Benzels Spine Surgery 2 Volume Set Techniques Complication Avoidance and Management 5Th Edition Michael P Steinmetz MD Editor Full Chapter

Benzel's Spine Surgery, 2-Volume Set:
Techniques, Complication Avoidance

and Management 5th Edition Michael P
Steinmetz Md (Editor)
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Benzel’s Spine Surgery
Techniques, Complication Avoidance,
and Management
FIFTH EDITION
MICHAEL P. STEINMETZ, MD
William P. and Amanda C. Madar Endowed Professor and Chair
Department of Neurosurgery
Cleveland Clinic Lerner College of Medicine
Director Center for Spine Health
Neurological Institute
Cleveland, Ohio
SIGURD H. BERVEN, MD
Professor in Residence and Chief of Spine Service
Department of Orthopaedic Surgery
University of California, San Francisco
San Francisco, California
EDWARD C. BENZEL, MD
Emeritus Chairman
Neurological Institute, Cleveland Clinic
Cleveland, Ohio
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
BENZEL’S SPINE SURGERY: TECHNIQUES, COMPLICATION AVOIDANCE,

AND MANAGEMENT, FIFTH EDITION ISBN: 978-0-323-63668-1
Copyright © 2022 by Elsevier, Inc. All rights reserved.
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Last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedication
This book is dedicated to our families and to the

physicians with whom we work and learn. To our
wives, Bettina, Za, and Mary, and our children,
thank you for your partnership, patience, and
sacrifice that enabled us to commit countless hours
to writing and editing for this edition. To the
community of physicians including mentors, past
and present partners, collaborators, fellows,
residents, and assistants, thank you for the lasting
and ongoing impact you have had on our education
and experience in providing evidence-based care
for our patients.
Sigurd Berven joined us as an editor for this

edition. His wisdom, collegiality, and drive led
to a renewed table of contents and a reinvigoration
of content and authors.
MICHAEL P. STEINMETZ
SIGURD H. BERVEN
EDWARD C. BENZEL
v
List of Contributors
Ali R. Abtahi, DO, MSc Basel Sheikh Alshabab, MD Paul A. Anderson, MD

University of Iowa Hospitals and Postdoctoral Research Fellow Professor
Clinics Spine Service Department of Orthopaedics Surgery
Division of Plastic and Reconstructive Hospital for Special Surgery and Rehabilitation
Surgery New York, New York University of Wisconsin
University of Iowa Madison, Wisconsin
Anthony M. Alvarado, MD
Iowa City, Iowa
Resident Physician Lilyana Angelov, MD, FAANS, FRCS(C)
Owoicho Adogwa, MD, MPH Department of Neurological Surgery The Kerscher Family Chair for Spine
Assistant Professor University of Kansas Medical Center Tumor Excellence
Department of Neurosurgery Kansas City, Kansas Head Section of Spine Tumors
Chief of Neurological Surgery Professor,
Mohammed Ali Alvi, MBBS, MS
North Dallas Veterans Affairs Hospital Department of Neurological Surgery,
Senior Research Fellow
University of Texas Southwestern CCLCM of CWRU
Mayo Clinic Neuro-Informatics
Medical School Rose Ella Burkhart Brain Tumor &
Laboratory
Dallas, Texas Neuro-Oncology Center,
Department of Neurologic Surgery
Department of Neurosurgery,
A. Karim Ahmed, MD Mayo Clinic
Resident Physician Rochester, Minnesota
Cleveland Clinic
Aboubakr Amer, MD Cleveland, Ohio
Johns Hopkins University School of
Medicine Paul M. Arnold, MD, FACS
Ohio State University
Baltimore, Maryland Professor of Neurosurgery
Columbus, Ohio, Department of
Carle Illinois College of Medicine;
Ana Ainechi, BS, MSE Neurosurgery
Chairman, Department of
Researcher Ain Shams University
Neurosurgery;
Department of Neurosurgery Cairo, Egypt
Associate Medical Director
Christopher P. Ames, MD Director of Research
Medicine
Professor of Clinical Neurological Carle Neuroscience Institute
Baltimore, Maryland
Surgery and Orthopaedic Surgery Urbana, Illinois
Nima Alan, MD Director of Spinal Deformity & Spine
Carl-Eric Aubin, PhD, ScD(hc), P.Eng
Resident Physician Tumor Surgery
Professor of Mechanical Engineering
Department of Neurosurgery Co-Director, Spinal Surgery and UCSF
Polytechnique Montreal
University of Pittsburgh Medical Center Spine Center
Sainte-Justine University Hospital
Pittsburgh, Pennsylvania Director, Spinal Biomechanics
Center
Laboratory
Jessica Albanese, MD Montreal, Quebec, Canada
Director, California Deformity Institute
Resident Physician
University of California, San Francisco Junseok Bae, MD
San Francisco, California Director
University of Nevada, Las Vegas
Department of Neurological Surgery
Las Vegas, Nevada Simon G. Ammanuel, BS
Wooridul Spine Hospital
Medical Student
Ilyas Aleem, MD, MSc Seoul, South Korea
Assistant Professor
University of California, San Francisco Mark Bain, MD, MS
San Francisco, California Staff Neurosurgeon
University of Michigan
Cerebrovascular Center
Ann Arbor, Michigan Neel Anand, MD
Cleveland Clinic
Professor of Orthopaedic Surgery
Joao Paulo Almeida, MD Cleveland, Ohio
Advanced Endoscopic and Open Skull
Director, Spine Trauma Joshua Barber, MD
Base Surgery Clinical Fellow
Minimally Invasive Spine Surgery Orthopaedic Spine Fellow
Cedars Sinai Medical Center Department of Orthopaedic Surgery
Cleveland Clinic
Los Angeles, California University of California, Davis
Cleveland, Ohio
Sacramento, California
vii
viii List of Contributors
Eli M. Baron, MD Barrett S. Boody, MD Jose A. Canseco, MD, PhD

Associate Professor of Neurosurgery Orthopaedic Spine Surgeon Orthopaedic Spine Fellow
Director, Spine Trauma Indiana Spine Group Rothman Orthopaedic Institute
Department of Neurosurgery Carmel, Indiana Philadelphia, Pennsylvania
Cedars Sinai Medical Center
Daniel Bowles, MD David S. Casper, MD
Los Angeles, California
Spine Research Fellow Assistant Professor
Hersimren Kaur Basi, MD Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Assistant Professor Rothman Orthopaedic Institute University of Pennsylvania
Department of Pain Management Philadelphia, Pennsylvania Philadelphia, Pennsylvania
Cleveland Clinic Lerner College of
Charles Branch, MD Matthew Cassidy, CNIM
Medicine of Case Western Reserve
Chair Intraoperative Neuromonitoring
University
Department of Neurosurgery Workleader
Cleveland Clinic
Wake Forest Baptist Health Department of Intraoperative
Cleveland, Ohio
Winston-Salem, North Carolina Neuromonitoring
Asef Bawahab, MD Cleveland Clinic Foundation
Nathaniel Brooks, MD, FAANS
Postdoctoral Research Fellow Cleveland, Ohio
Associate Professor
Department of Orthopedic Surgery
Department of Neurological Surgery Samuel T. Chao, MD
Long Beach Memorial and Miller
University of Wisconsin Professor
Children’s & Women’s Hospital
Madison, Wisconsin Brain Tumor & Neuro-Oncology
Long Beach, California
Center/Radiation Oncology
Aaron J. Buckland, MBBS, FRACS
Edward C. Benzel, MD Cleveland Clinic Lerner College
Associate Professor Orthopaedic
Emeritus Chairman of Medicine, Case Western Reserve
Surgery
Department of Neurosurgery University
Director of Spine Research
Neurological Institute, Cleveland Clinic Cleveland Clinic
NYU Langone Health
Cleveland, Ohio Cleveland, Ohio
New York, New York;
Sigurd H. Berven, MD Melbourne Orthopaedic Group Grégoire P. Chatain, MD, MSc
Professor in Residence and Chief of Melbourne, Australia Resident Physician
Spine Service Department of Neurological Surgery
Thomas J. Buell, MD
Department of Orthopaedic Surgery University of Colorado School of
Fellow Physician
University of California, San Francisco Medicine
San Francisco, California Aurora, Colorado
Duke University Medical Center
Adam K. Bevan, MD, PhD Durham, North Carolina Lee Onn Chieng, MD
Resident Physician Resident Physician
Shane Burch, MD
Department of Neurosurgery Department of Neurosurgery
Professor in Residence
Washington University School of Beaumont Health
Medicine Royal Oak, Michigan
St. Louis, Missouri
San Francisco, California Woojin Cho, MD, PhD
Miranda Bice, MD Associate Professor of Orthopaedic
John F. Burke, MD, PhD
Clinical Assistant Professor Surgery
Resident Physician
Department of Orthopaedic Surgery & Albert Einstein College of Medicine
Rehabilitation Chief of Orthopaedic Spine Surgery
University of Wisconsin Research Director
Madison, Wisconsin Multidisciplinary Spine Center
Bilal B. Butt, MD Montefiore Medical Center
Mark Bilsky, MD
Resident Physician New York, New York
Attending Neurosurgeon
Department of Neurosurgery Hoon Choi, MD, PhD
University of Michigan
Memorial Sloan-Kettering Cancer Assistant Professor of Neurosurgery
Ann Arbor, Michigan
Center Medical College of Wisconsin
Professor of Neurosurgery Mohamad Bydon, MD Milwaukee, Wisconsin
Weill Medical College of Cornell Professor of Neurologic Surgery
Susan R. Christopher, BSN
University Orthopaedic Surgery and Health
Neurosurgery Nursing & Research
New York, New York Services Research
Mayo Clinic
Erica F. Bisson, MD, MPH Lahey Hospital & Medical Center
Rochester, Minnesota
Professor of Neurosurgery Burlington, Massachusetts
Department of Neurosurgery Joaquin Camara, MD
Andrew S. Chung, DO
University of Utah Assistant Professor
Spine Surgeon
Salt Lake City, Utah Department of Neurosurgery
Sonoran Spine Institute
The Warren Alpert Medical School of
Donald Blaskiewicz, MD Phoenix, Arizona
Brown University
Assistant Professor
Providence, Rhode Island
University of California, San Diego
La Jolla, California
List of Contributors ix
Aaron J. Clark, MD, PhD Sanjay S. Dhall, MD Richard G. Ellenbogen, MD

Assistant Professor Associate Professor Professor and Chairman
Department of Neurological Surgery Department of Neurological Surgery Department of Neurological Surgery
University of California, San Francisco University of California, San Francisco University of Washington
San Francisco, California San Francisco, California Seattle, Washington
Domagoj Coric, MD Mohammad Diab, MD Ashraf N. El Naga, MD
Chief of Neurosurgery Professor of Orthopaedic Surgery Assistant Clinical Professor
Carolinas Medical Center Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Carolina Neurosurgery and Spine University of California, San Francisco University of California, San Francisco
Associates; San Francisco, California San Francisco, California
Spine Division Chief
Anthony M. DiGiorgio, DO, MHA John B. Emans, MD
Atrium Musculoskeletal Institute
Assistant Professor Professor of Orthopaedic Surgery
Charlotte, North Carolina
Department of Neurological Surgery Harvard Medical School;
Mark D. Corriveau, MD University of California, San Francisco Director Emeritus, Division of Spine
Department of Neurosurgery San Francisco, California Surgery
University of Wisconsin Health Department of Orthopaedic Surgery
John R. Dimar II, MD
Madison, Wisconsin Boston Children’s Hospital
Clinical Professor
Boston, Massachusetts
Ethan Cottrill, MS, MD PhD Candidate Department of Orthopaedics
Medical Scientist Training Program University of Louisville John W. Engstrom, MD
Johns Hopkins University School of Chief of Pediatric Orthopaedics Betty Anker Fife Professor
Medicine Norton Children’s Hospital Vice Chair, Clinical Affairs
Baltimore, Maryland Louisville, Kentucky Department of Neurology
Christopher Cychosz, MD Alexander B. Dru, MD
Department of Orthopaedic Surgery Resident Physician
University of Iowa Department of Neurological Surgery Thomas J. Errico, MD
Iowa City, Iowa University of Florida Associate Director of Pediatric
Gainesville, Florida Orthopaedic and Neurosurgery
Gregory Daubs, MD
Nicklaus Hospital
Resident Physician Jean Dubousset, MD
Coral Gables, Florida;
Department of Orthopaedic Surgery Professor of Pediatric Orthopaedics
Adjunct Professor of Orthopaedics and
University of Nevada Department of Pediatric Orthopaedics
Neurosurgery
Las Vegas School of Medicine Académie Nationale de Médecine
NYU School of Medicine
Las Vegas, Nevada Paris, France
New York, New York
Michael D. Daubs, MD Melissa R. Dunbar, MPH
Ehab Farag, MD, FRCA, FASA
Professor and Chair Research Manager
Professor of Anesthesiology
Department of Orthopaedic Surgery Department of Neurosurgery
University of Nevada Lahey Hospital and Medical Center
Medicine;
Las Vegas School of Medicine Burlington, Massachusetts
Director of Clinical Research
Las Vegas, Nevada
Zeyd Ebrahim, MD Department of General Anesthesia
Sara Davin, PsyD, MPH Staff Anesthesiologist Anesthesiology Institute
Director Department of General Anesthesiology Cleveland Clinic
Center for Comprehensive Pain Cleveland Clinic Cleveland, Ohio
Recovery Cleveland, Ohio
S. Harrison Farber, MD
Staff Psychologist
Jeff Ehresman, BS Resident Physician
Cleveland Clinic
Medical Student Department of Neurosurgery
Cleveland, Ohio
Department of Neurosurgery Barrow Neurological Institute
Russell C. DeMicco, DO Johns Hopkins University School of St. Joseph’s Hospital and Medical
Spine Medicine Fellowship Director Medicine Center
Center for Spine Health Baltimore, Maryland Phoenix, Arizona
Cleveland Clinic
J. Bradley Elder, MD Nida Fatima, MBBS, MD
Cleveland, Ohio
Associate Professor Research Fellow
Ashley de Padua, MD Director of Neurosurgical Oncology Department of Neurosurgery
Attending Physician Department of Neurological Surgery Massachusetts General Hospital
St. Luke’s University Hospital Network The Ohio State University Wexner Boston, Massachusetts
Bethlehem, Pennsylvania Medical Center
Graham T. Fedorak, MD, FRCS(C)
Columbus, Ohio
Peter B. Derman, MD, MBA Kapi’olani Medical Center for Women
Spine Surgeon & Children
Texas Back Institute Honolulu, Hawaii
Plano, Texas
x List of Contributors
Michael G. Fehlings, MD, PhD, Mark Frenkel, MD Ziya L. Gokaslan, MD, FAANS, FACS
FRCSC, FACS Neurosurgeon Julius Stoll MD Professor and Chair
Professor of Neurosurgery and Vice Neuroscience and Spine Associates Department of Neurosurgery
Chair of Research Naples, Florida The Warren Alpert Medical School of
Co-Director, University of Toronto Brown University
Jared Fridley, MD
Spine Program Neurosurgeon-in-Chief
Assistant Professor
University of Toronto Rhode Island Hospital and The Miriam
Director, Spinal Program Hospital
Rhode Island Hospital
Toronto Western Hospital Clinical Director, Norman Prince
The Warren Alpert School of Medicine
Gerald and Tootsie Halbert Chair in Neurosciences Institute
at Brown University
Neural Repair and Regeneration President, Brown Neurosurgery
Providence, Rhode Island
Senior Scientist, Toronto Western Foundation
Research Institute Joelle Gabet, MD Providence, Rhode Island
University Health Network Clinical Instructor
Zachary H. Goldstein, MD
Toronto, Ontario, Canada Department of Orthopaedic Surgery
Resident
Frank Feigenbaum, MD Department of Orthopaedic Surgery
Director Indiana University School of Medicine
Feigenbaum Neurosurgery Sumeet Garg, MD Indianapolis, Indiana
Medical City Dallas Hospital Associate Professor
Gerald A. Grant, MD, FACS
Dallas, Texas Department of Orthopaedics
Professor of Neurosurgery
University of Colorado
Lisa Ferrara, PhD Arline and Pete Harman Endowed
Aurora, Colorado
Chief Executive Officer Faculty Scholar
OrthoKinetic Technologies John W. German, MD Division Chief, Pediatric Neurosurgery
OrthoKinetic Testing Technologies Department of Neurosurgery Stanford University School of Medicine
Southport, North Carolina Albany Medical Center Stanford, California
Albany, New York
Richard G. Fessler, MD, PhD Mackenzie Grasso, MD
Professor of Neurosurgery Zoher Ghogawala, MD, FACS Resident Physician
Department of Neurosurgery Chairman of Neurosurgery Department of Orthopaedic Surgery
Rush University Medical Center Lahey Hospital and Medical Center Virginia Commonwealth University
Chicago, Illinois Burlington, Massachusetts; Richmond, Virginia
Michael Finn, MD Andrew J. Grossbach, MD
Tufts University School of Medicine
Associate Professor Assistant Clinical Professor
Department of Neurosurgery Associate Program Director
University of Colorado Christopher M. Gibbs, MD Department of Neurosurgery
Denver, Colorado Resident Physician The Ohio State University
Department of Orthopaedic Surgery Columbus, Ohio
Jeffrey S. Fischgrund, MD
University of Pittsburgh Medical Center
Chairman Jian Guan, MD
Pittsburgh, Pennsylvania
Department of Orthopaedic Surgery Staff Neurosurgeon
Beaumont Health System John L. Gillick, MD Pacific Neuroscience Institute
Royal Oak, Michigan Assistant Professor Torrance, California
Mark D. Fisher, MD, FACS Jeremy Guinn, BS, BA
Rutgers, New Jersey Medical School
Clinical Associate Professor Research Scholar
Newark, New Jersey
Cleft Team Co-Director Department of Neurological Surgery
Iowa Burn Center Staff Surgeon Christopher J. Gilligan, MD, MBA University of California, San Francisco
Division of Plastic & Reconstructive Surgery Vice Chair for Strategy San Francisco, California
The University of Iowa Hospitals and Department of Anesthesiology,
Raghav Gupta, MD
Clinics Perioperative and Pain Medicine
Resident Physician
Iowa City, Iowa Brigham and Women’s Hospital
Harvard Medical School
Ricardo B.V. Fontes, MD, PhD Keck School of Medicine
Assistant Professor University of Southern California
Department of Neurosurgery Christopher C. Gillis, MD Los Angeles, California
Rush University Medical Center Neurosurgeon
Yazeed M. Gussous, MBBS
Chicago, Illinois Neurosurgeons of New Jersey
Orthopaedic Spine Surgeon
West Long Branch, New Jersey
Michael A. Fox, MD Director of Spine Surgery
Resident Physician Atul Goel, MCh (Neurosurgery) Silicon Valley Medical Development
Department of Orthopaedic Surgery Professor and Head Mountain View, California
University of Pittsburgh Medical Center Department of Neurosurgery
Pittsburgh, Pennsylvania Seth G. S. Medical College and K.E.M
Hospital
Brett A. Freedman, MD
Mumbai, India
Associate Professor of Orthopaedics
Department of Orthopaedics
Mayo Clinic
List of Contributors xi
Richard D. Guyer, MD Daniel Hedequist, MD Daniel J. Hoh, MD

Co-Founder and President Associate Professor of Orthopaedic Associate Professor
Director of Spine Fellowship Surgery Department of Neurological Surgery
Orthopaedic Spine Surgery Harvard Medical School; University of Florida
Texas Back Institute Director, Division of Spine Surgery Gainesville, Florida
Plano, Texas; Department of Orthopaedic Surgery
Joshua Holt, MD
Clinical Associate Professor of Boston Children’s Hospital
Assistant Professor
Orthopaedic Surgery Boston, Massachusetts
University of Texas, Southwestern
Fraser C. Henderson Sr., MD University of Iowa
School of Medicine
Chief of Neurosurgery Iowa City, Iowa
Dallas, Texas
Doctors Community Hospital
Augusto Hsia, MD, CCD
Alexander F. Haddad, BS Lanham, Maryland;, Director
Medical Spine Staff
Medical Student Metropolitan Neurosurgery Group, LLC
Center for Spine Health
M. Kristi Henzel, MD, PhD Cleveland Clinic
Assistant Chief Cleveland, Ohio
Spinal Cord Injuries and Disorders Service
Jason Hsieh, MD, MS
Kirsty Hamilton, MBBS Louis Stokes Cleveland VA Medical Center;
Resident Physician
Department of Neurosurgery Assistant Professor, Physical Medicine
University of Arizona and Rehabilitation
Cleveland Clinic Foundation
Tucson, Arizona Case Western Reserve University
Cleveland, Ohio
Cleveland, Ohio
Tessa Harland, MD
Wellington K. Hsu, MD
Resident Physician Eric Z. Herring, MD
Clifford C. Raisbeck Distinguished
Department of Neurosurgery Department of Neurological Surgery
Albany Medical College University Hospitals Cleveland Medical
Professor
Albany, New York Center
Cleveland, Ohio
James S. Harrop, MD Northwestern University School of
Professor, Departments of Neurological Dominique Higgins, MD, PhD Medicine
and Orthopedic Surgery Resident Physician Chicago, Illinois
Director, Division of Spine and Department of Neurosurgery
John Hurlbert, MD, PhD
Peripheral Nerve Surgery Columbia University
Professor
Director Enterprise Neurologic Surgery New York, New York
Quality and Safety
Alan S. Hilibrand, MD, MBA University of Arizona
Neurosurgery Director of Delaware Valley
The Joseph and Marie Field Professor Tucson, Arizona
SCI Center
of Spinal Surgery
Thomas Jefferson University Steven W. Hwang, MD
Vice Chairman, Academic Affairs and
David J. Hart, MD Faculty Development
Shriners Hospitals for Children
Neurosurgeon Department of Orthopaedic Surgery
Philadelphia, Pennsylvania
Department of Neurological Surgery Sidney Kimmel Medical College
Forsyth Brain and Spine Surgery Rothman Institute at Thomas Jefferson Jordan C. Iordanou, MD, PhD
Winston-Salem, North Carolina University Resident Physician
Philadelphia, Pennsylvania Department of Neurological Surgery
Robert A. Hart, MD, MA, MHCDS
Loyola University Medical Center
Spine Surgeon Kevork N. Hindoyan, MD
Maywood, Illinois
Department of Orthopaedic Surgery Complex and Minimally Invasive
Swedish Medical Center Congress Orthopaedic Associates Andrew S. Jack, MD, MSc, FRCSC
Seattle, Washington Pasadena, California Complex Spine Surgeon
San Francisco, California Peripheral Nerve Surgeon
Waqaas A. Hassan, MD, MPH
Assistant Clinical Professor
Department of Orthopaedic Surgery Kevin Hines, MD
Division of Neurosurgery
Rothman Orthopaedic Institute at Resident Physician
University of Alberta
Thomas Jefferson University Department of Neurological Surgery
Edmonton, Alberta, Canada
Philadelphia, Pennsylvania Thomas Jefferson University
Philadelphia, Pennsylvania Karl Janich, MD
Amanda W. Hayes, MD
Resident Physician
Resident Physician Patrick W. Hitchon, MD
Department of Orthopaedic Surgery Professor
Medical College of Wisconsin
Virginia Commonwealth University Department of Neurosurgery
Milwaukee, Wisconsin
Health Systems University of Iowa
Richmond, Virginia Iowa City, Iowa Bowen Jiang, MD
Staff Neurosurgeon
Robert F. Heary, MD Jacob C. Hoffmann, MD
Professor of Neurological Surgery Associate Staff Surgeon
Providence St. Joseph Health
Hackensack Meridian School of Medicine Department of Orthopaedic Surgery
Fullerton, California
Nutley, New Jersey; Cleveland Clinic
Chief of Neurosurgery Cleveland, Ohio
Mountainside Medical Center
Montclair, New Jersey
xii List of Contributors
Fan Jiang, BSc, MDCM, FRCSC Adam S. Kanter, MD, FAANS Jon Kimball, MD
Clinical Associate Associate Professor of Neurological Clinical Instructor of Orthopaedic
Division of Neurosurgery, Department Surgery Surgery (Fellow)
of Surgery Chief, Division of Spine Surgery Department of Orthopaedic Surgery
University of Toronto Director, Minimally Invasive Spine Keck School of Medicine at University
Division of Neurosurgery Program of Southern California
Krembil Neuroscience Centre, Toronto Director, Neurosurgical Spine Los Angeles, California
Western Hospital Fellowship Program
Stanley Kisinde, MB ChB, PGD (DS,
Toronto, Ontario, Canada University of Pittsburgh Medical Center
PPM), MMed
Xavier F. Jimenez, MD, MA Department of Clinical Research
Director, Psychiatry Manish K. Kasliwal, MD, MCh, FAANS Scoliosis and Spine Tumor Center
Long Island Jewish Medical Director, Minimally Invasive Spine Texas Back Institute
Center/Northwell Surgery Plano, Texas
New York, New York Department of Neurological Surgery
Eric O. Klineberg, MS, MD
University Hospitals Case Medical
J. Patrick Johnson, MD, MS, FACS, Professor and Vice Chair
Center, CWRU
FAANS Chief of Service - Spine
Assistant Professor
Director, The Spine Center Co-Director, Spine Center
Cedars-Sinai Medical Center Adult and Pediatric Spine Surgery
Case Western Reserve University School
President and CEO Department of Orthopaedics
of Medicine
The Spine Institute Foundation University of California, Davis
Cleveland, Ohio
Los Angeles, California Sacramento, California
Mayank Kaushal, MBBS, MBA
G. Alexander Jones, MD, FAANS Efstathios Kondylis, MD
Postdoctoral Fellow
Associate Professor Resident Physician
Department of Neurological Surgery Department of Neurosurgery
Loyola University Medical Center Cleveland Clinic Foundation
Maywood, Illinois Cleveland, Ohio
Mena G. Kerolus, MD
Kristen E. Jones, MD, FAANS Dallas E. Kramer, BS
Resident Physician
Assistant Professor Medical Student
Department of Neurosurgery Rush Medical College
Rush University Medical Center
Adjunct Assistant Professor Rush University Medical Center
Chicago, Illinois
Department of Orthopaedic Surgery Chicago, Illinois
University of Minnesota Kyle Kesler, MD
William E. Krauss, MD
Minneapolis, Minnesota Department of Orthopaedic Surgery
Professor
University of Iowa
Jacob R. Joseph, MD Department of Neurological Surgery
Iowa City, Iowa
Assistant Professor Mayo Clinic
Department of Neurological Surgery Remi A. Kessler, BA Rochester, Minnesota
University of Michigan Medical Student
Ajit A. Krishnaney, MD
Ann Arbor, Michigan Department of Neurosurgery
Staff Surgeon
Icahn School of Medicine at Mount
Rushikesh S. Joshi, BS Department of Neurosurgery
Sinai
Medical Student Cleveland Clinic
New York, New York
University of California, San Diego Cleveland, Ohio
San Diego, California Tagreed Khalaf, MD
Justin Krogue, MD
Staff Physician
Rupa G. Juthani, MD Department of Orthopaedic Surgery
Assistant Professor of Neurosurgery University of California, San Francisco
Cleveland Clinic
Weill Cornell Brain and Spine Center San Francisco, California
Cleveland, Ohio
New York, New York
Varun R. Kshettry, MD
Jad G. Khalil, MD
Iain H. Kalfas, MD, FACS Staff Neurosurgeon
Associate Professor of Orthopaedic
Department of Neurosurgery Skull Base and Cerebrovascular Surgery
Surgery
Cleveland Clinic Director, Advanced Endoscopic and
Director, Spine Surgery Fellowship
Cleveland, Ohio Microscopic Neurosurgery Laboratory
William Beaumont Hospital
Ricky R. Kalra, MD Royal Oak, Michigan
Rosa Ella Burkhardt Brain Tumor &
Neurosurgeon
Terrence T. Kim, MD Neuro-Oncology Center
Kalra Brain & Spine
Director of Education and Fellowship Cleveland, Ohio
Plano, Texas
Neeraj Kumar, MD
James D. Kang, MD Cedars-Sinai Medical Center
Professor
Thornhill Family Professor of Los Angeles, California
Department of Neurology
Orthopaedic Surgery
Mayo Clinic
Harvard Medical School
Chair, Department of Orthopaedic
Surgery
Brigham and Women’s Hospital
List of Contributors xiii
Shekar N. Kurpad, MD, PhD Hai V. Le, MD Marcus Z. Ling, MBBS, FRCSEd(Orth)
Sanford J Larson Professor Assistant Professor Orthopaedic Surgeon
Chairman, Department of Neurological Department of Orthopaedics Department of Orthopaedic Surgery
Surgery University of California, Davis Singapore General Hospital
Co-Director, Center for Neurotrauma Sacramento, California Singapore
Research
Andrew Lee, MD Victor P. Lo, MD, MPH
Medical Director, Neuroscience Service
Orthopaedic Spine Fellow Neurosurgeon
Line
Department of Orthopaedic Surgery Department of Neurosurgery
Froedtert Health and The Medical
University of California, San Francisco Kaiser Permanente – Southern
College of Wisconsin
San Francisco, California California Permanente Medical Group
San Diego, California
Nathan J. Lee, MD
Collin M. Labak, MD
Resident in Orthopaedic Surgery S. Scott Lollis, MD
Department of Orthopaedic Surgery Associate Professor of Surgery
University Hospitals Cleveland Medical
Columbia University Medical Center Division of Neurosurgery
Center
New York-Presbyterian Hospital University of Vermont Medical Center
Cleveland, Ohio
New York, New York Burlington, Vermont
Hubert Labelle, MD
Sang-Ho Lee, MD, PhD Joseph M. Lombardi, MD
Professor
Department of Neurosurgery Assistant Professor of Orthopaedic
Department of Surgery
Chungdam Wooridul Spine Hospital Surgery
University of Montreal
Seoul, South Korea Department of Spine Orthopaedics
Montreal, Quebec, Canada
The Daniel and Jane Och Spine
Ronald A. Lehman Jr., MD
Bryan Ladd, MD Hospital
Professor of Orthopaedic Surgery,
Resident Physician Columbia University Medical Center
Tenure (in Neurological Surgery)
Department of Neurosurgery New York-Presbyterian Hospital
Chief, Reconstructive, Robotic & MIS
University of Minnesota New York, New York
Surgery
Minneapolis, Minnesota
Director, Adult and Pediatric Spine Donlin Long, MD, PhD
Virginie Lafage, PhD Fellowship Distinguished Service Professor of
Senior Director, Spine Research Director, Athletes Spine Center Neurosurgery
Hospital for Special Surgery Director, Spine Research Johns Hopkins University
New York, New York The Daniel and Jane Och Spine Baltimore, Maryland
Hospital
Joseph L. Laratta, MD Roger Long, MD
NewYork-Presbyterian/The Allen
Staff Spine Surgeon Clinical Professor
Hospital
The Neck & Back Institute of Kentucky; Department of Pediatrics, Division of
Assistant Clinical Professor Kurt Lehner, MD Endocrinology
Department of Orthopaedic Surgery Department of Neurosurgery University of California, San Francisco
University of Louisville Johns Hopkins Hospital San Francisco, California
Louisville, Kentucky Baltimore, Maryland
Jeffrey Lotz, PhD
Robert Lark, MD, MS Lawrence G. Lenke, MD Professor
Associate Professor Surgeon-in-Chief David S. Bradford, MD, Endowed Chair
Department of Orthopaedic Surgery NewYork-Presbyterian Och Spine of Orthopaedic Surgery
and Pediatrics Hospital Department of Orthopaedic Surgery
Duke University Medical Center Professor of Orthopaedic Surgery (in University of California, San Francisco
Durham, North Carolina Neurological Surgery) San Francisco, California
Chief of Spinal Surgery
Darryl Lau, MD Joseph G. Lyons, MD
Chief of Spinal Deformity Surgery
Assistant Professor Research Fellow
Co-Director, Adult and Pediatric
Department of Neurosurgery Department of Orthopaedic Surgery
Comprehensive Spine Surgery
NYU Langone Medical Center Northwestern University Feinberg
Fellowship
New York, New York School of Medicine
Columbia University Department of
Chicago, Illinois
Ilya Laufer, MD, MS Orthopaedic Surgery
Associate Professor of Neurosurgery New York, New York Jean-Marc Mac-Thiong, MD, PhD
Director, Spine Tumor Program Professor
Yingda Li, MBBS, FRACS
NYU Langone Health Department of Surgery
Neurosurgeon
Université de Montréal
William F. Lavelle, MD Department of Neurosurgery
Orthopaedic Surgeon
Associate Professor Westmead Hospital
Departments of Orthopaedic Surgery Sydney, Australia
CHU Sainte-Justine and Hôpital du
and Pediatrics
Isador H. Lieberman, MD, MBA, FRCSC Sacré-Coeur de Montréal
State University of New York Upstate
Director Montreal, Québec,Canada
Medical University
Scoliosis and Spine Tumor Center;
Syracuse, New York
President, Texas Back Institute
Plano, Texas
xiv List of Contributors
Andre Machado, MD, PhD Rory Mayer, MD Rajiv Midha, MSc, MD, FRCSC,
Chairman, Neurological Institute Staff Neurosurgeon FAANS, FCAHS
The Charles and Christine Carroll Baylor University Medical Center Professor and Head
Family Endowed Chair in Functional Clinical Assistant Professor Affiliated Department of Clinical Neurosciences
Neurosurgery Texas A&M Health Calgary Zone
Staff, Department of Neurosurgery Dallas, Texas Alberta Health Services
Cleveland Clinic University of Calgary Cumming School
Daniel J. Mazanec, MD
Cleveland, Ohio of Medicine;
Emeritus Physician
Scientist
Gary M. Mallow, BS Center for Spine Health
Hotchkiss Brain Institute
Department of Orthopaedic Surgery Cleveland Clinic
Calgary, Alberta,
Division of Spine Surgery Cleveland, Ohio
Canada
Kyle L. McCormick, MD
Chicago, Illinois Vincent J. Miele, MD
Resident Physician
Associate Clinical Professor
David G. Malone, MD Department of Neurosurgery
Clinical Assistant Professor Columbia University College of
University of Pittsburgh Medical Center
Department of Neurosurgery Physicians and Surgeons
University of Oklahoma New York, New York
Tulsa, Oklahoma Desimir Mijatovic, MD
Paul C. McCormick, MD, MPH
Center for Comprehensive Pain
Sunil Manjila, MD Professor
Recovery
Department of Neurosurgery Department of Neurosurgery
Ayer Neurosciences Institute Columbia University College of
Cleveland Clinic
Hartford Hospital & Hospital of Physicians and Surgeons
Cleveland, Ohio
Central Connecticut New York, New York
New Britain, Connecticut Anthony L. Mikula, MD
Kyle McGrath, BS
Resident Physician
Joseph C. Maroon, MD Medical Student Researcher
Clinical Professor, Vice Chair, Heindl Department of Neurosurgery
Mayo Clinic
Scholar in Neuroscience Cleveland Clinic
Department of Neurological Surgery Cleveland, Ohio;
University of Pittsburgh School of Medical Student Elliot Min, MD
Medicine Ohio University School of Medicine Resident Physician
Pittsburgh, Pennsylvania Dublin, Ohio Department of Neurosurgery
University of Southern California
Joseph P. Maslak, MD Ian T. McNeill, MD
Los Angeles, California
Orthopaedic Spine Surgeon Clinical Fellow
The CORE Institute Spine Surgery Shuichi Mizuno, PhD
Novi, Michigan Department of Orthopaedic Surgery Associate Professor
University of California, San Francisco Department of Orthopaedic Surgery
Elie Massaad, MD
San Francisco, California Harvard Medical School, Brigham and
Women’s Hospital
Massachusetts General Hospital Zachary A. Medress, MD
Boston, Massachusetts Resident Physician
Department of Neurosurgery Ali Moghaddamjou, MD
Morio Matsumoto, MD
Stanford University School of Medicine Resident Physician
Professor
Palo Alto, California Division of Surgery
University of Toronto
Keio University Joseph R. Mendelis, MD
Toronto, Ontario,
Tokyo, Clinical Fellow
Canada
Japan Department of Orthopaedic Surgery
University of California, San Francisco Joseph E. Molenda, MD
Michael L. Martini, PhD
San Francisco, California Resident Physician
Medical Student
Department of Neurosurgery Phillip G. Mendis, DO
Icahn School of Medicine at Mount Spine Medicine Associate Staff
Chicago, Illinois
Sinai Center for Spine Health
New York, New York Cleveland Clinic Arbaz Momin, BS
Cleveland, Ohio Medical Student
E. Kano Mayer, MD
Staff Physician Texas Spine & Scoliosis Lionel Metz, MD
Cleveland Clinic
Austin, Texas; Assistant Professor
Cleveland, Ohio
Affiliate Professor PM&R Department of Orthopaedic Surgery
University of Texas Dell Medical School University of California, San Francisco Eric Momin, MD
The University of Texas at Austin; San Francisco, California Clinical Instructor
Affiliate Professor Department of Neurosurgery
Texas A&M School of Medicine University of Wisconsin
Round Rock, Texas Madison, Wisconsin
List of Contributors xv
Nina Z. Moore, MD, MSE Dileep Nair, MD Jonathan Oren, MD

Associate Staff Neurosurgeon Section Head, Adult Epilepsy Associate Director Orthopaedic Spine
Cerebrovascular Center Epilepsy Center Surgery
Cleveland Clinic Foundation Cleveland Clinic Lenox Hill Hospital
Cleveland, Ohio Cleveland, Ohio New York, New York;
Assistant Professor of Orthopaedic
Dylan Morris, DO Zachary NaPier, MD
Surgery
Orthopaedic Spine Surgeon Spine Fellow
Zucker School of Medicine at Hofstra/
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Northwell
Kansas Orthopaedic Center Brigham and Women’s Hospital/
Hempstead, New York
Wichita, Kansas Massachusetts General Hospital
Boston, Massachusetts R. Douglas Orr, MD, FRCSC
Cole R. Morrissette, BA, MA
Assistant Professor of Orthopaedic
Medical Student Sean N. Neifert, BS
Surgery
Department of Orthopaedic Surgery Medical Student
Columbia University Irving Medical Department of Neurosurgery
Cleveland Clinic
Center Mount Sinai Health System
Cleveland, Ohio
Och Spine Hospital at NewYork- New York, New York
Presbyterian/Allen John E. O’Toole, MD, MS
Gregory Nemunaitis, MD
New York, New York Professor
Director of SCI Rehabilitation
Thomas E. Mroz, MD Neurological Institute
Chairman Cleveland Clinic;
Chicago, Illinois
Orthopaedic and Rheumatologic Professor of Medicine, Cleveland Clinic
Institute Learner College of Medicine Alp Ozpinar, MD
Director, Center for Spine Health Cleveland Ohio Resident Physician
Cervical Spine Surgery Department of Neurological Surgery
Adam Nessim, BS
Cleveland Clinic University of Pittsburgh Medical Center
Medical Student
Cleveland, Ohio Pittsburgh, Pennsylvania
Praveen V. Mummaneni, MD, MBA Albert Einstein College of Medicine Fortunato G. Padua, MD, MSc
Joan O’Reilly Endowed Professor Bronx, New York Research Fellow
Vice Chair of Neurosurgery Rothman Orthopaedic Institute
Tianyi Niu, MD
Co-director, UCSF Spine Center Philadelphia, Pennsylvania
Assistant Professor
Director, Spinal Deformity Surgery Paul Page, MD
Program Resident Physician
Gregory M. Mundis, MD Department of Neurosurgery Department of Neurosurgery
Co-Director San Diego Spine The Warren Alpert Medical School of University of Wisconsin
Fellowship Brown University Madison, Wisconsin
Spine Surgery Providence, Rhode Island
Paul J. Park, MD, MMS
Scripps Clinic Medical Group
John A. Norwig, MEd, ATC Resident Physician
La Jolla, California
Head Athletic Trainer Department of Orthopaedic Surgery
Tess Munoz, BS Sports Medicine Columbia University Irving Medical
Medical Student Pittsburgh Steelers Football Club Center
Department of Orthopaedic Surgery Pittsburgh, Pennsylvania Och Spine Hospital at NewYork-
Rothman Orthopaedic Institute at Presbyterian/Allen
Binnan Ong, DO, MA
Thomas Jefferson University New York, New York
Staff Physician
Spinal Cord Injuries and Disorders Vikas Parmar, MD
Sait Naderi, MD Service Resident Physician
Professor Louis Stokes Cleveland VA Medical Department of Neurosurgery
QbMed. Spine Center Center; University of Wisconsin
Istanbul, Turkey Assistant Professor, Physical Medicine Madison, Wisconsin
and Rehabilitation
Sean J. Nagel, MD Arati Patel, MD
Case Western Reserve University
Staff Surgeon Resident Physician
Cleveland, Ohio
Department of Neurosurgery Department of Neurological Surgery
Cleveland Clinic Kaine C. Onwuzulike, MD, PhD University of California, San Francisco
Cleveland, Ohio Assistant Professor of Neurosurgery San Francisco, California
Narihito Nagoshi, MD, PhD Parthik Patel, MD
Cleveland Clinic
Assistant Professor Research Fellow
Cleveland, Ohio
Department of Orthopaedics Department of Orthpaedic Surgery
Keio University School of Medicine Rothman Institute at Thomas Jefferson
Tokyo, Japan University
Tara Jayde Nail, MD
Tufts Medical Center
xvi List of Contributors
Rakesh Patel, MD Rick Placide, MD, PT Wilson Z. Ray, MD

Associate Professor Professor Professor
Chief of Spine Surgery Department of Orthopaedic Surgery Department of Neurosurgery
Department of Orthopaedic Surgery Medical College of Virginia, Virginia Washington University School of
University of Michigan Commonwealth University Medicine
Ann Arbor, Michigan Richmond, Virginia St. Louis, Missouri
Dominic Pelle, MD Andrew Platt, MD, MBA Pablo F. Recinos, MD
Assistant Professor Resident Physician Associate Professor
Spine Center Section of Neurosurgery Department of Neurological Surgery
Cleveland Clinic Department of Surgery Cleveland Clinic Lerner College of
Cleveland, Ohio University of Chicago Medicine of Case Western Reserve
Chicago, Illinois University
Enrique Peña, MD
Section Head – Skull Base Surgery
Assistant Professor Adam J. Polifka, MD
Cleveland Clinic
Department of Physical Medicine & Assistant Professor
Cleveland, Ohio
Rehabilitation Department of Neurosurgery
Dell Medical Center at the University University of Florida Violette M. Recinos, MD
of Texas Gainesville, Florida Section Head, Pediatric Neurosurgery
Staff Physician Department of Neurological Surgery
David W. Polly, MD
Texas Spine & Scoliosis Cleveland Clinic
Chief of Spine Surgery
Austin, Texas Cleveland, Ohio
Professor
Courtney Pendleton, MD Department of Orthopaedic Surgery Patrick Reid, MD
Assistant Professor Department of Neurosurgery Assistant Professor
Department of Neurosurgery Minneapolis, Minnesota Department of Neurological Surgery
Stony Brook University Columbia University
Lawrence Poree, MD, PhD, MPH
Stony Brook, New York New York, New York
Professor and Director of
Brenton Pennicooke, MD, MS Neuromodulation Jackie Renfrow, MD
Assistant Professor of Neurological Department of Anesthesia and Assistant Professor
Surgery and Orthopaedic Surgery Perioperative Care Department of Neurological Surgery
Department of Neurological Surgery University of California, San Francisco Wake Forest Baptist Health
Washington University San Francisco, California Winston-Salem, North Carolina
St. Louis, Missouri
S. Rajasekaran, MS, DNB, FRCS(Ed), Daniel K. Resnick, MD, MS
Zach Pennington, BS M.Ch(Liv), FACS, FRCS(Eng), PhD Professor and Vice Chairman
Medical Student Chairman Department of Neurosurgery
Department of Neurosurgery Department of Orthopaedics and Spine University of Wisconsin School of
Johns Hopkins Hospital Surgery Medicine and Public Health
Baltimore, Maryland Ganga Medical Centre and Hospitals Madison, Wisconsin
Coimbatore, Tamilnadu, India
Mick J. Perez-Cruet, MD, MSc Tina Resser, MSN, ACNP-BC, FNP-
Vice Chairman and Professor Richard Rammo, MD BC, CNRN
Department of Neurosurgery Fellow Nurse Practitioner
Oakland University William Beaumont Department of Neurosurgery Cerebrovascular Center
Medical School Cleveland Clinic Cleveland Clinic Foundation
Beaumont Health System Cleveland, Ohio Cleveland, Ohio
Royal Oak, Michigan
Jonathan J. Rasouli, MD Laurence D. Rhines, MD
Graysen R. Petersen-Fitts, MD Associate Staff Neurosurgeon Professor
Department of Orthopaedic Surgery Department of Neurosurgery Department of Neurosurgery
Beaumont Hospital Cleveland Clinic Division of Surgery
Royal Oak, Michigan Cleveland, Ohio The University of Texas MD Anderson
Cancer Center
Thomas A. Peterson, PhD John K. Ratliff, MD
Houston, Texas
Assistant Adjunct Professor Professor
Department of Orthopaedic Surgery Department of Neurosurgery Dusty Richardson, MD
Bakar Computational Health Sciences Stanford University Department of Neurosurgery
Institute Stanford, California Billings Clinic
University of California, San Francisco Billings, Montana
Jeremy J. Rawlinson, PhD
Distinguished Scientist Ron Riesenburger, MD
Joshua Piche, MD Technical Fellow - Cranial and Spinal Director, Spine Center
Resident Physician Technologies, Medtronic Department of Neurosurgery
Department of Orthopaedic Surgery Memphis, Tennessee; Tufts Medical Center, Tufts University
University of Michigan Adjunct Professor School of Medicine
Ann Arbor, Michigan Department of Mechanical Engineering Boston, Massachusetts
Polytechnique Montreal
List of Contributors xvii
Sarah Rispinto, PhD Zaid Salaheen, BSc Eric Schmidt, MD

Staff Psychologist Medical Student Center for Spine Health
Center for Comprehensive Pain Recovery University of Toronto Department of Neurosurgery
Neurological Institute Toronto, Ontario, Neurologic Institute, Cleveland Clinic
Cleveland Clinic Canada Foundation
Cleveland, Ohio Cleveland, Ohio
Dino Samartzis, DSc
Joshua Rivera, BA Associate Professor of Orthopaedic Meic H. Schmidt, MD, MBA
Clinical Research Coordinator Surgery Professor and Chair of Neurosurgery
Department of Neurological Surgery Director, International Spine Research New York Medical College
University of California, San Francisco and Innovation Initiative Director, Brain and Spine Institute and
San Francisco, California Rush University Medical Center Director of Neurosurgery
Chicago, Illinois Westchester Medical Center
Richard Wayne Rosenquist, MD
Director of Neurosciences
Chairman Amer F. Samdani, MD
WMC Health Network
Department of Pain Management Chief of Surgery
Valhalla, New York
Cleveland Clinic Department of Neurosurgery
Cleveland, Ohio Shriners Hospitals for Children Frank J. Schwab, MD
Philadelphia, Pennsylvania Chief Emeritus of HSS Spine
Lindsey Ross, MD
Hospital for Special Surgery
Faculty Neurosurgeon Rahul G. Samtani, MD
New York, New York
Department of Neurosurgery Clinical Spine Surgery Fellow
Cedars-Sinai Medical Center Department of Orthopaedic Surgery Daniel M. Sciubba, MD
Los Angeles, California University of California, San Francisco Professor
San Francisco, California Departments of Neurosurgery,
Vincent Rossi, MD
Oncology, Orthopaedic Surgery, and
Resident Physician Rick Sasso, MD
Radiation Oncology
Department of Neurological Surgery Professor
Director, Spine Tumor and Spine
Atrium Health Department of Orthopaedic Surgery
Deformity Research
Charlotte, North Carolina Indiana University School of Medicine
Chief of Spine Surgery
Samuel S. Rudisill, BS Medicine
Indiana Spine Group
Research Assistant Baltimore, Maryland
Indianapolis, Indiana
Jonathan N. Sellin, MD
Division of Spine Surgery Alexander M. Satin, MD
Neurosurgeon
Rush University Medical Center Spine Surgeon
Neurosurgical Group of Texas
Chicago, Illinois Texas Back Institute
Houston, Texas
Plano, Texas
Paul Ruggieri, MD
Elias Shaaya, MD
Department of Radiology Jason W. Savage, MD
Cleveland Clinic Staff Spine Surgeon
Rhode Island Hospital
Cleveland Ohio Center for Spine Health
The Warren Alpert Medical School of
Cleveland Clinic
Won Hyung A. Ryu, MD, MSc, MTM Brown University
Cleveland, Ohio
Fellow Providence, Rhode Island
Department of Neurological Surgery Paul D. Sawin, MD
Saman Shabani, MD
Rush University Neurological Surgeon
Neurosurgery Resident
Chicago, Illinois AdventHealth Neuroscience Institute
Winter Park, Florida
Victor Sabourin, MD Medical College of Wisconsin
Resident Physician Andrew N. Sawires, MD Wauwatosa, Wisconsin
Department of Neurosurgery Resident Physician
Christopher I. Shaffrey, MD
Thomas Jefferson University Hospital Department of Orthopaedic Surgery
Philadelphia, Pennsylvania Lenox Hill Hospital
Chief, Spine Division
New York, New York
Michael M. Safaee, MD Duke University Medical Center
Resident Physician Aenor Sawyer, MD Durham, North Carolina
Department of Neurological Surgery Assistant Clinical Professor
Ganesh M. Shankar, MD, PhD
University of California, San Francisco Department of Orthopaedic Surgery
Assistant Professor
San Francisco, California University of California, San Francisco
Mina Safain, MD Massachusetts General Hospital
Assistant Professor of Neurosurgery Bradley T. Schmidt, MD Boston, Massachusetts
Tufts University School of Medicine Neurological Surgery Resident
Jianning Shao, BA
Attending Neurosurgeon Department of Neurological Surgery
Medical Student
Tufts Medical Center/Melrose- University of Wisconsin
Wakefield Hospital Madison, Wisconsin
Cleveland Clinic
Cleveland, Ohio
xviii List of Contributors
Alok D. Sharan, MD, MHCDS Gabriel A. Smith, MD Yoshiki Takeoka, MD, PhD
Director, Spine and Orthopaedics Neurosurgeon Research Fellow
NJ Spine and Wellness Department of Neurological Surgery Department of Orthopaedic Surgery
Matawan, New Jersey University Hospitals Cleveland Medical Brigham and Women’s Hospital
Center Boston, Massachusetts
Jeremy D. Shaw, MD
Cleveland, Ohio
Assistant Professor Claudio E. Tatsui, MD
Department of Orthopaedic Surgery John T. Smith, MD Associate Professor of Neurosurgery
University of Pittsburgh The Mary Scowcroft Peery Presidential Department of Neurosurgery
Pittsburgh, Pennsylvania Endowed Chair in Orthopaedics The University of Texas MD Anderson
Chief Scoliosis Service Cancer Center
Jian Shen, MD, PhD
Professor Houston, Texas
Spine Surgeon
Shen-Spine Nahom Teferi, MD
University of Utah
New York, New York Resident Physician
Salt Lake City, Utah
Kartik Shenoy, MD
Justin S. Smith, MD, PhD University of Iowa Hospitals and
Orthopaedic Spine Surgeon
Vice Chair and Chief of Spine Division Clinics
Harrison Distinguished Professor of Iowa City, Iowa
Nellis Air Force Base
Neurosurgery
Las Vegas, Nevada Albert E. Telfeian, MD, PhD
University of Virginia
Director, Department of Neurosurgery
Ajoy Prasad Shetty, MS, DNB Charlottesville, Virginia
Center for Minimally Invasive
Senior Consultant
Robert J. Spinner, MD Endoscopic Spine Surgery
Chair Rhode Island Hospital
Ganga Medical Center and Hospitals
Department of Neurologic Surgery The Warren Alpert Medical School of
Coimbatore, Tamilnadu, India
Burton M. Onofrio, MD Professor of Brown University
John H. Shin, MD Neurosurgery Providence, Rhode Island
Director, Spine Oncology and Spinal Professor
Nicholas Theodore, MD
Deformity Surgery Departments of Anatomy, Neurologic
Professor of Neurosurgery, Orthopaedic
Department of Neurosurgery Surgery, and Orthopaedic Surgery
Surgery & Biomedical Engineering
Massachusetts General Hospital Mayo Clinic
Boston, Massachusetts Rochester, Minnesota
Steven J. Shook, MD, MBA Morgan P. Spurgas, MD Medicine
Staff, Neuromuscular Center Resident Physician Director, Neurosurgical Spine Center
Neurological Institute Department of Neurosurgery Co-Director, Carnegie Center for
Cleveland Clinic Albany Medical College Surgical Innovation
Cleveland, Ohio Albany, New York Johns Hopkins University
Baltimore, Maryland
Harminder Singh, MD, FACS, FAANS Anthony J. Stefanelli, MD
Assistant Professor of Neurosurgery Resident Physician Alekos A. Theologis, MD
Department of Neurosurgery Department of Neurological Surgery Assistant Professor
Stanford University School of Medicine Thomas Jefferson University Department of Orthopaedic Surgery
Stanford, California Philadelphia, Pennsylvania University of California, San Francisco
Rahul Singh, MD Michael P. Steinmetz, MD
Comprehensive Spine Fellow William P. and Amanda C. Madar Nishanth Thiyagarajah, MS
Clinical Instructor Endowed Professor and Chair Student Researcher
Department of Neurosurgery Department of Neurosurgery Cerebrovascular Center, Neurological
Stanford University Cleveland Clinic Lerner College of Institute
Palo Alto, California Medicine Cleveland Clinic Main Campus
Director Center for Spine Health Cleveland, Ohio;
Ethan Sissman, MD
Neurological Institute Medical Student
Division of Spine Surgery
Cleveland, Ohio University of Louisville School of
Medicine
NYU Langone Health Swetha J. Sundar, MD
Louisville, Kentucky
New York, New York; Resident Physician
Division of Orthopaedic Surgery Department of Neurological Surgery Brian D. Thorp, MD, FACS
Tel-Hashomer “Sheba” Medical Center Cleveland Clinic Associate Professor
Ramat Gan, Israel Cleveland, Ohio Department of Otolaryngology/Head
and Neck Surgery
Zakariah K. Siyaji, BS Ishaan Swarup, MD
The University of North Carolina
Orthopaedic Spine Research Fellow Assistant Professor of Clinical
Chapel Hill, North Carolina
Department of Orthopaedic Surgery Orthopaedic Surgery
Division of Spine Surgery Department of Orthopaedic Surgery
Rush University Medical Center University of California, San Francisco
Chicago, Illinois San Francisco, California
List of Contributors xix
Vincent C. Traynelis, MD Alexander R. Vaccaro, MD, PhD, MBA Sarel J. Vorster, MD, MBA
Professor Professor Staff Surgeon
Department of Neurosurgery Department of Orthopaedic Surgery Department of Neurological Surgery
Rush University Medical Center Rothman Orthopaedic Institute at Cleveland Clinic
Chicago, Illinois Thomas Jefferson University Clinical Assistant Professor
Philadelphia, Pennsylvania Department of Neurological Surgery
Gregory R. Trost, MD
Professor and Vice-Chair Alison M. Vargovich, PhD
Medicine at Case Western Reserve
Department of Neurological Surgery Clinical Assistant Professor
University
Director, Spinal Surgery Program Department of Medicine
Cleveland, Ohio
University of Wisconsin School of University at Buffalo, SUNY
Medicine and Public Health Buffalo, New York Corey T. Walker, MD
Madison, Wisconsin Resident Physician
Sasha Vaziri, MD
Huy Q. Truong, MD Resident Physician
Barrow Neurological Institute
Fellow Lillian S Wells Department of
Phoenix, Arizona
Department of Neurosurgery Neurosurgery
Medical College of Wisconsin University of Florida Daniel J. Wallace, MD
Milwaukee, Wisconsin Gainesville, Florida Professor of Medicine
Associate Director, Rheumatology
John T. Tsiang, MD Anand Veeravagu, MD
Fellowship Program
Resident Physician Assistant Professor
Board of Governors
Department of Neurological Surgery Department of Neurosurgery
Cedars-Sinai Medical Center
Loyola University Health System Stanford University
David Geffen School of Medicine at
Maywood, Illinois Stanford, California
UCLA
Luis M. Tumialán, MD Michael Venezia, DO, MPH Los Angeles, California
Associate Professor of Neurological Orthopaedic Spine Fellow
Anthony C. Wang, MD
Surgery Department of Orthopaedic Surgery
Assistant Professor
Department of Neurosurgery University of California, San Francisco
Barrow Neurological Institute San Francisco, California
University of California, Los Angeles
St. Joseph’s Hospital and Medical
Kushagra Verma, MD, MS, FAAOS Los Angeles, California
Center
Department Orthopaedic Surgery
Phoenix, Arizona Jeffrey C. Wang, MD
MemorialCare Long Beach Medical
Co-Director, USC Spine Center
Zane A. Tymchak, MD, FRCSC Center
Professor of Orthopaedics and
Complex Spine Surgeon Long Beach, California;
Neurosurgery
Neurovascular Surgeon Clinical Assistant Professor Surgery
University of Southern California Spine
Division of Neurosurgery Western University of Health Science
Center
University of Saskatchewan Pomona, California
Keck School of Medicine at The
Saskatoon, Saskatchewan, Canada
Brandon Vilarello, BA University of Southern California
Unni Udayasankar, MD Medical Student Los Angeles, California
Professor of Radiology Vagelos College of Physicians and
Marjorie C. Wang, MD, MPH
Department of Medical Imaging Surgeons
University of Arizona College of Columbia University
Medicine New York, New York
Director, Spine Service Line
Tucson, Arizona
Stephanus V. Viljoen, MD Froedtert/Medical College of Wisconsin
Daniel Umansky, MD Department of Neurological Surgery Milwaukee, Wisconsin
Clinical and Research Fellow The Ohio State University
Michael Y. Wang, MD, FACS, FAANS
Department of Clinical Neurosciences Columbus, Ohio
Professor of Neurological Surgery and
University of Calgary Cumming School
Vibhu Krishnan Viswanathan, MS, Rehabilitation Medicine
of Medicine
DNB Miller School of Medicine, University
Hotchkiss Brain Institute
Associate Consultant of Miami
Calgary, Alberta, Canada
Department of Spine Surgery Chief of Neurosurgery
Juan S. Uribe, MD Ganga Medical Center and Hospital Director, Neurosurgical Spine
Chief, Division of Spinal Disorders Coimbatore, Tamilnadu, India Fellowship
Professor and Vice Chair University of Miami Hospital
Josephine Volovetz, MD, MS
Volker K.H. Sonntag Chair of Spine Miami, Florida
Resident Physician
Research
Department of Neurosurgery Xiaoyu Wang, PhD
Cleveland Clinic Department of Mechanical Engineering
Barrow Neurological Institute
Cleveland, Ohio Polytechnique Montreal
St. Joseph’s Hospital and Medical
Sainte-Justine University Hospital
Center
Center
Phoenix, Arizona
xx List of Contributors
Stuart L. Weinstein, MD, ABOS Michelle Williams, MD Michael Yang, MD

Ignacio V. Ponseti Chair and Professor Resident Physician Department of Neurosurgery
of Orthopaedic Surgery Department of Neurological Surgery Tufts Medical Center
Orthopaedic Surgery Wake Forest Baptist Health Boston, Massachusetts
Professor of Pediatrics Winston-Salem, North Carolina
Samir G. Yezdani, MD
Univerisity of Iowa Healthcare
James R. Wilson, DO Research Specialist
Iowa City, Iowa
Director of Spinal Cord Injury Department of Clinical Research
Michael H. Weisman, MD Medicine Shriners Hospitals for Children
Adjunct Professor of Medicine MetroHealth Rehabilitation Institute Philadelphia, Pennsylvania
Stanford University School of Medicine MetroHealth System;
Narayan Yoganandan, PhD
Distinguished Professor of Medicine Assistant Professor
Emeritus Physical Medicine and Rehabilitation
David Geffen School of Medicine at Case Western Reserve University
UCLA Cleveland, Ohio
Professor of Medicine Emeritus Yagiz Yolcu, MD
Leslie Wilson, PhD
Cedars-Sinai Medical Center Department of Neurologic Surgery
Professor
Los Angeles, California Mayo Clinic
Department of Pharmacy and Medicine
Karen Weissmann, MD University of California, San Francisco
Department of Orthopaedic Surgery San Francisco, California Robin Young, BAS, MBA
Universidad de Chile Founder and CEO
Timothy Witham, MD
Chief of the spine Surgery Department PearlDiver Technologies, Inc.
Professor of Neurosurgery and
Redsalud Publisher and Editor
Orthopaedic Surgery
MEDS RRY Publications, LLC
Lansdale, Pennsylvania
Kelly Wentworth, MD Johns Hopkins University
Adjunct Assistant Professor Baltimore, Maryland Adam Zanation, MD, FACS
Department of Medicine, Division of Distinguished Professor
Christopher E. Wolfla, MD
Endocrinology Department of Otolaryngology/Head
University of California, San Francisco, and Neck Surgery
Zuckerberg San Francisco General University of North Carolina–Chapel Hill
Hospital Chapel Hill, North Carolina
Aqib Zehri, MD
Jean-Paul Wolinsky, MD
Benjamin Whiting, MD Resident Physician
Professor of Neurosurgery and
Resident Physician Department of Neurosurgery
Orthopaedic Surgery
Department of Neurosurgery Wake Forest Baptist Health
Vice Chairman of Neurosurgery –
Cleveland Clinic Winston-Salem, North Carolina
Strategic Planning and Finance
Cleveland, Ohio
Director of Spinal Oncology Mehmet Zileli, MD
Robert G. Whitmore, MD Department of Neurosurgery Professor of Neurosurgery
Assistant Professor Northwestern University Feinberg Ege University
Department of Neurosurgery School of Medicine Izmir, Turkey
Tufts University School of Medicine Chicago, Illinois
Boston, Massachusetts, Director of
Eric J. Woodard, MD
Spinal Surgery
Chief of Neurosurgery
Lahey Hospital and Medical System
New England Baptist Hospital
Burlington, Massachusetts
Joseph Wick, MD
Hao-Hua Wu, MD
Resident Physician
Orthopaedic Surgery Resident
University of California, Davis
Sacramento, California
Preface
It was stated in the front matter of the second edition of this ensuing decision-making process involves the resolution (or
book that the second edition “was bigger and better than the the attempts at such) of many technical and quality-of-life–
first.” The same was true for the third edition. The fourth edi- related issues and dilemmas. A surgical procedure may be war-
tion was, without question, much bigger and better than the ranted if the sum of the costs (both financial and personal)
third. The fourth edition was unique in that Mike Steinmetz and risks is less than the sum of the benefits. Appropriate care
coedited the book with Ed Benzel, and the name of the is based on rational choices, and an informed assessment of
book was changed, with “Benzel’s” being added to the title the expected benefits of care compared with the expected risks
(Benzel’s Spine Surgery: Techniques, Complication Avoidance and of care. This risk/benefit analysis is of paramount concern and
Management), an honor that is treasured by the senior author. should be emphasized by the surgeon and realized by the
So, what can we say about the fifth edition? Well, first of patient. This book is designed to help surgeons achieve these
all, we added another editor, Sigurd Berven. This addition led goals, by minimizing the risk-taking component and by maxi-
to many other changes. With his input, the book was radically mizing the benefit component of this “equation.”
restructured, with many changes in flow and authorship and,
perhaps most importantly, the addition of multiple new era–
appropriate chapters. Knowledge and information regarding
REPETITION
the appropriate management of spinal disorders continues We learn most effectively by having data presented in a repeti-
to grow, and our textbook endeavors to keep up with rapid tive manner, often from different perspectives, using differ-
changes in the field of spine surgery. The authors contributing ing techniques. A true understanding of a concept or body of
to the fifth edition have been leaders in development of knowledge involves the spiral of learning, which often involves
techniques and evidence-based approaches to the spine. multiple exposures to information so that a solid database
Our mission has not changed from the first to this, the fifth, (foundation of knowledge) is acquired. New (raw) data are
edition. Our mission is to assist the spine surgeon to avoid, then added and assimilated. This “expanded” knowledge base
identify, and manage complications. This edition remains a can then be applied to, and enhanced by, additional basic sci-
techniques book but provides much, much more, as did the ence, clinical input, and applications. This entire process is
fourth edition. In addition to highlighting the “how to’s,” and perpetually refined and reshaped by new experiences, such
providing significant discussion regarding the “when to’s,” the as clinical encounters or through reading and other sources
“when not to’s,” and the “whys” associated with the decision- of learning (Fig. 1). Repetition is the mother of learning.
making process, this edition adds additional dimensions, Repetition is, indeed, good—very good.
specifically associated with data assessment and clinical
paradigm shifts.
Decision making is, as it has been from the first edition
WHAT IS A COMPLICATION?
on, the central focus of this text. Decision making is facilitated The definition of what constitutes a complication is usually
by understanding both the triumphs and the mistakes of unclear and often the subject of debate. In a way, it’s like por-
our predecessors. Informed choice requires information on nography: “I cannot define it, but I know it when I see it.”
expected outcomes of nonoperative care, observed outcomes
of operative care, and patient and provider preferences and I shall not today attempt further to define the kinds of material
values. This book focuses on ethics, logic, nonoperative I understand to be embraced within that shorthand description
management, and controversies, with the goal of empowering [“hard-core pornography”]; and perhaps I could never succeed
the reader to make informed decisions and to engage in in intelligibly doing so. But I know it when I see it, and the
informed discussions regarding choice. motion picture involved in this case is not that.
The fundamentals are emphasized. The foundational Justice Potter Stewart, concurring opinion in Jacobellis v.
disciplines of anatomy, physiology, and physics, as well as the Ohio 378 U.S. 184 (1964), regarding possible
latter’s progeny, biomechanics, provide the foundation for all obscenity in The Lovers.
we do as spine surgeons. We focus on this foundation in our
practices and have striven to do so in the pages that follow. Perhaps complications and pornography alike do not
The six sections of the textbook are organized to include require strict definition, which may be too confining and, in
foundations and principles, pathophysiology of specific the case of complications, detract from the purpose of focusing
disorders of the spine, and the evaluation and management on its mitigation—that is, doing what’s right!
of spinal disorders, with an emphasis on techniques and In the prefaces to the prior editions of this book, reference
complications, with the final section focusing on how our was made to the Canada thistle as both a weed and a flower. To
community of physicians and scientists who care for patients some it is a weed, and to others it is considered a flower. On the
with spinal disorders may design future studies to further our one hand, it is an invasive and predatory plant that displaces
knowledge. and suffocates crops, whereas on the other hand, it is beautiful
in full bloom (Fig. 2). To the spine surgeon, the patient, and
RISK TAKING the attorney, a complication has different meanings, and often
different consequences. Postoperative pain (as subjective
Surgery is a risk-taking endeavor. The patient places as it may be) may not be considered a complication by the
himself or herself in the hands of the surgeon, and the surgeon. It may be perceived as annoying or even as a source
xxi
xxii Preface
Experience
Experience
Experience
Clinical application
Basic science application
Raw data Fig. 2. The Canada thistle.
Baseline knowledge the field in the pages that follow. These experts themselves
are not infallible. They address complications with which
they have had firsthand experience. We must seize the
opportunity to benefit from their wisdom and experience. A
wise person can learn from the observations and mistakes of
Fig. 1. The spiral of learning. others.
Like a Canada thistle, a complication implies different
of substantial distress to the patient. Conversely, it may be things to different people. We must put complications in their
viewed as a source of revenue, and therefore joy by a plaintiff appropriate perspective by clarifying their definition as they
attorney. Beauty is clearly in the eye of the beholder, and, pertain to the situation at hand. We should then actively avoid
without question, ugly is indeed a matter of perception and them and aggressively identify and manage them when they
perspective. do occur.
Thus the definition of a complication is not as clear as
outsiders (e.g., the lay public and the legal system) often believe,
or want to believe, is the case. With all this in mind, and in the
BIAS AND CONFLICT OF INTEREST
best interest of our patients, we should attain and maintain Bias and conflicts of interest can skew and pervert objectiv-
objectivity. The writings of Francis Weld Peabody from the ity. Please remember as you read the pages that follow that
early 20th century in his essay “The Art of Medical Care and all of us (including the contributors to this book) are biased
Caring” remain a priority: “One of the essential qualities of the and conflicted. It is literally impossible not to harbor biases.
clinician is interest in humanity, for the secret of the care of the Some are more obvious than others. Nevertheless, as with
patient is in caring for the patient.” We should not be swayed the definition of complications, the definition of bias and
by uneducated or undeserved accolades from the medically conflict of interest is often unclear. The value and driving
naive, or by threats from entrepreneurs or the devious. principles that the editors and contributors to the textbook
Complications must be defined to the best of our ability, share is to prioritize the patient and compassionate care for
avoided when possible, and aggressively managed when they the patient.
occur. Their avoidance, identification, and management should Finally, the fifth edition begins a new era for this book. It
not be charged with emotion and anger, but rather attacked involves reorganization-related improvements, reorganized
with an armamentarium of logic, thoughtfulness, science, and editorship, and improvements that come with an evolving
objectivity. Francis Moore wrote that “accountability for the maturation of the medical writing and editorial process.
results of care is the most fundamental requirement of the Please read, enjoy, and employ the messages and information
healthcare provider.” Although it may be impossible to avoid imparted.
all complication in spine surgery, we must be accountable and
responsible for how we manage our complications. Michael P. Steinmetz
The avoidance, identification, and management of the Sigurd H. Berven
complications of spine surgery are addressed by experts in Edward C. Benzel
1
PART
1 Fundamentals of the Spine
1 History of Spine Surgery

Sait Naderi, Edward C. Benzel
SUMMARY OF KEY POINTS

• A lthough most advances in spine surgery occurred with spinal disorders. They in fact used frames for reduction
in the 19th and 20th centuries, their roots date back of dislocation and gibbus (i.e., kyphosis) and applied some of
several thousand years. During the antique period, the knowledge gained from human and animal dissections.
some special spine disorders were described and Srimad Bhagwat Mahapuranam, an ancient Indian epic
treated using drugs and orthotics. (3500–1800 bce), depicts the oldest documentation of spinal
traction. A passage from this document describes how Lord
• The Greco-Roman age was associated with a better Krishna applied axial traction to correct a hunchback in one
understanding of spinal disorders and their treatment. of his devotees.1
Hippocrates and Galen were the most known figures The Edwin Smith Papyrus (2600–2200 bce) is the most
of this period. well-known document on Egyptian medicine. This document
• There was limited advancement during the Middle Ages. reports 48 cases. Imhotep (2686–2613 bce), a late second-
• Further advancements were made during the dynasty surgeon, authored this papyrus, which reported six
Renaissance. Many scientists contributed to the body cases of spinal trauma. Hence, nearly 4600 years ago vertebral
of knowledge in the fields of anatomy, neuroscience, subluxation and dislocation and traumatic quadriplegia and
and biomechanics during and after the Renaissance. paraplegia were described.2 In the early 21st century, it was
reported that Egyptian physicians described the “spinal djet
• Many technological advancements occurring since column concept.”3
the 1800s have also contributed to the spine-related Antique-period medicine was also influenced by the
sciences. Greco-Roman–period physicians.4 Hippocrates (460–375 bce)
• Finally, an understanding of spine biomechanics addressed the anatomy and pathology of the spine, describing
and metallurgy, as well as the use of imaging and the the normal curvatures of the spine, its structure, and the
microscope in spine care, have improved the surgeon’s tendons attached to it. He defined tuberculous spondylitis,
ability to perform spine surgery more safely and posttraumatic kyphosis, scoliosis, spinal dislocation, and
effectively. spinous process fracture. He addressed the relationship
between spinal tuberculosis and gibbus. According to
Hippocrates, spinous process fracture was not dangerous.
However, fractures of the vertebral body were more important.
The evolution of spine surgery has revolved around three He described two frames for reduction of the dislocated spine,
basic surgical goals: decompression, surgical stabilization, and including the Hippocratic ladder and the Hippocratic board.5
deformity correction. To emphasize their importance, these The details of Hippocratic treatment were recorded by Aulus
surgical goals form the framework for this chapter. However, Cornelius Celsus (25 bce–50 ce).
other related fundamental arenas—such as anatomy, biome- Aristotle (384–322 bce) focused on kinesiology. His
chanics, and nonsurgical treatment modalities—have contrib- treatises—“parts of animals, movement of animals, and
uted to the development of surgical concepts as well. progression of animals”—described the actions of the muscles.
Although most advances in spine surgery occurred in He analyzed and described walking, in which rotatory motion
the 19th and 20th centuries, their roots date back several is transformed into translational motion. Although his studies
thousand years. Without understanding and appreciating were not directly related to the spine, they were the first to
the past, it is not possible to understand and appreciate address human kinesiology and, in fact, biomechanics.6
the advancements of the past two centuries. Therefore, Galen of Pergamon (130–200 ce), another physician of the
before touching on the history of the spine over the past antique era, worked as a surgeon and anatomist. He studied
two centuries, this chapter presents a short examination of the anatomy of animals and extrapolated his findings to
spine medicine from the antique period, medieval period, human anatomy. His anatomic doctrines became the basis
and Renaissance. for medical education for more than 1200 years. He used the
terms kyphosis, scoliosis, and lordosis, and he attempted to correct
ANTIQUE PERIOD AND SPINE SURGERY these deformities. He also worked as the official surgeon of
gladiators in amphitheaters. Because of this position, he was
There is no evidence of surgical decompression and stabiliza- accepted as “the father of sports medicine.” He confirmed
tion or the surgical correction of deformity during the antique the observations of Imhotep and Hippocrates regarding the
period, except for laminectomy in a trauma case reported by neurological sequences of cervical spine trauma. Nevertheless,
Paulus of Aegina. However, it is known that physicians of the to the best of our knowledge, he did not operate for spinal
antique period were, to some extent, able to evaluate patients trauma.6,7
1
2 PART 1 Fundamentals of the Spine
Serefeddin Sabuncuoglu (1385–1468 ce), a Turkish

physician of the 15th century, wrote an illustrated atlas of
surgery,15 in which he described scoliosis, sciatica, low back
pain, and spinal dislocations. He delineated a technique for
reduction of spinal dislocations using a frame similar to that
designed by Abulcasis.
RENAISSANCE AND SPINE SURGERY

Gradually, the intellectual doldrums of the Dark Ages in
Europe evolved into the Renaissance. Academic centers were
established in Europe, as well as centers for the translation of
documents, similar to centers established in Islamic regions.
Thus the classics from the antique age were translated into
Latin from Arabic, making their scientific information avail-
able to the scholars and physicians of the Renaissance. During
this time, the Western world spawned disciplines, including
art, medicine, physics, and mathematics.
The works of Leonardo da Vinci (1452–1519 ce) are of
importance in this regard. Da Vinci worked on the philosophy
of mechanics and on anatomy in De Figura Humana. He
described spine anatomy, the number of vertebrae, and
the joints in detail. By studying anatomy in the context of
Fig. 1.1. Avicenna. mechanics, da Vinci gained some insight into biomechanics.
He considered the importance of the muscles for stability
in the cervical spine. However, his work was unpublished
Oribasius (325–400 ce), another physician of the antique for centuries, and his brilliant daydreaming had a limited
period, added a bar to the Hippocratic reduction device and scientific influence on biomechanics.16,17
used it to treat both spinal trauma and spinal deformity.8,9 Andreas Vesalius (1514–1564 ce), an anatomist and
One of the most important figures dealing with spinal physician, wrote his famous anatomy book, De Humani
disorders during the end of this period was Paulus of Aegina Corporis Fabrica Liberi Septum, which changed several
(625–690 ce). He collected what was known from the previous doctrines described by Galen. Actually, it took several
1000 years in a seven-volume encyclopedia. Paulus of Aegina centuries for the world to accept that Galen had made errors
not only used the Hippocratic bed, but also worked with a that Vesalius corrected. Because he described and defined
red-hot iron. He is credited with performing the first known modern anatomy, he is commonly accepted as the “father of
laminectomy. This was performed for a case of spinal fracture anatomy.” He described the spine, intervertebral discs, and
resulting in spinal cord compression. He emphasized the use intervertebral foramina. His biomechanical point of view
of orthoses in spinal trauma cases.6,10 regarding the flexion extension of the head was similar to
that of Avicenna.18
The early anatomic studies and observations were followed
MEDIEVAL PERIOD AND SPINE SURGERY by biomechanical advancements. Prominent among the
The studies and reports of Paulus of Aegina are the most contributors to those advancements was Giovanni Alfonso
important sources of information regarding this period of Borelli (1608–1679 ce), who described the biomechanical
medicine.11 This age was followed by the Dark Ages (ca. 500– aspects of living tissue. He is the founder of the “iatrophysics”
1000 ce) in Europe. Although Western medicine showed no concept—a term that subsequently became known as
progress during the Dark Ages, the Eastern world developed biomechanics. He is accepted as the “father of spinal
the science. The early Islamic civilizations realized the impor- biomechanics.” His book, De Motu Animalium, describes the
tance of science and scientific investigation. The most impor- movements of animals. He wrote that the intervertebral disc
tant books of the antique age were translated into Arabic and is a viscoelastic material that carries loads; he observed that
Persian. Therefore using the Western doctrines, the Islamic muscles could not bear the loads alone, so he concluded that
civilizations discovered new information and were able to the intervertebral discs had a function in load-bearing. He
contribute further. In terms of spine medicine, several impor- was the first scientist to describe the human weight center
tant contributors, including Avicenna and Abulcasis, added to (center of gravity).19,20
this movement. The studies and accomplishments of the Renaissance
Avicenna (981–1037 ce), a famous physician from present- period were not limited to the aforementioned. Many scientists
day Uzbekistan, worked in all areas of medicine (Fig. 1.1). contributed to the body of the literature in this period. The
His famous book, the Canon of Medicine, was a seminal advancements from this period resulted in the formation of
textbook until the 17th century in Europe. He described the early modern surgery, beginning in the 19th century.
biomechanics-related anatomy of the spine, as well as flexion,
extension, lateral bending, and axial rotation of the spine.12
Avicenna also used a traction system similar to the system
EARLY MODERN PERIOD AND SPINE SURGERY
described by Hippocrates.13 Many developments and inventions contributed to the prog-
Abulcasis (936–1013 ce), a famous Arabian surgeon of the ress and evolution of spine surgery (Box 1.1). Each of these
11th century, wrote a surgery treatise, “At-Tasnif.” He described steps had an important impact on the improvement of spine
several surgical disorders, including low back pain, sciatica, health care and inspired other developments. Advances in
scoliosis, and spinal trauma. He recommended the use of nursing care, anesthesiology, and asepsis and antisepsis, as
chemical or thermal cauterization for several spinal disorders. well as the development of antibiotics, increased the braveness
He also developed a device to reduce the dislocated spine.14 of surgeons to do surgery. The improvement of spine imaging
History of Spine Surgery 3
BOX 1.1 Developments and Inventions Contributing to 1

Spine Surgery
Developments in anesthesiology
Developments in nursing care
Developments in asepsis and antisepsis
Developments in radiodiagnostics
Development of metallurgy
Invention of spine instruments
Invention of biomaterials
Understanding of spine biomechanics
assisted with the diagnosis of spinal disorders. Developments

in surgical techniques and instrumentation improved surgical
techniques of spinal disorders.21-23 The early modern period
continued with many more developments and inventions—
particularly in the fields of metallurgy, biomaterials, biome-
chanics, and imaging—after the 1960s. This period continued
with the progression of minimally invasive techniques.24
Spinal Decompression and the Early Modern

Period Fig. 1.2. First page of HJ Cline Jr.’s historic laminectomy, as reported
by G Hayward. (From Cline HJ Jr [cited by Hayward G]. An account
Although an open decompression of the spinal canal for spi- of a case of fracture and dislocation of the spine. N Engl J Med Surg.
nal cord compression was recommended by some surgeons 1815;4:13.)
as early as the 16th and 18th centuries (e.g., Pare, Hildanus),
there is no evidence of successful intervention except for a case
reported by Paulus of Aegina before the 19th century.
Spinal decompression in the early modern period was well-publicized operation for a traumatic spinal injury
primarily via laminectomy. Throughout most of the 19th stimulated a heated debate over the “possibility” of spine
century, laminectomy was developed and its utility debated surgery that persisted for nearly a century. At the center
as the only surgical approach to all spinal pathologies, of this debate was HJ Cline, Jr., a little-known British
including tumor, trauma, and infection. At the dawn of the surgeon.
20th century, the indications for laminectomy were extended In 1814, Cline performed a multilevel laminectomy for
to the decompression of spinal degenerative disease, an a thoracic fracture-dislocation associated with signs of a
understanding of which had eluded 19th-century surgeons complete paraplegia (Fig. 1.2).26 The patient was a 26-year-
because they failed to appreciate the connection between its old man who fell from the top of a house. “He was bled
clinical and pathological manifestations. previous to his admission” to St. Thomas’s Hospital in
During the 19th century, spine surgery was performed London, “and some imprudent attempts were made to
almost exclusively for neural element decompression. relieve him by pressing the knees against the injured part,
Numerous nonoperative approaches to deformity correction which only increased the pain and inflammation.”26 Upon
were attempted over the centuries, but the surgical approach admission to the hospital the patient was examined by Cline,
to deformity correction was a 20th-century development. who “ascertained that some of the spinous processes . . . were
The techniques of spinal stabilization were also a product of broken off and were pressing upon the spinal marrow . . .
the 20th century—both spinal fusion and internal fixation [and] who resolved to cut down and remove the pressure
appearing around the turn of the 20th century. Moreover, from the spinal marrow.”26
a failure to recognize the implications for treatment of The patient was observed overnight in the hospital, and on
degenerative spinal disease, including spondylosis and the day following admission, Cline performed his proposed
degenerative disc disease, meant that the solution to these operation. Although the operation was performed within 24
problems had to wait for the new century. hours of injury, Cline was unable to reduce the dislocation or to
Thus during the 19th century, the indications for spine achieve a complete decompression of the neural elements. The
surgery were limited to the treatment of tumor, trauma, patient survived for 3 days after surgery, with increasing pain
and infection.25 Although each of these conditions posed and a steadily increasing pulse. Following the patient’s death
unique clinical and surgical problems, they shared the need “on an examination of the body by Mr. Cline, it was found
for surgical decompression. Throughout the early modern that the spinal marrow was entirely divided.”26 Despite the
period, surgical decompression of the spine was the single severity of the neural injury and the complexity of the fracture-
most common reason to undertake the risks of spine surgery, dislocation, the untoward outcome of this unfortunate case
and laminectomy was the most commonly used technique to would remain a topic of conversation for almost a century,
achieve it. providing ample ammunition for the opponents of spine
surgery.
Cline’s case was not an isolated mortality. In 1827, for
Birth and Development of the Laminectomy example, Tyrell27 reported 100% mortality for a small series
of patients with surgically treated spinal dislocation and
HJ Cline, Jr. and the Argument Against Spine Surgery neurological injury. Other reports (e.g., Rogers28 in 1835)
At the beginning of the 19th century, the prospects for were often equally discouraging. Looking back on these early
spine surgery appeared grim. The dismal results of a years of the debate about spine surgery, the early 20th century
British surgeon Donald Armour29 described the controversy

this way:
This [Cline’s operation] precipitated and gave rise to

widespread and vehement discussion as to its justification.
This discussion, often degenerating into bitter and virulent
personalities, went on many years. Astley Cooper, Benjamin
Bell, Tyrell, South, and others favored it, while Charles Bell,
John Bell, Benjamin Brodie, and others opposed it. The effect
of so eminent a neurologist as Sir Charles Bell against the
procedure retarded spinal surgery many years—the operation
was described with such extravagant terms as “formidable,”
“well-nigh impossible,” “appalling,” “desparate [sic] and
blind,” “unjustifiable,” and “bloody and dangerous.”
Of course, surgical fatalities in this period were caused as

much by septic complications and anesthetic inadequacies as
they were to surgical technique. The lack of an effective means
of pain control during surgery intensified the problem of
intraoperative shock and made speed essential. Furthermore,
the problems of wound infection and septicemia were both
predictable and frequently fatal. These hindrances to surgery
were not ameliorated until the introduction of general
anesthetic agents (i.e., nitrous oxide, ether, and chloroform)
in the mid-1840s and the adoption of Listerian techniques
(using carbolic acid) in the 1870s.30
AG Smith and the First Successful Laminectomy

Despite these risks, a little-known surgeon named Alban G
Smith from Danville, Kentucky performed a laminectomy Fig. 1.3. Title page of journal that contains the first successful report
in 1828 on a patient who had fallen from a horse and sus- of a laminectomy. The surgeon and the author of the report was
tained a traumatic paraplegia. To Smith’s credit, his patient Alban G Smith of Danville, Kentucky. (From Smith AG. Account of a
not only survived the operation but achieved a partial case in which portions of three dorsal vertebrae were removed for the
neurological recovery. The operative technique and surgi- relief of paralysis from fracture, with partial success. North Am Med
cal results were reported in the North American Journal of Surg J. 1829;8:94-97.)
Medicine and Surgery in 1829 (Fig. 1.3).31 Smith’s procedure
comprised a multilevel laminectomy through a midline
incision, involving removal of the depressed laminae and The neurologist’s diagnosis was immediate and
spinous processes, exploration of the dura mater, and clo- unequivocal: the cause of Gilbey’s symptoms was located
sure of the soft tissue incision. Although the report of this in his spine, where a tumor was causing compression of the
landmark case appears to have attracted little attention at thoracic spinal cord. Although no intraspinal tumor had ever
the time, it is a significant technical achievement and places been resected successfully, Gowers referred the patient to his
Smith among the pioneers of the early modern period in London surgical colleague, Victor Horsley (Fig. 1.5). After all,
spine surgery. Gowers had himself asserted, in his authoritative textbook,
Manual of Diseases of the Nervous System, that removal of an
intradural spinal cord tumor was “not only practicable, but
Laminectomy for Extramedullary Spinal Tumors actually a less formidable operation than the removal of
During the half century after Smith’s historic operation, the intracranial tumors.”34
primary indication for laminectomy was spinal trauma. In the Horsley acted quickly. Within 2 hours of the initial
latter part of the 19th century, the indications for laminectomy consultation, a skin incision was made at 1 pm, June 9, 1887,
were extended to tumor and infection.32 The first and most at the National Hospital, Queens Square, London. Despite his
celebrated surgical case for spinal tumor in the 19th century, precipitous decision to undertake this dangerous operation,
that of Captain Gilbey, was also the first successful one, and it Horsley did not approach the operation unprepared. Although
played an important role in the rehabilitation of the laminec- the Act of 1876 made it a criminal offense to experiment on
tomy as a safe and effective procedure. a vertebrate animal for the purpose of attaining manual skill,
Captain Gilbey was an English army officer who suffered Horsley had repeatedly practiced the proposed procedure in
the misfortune of losing his wife in a carriage accident in the course of his surgical experimentation. Despite some initial
which he also was involved. Although Gilbey himself escaped difficulty in locating the tumor, an intradural neoplasm in the
serious injury, he soon began to experience progressive dull upper thoracic spine causing compression of the spinal cord
back pain, which he attributed to the accident. As the pain was identified and safely resected. The pathological diagnosis
became relentless, Gilbey sought the advice of a series of was “fibromyxoma of the theca.”
physicians, all of whom were unable to identify the source Follow-up 1 year later revealed almost complete
of his pain. Eventually, Gilbey was referred to the eminent neurological recovery. The patient was walking without
London neurologist William Gowers, who elicited from the assistance and had returned to his premorbid work schedule.
patient a history of back pain, urinary retention, paraplegia, He remained well, with no evidence of tumor recurrence, up
and loss of sensation below the thoracic level (Fig. 1.4).33 to the time of his death from an unrelated cause 20 years later.
Laminectomy for Intramedullary Spinal Tumor 1

In 1890, Fenger attempted to remove an intramedullary
spinal tumor in an operation that resulted in the patient’s
death.35 In 1905, Cushing36,37 also attempted to remove
an intramedullary spinal cord tumor but decided to abort
the procedure after performing a myelotomy in the dorsal
column. To Cushing’s surprise, the patient improved after
surgery. In 1907, von Eiselsberg38 successfully resected an
intramedullary tumor.
The unexpected improvement that was observed in the
patient reported by Cushing attracted the attention of New
York surgeon Charles Elsberg. Elsberg39 described Cushing’s
technique, which he aptly named the “method of extrusion.”
The technique was intended to remove an intramedullary tumor
by spontaneous extrusion of the tumor through a myelotomy
made in the dorsal column. The rationale for this method was
predicated on the theory that an intramedullary tumor was
associated with an increase in intramedullary pressure. Release
of this pressure by a myelotomy that extended from the surface
of the spinal cord to the substance of the tumor was expected
to provide sufficient force to spontaneously extrude the
tumor. According to Elsberg, the advantage of this procedure
over a standard tumor resection was that it required minimal
manipulation of the spinal cord and therefore minimal spinal
cord tissue injury.
Because the spontaneous extrusion of an intramedullary
tumor occurred slowly, Elsberg performed these procedures in
two stages. In the first stage, a myelotomy was fashioned in the
dorsal column, extending from the surface of the spinal cord
to the tumor (Fig. 1.6A).
Fig. 1.4. William R Gowers. When the tumor was identified and observed to begin to
bulge through the myelotomy incision, the operation was
concluded, the dura mater was left opened, and the wound
closed. In the second stage of the procedure, which was
performed approximately 1 week after the first stage, Elsberg
reopened the wound and inspected the tumor (Fig. 1.6B).
Typically, the tumor was found outside the spinal cord, and
the few adhesions that remained between the spinal cord and
the tumor were sharply divided. After the tumor was removed,
the wound, including the dura mater, was closed.
Variations in Laminectomy Technique

By the last decade of the 19th century, after the case of
Captain Gilbey, the possibility of safely performing a spi-
nal operation was established in the collective surgical con-
sciousness. Furthermore, new anesthetic techniques and
aseptic methods had become available to most practicing
surgeons.40 All of these factors increased the appeal of the
laminectomy to surgeons and widened its range of applica-
tion. For example, after Horsley’s widely publicized success
for resecting a spinal tumor, many similar operations were
soon described in the literature,41-46 and in 1896 Makins
and Abbott47 reported 24 cases of laminectomy for verte-
bral osteomyelitis.
Although the safety and efficacy of the laminectomy had
convinced many proponents of the utility of the procedure,
toward the end of the century surgeons began to worry about
postoperative instability. Advances in operative technique and
perioperative management meant that more and more patients
survived the operation and ultimately became ambulatory,
which further heightened concern about stability.
In 1889, Dawbarn48 described an osteoplastic method
of laminectomy that addressed this concern. Instead of a
midline incision, Dawbarn described two lateral incisions
Fig. 1.5. Sir Victor Horsley. that were carried down to the transverse processes. The lateral
incisions were connected in an H-like fashion, and superior
Fig. 1.7. Charles A Elsberg.
B
Fig. 1.6. A, The first stage in an intramedullary spinal cord tumor
Charles A Elsberg: The Laminectomy in Stride
resection by the extrusion method. Note that the tumor is bulging Charles A Elsberg was one of the most influential writers on
through the myelotomy incision. The wound was subsequently spinal decompression (Fig. 1.7). Working at the Neurological
closed. B, The second stage in an intramedullary spinal cord tumor Institute of New York, which he had helped to found, Elsberg52
resection by the extrusion method, 1 week after the first stage. Note published his first series of laminectomies in 1913. In 1916, he
that the tumor has spontaneously extruded since the first operation published his classic text, Diagnosis and Treatment of Surgical
and now may be removed easily. (From Elsberg CA, Beer E. The Diseases of the Spinal Cord and Its Membranes.53 Although this
operability of intramedullary tumors of the spinal cord: a report of two publication represents a landmark in the history of spine sur-
operations with remarks upon the extrusion of intraspinal tumors. Am gery, it constitutes more of a culmination than an innovation
J Med Sci. 1911;142:636-647.) in spine surgery. Elsberg’s work on spine surgery, coming as it
did at the end of a century of evolution of the decompressive
laminectomy, effectively codified 19th and early 20th century
and inferior flaps—including skin, muscle, fascia, and bone— developments.
were then turned. In closing the wound, the intact flaps were In his textbook, Elsberg outlined the surgical indications
reflected back and reapproximated in their normal anatomic and contraindications for laminectomy. He noted the
positions. beneficial effects in his own large series of laminectomies and
Although not all surgeons subscribed to the osteoplastic puzzled over the benefits that may occur in the absence of
method, many turn-of-the-century surgeons were largely evident increased intradural pressure, such as in patients with
preoccupied with modifications of this procedure.49 At multiple sclerosis. He argued that the primary indications for
the same time, however, a more important innovation in operation were cases of tumor, trauma, and infection that were
laminectomy technique, the hemilaminectomy, was developed associated with symptoms localized to a spinal level. Patients
independently in both Italy50,51 and the United States.51 with progressive symptoms should be operated on quickly, in
In 1910, AS Taylor of New York described the the absence of contraindications such as metastatic cancer or
hemilaminectomy: a midline incision, a subperiosteal advanced Pott disease.
paravertebral muscle takedown, and the removal of a Given the exhaustive scope of these early Elsberg
hemilamina with a Doyen saw.51 The advantages of the publications—which, in addition to tumor, trauma, and
hemilaminectomy over the cumbersome osteoplastic method infection, also review the management of congenital spine
were obvious, and Taylor argued that, compared with the disease—conspicuously little is said about the most common
laminectomy, the hemilaminectomy interfered less with the late 20th-century indication for laminectomy: degenerative
mechanics of the spine. Despite such detractors as Charles spine disease. The tardy development of a treatment for
Elsberg, who responded that the field of view was narrow and degenerative spine disease should be understood in the larger
the effect of laminectomy on spinal mechanics negligible, context of 19th and early 20th century knowledge of spinal
Taylor successfully championed its use. pathology.
Fig. 1.9. Walter E Dandy.
Fig. 1.8. Rudolph Virchow.

and illustrated how weakening of the annulus fibrosus could
result in dorsal displacement of the nucleus pulposus. The
Unlike degenerative disease, tumor, trauma, and infection nucleus pulposus, he argued, could in turn result in low
were already well known in antiquity. Although the concept of back pain and paraparesis. What eluded Goldthwaite and the
localization of function in the nervous system was undeveloped surgeons before him, however, was the connection between a
during the 19th century, the diagnosis and localization of herniated disc and radiculopathy.
tumor, trauma, and infection, particularly in their late stages, In a 1929 issue of the Archives of Surgery Walter E Dandy60
were not especially difficult. Degenerative disease, on the published a description of two cases of herniated lumbar discs
other hand, possessed a more subtle pathophysiology that causing a cauda equina syndrome (Fig. 1.9). Dandy correctly
was not as easily characterized, especially without the help of described how “loose cartilage from the intervertebral disc”
radiography. Thus, recognition of degenerative spine disease produced the symptoms of cauda equina compression that
eluded the 19th-century surgeon. This tardy appreciation were relieved alter surgical decompression. He considered
for the clinical, surgical, and pathological importance of that, in the second decade of the 20th century, more than 20
degenerative spine disease deserves further mention. years after the first spinal fusion operations, intervertebral
disc disease could be added to the list of indications for
Laminectomy for Intervertebral Disc Herniation. decompressive laminectomy.
Intervertebral disc pathology was first described by Rudolph Despite the several aforementioned publications on
Virchow54 in 1857 (Fig. 1.8). Virchow’s description of a intervertebral disc herniation, the concept of disc herniation
fractured disc was made at autopsy on a patient who had and its relationship to radiculopathy was defined by Mixter
suffered a traumatic injury. and Barr.
In 1896, the Swiss surgeon T Kocher55,56 identified and Several studies were performed in North America, but
described a traumatic disc rupture at autopsy of a patient who an anatomic, radiological, and microscopic study was
had fallen 100 feet and landed on her feet. Although Kocher performed on 5000 human spines in the Dresden Pathology
recognized that the L1.2 disc was displaced dorsally, no clinical Institute by Schmorl and Junghanns. The results of this study
correlation was suggested. were published in a book titled The Human Spine in Health
The first transdural intervertebral discectomy was reported and Disease. In 1932, Barr, an orthopedic surgeon from
by Oppenheim and Krause57 in 1908. However, they reported Massachusetts General Hospital, was assigned to write a
the disc as “enchondroma.” critique of this study.
In 1911, George Middleton,58 a practicing physician, and In June of 1932, Barr attempted to treat a patient with an
John Teacher, a Glasgow University pathologist, described extruded disc herniation. Following a 2-week unsuccessful
two cases of ruptured intervertebral disc observed at autopsy. course of nonoperational treatment, Barr consulted with
Like Virchow and Kocher before them, however, Middleton Mixter. Mixter recommended a myelogram, which revealed a
and Teacher, although they described the pathology, failed to filling defect. Mixter subsequently operated on the patient and
postulate its connection with radiculopathy or back pain. removed the “tumor.” Barr studied the “tumor” specimens.
In 1911, Joel Goldthwaite59 made this connection. In an Because he contributed to Schmorl’s study published in
article on the lumbosacral articulation, Goldthwaite described German, Barr remembered the microscopic appearances in
Schmorl’s study and realized that the specimen from this index
patient was the nucleus pulposus. After this finding, Mixter,
Barr, and Mallory (a pathologist) reevaluated all the cases that
were diagnosed (or misdiagnosed) as chondroma in recent
years at Massachusetts General Hospital. They retrospectively
diagnosed most of these cases as ruptured intervertebral
discs. Mixter and Wilson operated on the first ruptured disc
herniation diagnosed preoperatively on December 31, 1932.
Mixter and Barr reported the case in the New England Surgical
Society on September 30, 1933.61,62
In the late 1930s, Love63 from the Mayo Clinic reported on
an extradural laminectomy technique. In 1967, Yasargil64 used
the microscope for discectomy. Yasargil64 and Caspar reported
the first results of the lumbar microdiscectomy.65
Laminectomy for Cervical Disc Herniation. In 1905 Watson

and Paul66 performed a negative exploration for cervical spinal
cord tumor. They found an anterior extradural mass in the
intervertebral disc at autopsy. This may be the first reported
case of cervical disc herniation. The first dorsal approach was
performed by Elsberg67 in 1925. He found a “chondroma” in
a quadriparetic patient.
Laminectomy for Spinal Stenosis. Unlike the herniated

intervertebral disc, the stenotic spinal canal was described
comparatively early in the 19th century. Portal,68 in 1803, Fig. 1.10. Percival Pott.
observed that a small spinal canal may be causally related to
spinal cord compression, leading to paraplegia. No clinical
reports of this entity were published, however, until 1893 of spinal decompression.76 This was in part related to the
when William A. Lane69 described the case of a 35-year-old decrease in surgical mortality associated with the adoption
woman with a progressive paraplegia and a degenerative of the Listerian methods beginning in the 1870s, and it
spondylolisthesis. The patient improved after a decompressive was only natural then that the laminectomy would play a
laminectomy. role in the management of Pott disease. As in many of its
Further demonstration of the efficacy of decompressive applications, however, disenchantment arose with the results
laminectomy for spinal stenosis came from Sachs and Frankel70 of laminectomy, and alternative approaches were therefore
in 1900. They published an account of a 48-year-old man with sought.77 The most promising of these approaches was
neurogenic claudication and spinal stenosis whose symptoms Ménard’s so-called costotransversectomy.
improved after a two-level laminectomy. Recognition of the
degenerative nature of the clinical entity of spinal stenosis was
established by Bailey and Casamajor71,72 in 1911 in a report
Ménard’s Costotransversectomy
on a patient who was successfully decompressed by Charles Like many surgeons at the beginning of the 20th century,
Elsberg. In his 1916 textbook, Elsberg53 later wrote, “a spinal Ménard78 was disappointed by the surgical results from the
operation may finally be required in some cases of arthritis or laminectomy. In 1894, he described the costotransversectomy
spondylitis on account of compression of the nerve roots or as an alternative method for achieving Pott’s goal, namely
the cord by new-formed bone.” drainage of the paraspinal abscess. The advantage of the cos-
In 1945, Dr. Sarpyener, a Turkish orthopedic surgeon, totransversectomy over the laminectomy lay in the improved
described congenital lumbar spinal stenosis.73 This report exposure it provided of the lateral aspect of the vertebral col-
was followed by a report on adult spinal stenosis from Dr. umn. The procedure was also known as the “drainage latéral,”
Verbiest.74 In 1973, Hattori75 described the technique of emphasizing that the goal of the procedure was to drain the
laminoplasty. lateral, paravertebral tubercular abscess.
As described by Ménard, the costotransversectomy involved
an incision overlying the rib that was located at the apex of the
APPROACHES TO THE SPINE kyphos. The rib was then skeletonized and divided about 4 cm
distal to the articulation with its corresponding vertebra, from
Dorsolateral Approaches to the Spine which it was disarticulated and removed. These maneuvers
In 1779, Percival Pott described a condition involving spinal provided access to the tuberculous focus, which was exposed
kyphosis and progressive paraplegia in a now-classic mono- and then decompressed directly (Fig. 1.11). Ménard did not
graph titled “Remarks on that kind of palsy of the lower limbs intend to totally remove the lesion, but rather to simply
which is frequently found to accompany a curvature of the decompress the abscess.
spine and is supposed to be caused by it; together with its The surgical results of Ménard’s costotransversectomy far
method of cure; etc.” (Fig. 1.10). For the management of this surpassed the results obtained with the laminectomy. Ménard
condition, which now bears his name, Pott recommended the experienced several successes among his first 23 cases, including
use of a paraspinal incision to drain pus from the invariably significant motor improvement.79 Regrettably, these promising
present paraspinal abscess. For almost a century, this simple initial surgical results began to sour with time because it
surgical procedure became a standard part of the treatment of became increasingly clear that two major complications
Pott’s paraplegia. were occurring with increasing frequency: postoperative
By the late 19th century, however, the laminectomy had development of secondary infection and the postoperative
received widespread acceptance as a safe and effective method formation of draining sinus tracts. Both problems resulted
Fig. 1.11. Drainage of a tubercular abscess via the

costotransversectomy of Ménard. (From Ménard V. Causes de
la paraplegia dans le mal de Pott. Son traitement chirurgical par
I’ouverture direct du foyer tuberculeux des vertebras. Rev Orthop.
1894;5:47-64.)
from the opening up of the abscess. Because no antitubercular

chemotherapeutic agents were available at the time, the
consequences of the infections that ensued after surgery were
frequently disastrous, resulting in significant surgical mortality. Fig. 1.12. Sanford J Larson.
As Calot80 grimly put it in 1930, “[t]he surgeon who, so far as
tuberculosis is concerned, swears to remove the evil from the
very root, will only find one result waiting him: the death of In the interval between Seddon’s 1935 description of the
his patient.” The operation of Ménard thus fell into disrepute, lateral rhachotomy and Capener’s 1954 report of the same
and in time even Ménard abandoned it. operation, the emergence of a new treatment, antitubercular
chemotherapy, was to transform the history of the treatment of
Pott’s paraplegia. In 1947, streptomycin first became available
Capener’s Lateral Rhachotomy for clinical use. This was followed by the introduction of
Like Ménard, the English surgeon Norman Capener para-aminosalicylic acid in 1949 and isoniazid in 1952. The
attempted to find a surgical solution to the problem of effect of the introduction of these new chemotherapeutic
Pott’s paraplegia. Capener modified Ménard’s costotransver- agents on the treatment of tuberculosis was spectacular. With
sectomy in a procedure that he developed and began using the addition of streptomycin alone, the average relapse rate
in 1933, which was first reported by HJ Seddon81 in 1935. of tuberculosis was decreased by 30% to 35%. Although the
Departing from the emphasis of Pott and Ménard, who sim- effect of antitubercular chemotherapy was not as substantial
ply decompressed the tubercular abscess, Capener attempted for the treatment of spinal tuberculosis as for the pulmonary
to directly remove the lesion, which typically consisted of a form, its mere availability raised new questions about the
ventral mass of hardened material. To achieve his more radi- optimal management of Pott’s paraplegia and, in particular,
cal goal of spinal decompression, Capener required a more about the indications for surgical intervention.
lateral or ventral view of the vertebrae than was afforded by
Ménard’s approach.
Capener’s solution was to adopt Ménard’s costotransver-
Larson’s Lateral Extracavitary Approach
sectomy but with this difference: whereas Ménard approached In 1976, Sanford J. Larson and colleagues83 at the Medical
the spine via a trajectory that was medial to the erector spi- College of Wisconsin published an influential article that
nae muscles, Capener82 transversely divided the muscles helped to popularize Capener’s lateral rhachotomy, which
and retracted them rostrally and caudally. He named his they modified and renamed the lateral extracavitary approach
new approach the lateral rhachotomy to distinguish it from (Fig. 1.12). This approach has been used more for trauma
Ménard’s costotransversectomy. The simple change in dissection and tumor than for tuberculosis. The technical difference that
planes distinguishes these two techniques by producing a sig- distinguishes the lateral rhachotomy from the lateral extracav-
nificantly different trajectory and surgical exposure. Although itary approach lies primarily in the treatment of the paraspi-
the operation was designed for the surgical treatment of Pott’s nous muscles.
paraplegia, Capener later drew attention to the versatility of Whereas Capener’s procedure involves transversely dividing
the approach and its appropriateness for a variety of patholog- these muscles and reflecting them rostrally and caudally,
ical processes, including “the exploration of spinal tumors, the Larson’s procedure uses a surgical exposure with a trajectory
relief of certain types of traumatic paraplegia, and the drainage ventral to the paraspinous muscles, which are then reflected
of suppurative osteitis of the vertebral bodies.”82 medially to expose the ventrolateral aspect of the spine. Later in
It was perhaps unfortunate that for 19 years the only the procedure, these muscles are redirected laterally to provide
description of Capener’s lateral rhachotomy was in a single access for instrumentation of the dorsal aspect of the spine,
case report published by another surgeon.81 Not until 1954 using the same surgical exposure as that for the ventrolateral
did Capener himself describe the procedure, and even then he approach. Although neurosurgeons, as spine surgeons, had
still chose not to publish the results of his 23 cases.82 traditionally emphasized spinal decompression over spinal
stabilization, an essential aspect of the significance of Larson’s often used to achieve stabilization, but these also frequently
overall contribution to the discipline of spine surgery lies in suffered a similar fate: pseudarthrosis.85
the fact that, as a neurosurgeon, he dedicated his career to the By the 1960s, however, a half century of experience with
advancement of reconstructive spine surgery. spinal fusion and instrumentation suggested the concept of
the “race between bony fusion and instrumentation failure.”
SPINAL STABILIZATION AND DEFORMITY The improved surgical results that arose from the application
of this important surgical concept provided support for the
CORRECTION successful strategy of combining spinal instrumentation with
The history of surgical stabilization and deformity correction meticulous fusion.
must include a description of the birth and evolution of spinal
fusion and spinal instrumentation. Special emphasis must be
given to the role of spinal biomechanics and its influence on
Spinal Fusion
the development of internal fixation. Many factors hindered The idea of using spinal fusion for stabilization is attributed
the development of surgical approaches to the decompression, to Albee86 and Hibbs,87 who, in 1911, independently reported
stabilization, and deformity correction of the ventral spine. its use (Fig. 1.13). Although these early operations were per-
The development and mastery of the special techniques that formed to prevent progressive spinal deformation in patients
were required to safely manage ventral spinal pathologies did with Pott disease, the procedure was later adopted in the
not appear until after the beginning of the 20th century, in management of scoliosis and traumatic fracture. The method
part because they depended on advances in anesthetic tech- described by Hibbs, which was most frequently used, involved
niques and a more sophisticated approach to perioperative harvesting an autologous bone graft from the laminae and
management. overlaying the bone dorsally. Despite later improvements in
Except for degenerative disease, the technique and this technique, however, such as the use of autologous iliac
indications for decompressive laminectomy were well- crest graft, the rate of pseudarthrosis, particularly in scoliosis,
established by the turn of the 20th century. The idea of remained unacceptably high.88
spinal decompression, previously the exclusive province In the 1920s, Campbell89 described posterolateral fusion
of surgical pioneers, had demonstrated its clinical utility (trisacral fusion and iliac crest grafting). In 1922, Kleinberg90
with results that fully justified its acceptance into standard used xenograft for spinal fusion. Anterior lumbar interbody
surgical practice. However, the idea of decompression, fusion (ALIF) was described by Burns91 in 1933, and by Capener
which had dominated spine surgery during the 19th century, in 1936.92 In 1944, Iwahara proposed a retroperitoneal
did not exist alone. Indeed, before the dawn of the 20th technique,93 and soon after, in 1948, Lane and Moore reported
century, attention had already turned to another surgical the first use of ALIF for the treatment of lumbar degenerative
idea: spinal stabilization. Of course, many attempts at disc disease. 94
surgical stabilization of the unstable spine had been made O’Brien et al. proposed the use of comprising femoral
during the 19th century and before. However, the ancient cortical allograft rings packed with autogenous cancellous
admonition that vertebral fractures constituted an “ailment bone graft.95
not to be treated” was reinforced by the surgeon’s singular Posterior lumbar ınterbody fusion (PLIF) was first
lack of success. And, thus, despite early attempts at spinal performed in 1945 using laminectomy bone chips by Briggs
stabilization in the latter part of the 19th century, spinal and Milligan,96 and in 1946 by Jaslow, using an excised portion
decompression remained the primary indication for surgery of spinous process rotated and inserted into the intervertebral
of the spine, until World War II. space.97
Recognition of the idea that compression of the neural Cloward, in the late 1940s, used impacted blocks of iliac
elements in cases of tumor, trauma, and infection could be crest.98 He removed the disc, prepared endplates, and inserted
responsible for neurological compromise was the crucial first dowels or struts.
step needed to develop the idea that spinal decompression In 1959, Boucher described an alternative spine fusion
could improve neurological outcome. The invention of method.99 In 1985, Harms described transforaminal lumbar
a technical means to achieve decompression, namely interbody fusion.100
laminectomy, represented the next necessary step in bringing
this concept into clinical practice. Similarly, the idea of spinal
stabilization arose from the observation that the unstable
Interbody Cages
spine was at risk for the development of progressive deformity, Modern interbody fusion started with the use of interbody
and that surgical intervention might prevent such deformities. cages. The first interbody cage was used by Bagby for the treat-
Of course, bringing this concept into practice depended on ment of Wobbler syndrome in horses. It was known as a Bagby
achieving an adequate technical means. Indeed, two technical basket, and comprised a stainless steel cylinder filled with horse
advances were developed around the beginning of the 20th autograft.101 In the late 1980s, Kuslich changed its design and
century that provided a means for spinal stabilization that adapted it to human intervertebral discs. It was designed as a
would revolutionize the practice of modern spine surgery.84 threaded hollow titanium cylinder with thick perforated walls,
allowing for the cage to be screwed onto the endplates of the
BIRTH AND DEVELOPMENT OF SPINAL FUSION AND adjacent vertebrae, thus promoting stabilization and fusion.
Furthermore, the hollow cage could be packed with cancel-
SPINAL INSTRUMENTATION lous bone chips, which eliminated the need for autografts. The
Both spinal fusion and spinal instrumentation were born Bagby and Kuslich titanium cage (Spine-Tech, Minneapolis,
around the turn of the 20th century as methods of stabiliz- MI, USA) was the first PLIF cage used in humans in 1992.102
ing the unstable spine. For many years, these two technical Soon after, different modified cages were introduced by oth-
advances were developed and applied essentially indepen- ers. Ray reported a new self-tapping cage with less artifact in
dently, with results that were often complicated by pseudar- imaging study, which could be implanted using both posterior
throsis. Early attempts at spinal instrumentation in particular (PLIF) and anterior (ALIF) approaches.103,104
failed to gain popularity because of their inability to maintain As an alternative to titanium cages, the polyetheretherketone
more than immediate spinal alignment. Spinal fusions were (PEEK) fusion cage, or Brantigan cage, was introduced by
A B
Fig. 1.13. A, Fred Albee. B, Russell Hibbs.
AcroMed,105 pioneered by polymer engineer Carl McMillin.

Subsequently, many different designs of PEEK cages have been
used.
In 1977, Callahan and colleagues106 used bone for lateral
cervical facet fusion.
Several ventral cervical fusion techniques were described in
the 1950s. Robinson and Smith107 described their technique in
1955, and Cloward108 described his cervical fusion technique
in 1958.
Spinal Instrumentation and Clinical Biomechanics

Like spinal fusion, internal fixation was first applied around
1900. These early constructs used tension-band fixators that
were applied dorsally, primarily in cases of trauma. The limi-
tation of the constructs, however, soon became apparent,
because the metals they contained were subject to the corro-
sive effects of electrolysis.
With the introduction of vitallium by Venable and Stuck109 Fig. 1.14. Radiograph showing no bone changes in a dog limb
in the 1930s, a metal was found that was previously used around vitallium screws (right), but erosion of bone around steel
successfully as a dental filling material and that had proven screws (left). (From Venable CS, Stack WG, Beach A. The effects on
resistant to electrolysis (Fig. 1.14).110 Further attempts at bone of metals; based upon electrolysis. 1937;105(6):917–938.)
internal fixation during the 1930s and 1940s included
fixed-moment arm cantilever constructs. These also failed to
maintain alignment.111,112 In 1963, Holdsworth114 published his results and proposed
a classification scheme of subaxial spinal fractures based on
a two-column model of spinal stability. Four categories of
FW Holdsworth fractures were identified on the basis of the mechanism of
In the 1950s, the British orthopedic surgeon Sir Frank W injury and on the presence or absence of spinal stability. The
Holdsworth113 performed perhaps the first large systematic study latter determination rested significantly on the integrity of
of the problem of internal fixation for the treatment of posttrau- the dorsal ligaments. Holdsworth categorized the fractures as
matic fracture. Although the constructs he used, which employed follows:

cantilever beams attached to the spinous processes, were tradi-
1. Pure flexion. A pure flexion mechanism is usually associated
tional, Holdsworth’s emphasis on patient selection brought the
with an intact dorsal ligamentous complex and no evidence
process of surgical spinal stabilization to a new, more sophis-
of spinal instability. The vertebral body absorbs the greater
ticated level. His rationale for patient selection was based on a
part of the impact, and the result is a wedge compression
biomechanical definition of instability that he had derived from
fracture.
a study of a large number of spinal-injured patients.
Fig. 1.15. Berthold Hadra. Fig. 1.16. Paul Harrington.
2. Flexion-rotation. A rotation or flexion-rotation mechanism

causes disruption of the dorsal ligamentous complex and spinal stabilization, which was heralded by Holdsworth, was
results in an unstable fracture-dislocation. It is usually as- brought home in the 1960s with the work of the “father of
sociated with paraplegia. modern spinal stabilization,” Paul Harrington (Fig. 1.16).
3. Extension. An extension mechanism, which is usually sta- In 1945, after military service in World War II, Paul
ble, most frequently occurs in the cervical spine. It may be Harrington118 entered into orthopedic practice in Houston,
associated with a fracture of the dorsal elements, with an Texas. Within 2 years, Harrington was faced with the orthopedic
intact dorsal ligamentous complex. problems of a large population of patients with poliomyelitis,
4. Compression. A compression, or “burst,” fracture is caused which at that time had reached epidemic proportions. The
by forces transmitted directly along the line of the vertebral involvement of the trunk, which afflicted many of these
bodies. All of the ligaments are usually intact, and the frac- patients, often resulted in scoliotic spinal deformity in
ture tends to be stable). association with cardiopulmonary compromise. The presence
of cardiopulmonary compromise in a patient with scoliosis
Holdsworth’s classification was important, as he himself often meant that the standard cast corrective measures could
observed, not as a biomechanical theory (although it was this not be applied safely. Furthermore, in 1941, the American
too), but because it had implications for treatment. At around Orthopaedic Association119 published a report on the results
the same time that Holdsworth’s article appeared, several of treatment in 425 cases of idiopathic scoliosis. The report
other classifications of spinal fractures were proposed. With was quite discouraging. Among those patients treated by
the introduction of modern spinal biomechanics, a new era in exercises and braces, but without spinal fusion, the deformity
spine surgery had begun.115,116 progressed in 60% and remained unchanged in 40%. In
another group of patients who underwent surgical correction
PAUL HARRINGTON AND THE BIRTH OF MODERN and fusion, 25% (54 of 214) developed pseudarthrosis, and
29% had lost all correction. Among the entire group, the
SURGICAL STABILIZATION result for 69% was considered fair or poor, and only 31% were
In his 1891 report of a case of interspinous wiring for cervical rated good to excellent. It was against this backdrop of dismal
fracture, Berthold Hadra117 considered in what circumstances results from nonoperative treatment and dorsal spinal fusion
his newly described procedure would be indicated (Fig. 1.15). that Harrington began his seminal work.
Hadra concluded that his procedure might be indicated for After an initial (unsuccessful) trial of internal fixation with
“any deviation of a vertebra.”117 Despite the prescience of his facet screw instrumentation,120 the method was abandoned in
innovation, the substance of Hadra’s comment is remarkable, favor of a combination of compression and distraction hooks
not so much for what it contains as for what is missing from it; and rods made of stainless steel. The advantages of these
namely, any hint of consideration of biomechanical principles. instruments in the establishment of deformity correction
When one considers the importance of biomechanical prin- became obvious: for the first time in the history of spinal
ciples in Holdsworth’s 1963 classification of spinal fractures, stabilization, spinal instruments provided compression,
Hadra’s early 20th-century approach to spinal stabilization distraction, and three-point bending forces, which proved
serves to underline how much progress was made in the inter- equally useful in deformity correction as they did in the
val. The significance of this new (biomechanical) approach to maintenance of posttraumatic stability. Nineteen patients were
rods as the spinal instrumentation of choice for the surgical

fixation and correction of scoliosis. 1
VENTRAL APPROACHES TO THE SPINE

Dorsal decompression via the laminectomy had become well-
established by the turn of the 20th century and was codified by
Charles Elsberg in his 1916 textbook Diagnosis and Treatment
of Surgical Diseases of the Spinal Cord and Its Membranes.
Interestingly, whereas this period marked the culmination of
dorsal decompression in spine surgery, it also signified the
beginning of procedures for dorsal stabilization and defor-
mity correction, as pioneered by Hadra (1891), Albee (1911),
and Hibbs (1911). The groundwork for further development
in this area was laid with the classification scheme of spinal
fractures by mechanism and stability, as initially proposed
by Holdsworth in 1963. This introduction into clinical prac-
tice of the principles of spinal biomechanics is also found in
the work of Harrington in the 1950s and 1960s in his devel-
opment of a novel system of dorsal thoracolumbar instru-
mentation. Although Harrington later recognized the need
to supplement his instrumentation with meticulous spinal
fusion, and many modifications and innovations have since
been made in dorsal instrumentation, successful outcomes in
dorsal decompression, stabilization, and deformity correction
had been achieved by the 1960s.
Fig. 1.17. Eduardo Luque. Nothing, however, has been said thus far about the
achievement of these goals in the ventral spine, where a
significant portion of spinal pathology is located. As it happens,
observed during the early phase of Harrington’s investigation the first successful interventions for stabilization of the ventral
of dorsal instrumentation. The results of this investigation spine were achieved in the same time frame as the dorsal ones
were published in 1962.118 The longevity of Harrington’s (i.e., in the first half of the 20th century). What is peculiar about
spinal instrumentation system, which remains in use today, is surgery of the ventral spine is that a decompressive procedure
a testimony to both its safety and its efficacy. must be accompanied almost invariably by simultaneous
Nevertheless, despite a frequent and gratifying correction stabilization, which often includes measures to correct
of the poliomyelitis curvature, the loss of that correction was deformity. Therefore, the history of the major goals of ventral
commonly discovered within 6 to 12 months after surgery. In spine surgery—that is, decompression, stabilization, and
part, the failure to maintain the alignment achieved at surgery deformity correction—has been one of parallel developments,
was the result of frequent instrument failure, most commonly not serial ones, as was the case for the dorsal spine. In other
instrument fracture and disengagement of the hooks. words, the history of stabilization and deformity correction of
However, more fundamentally, Harrington recognized that the dorsal spine developed in the half century following the
the concept of a dynamic correction system was inherently establishment of dorsal decompression. All three goals were
flawed: the complication of instrument failure would be far achieved in the ventral spine during the same 50 years.
less significant if a spinal fusion could maintain the deformity
correction achieved by the placement of the implant.121
The underlying principles that emerged from Harrington’s
Ventral Decompression and Stabilization
early failures, then, became clear: (1) because spinal The primary difficulty in applying ventral techniques to the
instruments fail over time, they should be applied as a strictly spine was in the surgical approach. The relative technical ease
temporary measure; and (2) after instrumentation failure, and low morbidity associated with a dorsal approach to the
a successful spinal fusion will maintain stabilization. As a dorsal spine provided ample opportunity for the early devel-
corollary to these principles, Harrington acknowledged that opment of dorsal spinal techniques.
there is a “race between instrumentation failure and the Although ventral approaches to the cervical spine were
acquisition of spinal fusion.” It stands to reason that if fusion performed as early as 1894 by Chipault, the development of
is attained before instrumentation failure, the maintenance ventral approaches to the lumbar and thoracic spine required
of deformity correction and stabilization will have been much more experience, as well as the establishment and
achieved. An understanding of the importance of a successful development of abdominal and thoracic surgery principles
fusion in an instrumented spine is one of Harrington’s most and techniques.122
significant contributions to spine surgery and marks the By contrast, ventral approaches to the ventral spine required
birth of the modern era of spinal stabilization and deformity transgression of the abdomen or chest, which (similar to the
correction. head) up until the 1880s remained sanctuaries not to be
The Harrington systems contributed to development of opened, except by accident.25
many other systems. The Luque system was another rod system In part, the late development of abdominal and thoracic
developed by Dr. Eduardo Luque of Mexico City, Mexico surgery was a product of the problem of infection: cognizant of the
(Fig. 1.17). The Luque system consisted of two stainless steel morbidity and mortality related to hospital-acquired gangrene,
“L”-rods that were fixated to laminae using sublaminar wires to few patients who entered a surgical ward in the 19th century did
treat scoliosis. This system has been used as a cheap alternative so with the hope of leaving alive. The reluctance to adopt the
to the Harrington system in many countries. By the mid- principles of antisepsis as first enunciated by Lister123 in 1867 and
1980s, Luque rods increasingly began to replace Harrington a slowness to accept its theoretic foundation—the germ theory
of disease—meant delays for the development of abdominal and thoracic surgeons, but even then, good control of respiration
thoracic surgery. However, even after the practice of antiseptic by a reliable apparatus was not widely available until the late
surgery became generally accepted, early 20th-century surgeons 1930s.
still approached abdominal surgery with trepidation.
Anyone who would contemplate surgically violating the
thoracic cavity had to grapple with the technical problem
W Müller
of the pressure relationships in the chest.124 Beginning in The first report of a successful attempt to approach the ventral
1903, Ferdinand Sauerbruch of Breslau conducted a series thoracic or lumbar spine is attributed to Müller.125 In 1906,
of experiments that led to the development of an apparatus Müller performed a transperitoneal approach to the lumbo-
in which negative pressure for the open thorax could be sacral spine in a patient with a suspected sarcoma. At opera-
maintained, and around 1910, endotracheal or insufflation tion, Müller found tuberculosis. After curetting the infected
anesthesia became available (Fig. 1.18). This alleviated one bone, Müller applied iodoform powder and closed. The surgi-
of the major technical difficulties confronted by would-be cal result was excellent. Notwithstanding the success of this
initial operation, however, later attempts at the same proce-
dure failed miserably. After several misadventures that ended
in disaster, Müller was forced to abandon further attempts at
a ventral exposure.
BH Burns
Perhaps the next published report of a successful ventral expo-
sure did not appear until 1933, when the British surgeon BH
Burns91 performed a ventral interbody fusion of the lumbosa-
cral spine for an L5–S1 spondylolisthesis (Fig. 1.19). Before
the Burns procedure, the only method available to stabilize an
unstable spondylolisthesis was a dorsal fusion. However, the
results of dorsal fusion for ventral instability, as Burns himself
learned firsthand, proved unsound both in theory and in prac-
tice. Faced with a high incidence of failed dorsal fusions, Burns
chose to take a transabdominal, transperitoneal approach to
the lumbosacral spine, which he first investigated on three
cadavers before operation. The first operation involved a
14-year-old boy who presented with low back pain and neu-
rogenic claudication after jumping from a height. A radio-
Fig. 1.18. An early version of Sauerbruch’s negative-pressure graph of the lumbosacral spine showed an L5 spondylolysis
chamber. and a grade II L5–S1 spondylolisthesis. A tibial autograft was
A B
Fig. 1.19. A, Lateral radiograph of lumbar spine showing the graft placement in BH Burns’s operation for spondylolisthesis. (From Burns BH. An
operation for spondylolisthesis. Lancet. 1933;1:1233. With permission.B, Illustration of Burns’s operation. Ventral view.)
taken and tamped into a hole drilled obliquely from L5 to S1. stabilizing the spine, which, if not already unstable, was
Convalescence was uneventful, and pain relief was achieved, certainly rendered unstable by resection of the major load- 1
even on ambulation at 2 months postoperatively. bearing element. He accomplished this goal by fashioning
a ventral interbody fusion, which both provided significant
stability and facilitated spinal fusion (Fig. 1.21). However,
Ito and Others despite Ito’s successes—all except two of his 10 cases
Like the landmark operations of Albee and Hibbs, the first showed a healing by primary intention––and despite his
reported series of ventral spinal operations constituted a group acknowledgment of the inadequacies of the dorsolateral
of surgical treatments for spinal tuberculosis. In their 1934 approach, Ito himself used the costotransversectomy
article, “A New Radical Operation for Pott’s Disease,” Ito and approach in the two cases of thoracic Pott disease included
colleagues126 observed that the surgical stabilization proce- in his series.
dure described by Albee and Hibbs did not differ significantly
from nonoperative immobilization; the goal in both instances
was to rest and unload the diseased spine. On the other hand,
Hodgson and Stock
Ito, a professor of orthopedic surgery from Kyoto, Japan, pro- Thus it fell to another group of surgeons treating Pott disease to
posed a decompressive procedure, which he believed provided develop a true ventral approach to the thoracic spine. In 1956,
a definitive surgical treatment. Hodgson and Stock131 published their first report on ventral
Of course, the obstacles that Ito confronted in devising a spinal fusion for Pott disease. These authors acknowledged
ventral approach to the spine were considerable. In addition the contributions of Ito and colleagues, and they repeated Ito’s
to the obvious anatomic obstacles, all early 20th-century spine assessment of the restricted field of view afforded by the cos-
surgeons faced the seemingly intractable problem of infection. totransversectomy. They noted that this field of view provided
Although postoperative infections posed major difficulties insufficient exposure to determine the extent of the lesion or
for the development of (clean) abdominal and thoracic to confidently undertake its complete resection. What is more,
surgical procedures, these difficulties were compounded when the limited exposure of the costotransversectomy left no room
the surgical indication was infection, as in the case of Pott to accurately insert a ventral bone graft, which they consid-
disease. Indeed, previous attempts to surgically decompress ered to offer the best chance for fusion because the bone graft
tuberculosis of the ventral spine via a lateral approach would be placed in a compression mode.
(i.e., a costotransversectomy) met with a high incidence Hodgson and Stock also joined Ito and colleagues
of complications from postoperative secondary infection, in emphasizing decompression, rather than simple
permanent fistulas, or persistent spinal tuberculosis resulting stabilization, as a method to arrest further vertebral
from incomplete removal of infected bone.56,78,127,128 destruction (which may be responsible for neural element
In part, these operations failed because they were performed compression and progressive kyphotic deformity) and as a
before 1910, in the age of antiseptic, rather than aseptic, means to eradicate the spinal focus of disease. Their approach
surgery. Perhaps they also failed in part because they predated to the thoracic spine via a thoracotomy, the first significant
the introduction of antimicrobial chemotherapy. However, series of such an approach described, was facilitated by
the unsatisfactory results that these operations yielded were developments in the medical management of tuberculosis,
also, importantly, attributed to the poor surgical exposure
of the vertebral bodies that the lateral approach provided.
Recognizing this, Ito proposed a decompression operation that
would adequately resect infected vertebrae to fully eradicate the
presence of tuberculosis in the spine. Drawing on experience
with the transabdominal approach, which he had previously
used for another purpose, Ito reported his operative technique
and surgical results on 10 patients with moderately advanced
Pott disease. The possibility of approaching the ventral spine
occurred to Ito and colleagues after repeated operations
using their original technique for lumbosacral sympathetic
ganglionectomy. In 1923, Ito and Asaini129 originated this
technique for the purpose of improving lower extremity
circulation, and they reported their results to the Japanese
Surgical Society in 1925. The technique was subsequently
modified to provide an extraperitoneal approach to the
lumbar spine and was adopted for their radical operation for
Pott disease (Fig. 1.20).
The work done by Ito and his colleagues was beneficial
for several reasons. First, they recognized the need to address
the pathology directly, despite the technical difficulties that
such an approach presented. Second, at a time when the
major surgical treatment for Pott disease was dorsal fusion,
Ito proposed a radical new surgical therapy: decompression.
An attempt to eradicate spinal infection by surgical
decompression represented an alternative approach to the
standard stabilization procedure originated by Albee and
Hibbs. In another sense, the idea of decompression harkened
back to the 19th-century laminectomy for Pott disease, which Fig. 1.20. Extraperitoneal exposure of the body of the lumbar
was largely abandoned because of disappointing results, vertebra and resection of the body with a chisel. (From Ito H, Tsuchiya
after the introduction of dorsal spinal fusion.130 Finally, J, Asaini G. A new radical operation for Pott’s disease. J Bone Joint
Ito recognized the need, and established the technique, for Surg. 1934;16:499-515.)
the problem of severe kyphotic deformity, causing cardio-

pulmonary compromise.
On a larger scale, however, the problem of progressive
spinal deformity did not receive the attention of these
early authors, and no method of ventral internal fixation
was yet available to spinal surgeons who wished to
establish and maintain a deformity correction via a ventral
approach. As mentioned, Paul Harrington addressed the
problem of scoliotic deformity by the development of
dorsal thoracolumbar distraction rods in the 1960s, and
in doing so he initiated the modern instrumentation
revolution.
Harrington’s method of scoliosis reduction was based on
the principle of lengthening the short (concave) side of the
curve. After the introduction of a meticulous fusion technique
to supplement the immediate rigid internal fixation achieved
by the implant, the Harrington instrumentation system
proved both a safe and effective corrective measure, an
assessment that is corroborated by its long and successful
history of clinical application. Nevertheless, the principle
of simple dorsal distraction had its drawbacks. First, the
Harrington method requires that the fusion be extended
at least two levels above and below the extent of the spinal
curvature, thus decreasing mobility in otherwise normal
spinal motion segments. Second, in most instances, the
distribution of force application with the Harrington
instrumentation system is uneven, such that the total force
applied is borne only by the two vertebrae attached to the
upper and lower hooks. Finally, for patients who require a
simultaneous ventral decompression and dorsal stabilization
procedure, this could be accomplished only through a two-
stage operation involving two separate incisions and surgical
exposures. Thus, the arrival of a ventral instrumentation
system, introduced by Dwyer and associates132 in 1969,
proved an important addition to the spinal surgeon’s surgical
armamentarium.
Fig. 1.21. Schematic illustration of the insertion of ventral bone graft.
(From Ito H, Tsuchiya J, Asaini G. A new radical operation for Pott’s AF Dwyer
disease. J Bone Joint Surg. 1934;16:499-515.)
A. F. Dwyer was an orthopedic surgeon from Australia who
appears to have originated his method in an effort to pro-
vide an alternative to the Harrington technique for treating
including the introduction of chemotherapeutic agents (not scoliotic deformity reduction. In his initial report of 1969,
available to Ito and colleagues) and safer, more effective Dwyer described a method of ventral instrumentation in
anesthetic techniques. The benefits of this approach, then, which compressive forces are applied to the convex side of
despite its technical difficulties, were incontrovertible; it the curve at each segmental level. The technique comprises
facilitated decompression, stabilization, and deformity excision of the discs at the motion segments involved and
correction through a single incision and surgical exposure, the insertion of vertebral body screws into the convex aspect
providing excellent neurological and anatomic results. The of the curve. A titanium cable is then threaded through the
authors took account of the unique anatomic features of heads of the inserted screws, and tension is applied, provid-
the cervicothoracic and thoracolumbar junctions, where the ing corrective bending moments at the intervertebral spaces.
approach was appropriately modified. The tension is maintained by swaging the threaded cable on
the screw heads.
Ventral Deformity Reduction and the Development In a follow-up article published in 1974, Dwyer and
of Ventral Instrumentation Schafer133 reported their results of treatment in 51 cases,
which demonstrated a generally favorable record of
The contributions of Burns, Ito and associates, and deformity correction and only a 4% rate of pseudarthrosis.86
Hodgson and Stock were seminal in the history of spine Furthermore, some of the disadvantages of the Harrington
surgery. They opened new vistas in the management of spi- dorsal instrumentation system were overcome: fusion
nal pathologies, and their techniques were later applied could be restricted to the motion segments of the curve
to an increasingly wide range of pathological conditions, only; the load borne by the instrumentation device
including tumor, trauma, disc disease, and spinal defor- was evenly distributed over the curve; and the exposure
mity. The methods of Ito and associates were particularly necessary for ventral decompression, stabilization, and
prescient. They accomplished, with a single incision, the deformity correction was achieved using a single incision.
goals of both decompression and spinal stabilization, and Although the initial enthusiasm for the Dwyer device was
they achieved both of these goals in the most effective pos- later diminished by the recognition that it encouraged
sible manner. The establishment of deformity correction the tendency of the spine toward progressive kyphosis
was addressed in the report by Hodgson, who confronted and provided no resistance to axial loading, the generally
successful application of this ventral instrumentation system X-rays were discovered by Conrad Roentgen (1845–1923).142
stimulated the development of additional ventral implants, Roentgen, working at Würzburg University, invented the x-ray 1
such as the instrumentation systems of Zielke and Pellin134 tube on November 8, 1895. This introduced a new era in the
and Kaneda and associates.135 field of medicine. Radiographic imaging using x-rays is now a
routine part of diagnostic techniques worldwide. Roentgen was
awarded the first Nobel Prize in physics for his discovery.
LAMINOPLASTY The invention of plain-film radiography quickly changed
Cervical laminoplasty has been used to avoid problems asso- diagnostic algorithms. Sicard and Forestier were injecting the
ciated with laminectomy, such as kyphosis and postlaminec- radiopaque contrast medium Lipiodol into facet joints during
tomy membrane. Kirita performed the first laminoplasty, in the first World War.143 In 1920, an incidental injection of contrast
which the laminae were thinned, the midline parts drilled, medium into the dural sac (instead of the facet joint) provided
and lateral aspects bent and lifted up.136 Another technique, the first myelogram. In 1942, Steinhausen recommended
the Z laminoplasty technique, was described by Oyama, and the use of iodophenylundecylic acid (Pantopaque). Hence,
involved thinning the lamina, cutting them in a Z shape, and Pantopaque myelography was used routinely for the diagnosis
lifting them up and suturing them to each other.137 of spinal tumors and disc disorders for decades.144 Since the
Tsuji reported floating laminectomy, in which he cut 1970s, new contrast media, such as Thorotrast, Conray, Dimeray,
laminae bilaterally and left them completely free, without and Metrizamid, have been used for myelography.
fixation.138 Discography has been used since its introduction by
Hirabayashi et al. reported expansive open-door Lindblom.145 It was widely used for both lumbar and cervical
laminoplasty, in which the lamina was cut on one side and imaging throughout the 1950s and 1960s. The invention of CT
thinned on the other side. The lamina was then lifted up and decreased its popularity. After the introduction of spine MRI,
pushed toward the contralateral side. To prevent the open however, discography had a resurgence, with an increased interest
door from closing, they sutured the ligaments.139 in the black disc, high-intensity zones, and discogenic pain.
Kurokawa et al. developed spinous process splitting In 1972, Oldendorf, Hounsfield, and Ambrose reported
laminoplasty, in which both the spinous processes and the successful use of CT for diagnosing spinal disorders.146,147
laminae are split in the midline, the laminofacet junctions Hounsfield was awarded the Nobel Prize for physiology
are thinned, and the laminae are lifted up bilaterally.140 This or medicine in 1979 for this invention. Soon thereafter,
technique is known as French-door laminoplasty. Currently Damadian invented the MRI scanner.148
there are many modifications of laminoplasty.
SUMMARY
MINIMALLY INVASIVE SPINE SURGERY, ROBOTICS, The technical accomplishment of performing surgery on the
AND NAVIGATION ventral spine provides perhaps a useful marker for the end-
The concept of minimally invasive surgery (MIS) was intro- point of the history of “early modern” spine surgery. By 1970,
duced in 1987, with a report of the first laparoscopic cholecys- it may be argued, the basic groundwork had been laid for
tectomy. This technique was soon accepted and used in other the subsequent advances, particularly in spinal instrumenta-
fields, including spine surgery. The main advantages of MIS are tion, that have been made since the 1990s. These advances
less pain, less blood loss, and less tissue trauma, while simul- include an emphasis on location-appropriate decompression;
taneously allowing for quicker return to work for the patient. the development of segmental spinal instrumentation by ER
The major disadvantage of MIS is the learning curve required Luque in the early 1970s149-153; the refinement and prolifera-
of both surgeon and surgical team. tion of pedicular instrumentation techniques, first described
Endoscopic intervertebral disc surgeries, MIS fusion by Harrington in 1969154,155 ; the introduction of universal
techniques, robotic surgeries, and navigation-based surgeries spinal instrumentation by Cotrel and associates156; the further
are the major MIS strategies. development of ventral thoracolumbar instrumentation by
In 1985, Unimation (Danbury, CT, USA) introduced the Zielke, Kostuik,157 and Kaneda; the introduction of ventral cer-
first-ever surgical robot for neurosurgical brain biopsy, the vical instrumentation by Caspar and associates in 1989158; and,
Programmable Universal Machine for Assembly 560 (PUMA most recently, the application of endoscopic techniques.159
560. The PUMA 560 was also used to perform a transurethral In conclusion, this chapter has sought to organize and
biopsy of the prostate. After achieving success using these present the history of spine surgery as a series of attempts to
techniques, the National Air and Space Administration improve the surgeon’s ability to more safely and effectively
began a research project with the goal of performing remote achieve spinal decompression, stabilization, and deformity
surgery in space. With time, many robotic systems were used correction—the three major goals of spine surgery. The
in different subspecialities. The SpineAssist (Mazor Robotics occasionally formidable obstacles encountered by those
Ltd., Caesarea, Israel) gained Food and Drug Administration surgeons who have participated in this century-long odyssey
approval in 2004. The main advantages of robotic systems are were frequently managed, if not overcome, by concentrated
reduced radiation exposure and increased accuracy in screw and indefatigable effort. Alas, many of the same obstacles
positioning. Mazor Robotics introduced Renaissance and that faced the early spinal surgeons—including blood loss,
Mazor X. Subsequently, the Da Vinci and Globus Medical pseudarthrosis, instrumentation failure, and neurological
ExcelsiusGPS141 were introduced. injury—continue to challenge and vex even the best-equipped
contemporary spinal surgeons.
SPINE IMAGING
KEY REFERENCES
The diagnosis of the spinal processes could be performed via 6. Naderi S, Andalkar N, Benzel EC. History of spine biomechanics.
different diagnostic methods, including plain film radiogra- Part I. The pre-Greco-Roman, Greco-Roman, and medieval roots
phy, myelography, discography, computed tomography (CT), of spine biomechanics. Neurosurgery. 2007;60(2):382–390; dis-
and magnetic resonance imaging (MRI). cussion 390-391.
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Schubert—Maker of Songs
And now we come to Franz Peter Schubert (1797–1828), born in

Vienna of a schoolmaster father, and a mother, who, like
Beethoven’s, was a cook.
The musical comedy, Blossom Time, was built upon some of
Schubert’s most beautiful melodies and episodes from his life. We
must never trust too far stories told this way, which often contain
unreliable details, however this charming operetta gives an
interesting glimpse of Schubert’s devotion to composition. It is true
that he wrote wherever he was, covering his cuffs as well as the
menus and programs in the taverns with the endless flow of themes
which eventually became world-famous songs. Schubert was not a
mere writer of songs; he created the form known as Lieder and
through all his works, torrents of melody seemed to spring from him
eternally.
He was the thirteenth of nineteen children, five of which were of a
second marriage, and there was no wealth or luxury for Franz, so his
father worked hard to pay for his music lessons.
His teacher said that no matter what he tried to teach him in
violin, piano, singing, the organ or thorough-bass, Franz knew it
already, for he learned everything almost at a glance.
He was first soprano in the church choir of Lichtenthal and the
beauty of his voice attracted much attention. He also played the
violin in the services, and stole little stray minutes to write songs or
pieces for strings and piano.
When he was sent to the school for Imperial choristers the boys
laughed at his coarse, grey clothing, the big “Harold Lloyd
spectacles,” and his retiring, bashful manners. They soon changed
when they discovered the astonishing things he could do. His home-
spun clothes were exchanged for the uniform trimmed with gold lace
worn by the Imperial choristers, who formed an orchestra to practise
daily music by Haydn, Mozart, Cherubini and Beethoven. Among
them was Spaun and when he won his confidence, Franz told him
that he had written many pieces and he would write more, but could
not afford to buy the music paper. His new friend made it possible
for Schubert to have paper and many other luxuries, in which Spaun
did something to benefit the world,—a little kindness which brought
great results.
The extreme ease with which Schubert absorbed all learning made
him neglect the study of counterpoint, because after all he could not
give all his time to music, for he was a schoolteacher and had to work
hard to get along. His heart was not in his work, for while hearing the
pupils recite he wrote themes on every scrap of paper he could find.
He wrote with lightning rapidity. The early songs met with
immediate favor which encouraged him to write music in larger
form. He was of the people and wrote from the heart, and to the
heart. He hoped for the same success with his symphonies and
chamber music, but the symphonies never reached the perfection of
his songs, and his disappointment was keen when the critics did not
rate them as highly.
However, the steady flow of melody, the torrent of themes, never
ended and his chamber music is like a song with lovely play of
instruments. Who can forget the haunting beauty of the Unfinished
Symphony? This was left unfinished, indeed, not by Schubert’s death
as many suppose, but the composer felt that he had arrived at a
summit of beauty in the second movement, and he dared not add a
third, lest he could not again reach the heights.
His tenth and last symphony in C major takes an hour to perform
and is heard frequently. Robert Schumann wrote that it was of
“Heavenly length.”
Schubert lived when the romantic poets gave him wonderful verse
for his texts. He loved the literature of Goethe and Heinrich Heine,
both of whom knew the hearts of the simple people.
The world will never forget the wonderful heritage left by this
genius who died at thirty-two leaving vast quantities of great works.
Besides creating new forms in song he also gave the pianists pieces
that were new and important. He left no concertos, nor did he write
for solo violin, but his piano sonatas and chamber music are of value.
Der Erl-Koenig (The Erl King), Der Doppelganger (The Shadow),
and Death and the Maiden, all sounded the last note in tragedy, and
he also wrote many lovely songs in lighter mood.
The Well Favored Mendelssohn
Most masters who have left the world richer for having lived, were
born in poverty and knew the sorrows of privation, not so with Felix
Mendelssohn-Bartholdy (1809–1847), loved by the many who have
played his Songs Without Words, or who have heard Elman’s fingers
fly over his violin in the concerto, said to be the best writing ever
done for that instrument.
Popular as are many works from the polished and fluent pen of
Mendelssohn, the oratorios Elijah and Saint Paul are noble for these
contain some of the most dramatic and inspired writing. In that work
which is typical of Mendelssohn and his personality, he showed more
characteristics of the older classical school than of the romantic. If he
had lived during the classical period he would have been a greater
composer, for he was romantic by influence and classic in taste.
Has not the Spring Song the shimmer of spring and the Spinning
Song the whir of the wheels? One can easily imagine the kindly touch
of a loving hand in Consolation, while the Hunting Song is alive and
going. This is the romantic music that became the model for
thousands of small pieces.
It in said frequently that if Mendelssohn had been less
conventional, his work would have been more forceful, because he
had much that was truly fine.
Mendelssohn lived among the most brilliant literary lights of his
day. His refinement was reflected in his music. He was petted by an
adoring father, mother and sisters, who gave him every opportunity
to study and compose, and he was much sought after socially. He
devoted much time to the study of languages, sketching in water
colors and traveling in Italy and Switzerland. His sister Fanny, whose
musical education was of the utmost assistance to her brother whom
she idolized, would have been famous but for her father’s prejudice
against women in professional life. She was a gifted composer and it
is claimed that she wrote many of her brother’s songs and some of
the Songs Without Words.
Her death was a mortal blow from which Mendelssohn never
recovered. Extremely sensitive, his affection for his family was most
intense and filled his life.
His grandfather was the eminent philosopher Moses Mendelssohn,
who being a Hebrew, was open to the sorrows caused by prejudice.
He was such a great man, however, that he succeeded in breaking
down barriers not only for himself, but for his race.
Abraham Mendelssohn was pleased to call himself, “First the son
of the famous Moses Mendelssohn, then the father of the eminent
Felix Mendelssohn.” His banking house in Berlin is still in the family.
The most noted musicians and artists were entertained in the
Mendelssohn home, and heard the compositions of the gifted young
man. In 1821 the boy was taken to Goethe’s home where he played
and improvised for the poet. He was delighted with him for his
musical talent, and because he had inherited the gift of conversation
and letters from his grandfather, of whom Goethe was very fond.
Young Mendelssohn never shocked the great old poet as did
Beethoven, for his manner was always correct.
In 1825 Mendelssohn went to Paris to Cherubini who was asked
whether his talent justified cultivation beyond the average stage. The
master was very enthusiastic, but his father would not leave him in
Paris, even in charge of the noted teacher. Returning to Berlin he
wrote the overture to Midsummer Night’s Dream (1826). It reflects
the dancing elves and the humor of Shakespeare, while the orchestra
has a delicate touch, similar to that shown by Berlioz at the same
period. Mendelssohn was only seventeen when he wrote it, with all
its finish and its flawless musical treatment. Much that he did at that
period shows his natural flow of genius. Music seemed to gush from
his soul like pure, fresh water from a spring, making one think of
cool fountains, sparkling with melody and clarity. These qualities are
also in the Fingal’s Cave or Hebrides overture, and he takes you on
his delightful trips in Calm Sea and Prosperous Voyage. The way
these numbers reflect his impressions and the way he transmitted
them to others is typical of the Romantic School. The purity of his
musical form related him to the classical and gave inklings of the
Symphonic Tone Poem.
In his symphonies Mendelssohn also told tales of his travels, as in
the Italian Symphony, and in his Scotch Symphony in which he
made use of Scotch folk tunes. He also wrote much chamber music.
He left some piano concertos which may not attract the professionals
of today but are the joy of many piano students who play them
arranged for two pianos.
Mendelssohn tried operas but like many others failed to find a
good libretto. This was the trouble with one he produced in Berlin.
Added to this there were many intrigues and jealousies at the opera
house which turned him bitterly against that city.
However, he accomplished one of the greatest things ever done for
music. The works of Bach and Handel had been so neglected that
they were almost forgotten. He knew them well, and wanting others
to love them as he did, he assembled a great chorus and gave Bach’s
Passion according to Saint Matthew. This was the first performance
since Bach’s death, and it brought these works back to us. Imagine
Mendelssohn’s popularity and talent as a conductor to have been
able to do this at the age of twenty! Then he traveled again, and after
roaming through Italy, Switzerland and France, he went to London
where he created a stir as pianist, composer and conductor. Besides
his splendid education he had a winsome and attractive personality,
and his success was very great. He made, in all, nine visits to
England.
Having been brought up in the Christian faith, he married the
daughter of a French Protestant minister and had five children. They
went to live in Germany and becoming conductor of the Leipsic
Gewandhaus orchestra, he made the city the musical center of
Germany. He founded the Leipsic Conservatory of Music (1843),
where he gave his old teacher Moscheles an important post. This
conservatory is well known here for many American musicians of the
last generation were educated there.
Mendelssohn conducted many festivals and he always aroused new
interest in Bach, whom he presented at every opportunity.
His Saint Paul had success in Duesseldorf (1837), and during his
last visit to England (1846), he gave at the Birmingham festival
Elijah, second today in popularity only to Handel’s Messiah.
When Mendelssohn returned to Leipsic, he showed traces of
overwork and the death of his sister coming at the same time, made
him unable to resist the strain. He died November 4, 1847, when only
38. His happy life shines through his music so full of beauty and
sunshine.
Schumann—The Supreme Poet
Robert Schumann (1810–1856), a tower of beauty, strength,

imagination and dramatic fervor even judged by 20th century
standards, still thrills us as we recognize his genius. What a price he
paid for his life filled with joys and griefs!
We are grateful for the solidity of his building, his breadth of
vision, the wonders of his imagination, the beauty of his poetic fancy,
and above all, the vastness of his musical knowledge. A peak among
the composers of the Romantic School, he has scaled the heights of
dramatic fervor as he has touched the sun-flecked valleys. To him we
owe the naming of pieces, and the feeling of emotion which the
composer felt when he named them,—The Happy Farmer, The
Prophet Bird, The Rocking-Horse, End of the Song, The Child Falls
Asleep, etc.
All who have been milestones in music have been well educated,
yet how unjustly people say musicians know nothing but music.
Many have not had only culture from their studies, but also have
come from refined homes. So Schumann, born at Zwickau, Saxony,
had an educated father, a book-seller. His mother wanted Robert to
be a lawyer, and did not wish his musical talent to interfere. He
began to compose and study music at seven, but he studied law,
literature and philosophy, later, at the University of Leipsic.
After a year he went to the famous University of Heidelberg
(1829), which has always been proud that the great composer was
one of its students.
Schumann returned to Leipsic on account of the musical life. With
his return began the romance of his life, one of the most beautiful
love stories in musical history. He studied with Frederick Wieck,
whose little daughter Clara was a prodigy pianist. He became a
member of the household and was charmed by the talent of the child.
Meanwhile he was studying as pianist, and being ingenious, he
invented an instrument to develop his weak fourth finger, but it
ruined his hand and unfitted him for his career.
Now he gave more attention to composition and to musical
criticism. This gave him the chance to help some of the brilliant
musicians of the day. He brought Chopin to the notice of Germany,
and proclaimed the genius of young Johannes Brahms. He also
formed a deep friendship for Mendelssohn.
Valuable as are all writings which reveal his thoughts, his richest
gift to the world was his music, in which he preached the gospel of
beauty.
As Schumann grew into manhood he began to know the depths of
sorrow, some of his finest works having been an outburst of his
tortured soul. Clara Wieck was now a young woman and a great
pianist. It was natural that an affection should spring up between
them. But Clara’s father had greater hopes. He could not see a
struggling young musician and critic as the husband of his talented
child. During this long and painful courtship when Schumann dared
not speak his love to Clara he wrote compositions with which to tell
his story, and she understood. One of these expressions was the
lovely Warum asking the question, “Why?” so longingly.
In those days a case could be brought into court and the reason
demanded why a parent should refuse to allow a marriage.
Schumann went to law, and the court decided that Wieck’s objections
were without cause. But the year of strain told upon his health and
nerves and he began his married life under a cloud of illness. The
young pair were ideally happy, he wrote glorious music, and she took
pride in playing his piano works on all her programs.
With all her accomplishments—and she was a great artist—she was
first a devoted wife who cared for her husband as though he had
been her child. Schumann’s very finest work was done during these
years. His inspiration drove him chiefly to songs, full of lyric beauty
like Schubert’s; indeed, when speaking of lieder the names of
Schubert and Schumann are always linked.
Mendelssohn urged Schumann to teach in the Leipsic
Conservatory, but he left there soon to make a tour of Russia with his
wife. That year they settled in Dresden, a quieter city, because his
nerves were beginning to forecast the shadow of his future.
Mendelssohn loved Schumann and admired him as composer,
writer and critic. He conducted the first performance of Schumann’s
B flat symphony at a Gewandhaus concert of Clara Schumann, and
the happiness of the three was tremendous. Schumann did not think
of himself alone, but was always trying to help his colleagues.
Schubert wrote his C major symphony in March of the year he died
and never heard it, but Schumann had the score sent to Mendelssohn
in Leipsic for its first performance after a wait of eleven years.
Notwithstanding his nerves, Schumann was now in his full power
and the amount he wrote is incredible. Most of his chamber music
was written in 1842, three of the string quartets being dedicated to
Mendelssohn. The work that gave him fame all over Europe was the
quintet for piano and strings, opus 44; with Clara at the piano,
Berlioz heard its first performance and spread the news of his genius
through Paris. About this time the Variations for Two Pianos were
written and played by Robert and Clara Schumann.
Another interesting and popular number is Carnaval, a collection
of named sketches in three-four time each one portraying some
person or thing. Eusebius and Florestan have caused much curiosity
—the secret is that Schumann was a student of himself and these
were meant to show his conflicting moods. Chopin is represented,
also Mendelssohn, while Chiarina is Clara.
A strange thing happened to Schumann in Vienna. He was visiting
the graves of Beethoven and Schubert which are not far apart, and he
found a steel pen on Beethoven’s tomb. He took this for an omen, but
used it only for his most precious works. He wrote the B flat
symphony with it and the magic seemed to work!
Schubert is universally praised for the beauty of his themes, but
who could surpass the loveliness of Schumann’s melodies? The
contrasts between the exquisite little tone-pictures of Kinderscenen
and the grandeur of the sonatas and the Fantasia mark the breadth
of his genius, while the amount he accomplished in his short span of
life was marvelous.
He was but twenty-five when he first showed mental trouble, and
at forty-four his case was hopeless. He tried to end his life by
jumping into the Rhine and was taken to an asylum near Beethoven’s
birthplace, Bonn, where he died two years later, survived by his wife
and two daughters.
What a price he paid for his life filled with joys and griefs!
Chopin—“Proudest Poet-Soul”
Robert Schumann wrote that Chopin was “the boldest, proudest

poet-soul of his time.” Such a tribute from him meant more than all
the praise we can give him now; it shows that he had admiration and
respect from his rivals as he had idolatry from the literary, artistic
and refined circles of Paris.
Frederic Chopin (1809–1849) was born in Poland of a French
father and a Polish mother. The difference one finds in the date of his
birth, February 22 or March 1, is owing to the difference between the
Russian and Polish calendars, and those of other countries.
Like Mozart he showed talent very early and at nine played his first
public concert. His mother, unable to be present, asked him what the
audience liked best. “My collar, Mamma!” he answered, proud of the
little lace collar on the black velvet jacket! He was elegant then, and
always kept his air of distinction, and a love for beauty.
Shortly after beginning music study, Chopin tried to compose, and
felt such authority that he undertook to change certain things written
by his teacher. His earliest work was a march dedicated to the Grand
Duke Constantin, which was arranged for brass-band and printed
without the composer’s name.
From his two teachers in Poland, both ardent patriots, Chopin
must have absorbed much of the national feeling so strongly marked
in his works. As it was a day of flashy salon (Page 322) playing, his
teacher, Joseph Elsner, felt that Chopin was the founder of a new
school in which poetic feeling was leading music out of the prevailing
empty acrobatic finger feats!
The world owes much to that wise teacher who instilled a love of
Bach into his young pupil. He answered some one who blamed him
for allowing Chopin too much freedom: “Leave him alone! he treads
an extraordinary path because he has extraordinary gifts and follows
no method, but creates one. I have never seen such a gift for
composition.” Later he marked his examination papers: “Chopin,
Frederic (pupil for three years), astounding capacity, musical
genius.”
At fifteen Chopin was adored by his companions and always held
the affection of those who knew him. He seems to have been the
original “matinee idol” of Paris, whenever he played, for he was the
most poetic and finest pianist ever heard.
Though Chopin was seemingly French in manner, habits and
tastes, he was extraordinarily patriotic and his music is perhaps the
finest expression of Poland the world has ever seen.
No one has surpassed, or even equalled Chopin in writing for the
piano. He understood its possibilities, limitations, tonal qualities and
power to express emotion.
He did not leave a great quantity of compositions, but a well-
ordered collection of music, so individual that even today, with all his
imitators, when we hear Chopin—(and where is there a piano recital
without at least one number?)—we instantly recognize it as his.
Strongly marked rhythms are among his most fascinating
characteristics. He glorified and elaborated the dances of Poland, as
had others in the past, who made art pieces of the gavotte, minuet,
bourrée, gigue, etc.
What lovelier numbers on a program than Chopin’s mazurkas,
polonaises, waltzes? There is also irresistible swing in the Ballades,
Impromptus, the Berceuse, Barcarolle, and what could rival in
fantasy the Nocturnes or Preludes? The Etudes cover a variety of
moods, while his Scherzos stand alone in piano literature.
Chopin left no symphonies, no chamber music, except two piano
sonatas and one for ’cello and piano, and what he did for voice could
be told in a few words. He also wrote two piano concertos in which
the piano work is beautiful but the orchestration is not as fine.
These concertos and his piano sonatas were the largest forms in
which he wrote, proving that he could have succeeded here had he
not chosen to perfect music in the smaller forms.
Chopin never had a fair start in life in the way of health, and while
his delicate appearance made him the more interesting, especially to
the ladies, he was a real sufferer. It would be unfair to believe that his
work would have been greater had he enjoyed complete health, for
his unhappiness and his sufferings gave him a sense of the
mysterious and the beyond. He lived in a world far from material
things and seemed able to translate all he felt into music.
He had the devotion of many idolizing friends, tireless in their
efforts to make him happy and keep him working so that he should
not brood over his illness (tuberculosis). Foremost among these was
the famous French novelist George Sand, whose love and
companionship were the source of rare inspiration and comfort. She
was a woman of vast mental and physical power and seemed to
impart her strength to him. But Chopin was a favorite not only with
women but among the men, as we learn through the letters he left.
We find many from Schumann, Mendelssohn, Liszt, Delacroix, the
French painter, and innumerable others.
Concertizing began to fatigue him beyond endurance. Returning to
Paris from a tour during a hard winter in England, he grew so ill that
he rarely left his bed, although he did not die until the following
October, 1849.
Chopin had asked that the Mozart Requiem be given at his funeral,
which occurred October 30, from the Madeleine Church in Paris. The
singer Lablache who had sung the Mozart number at Beethoven’s
funeral also performed this tribute for Chopin.
In addition to the Requiem, Lefebure-Wely, one of the fine
organists of Paris, played Chopin’s preludes in B and E minor, and
the familiar funeral march from the first sonata was arranged for
orchestra and played for the first time.
Heller—The Children’s Chopin
We may not find the name of Stephen Heller (1813–1888) on

many of the “grown-up” programs, but no pupils’ recitals are
complete without several of his lovely melodies.
He was the friend of children and devoted himself more to
teaching and writing for the young minds and small hands than did
any of his companions. Heller was intended for a lawyer, but his
talent as shown at nine was great enough for him to study with Carl
Czerny in Vienna. He became a fine concert pianist and toured
Europe. Taken ill during one of these tours, he was adopted by a
wealthy family who allowed him all the time he wanted for
composing. Most of his study was done in Paris where he was a
friend of Berlioz, Chopin, Liszt and other prominent artists of the
day.
He left several hundred piano pieces, nearly all masterpieces in a
field where he stands practically alone. He wrote in the style
developed by Mendelssohn and Schumann, and what Chopin is to
the music world of the “grown-ups,” Heller is to the young student.
Painted by
Kriehuber.
Franz Schubert.
After the Painting
by Bendemann.
Robert Schumann.
Felix Mendelssohn-Bartholdy.
After the Painting
by F. V. Delacroix.
Frédéric Chopin.
Poet Music Writers.
(Romantic School.)
After a painting by
Lenbach.
Richard Wagner, the Wizard.

CHAPTER XXV
Wagner—the Wizard
Wilhelm Richard Wagner

1813–1883
Richard Wagner, the Wizard, called out of the past a vast company
of gods and goddesses, giants, knights and heroes, kings and queens.
He made them live for us with all their joys and sorrows, loves and
hates, in his great music dramas, for which he has been recognized as
one of the rare geniuses of the world.
Evoked by his music-magic they pass before us,—the gods and
heroes of Walhalla,—Wotan, Brünnhilde, valiant Siegfried, Pfafner
the giant who is turned into a dragon, Mime the dwarf, the Rhine
Maidens and the Valkyries; Parsifal the guileless youth who became
the Knight of the Holy Grail, and Lohengrin his son, the beautiful
knight who marries Elsa, a lady of rank of the Middle Ages.
We see the minnesingers Tannhäuser and Wolfram von
Eschenbach in one of their famous Minstrel Tournaments with the
hand of the lovely Elizabeth as a prize; we also meet the lovable
shoemaker-mastersinger Hans Sachs in Nüremberg, of the 16th
century, and David his merry apprentice, lovely Eva Pogner and the
charming knight Walter von Stolzing, and Beckmesser the clownish
mastersinger; then there are the imperious Irish Queen, Isolde and
Tristan, her lover, with Kurvenal his faithful servant. Wagner makes
not only the mythological persons relive but he brings back realistic
pictures of the everyday life and customs of the German people of the
Middle Ages.
Wagner had his idea of what opera should be and nothing short of
his ideal interested him. He kept to his purpose and accomplished
miraculous things whether he suffered or starved or was banished
from his country.
Richard was born at a time, favorable for hearing and knowing the
Viennese composers of the 18th and early 19th centuries, who had
increased the importance of the orchestra. He could hear too the
music of Schumann and Schubert, with all the new beauty and warm
feeling they radiated. This new depth appeared not only in the
orchestra but also in piano and vocal music. In Wagner’s time,
people felt deeply about everything,—science, philosophy, literature,
and especially politics; and many were the quarrels and discontents
among nations. Even our own country was torn by a cruel war.
Wagner listened to the works of Mozart and of Beethoven, whom
he admired immensely. He approved of Beethoven’s use of the
chorus in the Ninth Symphony, which had no little effect on his work
and ideals.
Among the people who most influenced Wagner was Gluck, who
first fought for sincerity and truth in opera drama. Gluck did not
have the advantage of the grown up orchestra and freer forms, yet
Gluck did so much to free opera that Wagner was fortunate indeed to
have come after him. Another great influence was Weber, who mixed
everyday story in a delightful play of fancy and picturesqueness.
Wagner, after hearing Weber’s Die Freischütz, was very much
impressed.
Meyerbeer, a contemporary, although rather artificial and always
working for effects, nevertheless showed Wagner the value of
gorgeous scenic productions. Wagner was fond of the stage, and
Meyerbeer’s big scenes sank into the mind of the young composer-
poet, who liked to be called a poet rather than a musician!
Musically, Franz Liszt was probably the greatest influence in
Wagner’s life and we often hear in Wagner’s works bits of melody
which remind us of Liszt.
It is not fair to say that he was great just because he followed
Gluck, Weber, and Mozart, for he brought music out of its old ruts
and was copied by hundreds of composers.
The hero of this chapter was born in Leipsic in 1813 and was the
youngest of nine children. His father died shortly after his birth and
his mother married an actor playwright named Geyer and they all
went to live in Dresden. His stepfather felt that Richard had musical
gifts and he proved a very kind and wise parent. He died when the
boy was only eight.
Richard must have been a most interesting little chap, for he
always did everything with what we would call “pep” and persistence.
He loved poetry and was devoted to the theatre. His stepfather had
always allowed him to go “back stage” at the playhouse, so the youth
became familiar with stage craft, which he used later in producing
his music dramas.
He read the Greek and German poets and dramatists at a very
early age. He was the first of the musical geniuses to be trained in the
arts before he started music. So we can picture a little chap, “stage-
struck,” studying when he should, seeing plays when he could, and
listening to the works of Weber and Beethoven which enchanted
him, and storing up ideas, but as yet showing no great leaning
toward music as a profession.
The family moved back to Leipsic in 1827 where he went to school
until he entered the university in 1831. He heard much orchestral
music and became so deeply charmed with Beethoven, that he copied
the Ninth Symphony from a score, to become familiar with it. The
Ninth Symphony with chorale takes about two hours to perform,
imagine how long it took to copy it! An instance of the wizard’s
energy and “stick-to-it-iveness”!

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Benzel's Spine Surgery, 2-Volume Set:

Techniques, Complication Avoidance

BENZEL’S SPINE SURGERY: TECHNIQUES, COMPLICATION AVOIDANCE,

Copyright © 2022 by Elsevier, Inc. All rights reserved.

Previous editions copyrighted 2017, 2012, 2005, 1999.

Library of Congress Control Number: 2020951843

Content Strategist: Humayra Khan

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to our families and to the

Sigurd Berven joined us as an editor for this

Ali R. Abtahi, DO, MSc Basel Sheikh Alshabab, MD Paul A. Anderson, MD

Eli M. Baron, MD Barrett S. Boody, MD Jose A. Canseco, MD, PhD

Aaron J. Clark, MD, PhD Sanjay S. Dhall, MD Richard G. Ellenbogen, MD

Richard D. Guyer, MD Daniel Hedequist, MD Daniel J. Hoh, MD

Nina Z. Moore, MD, MSE Dileep Nair, MD Jonathan Oren, MD

Rakesh Patel, MD Rick Placide, MD, PT Wilson Z. Ray, MD

Sarah Rispinto, PhD Zaid Salaheen, BSc Eric Schmidt, MD

Stuart L. Weinstein, MD, ABOS Michelle Williams, MD Michael Yang, MD

1 History of Spine Surgery

SUMMARY OF KEY POINTS

Serefeddin Sabuncuoglu (1385–1468 ce), a Turkish

RENAISSANCE AND SPINE SURGERY

BOX 1.1 Developments and Inventions Contributing to 1

assisted with the diagnosis of spinal disorders. Developments

Spinal Decompression and the Early Modern

British surgeon Donald Armour29 described the controversy

This [Cline’s operation] precipitated and gave rise to

Of course, surgical fatalities in this period were caused as

AG Smith and the First Successful Laminectomy

Laminectomy for Intramedullary Spinal Tumor 1

Variations in Laminectomy Technique

Fig. 1.7. Charles A Elsberg.

Fig. 1.9. Walter E Dandy.

Fig. 1.8. Rudolph Virchow.

Laminectomy for Cervical Disc Herniation. In 1905 Watson

Laminectomy for Spinal Stenosis. Unlike the herniated

Fig. 1.11. Drainage of a tubercular abscess via the

from the opening up of the abscess. Because no antitubercular

AcroMed,105 pioneered by polymer engineer Carl McMillin.

Spinal Instrumentation and Clinical Biomechanics

Fig. 1.15. Berthold Hadra. Fig. 1.16. Paul Harrington.

2. Flexion-rotation. A rotation or flexion-rotation mechanism

rods as the spinal instrumentation of choice for the surgical

VENTRAL APPROACHES TO THE SPINE

the problem of severe kyphotic deformity, causing cardio-

And now we come to Franz Peter Schubert (1797–1828), born in

Robert Schumann (1810–1856), a tower of beauty, strength,

Robert Schumann wrote that Chopin was “the boldest, proudest

We may not find the name of Stephen Heller (1813–1888) on

Poet Music Writers.

Richard Wagner, the Wizard.

Wilhelm Richard Wagner

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2. Flexion-rotation. A rotation or flexion-rotation mechanism