic Muscles— arise outside of, but act on, the structure under consideration. An example would be
a muscle that originates in the spine but moves an upper extremity, such as the arm.
Facet Joint—The synovial joint between the superior articular process of one vertebra and the inferior
articular process of an adjacent vertebra.
Flexion—the act of bending a joint or limb in the body by contracting the flexor muscles, decreasing the
angle between body parts
Force—Exerted energy that creates motion in a stationary body or changes the velocity or direction of a
moving body. Cause of power.
Gibbus—A sharply angular kyphotic deformity.

Hematoma—A localized collection of blood due to break in the wall of a blood vessel, usually clotted.
Herniation—abnormal protrusion of tissue through an opening
Herniated Intervertebral Disc (HID)—outpouching of a disc.
Herniated Nucleus Pulposus (HNP)—extrusion of the nucleus pulposus through the ruptured annulus fi-
brosis.
Histology—the study of the microscopic anatomy of cells and tissues.
Hydroxyapatite (HA)—The lattice–like structure of bone composed of calcium and phosphorous crystals
which deposits collagen to provide the rigid structure of bone.
Hyperesthesia—A condition of excessive sensitivity to stimuli.
Iatrogenic—adverse effects of medical care.
Idiopathic—disease with unknown cause.
Interbody Fusion—the intervertebral disc is removed and replaced with a bone spacer. Joining of two or
more vertebrae, often stabilized with devices (screws, rods, plates, cages) and bone grafts.
Intervertebral Disc—The shock-absorbing structure that separates each vertebra.
Intervertebral Foramen (foramina)—openings on the left and right side of the spinal column between ver-
tebrae that are formed by a superior and inferior notch in the pedicles of contiguous vertebrae they give
passage to the spinal nerves from the spinal canal
Intrinsic Muscles—muscles fully contained within the structure under consideration. An example would be
muscle that originates and inserts in the spine.
Innervation—The supply of nerves to a body part.
Insidious—undetectable development of disease. Gradual onset.
Ipsilateral–relating to the same side, with reference to a given point
Kinematics—a branch of dynamics that deals with aspects of motion apart from considerations of mass
and force.
Kyphoplasty—A procedure in which a collapsed vertebra is restored with an inflatable balloon, the balloon
is withdrawn and acrylic cement is injected into the vertebral body to stabilize it.
Kyphosis—Outward curvature of the thoracic region of the spine resulting in a rounded upper back, seen
in the sagittal plane.
Lamella (pl. lamellae)—A thin layer or membrane, especially in bone.
Lamina (pl. laminae )—A broad plate that extends dorsally and medially from the pedicles; vertebral
plates of bone that form the posterior walls of each vertebra.

Laminectomy—A surgical procedure in which the posterior arch of a vertebra is removed.
Larynx—A tube-shaped organ in the neck that contains the vocal cords. Voice box.
Lateral—denoting a position farther from the median plane or midline of the body.
Levoscoliosis—curve is to the left.
Ligament—Tough band of connective tissue that connects various structures, such as bone to bone.
Ligamentum Flavum—runs between the laminae from the axis to the sacrum, covering the spinal cord.
Maintains erect posture and closes space between arches.
Load—An external force applied to an object
Lordosis—Posterior concavity of the spine as seen in the sagittal plane. i.e., cervical and lumbar lordosis.
Lumbarization—a partial or complete free moving first sacral segment; looks like a sixth lumbar vertebral
body
Medial—denoting a position closer to the median plane or midline of the body.

Mechanism of Injury—The way in which an injury occurs.
Myelopathy—Impingement on a spinal cord
Neuron— Nerve cell.
Nerve Root—the initial segment of a nerve leaving the central nervous system.
Non-union—Failure of a fracture to unite (heal).
Ossification—the process of forming bone in the body.
Osteoarthritis (OA)—most common form of arthritis. It is degenerative and chronic in nature; and may be
exaggerated by mechanical and biological issues.
Osteoblast—A bone cell that forms bone tissue by producing a matrix that mineralizes.
Osteoclast—A bone cell that breaks down and removes bone tissue.
Osteoconduction—Ability to form a 3D matrix into which blood vessels and bone cells can grow.
Osteogenesis—the process of bone development, growth or repair.
Osteoinduction—The migration, multiplication, and differentiation of stem cells into osteoblasts, which
start to build a bony matrix.
Osteomalacia—softening of bone due to decreased vitamin D deficiency
Osteonecrosis—death of bone due to decreased blood flow
Osteopenia—“low bone mass, weakening of the bone.

Osteoporosis—a systemic disorder where decrease bone mass and density makes bones weak and suscep-
tible to fracture.
Osteosclerosis—abnormal hardening of bone
Paresthesia—the sensation of burning, numbness and tingling on the skin
Pathology—The study and diagnosis of disease. Also used informally to refer to disease or injury.
Periosteum—a dense layer of vascular connective tissue enveloping the bones except at the surfaces of
the joints.
Peripheral Nervous System (PNS)—The nerves and ganglia outside the brain and spinal cord (CNS).
Pharynx—the membrane-lined cavity behind the nose and mouth, connecting them to the esophagus (the
throat).
Phyte—outgrowth
Plexus—branching network of intersecting nerves (motor and sensory nerves).
Posterior—located toward the back of a structure
Proximal—closer to a point of reference.
Pseudoarthrosis—failure of fusion; nonunion. A false joint
Radiculopathy—impingement on a nerve root
Radiolucent—Absorbing few x-rays and appearing black on radiographs (air, for example).
Radiopaque—Absorbing large amounts of x-rays and appearing white on radiographs (metal implants, for
example).
Reflex—An involuntary and nearly instantaneous response to a stimulus.
Resection— The surgical removal of part of a structure, such as bone.
Resorption—The removal of bone tissue by a normal physiological process or as part of a pathological pro-
cess, such as an infection.
Rhizotomy—Surgical procedure to sever a nerve root
Rotation—The movement of a fracture about its normal or abnormal coronal axis.

Retrolisthesis—posterior slippage of one vertebra over another
Sagittal (plane)—Refers to a lengthwise cut that divides the body into right and left portions.
Sacralization—fusion of L5 to the first sacral segment. Sacrum appears as six segments.
Scheurmann’s Disorder—a developmental disorder in which the normal curve in the upper spine is in-
creased due to the vertebrae being wedge shaped and causing a “hunchback”.
Schmorl Nodes—inferior or superior extension of the IVD into the vertebral bodies. Degenerative.
Scoliosis—side-to-side (lateral) curve in the back. Lateral and rotational deviation of the spine from mid-

Shear Force—force that acts perpendicular to the surface of an object to slide it out of normal align-
ment.
Spina Bifida—neural tube defect (congenital defect) common of the lumbosacral region. Part of the ver-
tebra and spinal nerve tissue fail to develop properly.
Spinal Canal—Hallow cavity, formed by the vertebral body, pedicles, and lamina in which the spinal cord
and nerves travel through.
Spinal Cord—part of CNS below the brainstem and above the cauda equina, extending to L2 in adults
and S2 in infants.
Spondylitis—Inflammation of the joints of the spine.
Spondylo—vertebra.
Spondylolysis—Stress fracture in pars portion of lumbar vertebrae (the fracture of pars only, no move-
ment).
Spondylolisthesis—Anterior slippage of one vertebra over another (slipping forward).
Stenosis—narrowing or obstruction of a passage in the body.
Stress—pressure or tension exerted on an object, or the load per unit of area.
Superior—Situated above or directed upward toward the head of an individual.
Synovial Joint—a movable joint in which the articular surfaces, coated in synovial fluid, lubricate and
nourish the joint.
Tension—Force that stretches or elongates an object.
Torsion—Force that twists or rotates.
Transforaminal Lumbar Interbody Fusion (TLIF)— A surgical procedure that accesses the lumbar verte-
bra laterally through the intervertebral foramen to decompress and fuse them.
Transverse—Refers to a cut that divides the body into superior and inferior portions.
Vertebra(e) singular (pl.)—One (a group) of the bones in the spinal column
Vertebral Endplates—The superior and inferior plates of cartilage tissue and thin layer of cortical bone
of the vertebral body adjacent to the intervertebral disc.
Vertebroplasty—A percutaneous procedure in which cement is injected into a weakened or collapsed
vertebra.
Wolff’s Law—bone in a healthy person or animal will adapt to the loads placed on it.
Zygapophyseal Joint—the synovial joint formed in the middle of the inferior and superior articular pro-
cesses of adjacent vertebrae.

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Khurana) 416 (Springer Science & Business Media, 2009).
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4. Marieb, E.N. and Hoehn, K. (2016) Human anatomy & physiology [Pearson Education]
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7. Stevenson, S., Emery, S.E. & Goldberg, V.M. Factors affecting bone graft incorporation. Clin Orthop Relat
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The Angle Orthodontist 63: 3, 175-188 (1994).
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www.sciencedirect.com>.

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Chapter 2—Bone Biology……………….……...……………………………………………………………………….8

Chapter 3—Spinal Vertebrae……………….……………………………………………………………………….15

Chapter 4—Intervertebral Disc…...………………………..………………………………………………………20

Chapter 6—Nervous System…….………..…………………….…...………………………………………………26

Chapter 8—Internal Organs & Circulation….......….…………………….…………………………………..35

Chapter 13—Surgical Treatment Options..……….…………....…………………..………………………..78

Chapter 14—Surgical Instruments..…………..…………….………..…….………….…………………………85

Chapter 15—Operating Room Tables..…………………….……….…..……………………………………..100

Anatomical Planes and Orientation

Medial Toward the midline of the body

Lateral Away from the midline of the body

Proximal Closer to the center of the body or reference point

Distal Away from the center or the reference point

Superior Upper, above

Inferior Lower, below

Anterior Toward the front

Posterior Toward the back

Cranial (Cephalad) Toward the head

Caudal Toward the tail, tail end

Dorsal Posterior, back

 The spine is located to the back or posterior of the body.

 The spine and sternum sit in the body’s midline.

The Numbers Game

 Twelve (12) vertebrae in the thoracic spine (mid-back)

 Five (5) vertebrae in the lumbar spine (lower back)

 Five (5) fused sacral vertebrae (sacrum)

The vertebral bodies within each region are identified by combining

 Attaches to muscles and

One major function of the spine, is to  Absorbs shock

Normal Spinal Curves:

Cervical spine: lordosis, 20°-40°

Lumbar spine: lordosis, 30°-50°

At birth, the spine has only one kyphotic curve, known as a

BONE CELLS (Figure 3)

Due to this, we say that the skeleton is a dynamic sys-

Figure 5. Bone Remodeling Cycle

As previously mentioned, there are seven cervical, twelve thoracic, five

Cervical: 45° frontal plane; this orientation

Thoracic: 65° frontal plane; movement is

Lumbar: 90° sagittal plane; the orientation

8 cervical nerve roots

12 thoracic nerve roots

5 lumbar nerve roots

5 sacral nerve roots

1 coccygeal nerve root

Dermatome Shaded areas indicate dermatomes on all surfaces of the body

An area of skin that is mainly innervated by a single

Anterior Cervical Muscles

Deepest of the three is the longus colli. It is located

Anterior Lumbar Muscles

The oblique muscles of the abdomen consist of three muscles—the external

Axial T2 MRI displaying the Erector Spinae,

Posterior Lumbar Muscles

The multifidis is part of the tranversospinalis muscle

Circulation of the Cervical Region

Carotid Sheath and Contents

Circulation of the Vertebral Bodies

Spinal Arterial and Venous Circulation

Normal MRI displaying segmental

Region Specific Anatomy

Atlanto-Occipital Joint Complex