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IFC.indd 1 22-12-2020 21:34:24
Revision Lumbar
Spine Surgery
Revision Lumbar
Spine Surgery

Robert F. Heary, MD
Chief, Neurosurgery Service
HMH Mountainside Medical Center
Montclair, NJ
Professor of Neurological Surgery
Hackensack Meridian School of Medicine
Nutley, NJ
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

REVISION LUMBAR SPINE SURGERY, FIRST EDITION ISBN: 978-0- 323712019

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

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List of Contributors

A. Karim Ahmed, MD Paul A. Anderson, MD

Resident Professor
Department of Neurosurgery Orthopedic Surgery and Rehabilitation
Johns Hopkins School of Medicine University of Wisconsin
Baltimore, MD Madison, WI

Fadi Al-Saiegh, MD Paul M. Arnold, MD, FACS

Resident Physician Professor of Neurosurgery
Department of Neurosurgery Carle Illinois College of Medicine at the University
Thomas Jefferson University and Jefferson Hospital of Illinois
for Neuroscience Chairman
Philadelphia, PA Department of Neurosurgery
Associate Medical Director and Director of
Todd J. Albert, MD Research
Surgeon in Chief Emeritus Carle Neuroscience Institute
Hospital for Special Surgery Urbana, IL
Professor Department of Orthopaedic Surgery Weill
Cornell Medical School Edward Benzel, MD
New York, NY Emeritus Chairman
Department of Neurosurgery
Ilyas Aleem, MD, MS, FRCSC Neurological Institute, Cleveland Clinic
Assistant Professor Cleveland, OH
Orthopaedic Surgery
University of Michigan Erica F. Bisson, MD, MPH
Ann Arbor, MI Professor
Department of Neurosurgery
Anthony M. Alvarado, MD Clinical Neurosciences Center
Resident Physician University of Utah
Neurological Surgery Salt Lake City, Utah, USA
University of Kansas Medical Center
Kansas City, KS Alessandro Boaro, MD
Neurosurgeon
Christopher P. Ames, MD Institute of Neurosurgery
Professor of Clinical Neurological Surgery Department of Neurosciences, Biomedicine, and
Professor of Orthopaedic Surgery Movement Sciences
Director of Spinal Deformity & Spine Tumor University of Verona
Surgery Verona, Italy
Co-Director, Spinal Surgery and UCSF Spine
Center Barrett S. Boody, MD
Director, California Deformity Institute Orthopedic Spine Surgeon
Director, Spinal Biomechanics Laboratory Orthopedic Surgery
University of California Indiana Spine Group
San Francisco, CA Carmel, IN

v
vi List of Contributors

Darrel S. Brodke, MD Zachary H. Goldstein, MD

Professor and Executive Vice Chair Resident Physician
Department of Orthopedics Department of Orthopedic Surgery
University of Utah Indiana University School of Medicine
Salt Lake City, UT Indianapolis, IN

Nathaniel P. Brooks, MD Michael W. Groff, MD

Associate Professor Vice-Chairman, Director of Spinal Surgery
Department of Neurological Surgery, University of Department of Neurosurgery
Wisconsin School of Medicine and Public Health Brigham and Women’s Hospital, Harvard School
Madison, WI of Medicine
Boston, MA
Thomas J. Buell, MD
Fellow Physician Raghav Gupta, MD
Department of Neurosurgery Resident Physician
Duke University Department of Neurological Surgery
Durham, NC University of Southern California
Los Angeles, CA
Rebecca M. Burke, MD, PhD
Chief Neurosurgical Resident Tessa Harland, MD
The University of Virginia Resident
Charlottesville, VA Neurosurgery
Albany Medical Center
Jose A. Canseco, MD, PhD Albany, NY
Spine Surgery Fellow
Spine James S. Harrop, MD, MSQHS
Rothman Orthopaedic Institute Professor of Neurological and Orthopedic Surgery
Spine Surgery Fellow Sidney Kimmel Medical College at Thomas
Orthopaedics Jefferson University
Thomas Jefferson University Section Chief
Philadelphia, PA Division of Spine and Peripheral Nerve Disorders
Thomas Jefferson University Hospital
Joseph S. Cheng, MD, MS Philadelphia, PA
Frank H. Mayfield Professor and Chair
Department of Neurosurgery Robert F. Heary, MD
University of Cincinnati College of Medicine Chief, Division of Neurosurgery
Cincinnati, OH HMH Mountainside Medical Center
Montclair, NJ
Dean Chou, MD Professor of Neurological Surgery
Professor of Neurosurgery Hackensack Meridian School of Medicine
University of California San Francisco Nutley, NJ
San Francisco, CA
Stanley Hoang, MD
Jeff Ehresman, MD Assistant Professor
Research Fellow Neurosurgery Center
Johns Hopkins University School of Medicine Ochsner LSU Health Shreveport
Baltimore, MD Shreveport, LA

Sapan D. Gandhi, MD Kenneth J. Holton, MD

Orthopaedic Spine Surgeon Spine Research Fellow
Beth Israel Deaconess Medical Center Orthopaedic Surgery
Harvard Medical School University of Minnesota
Boston, MA Minneapolis, MN
 List of Contributors vii

Rajbir S. Hundal, MD Daniel P. Leas, MD

Orthopaedic Surgery Resident Carolina Neurosurgery and Spine Associates
Department of Orthopaedics Assistant Professor
University of Michigan Department of Orthopaedic Surgery
Ann Arbor, MI Atrium Health
Charlotte, NC
Jacob R. Joseph, MD
Clinical Assistant Professor of Neurological Ronald A. Lehman Jr., MD
Surgery Professor of Orthopaedic Surgery, Tenure (in Neurological
University of Michigan Surgery)
Ann Arbor, MI Chief, Reconstructive, Robotic & MIS Surgery
Director, Adult and Pediatric Spine Fellowship
Iain H. Kalfas, MD, FACS Director, Athletes Spine Center
Head, Section of Spinal Surgery Director, Spine Research
Department of Neurosurgery The Daniel and Jane Och Spine Hospital
Cleveland Clinic New York, NY
Cleveland, OH
Lawrence G. Lenke, MD
Adam S. Kanter, MD, FAANS Surgeon-in-Chief
Associate Professor of Neurological Och Spine Hospital at New York-Presbyterian/Allen
Surgery Professor of Orthopedic Surgery (in Neurological Surgery)
Chief, Division of Spine Surgery Chief of Spinal Surgery
Director, Minimally Invasive Spine Chief of Spinal Deformity Surgery
Program Co-Director, Adult and Pediatric Comprehensive Spine
Director, Neurosurgical Spine Fellowship Surgery Fellowship
Program Department of Orthopedic Surgery
University of Pittsburgh Medical Center Columbia University
Pittsburgh, PA New York, NY

Yoshihiro Katsuura, MD Jason I. Liounakos, MD

Director Resident
Spine Surgery Neurological Surgery
Adventist Health Howard Memorial University of Miami
Hospital Miami, FL
Willits, CA
Rory Mayer, MD
Han Jo Kim, MD Staff Neurosurgeon
Associate Professor Department of Neurosurgery
Orthopaedic Surgery Baylor University Medical Center
Hospital for Special Surgery Baylor Scott & White Health
New York, NY Dallas, Texas

Jun S. Kim, MD Praveen V. Mummaneni, MD, MBA

Adult and Pediatric Spine Surgery Joan O’Reilly Professor & Vice Chairman
Department of Orthopaedic Surgery and Neurological Surgery
Neurosurgery Co-Director, UCSF Spine Center
Mount Sinai West University of California, San Francisco
Icahn School of Medicine at Mount Sinai San Francisco, CA
New York, NY
Rani Nasser, MD
Kamal Kolluri Assistant Professor
Intern Department of Neurosurgery
University of California University of Cincinnati College of Medicine
San Francisco, CA Cincinnati, OH
viii List of Contributors

Ahmad Nassr, MD Frank M. Phillips, MD

Consultant Ronald DeWald, Endowed Professor of Spinal
Department of Orthopedics Deformities
Mayo Clinic College of Medicine Director, Division of Spine Surgery
Rochester, MN Section Head, Minimally Invasive Spine Surgery
Fellowship Co-Director, Spine Surgery
Robert J. Owen, MD Rush University Medical Center
Orthopedic Spine Surgeon Chicago, IL
Peachtree Orthopedics
Atlanta, GA Julie G. Pilitsis, MD, PhD
Chair
Fortunato G. Padua, MD, MSc, BS Neuroscience & Experimental Therapeutics
Research Fellow Professor of Neurosurgery and Neuroscience &
Orthopaedics Experimental Therapeutics
Rothman Orthopaedics Albany Medical College
Philadelphia, PA Albany, NY

Paul Park, MD David W. Polly, Jr., MD

Professor of Neurosurgery Chief of Spine Surgery
University of Michigan Professor of Neurosurgery
Ann Arbor, MI Department of Orthopaedic Surgery
University of Minnesota
Paul J. Park, MD, MMS Minneapolis, MN
Chief Resident, Department of Orthopedic Surgery
Columbia University Irving Medical Center/New York Eric A. Potts, MD
Presbyterian Attending Neurosurgeon
The Daniel and Jane Och Spine Hospital Goodman Campbell Brain and Spine
New York, NY Ascension St. Vincent Hospital
Carmel, IN
Arati B. Patel, MD
Resident Physician Raj D. Rao, MD
Neurological Surgery Professor and Chairman
University of California, San Francisco Department of Orthopaedic Surgery
San Francisco, CA George Washington University
Washington, DC
Rakesh Patel, BS, MD
Associate Professor Daniel K. Resnick, MD, MS
Orthopedics Professor and Vice Chairman
University of Michigan Department of Neurosurgery
Ann Arbor, MI University of Wisconsin School of Medicine and Public
Health
Brenton Pennicooke, MD, MS Madison, WI
Assistant Professor of Neurological Surgery and
Orthopaedic Surgery Joshua Rivera, BA
Department of Neurological Surgery Clinical Research Coordinator
Washington University in St. Louis University of California
St. Louis, MO San Francisco, CA

Zach Pennington, BS Mohamed Saleh, MD

Medical Student Chief Resident
Department of Neurosurgery Department of Neurosurgery
Johns Hopkins Hospital University of Cincinnati College of Medicine
Baltimore, MD Cincinnati, OH
 List of Contributors ix

Jose E. San Miguel, MD, PhD Kevin Swong, MD

Orthopaedic Surgery Resident Assistant Professor of Neurological Surgery
University of Minnesota Northwestern Memorial Hospital
Minneapolis, MN Chicago, IL

Rick C. Sasso, MD Lee A. Tan, MD

Professor Assistant Professor of Neurological Surgery
Chief of Spine Surgery University of California, San Francisco Medical Center
Department of Orthopaedic Surgery San Francisco, CA
Indiana University School of Medicine
Indiana Spine Group Daniel J. Thomas, BA
Indianapolis, IN Research Assistant, Spine Team
Rothman Institute
Shelly K. Schmoller, PA-C Philadelphia, PA
Neurosurgery
University of Wisconsin Hospital and Clinics Huy Q. Truong, MD
Madison, WI Resident
Department of Neurosurgery
Daniel M. Sciubba, MD Medical College of Wisconsin
Professor Milwaukee, WI
Departments of Neurosurgery, Oncology, Orthopaedic
Surgery, and Radiation Oncology Alexander R. Vaccaro, MD, PhD, MBA
Director, Spine Tumor and Spine Deformity Richard H. Rothman Professor and Chairman,
Johns Hopkins University School of Medicine Department of Orthopaedic Surgery
Baltimore, MD Professor of Neurosurgery
Co-Director, Delaware Valley Spinal Cord
Christopher I. Shaffrey, MD Injury Center
Professor of Orthopaedic and Neurological Surgery Co-Chief of Spine Surgery
Chief, Spine Surgery and Spine Care Sidney Kimmel Medical Center of Thomas Jefferson
Duke University Medical Center University
Durham, NC Philadelphia, PA

Breanna L. Sheldon, MS Michael Y. Wang, MD FACS

Medical Student (MS3) Professor, Neurological Surgery & Rehab Medicine
Department of Neuroscience and Experimental Spine Fellowship Director
Therapeutics Chief of Neurosurgery, University of Miami
Albany Medical Center Hospital
Albany, NY University of Miami Miller School of Medicine
Miami, FL
Brandon A. Sherrod, MD
Resident Timothy J. Yee, MD
Department of Neurosurgery Resident
Clinical Neurosciences Center Department of Neurosurgery
University of Utah University of Michigan
Salt Lake City, Utah, USA Ann Arbor, MI

Peter Shorten, MD Chun-Po Yen, MD

Orthopaedic Spine Surgeon Associate Professor
Community Hospital Department of Neurological Surgery
Grand Junction, CO University of Virginia
Charlottesville, VA
Justin S. Smith, MD, PhD
Vice Chair and Chief of Spine Division Ulas Yener, MD
Harrison Distinguished Professor University of Virginia
Department of Neurosurgery Spine Fellow in the Department of Neurosurgery
University of Virginia Department of Neurosurgery
Charlottesville, VA Charlottesville, VA
Foreword
Patients with lumbar spine-related symptoms frequently
have their life put on hold as a result of their disabling back
pain. Patients who have surgery for these symptoms but then
end up with residual or recurrent symptoms have the added
burden of disappointment from a surgery that did not resolve
their issues. The diagnostic phrases used in the past—“failed
back surgery” or “postlaminectomy syndrome”—do not
demand the rigor in assessing these patients that they
deserve. These patients require a thoughtful approach into
the causes of failure of their index operation and precision
with the revision surgical technique.
With the experience and knowledge that come from over
25 years in a busy surgical practice that involves a large com-
ponent of revision lumbar spine surgery, Dr. Heary provides
outstanding insights into the challenges of revision surgery
on the lumbar spine and a systematic approach to these
patients. In putting together this comprehensive textbook, he
has gathered a distinguished group of coauthors, all interna-
tionally recognized spine surgeons themselves. His meticulous
preparation and attention to detail comes through—the book
is organized excellently, covering all potential predisposing
causes for failure and with clear descriptions of all aspects of
the challenging revision procedure.
With the increasing incidence of lumbar spine surgery
globally, a growing number of patients are going to require
revision surgery on the lumbar spine. As spinal surgeons, our
approach to the patient with persistent symptoms will distin-
guish not just the good from the excellent surgeon, but also
the good from the excellent patient outcome. Robert Heary’s
textbook Revision Lumbar Spine Surgery is the first of its kind
and will unquestionably help all spine surgeons in managing
this challenging subset of patients. It deserves a place on
every spine surgeon’s bookshelf.
Raj D. Rao, MD, MBA
President, Lumbar Spine Research Society
Professor of Orthopedic Surgery and Neurosurgery
Chairman, Department of Orthopedic Surgery
George Washington University
Washington, DC
xi
Preface
My initial sentiment is to just say “thank you” to all of the
contributing authors to this groundbreaking textbook. The
combination of remarkably talented neurological and ortho-
pedic spine surgeons who gave their time and energy to help
educate all of us amazes me. I am humbled and thankful to
the friends and colleagues who contributed to this textbook
with innovative thoughts and their willingness to share the
specific “tricks” that enable them each to manage revision
lumbar spine surgeries.
The idea for this book came out of a discussion I had at
one of our national spine meetings a few years ago. We were
debating the relative merits of minimally invasive spine sur-
gery when I stated that I make my living revising failed
minimally invasive surgery (MIS) cases. I explained that I
was astounded at the number of inadequate or excessively
aggressive decompressions, inaccurate screw placements,
failed fusion attempts, and sagittal balance malalignments
that were coming to my practice. Understandably, this is
the nature of a mature academic spine practice, and it is sub-
ject to bias. The multitude of patients doing very well after
their MIS procedures would have no reason to come to my
office. Nonetheless, the volume of patients I have continued
to see over the past two decades has made it clear to me that
some of the percentages of “good/excellent” results that are
reported from the podiums at our national meetings are
not necessarily translatable to all practices throughout the
United States.
The next issue that came up in this conversation was what
to do with failed lumbar surgery patients? Where do folks go
for their information on how to identify patients who might
benefit from revision surgeries? What kind of surgeries
should be offered for the optimal results in this specific “revi-
sion” surgery group? At this time, the overwhelming major-
ity of textbooks described how to identify and treat the first
(primary or index) surgery. Revision information was usually
relegated to a couple of paragraphs at the end of a chapter.
As more and more spinal surgeries are being performed
each year in the United States, the numbers of revision sur-
geries are also going up steadily. The exact numbers of revi-
sion lumbar spine surgeries performed annually are not as
easy to track as the primary cases because some registries
have not been as dedicated to tracking this aspect of the sur-
geries. Identifying the patients who have undergone prior
lumbar spine surgery who would benefit from additional sur-
gical treatment has, at times, been challenging.
I feel incredibly fortunate to have many friends and col-
leagues in both the fields of neurosurgery and orthopedic
surgery. I have learned so much from individuals on “both
sides of the aisle,” and many of these folks agreed to help out
and produce chapters on some particular aspects of revision
lumbar spine surgery. Because my own training was a neuro-
surgery residency followed by an orthopedic spine surgery
fellowship, I was exposed to all aspects of lumbar spine sur-
gery from microsurgical decompressions to major deformity
correction procedures. The message I have received over
many years of tackling these challenging conditions is that
regardless of whether the index surgery is small or large, the
potential for developing difficulties at some point down the
road exists.
Many spine surgeons typically think of revision spine
surgery issues as related to dealing with scar tissue, concerns
about dural tears with cerebrospinal fluid leakage, and
fusion and/or spinal stability issues. As is apparent from
reviewing the Table of Contents of this textbook, there are
far more concepts that benefit from detailed analyses. The
authors have added their own thoughts on the surgical indi-
cations for the various treatments offered in this textbook.
My own belief is that many of the indications for primary
lumbar spine surgery (typically pain or neurological con-
cerns) are similar to those for revision surgeries except that it
is widely believed that the revision surgeries are technically
more difficult to perform owing to distortions of the anat-
omy, scar tissue formation, and spinal stability/alignment
issues, and so on.
True experts in our field have been asked to provide their
specific surgical approaches and to give pointers for how and
why they deal with the unique aspects that revision surgeries
entertain. In addition, if problems occur subsequent to the
revision surgeries, strategies for dealing with these very com-
plex patients are addressed.
This textbook addresses the subset of lumbar spine sur-
gery patients who have previously undergone surgical inter-
vention. As such, it is a relatively unique contribution to the
field. I would like once again to thank the extraordinarily tal-
ented neurosurgeons and orthopedic spine surgeons who
generously donated their time, effort, and enthusiasm to
help produce a novel textbook on how to manage revision
lumbar spine surgery patients. I am hopeful that readers of
this textbook will be able to appreciate the skills provided to
all of us by these spine surgery experts. Please enjoy reading
xiii
xiv Preface

this book and keep it handy for review when a challenging

clinical situation presents itself.

Respectfully,
Robert F. Heary, MD
Chief, Division of Neurosurgery
HMH Mountainside Medical Center
Montclair, New Jersey
Professor of Neurological Surgery
Hackensack Meridian School of Medicine
Nutley, New Jersey
Acknowledgments
This textbook Revision Lumbar Spine Surgery was completed
with assistance provided by a variety of individuals. Raghav
Gupta, MD is a recent graduate of the Rutgers-New Jersey
Medical School in Newark, New Jersey. His assistance in all
aspects of this textbook has been noteworthy and is
greatly appreciated. Raghav just recently matched into the
University of Southern California Department of
Neurosurgery residency training program where I am sure he
will excel. My administrative assistants, Ms. Roxanne
Nagurka and Ms. Yesenia Sanchez, provided outstanding
support in coordinating submissions with our contributing
authors and the publishing team at Elsevier Medical
Publishers, Inc. I am very thankful to Raghav, Roxanne, and
Yesenia for the countless hours they worked helping to make
this textbook a reality. Lastly, my children (Declan, Maren,
and Conor) have been tremendously understanding of the
many hours this project has consumed and their ongoing
support makes work such as this feasible. I really appreciate
their willingness to accept the sacrifices required for comple-
tion of this effort.
xv
Contents

1. Anatomy and Physiology/Biology of Bone, 1 14. Lateral Lumbar Interbody Fusion, 113
Jose E. San Miguel, Kenneth J. Holton, and David W. Polly Jr. Jacob R. Joseph and Adam S. Kanter

2. The Role of Osteoporosis and Bone Diseases 15. Anterior-Posterior Surgeries, 120
in Revision Spine Surgery, 17 A. Karim Ahmed, Zach Pennington, Jeff Ehresman, and
Paul A. Anderson Daniel M. Sciubba

3. Medical Fitness Evaluation, 27 16. Unilateral Versus Bilateral Strut Placement in

Shelly K. Schmoller, Nathaniel P. Brooks, and Daniel K. Resnick Revision Spine Surgery, 126
Alessandro Boaro and Michael W. Groff
4. Indications, 36
Rory Mayer, Joshua Rivera, Dean Chou, 17. Robotics for Revision Spine Surgery, 131
and Edward C. Benzel Jun S. Kim, Paul J. Park, and Ronald A. Lehman Jr.

5. Imaging Considerations (Magnetic 18. Pedicle Subtraction Osteotomy, 140

Resonance, Computed Tomography, Ulas Yener, Thomas J. Buell, Rebecca M. Burke,
Myelography, Plain), 44 Christopher P. Ames, Chun-Po Yen, Christopher I. Shaffrey,
Eric A. Potts and Justin S. Smith

6. Dural Scarring and Repair Issues, 51 19. Vertebral Column Resection, 152
Robert F. Heary and Raghav Gupta Fortunato G. Padua, Jose A. Canseco, Daniel J. Thomas,
Lawrence G. Lenke, and Alexander R. Vaccaro
7. Decompression, 58
Stanley Hoang, Rani Nasser, Mohamed Saleh, 20. Revision Lumbar Deformity Surgery, 164
and Joseph S. Cheng Yoshihiro Katsuura, Han Jo Kim, and Todd J. Albert

8. Disc Herniation (Primary, Recurrent, 21. Postoperative Considerations, 170

Residual), 63 Rajbir S. Hundal, Rakesh Patel, Ahmad Nassr, and
Anthony M. Alvarado, Iain H. Kalfas, and Paul M. Arnold Ilyas Aleem

9. Instrumentation Options, 73 22. Adjacent Segment Disease After Fusion, 174

Sapan D. Gandhi and Frank M. Phillips Timothy J. Yee, Kevin Swong, and Paul Park

10. Autograft/Allograft/Cage/Bone 23. Pseudarthrosis/Nonunion, 181

Morphogenetic Protein, 84
Fadi Al-Saiegh and James S. Harrop
11. Minimally Invasive Surgery and Navigation, 88
Jason I. Liounakos and Michael Y. Wang
12. Anterior Lumbar Fusion, 97
Peter Shorten, Robert J. Owen, and Darrel S. Brodke
13. Revision Transforaminal Lumbar Interbody
Fusion, 106
Brenton Pennicooke, Kamal Kolluri, Arati B. Patel,
Lee A. Tan, and Praveen V. Mummaneni
Brandon A. Sherrod and Erica F. Bisson
24. Iatrogenic Spinal Instability: Causes,
Evaluation, Treatment, and Prevention, 186
Rick C. Sasso, Daniel P. Leas, Barrett S. Boody, and
Zachary H. Goldstein
25. Advances in Spinal Cord Stimulation, 191
Tessa Harland, Breanna L. Sheldon, Huy Q. Truong,
and Julie G. Pilitsis

xvii
1
Anatomy and Physiology/Biology of
Bone
JOSE E. SAN MIGUEL, KENNETH J. HOLTON, AND DAVID W. POLLY JR.

CHAPTER OUTLINE
Anatomy 1 Anatomy
Lumbar Spine Make-Up 1
Lumbar Spine Make-Up
Transitional Segments 1
Lumbar Spine Alignment 3 The typical vertebral column is composed of 33 vertebrae.
The lumbar spine usually has five mobile lumbar vertebrae,
Load Transmission 3
denoted as L1 L5. As a group, the lumbar vertebrae create a
Fusion Types and Area 3 lordotic curve. The vertebral bodies increase in size as the
Anteriorly Based Fusions and Approaches 3 spinal column descends, because of the increasing demands
Posteriorly Based Fusions and Approaches 4 of load bearing. The lumbar vertebrae have distinct features
Interbody Fusion From a Posterior Approach 4 that make them discernible from the cervical and thoracic
Basic Bone Biology 5 vertebrae. Most notable are the large vertebral bodies, which
Osteoclasts 5
consist of cancellous bone surrounded by cortical bone.
These bodies are wider transversely than they are deep ante-
Osteoblasts 5
roposteriorly. They also develop into a wedge shape as they
Wolff’s Law 5
descend the column, with the L5 vertebra having the greatest
Bone Grafting Area and Volume Available in Different difference between anterior and posterior height.1 This dif-
Approaches 5 ference creates the lumbosacral angle. The pedicles are short
Pain Generator Identification in Previously Fused Patients 8 and thick, arising from the upper third of the body. The
Pseudarthrosis 8 transverse processes are thin, long, and flat in the anteropos-
Sagittal Imbalance 9 terior (AP) plane. The articular processes are vertical and
Instability 9 large with a rounded enlargement on the posterior border,
Epidural Fibrosis 11 known as the mammillary process. The superior facets face
Arachnoiditis 11
posteromedially with a somewhat concave surface. The infe-
rior facets project downward and face largely laterally and
Wrong Diagnosis 11
anteriorly in concordance with the superior facets, with a
Implant Removal 11 slightly convex articulating surface. The inferior facet of the
Pedicle Screws 11 L5 vertebrae differs by having a flat articulating surface that
Interbody Devices 11 faces largely anteriorly. The spinous processes are short and
Looking for Pain Generators Outside of the Spine 12 broad and project perpendicularly from the body.
Sacroiliac Joint 12
Hip Joint 12 Transitional Segments
Greater Trochanteric Bursitis 12
The typical lumbar spine has five lumbar vertebrae, but up
Quadratus Lumborum Spasm 12
to 10% to 15% of the population is recognized with an
Piriformis Syndrome 12
anatomical variant known as a lumbosacral transitional
Cluneal Nerve Neuralgia 13 vertebra.2 The optimal method of classifying transitional
Summary and Conclusion 13 segments was outlined by Castellvi in 1984.3 Castellvi
References 13 described a classification system using radiographic imaging,
identifying four groups of lumbosacral transitional vertebrae

1
2 C H AP T E R 1 Anatomy and Physiology/Biology of Bone
based on their morphological characteristics (Fig. 1.1). Type I
includes a dysplastic transverse process, either unilateral (Ia)
or bilateral (Ib), presenting as triangular in shape, and mea-
suring at least 19 mm in width. Type II exhibits incom-
plete lumbarization/sacralization, either unilateral (IIa)
(Fig. 1.2) or bilateral (IIb), with a large transverse process
that follows the contour of the sacral ala. These are recog-
nized as incomplete by the appearance of a diarthrodial joint
between the transverse process and the sacrum. Type II is
• Fig. 1.1 Castellvi classification system: Ia, Ib, IIa, IIb, IIIa, IIIb, IV.
most consistently associated with lower back and buttock
pain. Type III describes complete lumbarization/sacraliza-
tion, either unilateral (IIIa) or bilateral (IIIb), in which the
transverse process has made complete fusion to the sacrum.
Type IV is mixed, with these patients exhibiting characteris-
tics of type II on one side and type III on the other. This sys-
tem is useful in classifying the morphology of the transitional
segments, but it does not provide enough accurate informa-
tion for numbering the involved segments.4

• Fig. 1.2 Left Castellvi type IIa transitional vertebrae.
Lumbar Spine Alignment
Lumbar spine alignment is dependent upon the pelvic inci-
dence (PI). The PI is a parameter that assesses the depth of
the femoral head to the midpoint of the sacral endplate. First
described in 1992 by Madam Duval-Beaupère,5 the concept
of PI has been used extensively since that time. We have
learned over the decades that PI drives the lumbar lordosis
(LL).6 The LL should be no more than 9 degrees greater or
less than the PI.6,7 Perhaps this is slightly more complex, and
patients with low PI should probably have a LL of PI plus 9
degrees and those with a high PI should probably have a LL
of PI minus 9 degrees. Also of importance is the distribution
of lordosis along the lumbar vertebrae.8 This is called the LL
distribution index, which indicates that approximately two-
thirds of the lordosis should be located from L4 to S1.9 This
has been further developed by Roussouly et al.,9 who looked
at the overall sagittal alignment of the lumbar spine, not only
focusing on the LL and the PI but also considering the sacral
slope. They highlighted the importance of the sacral slope
and lower lumbar curve in determining the global lordosis
and sagittal alignment of the spine. These lumbar angles of
interest can be seen in Fig. 1.3.
Load Transmission
Under normal physiological conditions, axial spine load
transmission should be homogenous across intervertebral
segments. It has been shown, with a high degree of specific-
ity, that some forms of low back pain correlate with abnor-
mal load transmission across vertebral bodies.10 During
spinal fusion, the primary goal is to provide a solid and uni-
form bony mass across a segment that allows for stable load
transmission. By the same token, failure to restore physiolog-
ical stress patterns of load transmission across intervertebral
segments during spine fusion has been hypothesized as
explaining why some patients remain symptomatic despite
evident fusion.11
Balanced load transmission is important to ensure con-
struct stability and avoid graft subsidence. Closkey’s12 work
on load transmission in fusions showed that approximately
30% cross-sectional area during interbody fusion is needed
CHAPTER 1 Anatomy and Physiology/Biology of Bone 3
• Fig. 1.3 Lumbar angles of interest.
to handle adequate load transmission across an intervertebral
space. Below this number the pressure point on the caudal
vertebra is too high and the graft can subside through the
superior aspect of the vertebra, leading to motion and poor
stability, and is associated with a higher risk of pseudarthro-
sis.13 Closkey’s findings are most relevant in anterior fusions
where graft material is under direct axial load compression,
and adequate cross-sectional area facilitates load transmission
and solid fusion. This has not been well recognized by many
surgeons and as a result inadequate spot-welds often exist
that are incapable of transmitting the load. Load transmis-
sion differs in posterior fusions; loads are transmitted by can-
tilever forces, which require more robust bone cross-
sectional area to support a similar load.
Fusion Types and Area
Not uncommonly, treatment for spine pathology requires a
fusion. Multiple approaches have been developed over time
that best tailor the patient’s needs. These can be roughly
divided into anterior and posterior approaches, each of them
with their particular advantages and disadvantages. Spine
surgeons use and combine techniques as necessary to best
treat the pathology at hand.
Anteriorly Based Fusions and Approaches
The three ways to approach the spine anteriorly are direct
anterior, oblique, and lateral. They all provide excellent
access to the disc space and end-plate preparation, and, if
necessary, allow placement of implants with large footprints
that minimize the risk of subsidence.14 More importantly,
we know from biomechanical studies that the anterior and
middle columns carry about 80% of spinal loads.15 When
taking this into consideration along with Wolff’s law of bone
4 C H AP T E R 1 Anatomy and Physiology/Biology of Bone
remodeling in response to applied stress, a fusion mass has
better potential for healing if placed anteriorly, where it is
under direct compression.16 Not only is an anterior fusion
under direct compression, but the anterior and middle col-
umn provide 90% of osseous contact between vertebrae, as
well as a more vascular bed.16 18 Distraction with a large
interbody implant provides better neuroforaminal decom-
pression.16 Additionally, it can be very powerful in deformity
correction in the coronal and sagittal planes. These
approaches are not suitable for patients that have central
canal stenosis, bony lateral recess stenosis, or high-grade
spondylosis.19
Direct anterior: In the direct anterior approach, the patient is
positioned supine and this is followed by a median,
paramedian, or mini-Pfannenstiel incision. This provides a
retroperitoneal corridor with direct access to the disc space.
Presurgical advanced imaging is necessary, as it will
determine the limitations imposed by visceral structures.
Most often, the direct anterior approach is used to access
the L4 L5 and L5 S1 disc spaces, with higher levels
limited by the degree of retraction on the vascular and renal
structures. There are drawbacks associated with this
approach such need for an access surgeon, risk of vascular
injury, and the possibility of retrograde ejaculation
secondary to injury to the hypogastric plexus.20 Previous
abdominal surgeries are not an absolute contraindication to
this approach, but should be taken into consideration as
they might make the exposure more difficult. Placement of
a ureteral stent can aid in the approach, and with a skilled
approach, revision anterior surgery can be done.21
Oblique: For the oblique approach to the anterior spine, the
patient is placed in a lateral decubitus position. Along the
flank, the surgical corridor is between the retroperitoneum
and the psoas muscle. This approach does not require
retraction of vascular structures or violation of the psoas
muscle. As such, the levels accessible to this approach are
from L1 to S1. Although vascular structures are not
manipulated directly, they are still at risk given their
proximity with the surgical field. The risk of retrograde
ejaculation is still present. Because the approach involves
dissection through the abdominal musculature, patients
can develop hernias or pseudohernias secondary to
denervation of the flank musculature.18 Furthermore, the
approach requires experience to adequately assess its
obliquity without inadvertent entry into the canal or
violation of the lateral annulus. Clinical experience suggests
that this is more technically challenging than the standard
straight anterior approach and to date no current data is
available on revision oblique approaches.
Lateral: The patient is placed in the lateral decubitus position.
For this approach, the surgical corridor is retroperitoneal
but transpsoas. The disc spaces accessible through this
approach are T12 L1 to L4 L5. Preoperative images
need to be obtained to determine if the planned region of
the lumbar spine can be accessed through this corridor,
with particular attention to the relationship between the
top of the iliac crest and the level to be accessed. Care must
be taken at the L4 L5 level to avoid injuring the femoral
nerve. This approach allows bilateral access to the lumbar
spine, which is advantageous for coronal plane deformity
correction, as it is better managed from the convex side.
The lumbar plexus is at risk during a transpsoas approach,
its position drifting more anteriorly with more-caudal
levels.19 About 5% of patients complain of sensorimotor
disturbances post surgically.19 Because the approach is to
the lateral abdominal musculature, the possibility of hernia
and pseudohernia are also present, but are minimized with
careful dissection to prevent denervation. This approach
allows resection of the disc transversely all the way across,
but the risks of this are contralateral vessel or visceral injury.
Posteriorly Based Fusions and Approaches
Posterior: For this approach, the patient is positioned prone,
which is followed by a midline approach. The fusion
procedure involves decortication of the lamina, with or
without the spinous processes, and typically involves the
facet joints. This fusion mass is in the least advantageous
position biomechanically, as it must support all the loading
via a cantilever loading technique, thus experiencing minimal
compression compared with its anterior counterpart.22
Even with a solid posterior fusion, there have been
instances of persistent anterior column pain demonstrated
by discography and later confirmed by clinical improve-
ment after anterior interbody fusion.23 Although this
fusion has long been the workhorse of the available surgical
techniques, it is not without its problems. Revision surgery
through a posterior approach is common. The main
increased risks from this are bleeding of the scar bed,
distorted landmarks depending on the prior intervention,
and possible incidental durotomy in patients with significant
laminectomy defects.
Posterolateral: The posterolateral fusion is the more commonly
used posterior approach and involves not only the lamina
and facet, but also the transverse processes. This puts the
axis of loading closer to the fusion mass and in a more
biomechanically advantageous position. A drawback of this
technique is that it requires more stripping of the muscles to
gain access to the grafting area. A variation of this is the
paraspinal or Wiltse-type approach. This variation provides
similar access with less muscle disruption24 and for many
years was a mainstay for fusion in young adults with
spondylolysis. It has also been used in a minimally invasive
fashion as a way of accessing the paraspinal or Wiltse plane.
However, more typically, the minimally invasive approaches
have involved a transforaminal lumbar interbody fusion.
Interbody Fusion From a Posterior Approach
A number of techniques over the years have used this
method of obtaining interbody fusion.25 It began with the
posterior lumbar interbody fusion, which involves significant
lamina resection and side-to-side dural mobilization to access

the disc space and place bone graft into this area. The next
advancement was the so-called transforaminal lumbar inter-
body fusion, which was originally described as a single-sided
approach that allowed cleaning out of approximately two-
thirds of the disc space and obtained an interbody fusion
with bone graft and/or structural interbody support.26,27
These techniques use a working window in which the thecal
sac and traversing nerve root form the medial border and the
exiting nerve root of the proximal vertebra forms the lateral
border. This technique has subsequently been a workhorse
approach when done bilaterally and combined with Smith-
Peterson osteotomy for both extensive disc clean-out and
bone grafting structural interbody support, which allow sig-
nificant sagittal plane realignment.28
Basic Bone Biology
Cortical and cancellous bone are found in all types of osseous
tissue. Cortical bone is densely organized, which provides
maximum strength and the ability to bear heavy loads, in addi-
tion to being resistant to bending and torsion. Cancellous
bone is found where forces can be applied at variable angles,
specifically at the epiphysis, flat bones, and vertebral bodies.
Bone is an exceptionally well-organized tissue that undergoes
constant remodeling to maintain homeostasis. This dynamic
balance exists between the osteoclast and the osteoblast.29
Osteoclasts
Osteoclasts are specialized cells derived from the monocyte-
macrophage lineage; these cells degrade bone to allow for
normal and pathological bone remodeling.30 Differentiation
into an osteoclast requires receptor activator of nuclear factor
kappa-B ligand (RANK Ligand) although its function is regu-
lated by many other cytokines.31 Upon recruitment to areas
of bone targeted for resorption, precursor cells will fuse with
each other to form multinucleated cells. These cells have pow-
erful acid-producing and enzyme-secreting machinery to
resorb calcified bone and degrade the extracellular matrix.30
Bone mass and quality have been shown to be directly
related to osteoclast activity, with all acquired forms of osteo-
porosis resulting from increased activity of these cells relative
to osteoblasts.31 Bisphosphonates have been developed to mit-
igate osteoclast-mediated bone loss.32 Another therapy aimed
at slowing bone resorption by osteoclasts is calcitonin.
Normally, this peptide is closely linked to bone metabolism
and has been shown to reduce vertebral osteoporotic fractures
in postmenopausal women when administered on a daily
basis.33 Besides their role in bone health, osteoclasts have been
shown to be involved in osteoblast differentiation, mobiliza-
tion of hematopoietic cells from the bone marrow into the
bloodstream, and immune responses.30
Osteoblasts
Osteoblasts are mesenchymal cells involved in depositing
and maintaining bone architecture.34 They do so by
CHAPTER 1 Anatomy and Physiology/Biology of Bone 5
producing organic components, such as bone and collagen,
and the inorganic components of the calcium/phosphate
matrix. Additionally, they have an important role in main-
taining bone health by regulating osteoclast function
through the production of a decoy receptor for RANKL, the
osteoprotegerin molecule.35 Parathyroid hormone (PTH) is
closely linked to calcium metabolism and has been shown to
have anabolic effects on bone physiology. When adminis-
tered at low and intermittent doses, activation of the PTH
pathway, as shown with teriparatide,36 can act through
osteoblasts to improve bone mass and architecture,37 provid-
ing physicians with another tool to combat the deleterious
effects of osteoporosis. As bone matures, osteoblasts can
become trapped in the matrix they deposit, turning into
residing osteocytes. These osteocytes act as mechanorecep-
tors to orchestrate the appropriate balance between osteo-
blasts and osteoclasts as they function to maintain adequate
bone homeostasis.29
Wolff’s Law
Wolff’s law states that bone will remodel in respond to the
stresses applied to it.38 In this way, bone that is exposed to
higher loads will respond by increasing its mass to better
resist external pressures. The opposite is also true, where
bone that experiences decreased loads will adapt by reducing
its mass, such as in long-term bedridden patients.39 This
concept has important implications in spine fusion, where
increased loading can be helpful to promote bone formation
and improve the likelihood of arthrodesis. From previous
studies we know that 70% to 80% of axial loads through the
spine pass anteriorly through the vertebral bodies.40 Here
interbody fusion devices seem to have their best utility; the
compressive load that is applied across the device provides
optimal conditions for bone formation.19
Bone Grafting Area and Volume Available
in Different Approaches
A variety of bone graft materials are available and used in
conjunction with instrumentation. An iliac crest autograft is
the gold standard; however, donor site morbidity occurs,
especially if structural autograft is used. Other materials are
allogeneic graft, demineralized bone matrix bone graft exten-
ders, and true bone graft substitutes.41 Of the graft substi-
tutes, the most studied is rhBMP-2 because it has been
shown to be as effective in fusion rates and clinical outcomes
as iliac crest bone graft.42
Posterior midline and facet (Fig. 1.4A, B): Although Hibbs43
developed the posterior midline technique, it was Moe44
who modified it and began to insert blocks of graft material
into cut-out articular facets for the purpose of fusion. Today,
this technique may be done with or without posterior
decompression (laminectomy) and most commonly uses
instrumentation. The areas of the vertebrae that can be
used in this fusion are the lamina (if not removed in
6 C H AP T E R 1 Anatomy and Physiology/Biology of Bone

A B C

D E

• Fig. 1.4 Visual depiction of grafting areas. (A) Facet, (B) posterior midline, (C) posterolateral, (D) posterior and posterolateral, (E) interbody.

• Fig. 1.5 L5 posterior midline/facet fusion: cross-sectional area available (left); cross-sectional area after fusion (right).

decompression), spinous process, and the facet joint
(example shown in Fig. 1.5). The facet joint is a vital part of
all posterior-based fusions, but isolated arthrodesis is not
common practice and has the disadvantage of very limited
area for grafting (an example of this is shown in Fig. 1.6).
The area available for fusion significantly increases
descending the column, because of the increasing size of the
vertebrae and increasing articulating facet surfaces, of which
the L5 S1 articulation is the greatest. Particular attention
to removing the articular cartilage within the facet and
intentionally bone grafting it probably leads to enhanced
success rates.44 The severity of disease will determine the
area that can be used in a posterior fusion, as this may be
decreased with the need for a laminectomy.
 CHAPTER 1 Anatomy and Physiology/Biology of Bone 7

•Fig. 1.6 Pre- and postoperative area for facet grafting: limited cross-sectional area available for graft (left); cross-sectional area of facet fusion
mass (right).

• Fig. 1.7 Posterolateral fusion: axial computed tomography image (left); outlined area depicts the fusion mass and the cross-sectional area of the
transverse processes (right).

Posterolateral (Fig. 1.4D): More commonly used than the
posterior midline approach, this technique was described by
Watkins45 and modified by Wiltse46 and provides greater
surface area for graft material because of the incorporation of
the transverse processes and pars. The facet, lamina, pars
interarticularis, and intertransverse processes are all used to
provide a sufficient fusion mass. In this technique the surface
area available for grafting is dependent on the cross-sectional
area of the transverse processes (Fig. 1.7), and the ability to
delicately and sufficiently decorticate them for adequate
blood supply. Careful dissection of the intertransverse
membrane is a crucial aspect of this technique as these
elements allow for an adequate area for grafting to occur.
Interbody (see Fig. 1.4E): The rate of primary and revision
posterolateral fusion surgeries has been slowly declining owing
to the use of interbody fusion procedures.47 Interbody fusions
are most commonly conducted at the lower lumbar disc
spaces, with the largest end-plate surface area located at the
superior end-plate of L5. Current techniques for this fusion
allow for restoration of disc height by use of various interbody
devices. As stated earlier in the chapter, Closkey12 determined
that grafting of a minimum 30% of the cross-sectional area of
the disc space is needed for adequate load transmission and
prevention of subsidence (Fig. 1.8). In theory, the entire disc
space is available for interbody fusion, especially when
accessed by an anterior approach. In practice, this is
8 C H AP T E R 1 Anatomy and Physiology/Biology of Bone
• Fig. 1.8 Interbody fusion: left outline shows graft area; right outline shows disc space available.
• Fig. 1.9 Failure of L4 L5 fusion (with L5 S1 disc replacement).
dependent on being able to adequately clean out the disc
space, insert the structural support, and place adequate graft
material, with too small an area risking failure (Fig. 1.9, risk
of subsidence; Fig. 1.10, inadequate fusion mass leading to
subsidence).
Pain Generator Identification in Previously
Fused Patients
In patients who have previously undergone spine fusion and
have persistent pain, the work-up can be complex and difficult.
It is crucial to obtain a thorough history of the symptoms before
and after surgery, if/how they changed, and whether any new
symptoms arose after the procedure. A thorough physical exam-
ination to narrow the list of potential sources of pain is pivotal
to achieving a correct diagnosis. The list of potential pain gen-
erators caused from a previous fusion can be substantial.48
Pseudarthrosis
Pseudarthrosis is a common complication of lumbar spine
surgery and it is imperative that it is ruled out as a source of
pain postoperatively. Patients will usually describe improve-
ment in their original symptoms after the surgery with subse-
quent worsening months afterward because of the continued
motion at the nonunion site. Radiographs of the spine are
valuable, particularly flexion-extension views if there is no
instrumentation. However, the best way to assess for non-
union is with a computed tomography (CT) scan; it provides
the most bony detail for assessing whether healing has
occurred or not. Three-dimensional reformations of the study

• Fig. 1.10 Failure of fusion by subsidence.
are very valuable, as the plane of the pseudarthrosis may not
necessarily be obvious in the standard reformatted cuts.
Imaging studies will show lucencies or halos around screws,
motion at the fused segments with flexion-extension radio-
graphs, and lack of bony bridging across the fusion mass.49
If a nonunion is detected, a superimposed surgical site
infection should be ruled out. If an infection is present, the
risk of pseudarthrosis is higher.
Treatment for sterile pseudarthrosis is revision surgery with
bone grafting and further stabilization of the segment.
Circumferential fusion has been shown to lead to higher
fusion rates in the setting of revision surgery for lumbar pseud-
arthrosis.50,51 Successful arthrodesis after revision surgery for a
previous lumbar pseudarthrosis has been shown to improve
clinical outcomes in most patients.51 However, outcomes
seem to be partially influenced by the initial diagnosis for the
index surgery, as patients with a diagnosis of spondylolisthesis
have done better than those with a diagnosis of degenerative
disc disease.52 Smoking, diabetes, and worker compensation
status have all been shown to be associated with poorer out-
comes after revision lumbar spine surgery.53,54
Sagittal Imbalance
Sagittal imbalance has been identified as the radiographic
parameter most highly correlated with adverse health status
CHAPTER 1 Anatomy and Physiology/Biology of Bone 9
outcomes.55 Sagittal balance can be defined radiographically
as the odontoid hip axis.56 This is the angle between the ver-
tical and the highest point of the odontoid process connecting
to the center of the bicoxofemoral axis.56,57 This can be visu-
alized as the ear over the hip with the hips and knees
straight. A positive sagittal imbalance places the patient out
of alignment; this occurs when the sagittal vertical axis lies
in front of the sacrum. Patients usually present with a tho-
racic spine hypokyphosis, vertebral retrolisthesis, increased
pelvic retroversion, and flexed hips and knees to be able to
maintain a horizontal gaze.58 These adaptations can be
extremely energy consuming, causing pain secondary to
back muscle strain and nerve compression. An example of
sagittal imbalance can be seen in Fig. 1.11.
There are different causes of sagittal imbalance after a
spine fusion; these include failure to restore the adequate
amount of LL, proximal or distal adjacent disc degeneration,
proximal vertebral body collapse/fracture, and thoracolum-
bar kyphosis without compensation of the lumbar spine.59 If
sagittal imbalance is determined to be the cause of back pain,
no solution short of revision surgery will improve the symp-
toms. In these patients, the possibility of a coexisting pseud-
arthrosis must be ruled out, as sagittal malalignment is a
powerful driver of this condition.60 The treatment of sagittal
imbalance is complex and full of risks,61 requiring vertebral
osteotomies such as Smith-Peterson osteotomy, pedicle sub-
traction osteotomy, or vertebral column resection. These are
powerful correction tools that should be used with good
judgment to restore the patient to a LL within the para-
meters of PI 5 LL 6 9 degrees suggested by Duval-
Beaupère. These techniques pose risk to the patient’s life;
however, they can provide great improvements in the
patient’s quality of life and symptoms.62,63 Correction of
sagittal imbalance can be seen in Fig. 1.12.
Instability
The spine is a complex structure that protects delicate tissues
while allowing a great deal of range of motion in all planes.
Stability of the spine is conferred by bony anatomy, ligamen-
tous stability, and coupled muscle activation.64 There are
multiple causes for dynamic instability of the spine including
traumatic, degenerative, neoplastic, and iatrogenic.65 The
most common cause for spine instability is iatrogenic and is
positively correlated with wider decompressions, greater liga-
mentous disruption, and a higher number of levels included
in the surgery.66
The etiology for back pain in the setting of instability is
complex. Increased intervertebral movement after surgery
can cause mechanical impingement of the spinal cord or
nerve roots, causing pain or neurological deficits.67
Instability of the spine can also lead to stretching of liga-
ments and the facet capsule, leading to irritation and activa-
tion of nociceptive pathways.68 From biomechanical studies
we know that a skeletonized spine is unable to counteract the
equivalent of an upper body mass during normal loads.69 In
its native setting, the spine relies on activation of muscles
10 C H AP T E R 1 Anatomy and Physiology/Biology of Bone

• Fig. 1.11 Sagittal imbalance.

• Fig. 1.12 Sagittal imbalance correction.


that traverse motion segments to increase stiffness and allow
higher load bearing.70,71 In patients with spine instability, it
has been proposed that the unstable segment requires a high-
er level of muscle activation to counteract motion, thus lead-
ing to fatigue and muscle sprains, which in turn activate
nociceptive pathways.72 If spine instability is diagnosed, the
solution is stabilization in the form of a fusion.
Epidural Fibrosis
Scar tissue formation is expected after surgery. Unfortunately,
scar formation after spine surgery can cause adhesions and
compression that can recreate or lead to new onset of symp-
toms after surgery.73 Biomaterials of fat grafts have been advo-
cated to try and minimize the formation of scar tissue, albeit
with marginal improvements.74 The use of surgical drains has
been recommended to help minimize epidural fibrosis.75 The
role of revision surgery for lysis of adhesions or removal of scar
tissue can lead to suboptimal results, with only about 50% of
patients noticing an improvement.76
Arachnoiditis
Arachnoiditis is inflammation of the middle layer of the
membranes covering the spinal cord. This inflammation is
driven by glial cells and can be triggered by trauma, tumor,
infection, or iatrogenically through surgery or other invasive
spinal procedures.77 Symptoms can range from motor and
sensory changes such as poor balance and abnormal reflexes,
to chronic and debilitating pain.78 The diagnosis of ara-
chnoiditis should be regarded as one of exclusion, but is sug-
gested by a lumbar magnetic resonance image (MRI) that
shows clumping of the cauda equina nerve roots.79 This phe-
nomenon causes inflammation of the nerve roots, thus ren-
dering them dysfunctional and a source of pain. Treatment
for arachnoiditis is mostly medical with the goal of reducing
pain with antiinflammatories, both steroidal and nonsteroi-
dal, as well as treating the pain with nerve pain medication.
Spinal cord stimulators have been shown to have some effect
in symptom control.80
Wrong Diagnosis
Failure of symptom resolution after surgery should always
raise the possibility of a wrong diagnosis. These patients’
symptoms do not improve and, if anything, can worsen after
surgery. It is imperative that the patient’s preoperative symp-
toms and imaging findings are reevaluated and, when possi-
ble, contrasted with the intraoperative findings.81 If these are
not in accordance, other sources of pain within the spine
should be considered.
Alternatively, incidental radiographic findings of the
spine may possibly correlate with patients’ symptomatology,
but are not necessarily the source of pain.81 Potential etiolo-
gies include aortic aneurysm, nephrolithiasis, perinephric
abscess, prostatitis, chronic pelvic inflammatory disease,
endometriosis, cholecystitis, and pancreatitis.82
CHAPTER 1 Anatomy and Physiology/Biology of Bone 11
Implant Removal
Although uncommon, retained spinal implants may be a
source of pain. Patients usually present with a pain-free inter-
val between the incision healing and the reemergence of back
pain.83 The patient most likely to benefit from implant
removal after spine fusion is one with prominent implants
that are directly tender to palpation at the prominence.84
Symptomatic hardware can be confirmed or refuted by local
anesthetic injections under image guidance to determine if it
is a pain generator.85 In the past, the higher use of stainless
steel implants caused an approximately 5% rate of nickel
allergy, which led to a higher rate of implant symptomatol-
ogy.86 Today, with titanium implants, implant removal for
symptomatology is most likely secondary to prominence.
Pedicle Screws
Pedicle screws have become the mainstay of spine fixation.87
By spanning the three columns of the spine, pedicle screws
provide added rigidity and stability to the fixation con-
struct.88 In turn, this has allowed surgeons to preserve addi-
tional motion segments, perform better corrections, and
achieve better fusion rates.89,90
In primary spine fusion cases, insertion of pedicle screws
with the straight-forward technique is well documented as
superior to the anatomic trajectory in terms of pull-out
strength and insertional torque,91 thus leading to more
stable constructs. In the revisional setting, the course of
action that provides the best fixation is unclear when there is
a previous screw tract along the straight-forward trajectory.
One alternative is to maintain the straight-forward trajectory
but increase the screw diameter. Alternatively, a new screw
can be placed along the anatomic trajectory.
Another technique to achieve better screw purchase in
bone is to obtain bicortical fixation at the anterior cortex of
the vertebral body.92 However, if this technique is pursued,
care must be taken to avoid damaging vital vascular struc-
tures anteriorly.93
In vertebral bodies with compromised bone quality, aug-
mentation with cement through fenestrated pedicle screws
has also been shown to increase stability of constructs.94
Interbody Devices
Interbody devices appear to have added to fusion success
rates. These devices provide structural anterior column sup-
port and carry loads while the biological goal of fusion is
achieved. There is great variability of device material and
geometry. The most common device materials have included
structural allograft bone, titanium mesh three-dimensional
printed formulations, and polyetheretherketone (PEEK)
either with or without titanium surface augmentation.95
Recently, additive manufacturing has been added to enhance
osseointegration. Expandable cages have been introduced to
enhance sagittal contour alignment while minimizing the
need for the access corridor for placement of the device.96
12 C H AP T E R 1 Anatomy and Physiology/Biology of Bone
The relative efficacy of this strategy has not yet been well
established. Regardless of the device used, placing adequate
graft material to achieve at least 30% cross-sectional area
bone healing is key to long-term success.12 In addition, device
settling by penetrating the vertebral end-plate is a challenge,
either with insertion or with cyclic loading before adequate
bone healing. This is probably a function of device geometry,
placement within the end-plate, and the regional bone den-
sity at that location, as well as the overall bone density and
loads applied during the healing process.97 In this regard, in
general, larger implants with greater surface bearing area may
have less settling.22 Lateral approach devices are able to span
side to side and load the ring apophysis, which is probably
beneficial in the initial loading.
Looking for Pain Generators Outside of
the Spine
Finally, in a patient with pain after a spinal fusion, pain gen-
erators existing outside of the spine are possible. These
include most notably the sacroiliac joint, the hip joint, quad-
ratus lumborum spasm, piriformis syndrome, and cluneal
nerve neuroma (Maingne). The process of identifying these
pain generators usually relies on a combination of imaging,
physical examination, and local anesthetic differential injec-
tions to try to identify the pain source.
Sacroiliac Joint
Attention to the sacroiliac joint has increased during the past
decade.98 This has been facilitated by a clear consensus of
the diagnostic algorithm to identify pathology from the
sacroiliac joint. The incidence of sacroiliac joint pain in
patients with chronic low back pain is estimated to be about
15%,99 whereas in patients with previous lumbar fusions
and continued pain it is about 3%.100,101 Interestingly, there
has been an association between sacroiliitis and lumbar spine
fusion. The mechanism is akin to adjacent segment disease,
where the longer lever arm and increased mechanical load
seen by the sacroiliac joint leads to irritation. The actual
mechanism for pain generation is unclear, but it suggests
capsular/ligamentous distention, hypermobility, and abnor-
mal joint mechanics versus shear forces across the sacroiliac
joint.102 Regardless of the pain generation mechanism, mul-
tiple studies have shown the association of sacroiliitis to lum-
bar fusion. Interestingly, Ha et al.103 in a prospective cohort
study showed that patients with a lumbar fusion to L5 were
less likely to suffer from sacroiliitis than patients who were
fused to S1. Multiple other studies have shown an associa-
tion between increased sacroiliac joint symptomatology and
lumbar spine fusion.85,104,105
Hip Joint
Lumbar spine and hip pathology can present with similar
symptoms; to complicate things even further sometimes
these underlying conditions can coexist in the same
patients.106 It is crucial to obtain a detailed history and phys-
ical exam. Hip pathology leading to pain can arise from
multiple disorders including osteoarthritis, osteonecrosis,
chondral injuries, or labral pathology. During the physical
exam, these patients tend to have groin pain, limping, and/or
decreased range of motion of the hip joint. Unless spine
pathology is present, these patients are not expected to have
pain below the level of the knee. AP and lateral x-rays of the
hip joint should provide good information on which to
anchor further diagnostic steps.
Greater Trochanteric Bursitis
This condition represents inflammation of the bursa over the
greater trochanter. Its prevalence is 10% to 20% in the gen-
eral population of the United States.107 It will present itself
with pain over the greater trochanter of the femur, although
at times can radiate distally along the iliotibial band. As such,
it can be commonly misinterpreted as a spine pathology.
Symptoms can be particularly bothersome at night while
patients are trying to sleep on the affected side, but pain can
also be exacerbated with prolonged standing or ambulation.
Risk factors for this condition are repetitive activities such as
running, climbing, bicycling, or standing for prolonged peri-
ods of time.107 On examination, the patient will have exqui-
site tenderness to palpation over the greater trochanter area.
Good symptom resolution can be achieved with nonopera-
tive interventions such as nonsteroidal antiinflammatories
and physical therapy. If these fail, then a therapeutic/diag-
nostic injection with corticosteroids and anesthetic will cor-
roborate the diagnosis and should provide significant relief.
Quadratus Lumborum Spasm
This condition will present itself with pain over the parame-
dian aspect of the lumbar spine, although it can spread onto
the flank.108 The pain is usually described as a deep ache,
although with activities patients can experience the sensation
of piercing pain without radiation to the lower extremi-
ties.109 On examination, the patient will have exquisite pain
with deep palpation along the distribution of the quadratus
lumborum muscle. Treatment for quadratus lumborum
spasm is physical therapy with dedicated stretching exer-
cises.110 If symptoms are recalcitrant, corticosteroid and
anesthetic injections under fluoroscopic guidance can be of
therapeutic and diagnostic purposes, respectively.
Piriformis Syndrome
Symptoms associated with this condition include pain along
the sciatic nerve distribution, low back and/or buttock pain, as
well as tenderness over the greater sciatic notch.111,112
Etiology is caused by compression of the nerve by the pirifor-
mis muscle, secondary to overuse and hypertrophy, versus
congenital variations where the sciatic nerve traverses the mus-
cle belly or its tendinous portion.113,114 Symptoms can be

elicited by the clinician with maneuvers such as the Freiberg,
Beatty, or flexion, abduction and internal rotation (FAIR) of
the hip, all of which are variants that increase the piriformis
muscle tension, leading to compression of the sciatic nerve
and, if the correct diagnosis, reproduction of symptoms.111
Cluneal Nerve Neuralgia
This condition, also known as Maigne syndrome, arises from
entrapment of the cluneal nerves along the posterior aspect of
the iliac crest.115 These are pure sensory nerves; the superior
cluneal nerve provides sensation to the lower lumbar area, the
groin region, and the lateral aspect of the proximal femur. In
turn, the medial cluneal nerve provides sensation to the but-
tocks.116 The etiology of the entrapment is thought to be the
thoracolumbar fascia for the superior cluneal nerve116 and
the long posterior sacroiliac ligament for the medial cluneal
nerve.115 Maigne showed superficial cluneal nerve entrap-
ment in 1991 with cadaveric dissections. Patients experienc-
ing this condition will have areas of pinpoint tenderness at
entrapment sites. Once these are identified, the diagnosis can
be confirmed with a local injection of corticosteroids and
anesthetic injection.116 Physical therapy has also been shown
to be a good adjunct to improve symptoms.117
Summary and Conclusion
Continued pain and disability after lumbar fusion surgery is
a challenging problem for both the patient and physician.
A clear understanding of the anatomy and physiology is a
must when searching for sources of pain in these patients.
Revision surgery requires identifying the pain generator and
achieving a durable biological solution of fusion. If a clear
source of pain is identified, where the history, exam, and
ancillary studies are in agreement, surgery can be considered.
Patients need to be aware that revision surgery carries a lower
rate of success when compared with primary procedures.
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2
The Role of Osteoporosis and Bone
Diseases in Revision Spine Surgery
PAUL A. ANDERSON
CHAPTER OUTLINE
Introduction 17
Adverse Consequences of Poor Bone Health 17
Epidemiology of Poor Bone Health in Spine Surgery 17
Bone Health Evaluation in Revision Spine Surgery 18
Dual Energy X-Ray Absorptiometry 20
Classification of Osteoporosis 20
Indications for Bone Densitometry 20
New Densitometric Technologies 20
Opportunistic Computed Tomography 21
Preoperative Bone Health Optimization 22
Preoperative Screening for Osteoporosis 22
Nutritional Supplementation 22
Sarcopenia and Fall Risk 23
Patient Education 23
Bone Densitometry and Medical Treatment 23
Referral to Bone Health Specialist 23
Conclusion 25
References 25
Introduction
Poor bone health can lead to failure of the primary spinal pro-
cedure and precipitate the need for a revision spine surgery.
Postoperative complications related to poor bone health
include failure of fixation, fracture, kyphosis, implant subsi-
dence, pseudarthrosis, and worsening sagittal and/or coronal
deformity. Elderly patients and those with comorbidities are at
an increased risk of having poor bone health. Thus the risk of
failure following spine surgery is higher in these patients.
Secondary fracture prevention programs have proven effective
to address osteoporosis after fracture, and can be applied before
spinal surgery, especially in those undergoing revision surgery.
Poor bone health includes deficits in bone mineral density
(known as osteopenia and osteoporosis), vitamin D defi-
ciency leading to a failure in mineralization (known as osteo-
malacia), and a breakdown in bone microarchitecture
(owing to deficits in bone quality). In addition, osteoporosis
affects the number, quality, and responsiveness of mesenchy-
mal stem cells needed to differentiate into osteoblastic
lineages. Low bone mass is an encompassing term for these
conditions but has also recently been defined as osteopenia
based on bone mineral density (BMD).
The purpose of this chapter is to review the diagnosis and
evaluation of the bone health of patients undergoing revision
spine surgery. The rationale for this review is the direct rela-
tionship between the need for revision surgery and poor
bone health. A systematic approach to assessing and optimiz-
ing bone health before revision surgery will be discussed.
Adverse Consequences of Poor
Bone Health
Adverse consequences of poor bone health include poorer surgi-
cal outcomes and greater complications, often leading to
increased rates of revision surgery (Table 2.1). Bjerke et al.1
reported fusion success rates and bone-related complications in
140 patients undergoing lumbar spinal fusion. They found that
osteoporotic patients had a 50% rate of nonunion compared
with 18% of those with normal bone density. Osteoporosis-
related complications including hardware failure, compression
fracture, kyphosis, and nonunion occurred in 19% of normal,
28% of osteopenic, and 67% of osteoporotic patients (Figs. 2.1
and 2.2). Other complications that have been reported relating
to osteoporosis include screw loosening, cage subsidence,
increased spondylolisthesis, sacral and pelvic insufficiency frac-
ture, durotomy, and revision surgery (see Table 2.1).2 20
Epidemiology of Poor Bone Health in
Spine Surgery
In patients undergoing primary spine surgery, low bone
mass and vitamin D deficiency are commonly observed. In
patients undergoing revision spine surgery, these factors are
likely even more prevalent. Vitamin D deficiency (defined as
17
18 C H AP T E R 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery

TABLE
2.1 Adverse Effects of Poor Bone Health on Outcomes of Spine Surgery

Nonunion Bjerke et al.,1 Cho et al.2

Screw loosening Bjerke et al.,1 Sakai et al.,3 Bredow et al.4
Hardware failure Bjerke et al.,1 Bernstein et al.5
Interbody cage subsidence Formby et al.,6 Tempel et al.7,8
Proximal junctional fracture Uei et al.,9 Meredith et al.10
Proximal junction al kyphosis Yagi et al.11
Increase spondylolisthesis Wang et al.,12 Andersen et al.13
Increased scoliosis Yu et al.14
Revision surgery Bjerke et al.,1 Sheu et al.,15 Puvanesarajah et al.16
Pelvic and sacral insufficiency fractures posterior fusion Meredith et al.,17 Papadopoulos et al.,18 Odate et al.,19 Klineberg et al.20
Compression fracture Formby et al.6

3
4
4 1 4

5
1

A B C

• Fig. 2.1 (A) 67-year-old female with steroid-dependent rheumatoid arthritis, Sjögren syndrome, obesity, and diabetes mellitus presented to an
outside hospital with neurogenic claudication. Sagittal magnetic resonance imaging demonstrated L4 L5 spondylolisthesis and spinal stenosis. She
was treated with oblique lumbar interbody fusion at L4 L5. Postoperatively, she did well until she fell 4 months postoperatively and was found to
have fractures at the inferior endplate of L4 and a complete fracture of the body of L5 with subsidence of the interbody cage toward S1. She
presented with severe back and leg pain. Evaluation included a dual energy x-ray absorptiometry scan that showed a hip T-score of 2 3.4 and lab
tests showed primary hyperparathyroidism. She is currently postoperative from parathyroidectomy. (B) Lateral postoperative radiograph after fall and
subsidence of interbody cage and fracture of L5. (C) Computed tomography after fall demonstrating poor bone quality, fractures of the endplates of
L2 and L4, and L5 vertebral body with cage subsidence. A region of interest of L3 showed mean Hounsfield units of 84 indicating osteoporosis.

25(OH) vitamin D ,20 ng/mL) occurs in 30% to 65% of
patients whereas vitamin D insufficiency (defined as 25
(OH) vitamin D 20 30 ng/mL) occurs in 27% to 40% of
patients. Osteopenia and osteoporosis are present in 30% to
50% and 10% to 20% of patients, respectively.21
Hills et al.22 retrospectively reviewed the role of endocrine
disorders in 169 patients with pseudarthrosis after spinal
fusion. Overall, endocrine disorders were present in 82% of
patients, and endocrinology referrals were made in 59 patients
(34.9%).22 Osteopenia and osteoporosis were the most com-
monly observed endocrine disorders. Before referral, these
were diagnosed in 18.9% of patients. After endocrinology
assessment, however, this number increased to 45%. Vitamin
D deficiency was also highly prevalent, occurring in 38% of
patients. Other endocrine disorders likely affecting skeletal
function included diabetes (27%), hyperparathyroidism (5%),
and sex hormone deficiency (18%).
Bone Health Evaluation in Revision
Spine Surgery
An essential component of the evaluation of a postoperative
patient is understanding the original indications for the
 CHAPTER 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery 19

AP Spine bone density Reference: L1–L4 Trend: L1–L4 (BMD)

BMD (g/cm2) YAT-Score %Change vs previous
1.42 Normal 2 2

1.30 1 1
1.18 0
0
1.06 –1
–1
0.94 Osteopenia –2

0.82 –3 –2

0.70 –4 –3
Osteoporosis
0.58 –5 –4
20 30 40 50 60 70 80 90 100 52 53 54 55
Age (years) Age (years)

1 2 3
BMD Young-Adult Age-Matched
Region (g/cm2) (%) T-Score (%) 2-Score
L1-L4 0.968 82 –1.8 91 –0.8

A
12 12

2017 5 5
2019
B C D E

HU - 87

12

• Fig. 2.2 (A) In 2009, a 55-year-old steroid-dependent female with Sjögren syndrome underwent a dual energy x-ray absorptiometry scan of the
lumbar spine. The diagnosis was osteopenia based on a T-score of 1.8. This was incorrectly interpreted since the degenerative changes at L3 L4
should not have been included in the measurement. The report at L1 L2, where the degenerative changes were eliminated, had a T-score of 3.3
indicating osteoporosis. A small degree of scoliosis was noted and was centered at L3 L4. She was prescribed a course of alendronate and
24 months of teriparatide. (B) She presented in 2017 with pain, progressive scoliosis, and height loss. An anteroposterior (AP) radiograph shows 27
degrees scoliosis with apex at L1 L2. (C) Lateral image showing severe disc collapse at L1 L2 and concave superior endplates of L3 and L4
suggesting osteoporosis fractures. (D) Sagittal T2 magnetic resonance image showing stenosis at L1 L2 with severe collapse of disc space. The
arrow points out erosion or fracture of the vertebral endplates of L1, L2, and L3. (E) The patient was treated with L1 L4 lateral interbody fusions
with cages and allograft and posterior instrumentation with cemented pedicle screws. She did well for 4 months and presented with increasing pain
and an inability to walk. Sagittal computed tomography (CT) showed pars fracture of L4, spondylolisthesis of L4 L5, and fracture of the superior
endplate of L5. Dual energy x-ray absorptiometry was performed showing osteopenia of the right hip. However, her fracture risk assessment tool
scores were 3.2% and 40.5% for 10-year hip and major osteoporotic fracture risk, respectively, indicating severe osteoporosis. (F) Axial CT of T12
with Hounsfield units of 87, indicating osteoporosis.
20 C H AP T E R 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery
surgery, patient comorbidities, postoperative course, and any
structural changes (seen on postoperative imaging) since sur-
gery. Bone health is likely to be a factor and therefore should
be completely evaluated before further surgery is considered.
Bone health evaluation consists of screening to determine if
bone densitometry is warranted, identification and treat-
ment of vitamin D and calcium deficits, assessment of nutri-
tional status, and analysis of falls and generalized muscle
weakness. Unfortunately, the spine surgeon’s attitude toward
screening for osteoporosis is relatively poor, with only
19% of surgeons reporting that they check dual energy x-ray
absorptiometry (DXA) when evaluating patients with
pseudarthrosis.23
Dual Energy X-Ray Absorptiometry
DXA is the gold standard to measure BMD. Results are
reported in gm/cm2 in regions of interest (ROI). The BMD
is used to determine statistical results (referred to as T-scores
and Z-scores). These indicate how many standard deviations
away a patient’s BMD is from a reference standard. T-scores
are most commonly used based on healthy young females as
the reference standard. Z-scores are used for premenopausal
females and men younger than 50 years and are compared
with age-gender matched controls.24 If possible, the total hip
and total femoral neck T-scores are used. If unavailable, then
lumbar spine T-scores (L1 L4) are used. Spine DXA is
often unreliable in spine patients with degenerative changes
or deformities; it is unreliable in those who have previously
undergone surgery. In patients for whom hip and spine
scores are not available, the one-third radius BMD is used.
To evaluate longitudinal changes, BMDs rather than T-scores
are used.
Classification of Osteoporosis
The World Health Organization classifies bone density
based on DXA T-scores (Table 2.224):
1. A T-score less than or equal to 22.5 indicates
osteoporosis
2. A T-score between 22.4 and 21.0 indicates osteopenia
3. A T-score greater than 21.0 signifies normal bone.
This definition has poor sensitivity as less than 50% of
patients who have had fragility fractures are classified as
osteoporotic; additionally, this classification system does
not aid in making treatment decisions. A more clinical def-
inition of osteoporosis has been proposed by the National
Bone Health Alliance (NBHA).25 This definition includes
any of the following as indicating osteoporosis: T-score
less than 22.5; the presence of a hip and spine fracture;
osteopenia and wrist, pelvis, or proximal humerus fracture;
and having a high 10-year hip and major fracture risk
based on the fracture risk assessment tool (FRAX;
Table 2.3).
The FRAX calculator is a 10-year fracture prediction tool
based on known risk factors.25a The risk factors used in calcu-
lating the FRAX have been established based on longitudinal
TABLE
2.2 Classification of Osteoporosis
World Health Organization24
Classification T-score
Normal . 21.0
Osteopenia (low bone mass) Between 21.0 and 22.4
Osteoporosis , 22.5
National Bone Health Alliance (NBHA)
Recommendations for Diagnosis of
Osteoporosis24
T-score # 22.5 of hip, spine, or one-third radius
Hip and spine fracture (low energy)
Osteopenia T-score and fragility fracture of wrist, pelvis, or
proximal humerus
Osteopenia and high fracture risk assessment tool (FRAX)
score
studies of large populations. The FRAX can be calculated with
or without the BMD. When used for treatment decisions, a
patient with a FRAX 10-year risk of hip or major fracture of
3% and 20%, respectively, is high risk and should be evalu-
ated for pharmaceutical treatment.24 In the case of screening
to determine if a patient needs a DXA, a lower threshold of
8.4% for a 10-year risk of major fracture is used.26
Indications for Bone Densitometry
The International Society of Clinical Densitometry (ISCD)
and National Osteoporosis Foundation (NOF) have devel-
oped guidelines to determine which patients should undergo
bone densitometry testing (Table 2.4).24,27 Any of the
“adverse outcomes” following spine surgery described in
Table 2.1 should prompt the need for bone densitometry
testing. In addition, reviewing relevant imaging studies such
as plain radiographs and computed tomography (CT) scans
(described later) to evaluate bone quality may identify
patients who should undergo DXA testing.
New Densitometric Technologies
New techniques in bone densitometry can aid in identifying
those patients with occult vertebral fractures and can provide
an improved understanding of bone microarchitecture.
Vertebral fracture assessment (VFA) is obtained during DXA
examination by placing the patient in the decubitus position
and scanning from T3 to L5. This produces an excellent lat-
eral image of the spine and has the advantage that the x-ray is
parallel to each disc space (eliminating parallax). Vertebral
fractures are found in up 30% of patients having DXA, the
majority of which are occult.24 The presence of fractures
indicates the diagnosis of osteoporosis and should be taken
into consideration when planning revision surgery.
 CHAPTER 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery 21

TABLE
2.3 Fracture Risk Assessment Tool

Risk Factors Results

Age Current smoker 10-year hip fracture risk (%)
Gender Glucocorticoid use 10-year major fracture risk (%)
Height Rheumatoid arthritis
Weight Secondary osteoporosis
Prior fracture Alcohol $ 3 units/day
Parent with hip fracture Femoral neck BMD (gm/cc) or T-score
(FRAX may be calculated without BMD data)
Treatment Criteria24
Hip fracture risk .3% or major fracture risk .20%
Screening criterion to determine who should have DXA based on FRAX with BMD26
Major fracture risk .8.4%

BMD, Bone mineral density; DXA, dual energy bone densitometry; FRAX, fracture risk assessment tool.
From Kanis JA, McCloskey EV, Johansson H, Oden A, Strom O, Borgstrom F. Development and use of FRAX in osteoporosis. Osteoporosis Int. 2010;21(suppl 2):
S407 S413.

Indications for Dual Energy Bone Opportunistic Computed Tomography

TABLE Densitometry in Evaluation of Revision
2.4
Spine Surgery Patients
Women age .65
Men age .70
History of fracture age .50
FRAX risk of major osteoporotic fracture .8.4%
High-risk medication use (i.e., corticosteroids)
Low body weight
Revision spine surgery age .50a
a
Author’s opinion.
From Schousboe JT, Shepherd JA, Bilezikian JP, Baim S. Executive
summary of the 2013 International Society for Clinical Densitometry Position
Development Conference on bone densitometry. J Clin Densitom.
2013;16:455 466.
The trabecular bone score (TBS) of the lumbar spine
(L1 L4) vertebral bodies is obtained using software and
standard DXA data. The TBS provides a measure of bone
microarchitecture that is independent of BMD. The micro-
architecture is assessed by textural analysis where large varia-
tion between adjacent pixels of cross-sections indicate
degraded microarchitecture compared with those without
variations. A TBS score is calculated and graded as degraded,
partially degraded, or not degraded bone. The TBS can be
substituted for BMD in FRAX, and has been correlated
with greater pedicle screw insertion strength when compared
with BMD.
Opportunistic CT is the use of CT already available in many
revision spine surgery cases, to assess for osteoporosis. CT is
based on the water-based linear attenuation coefficient in
each voxel of tissue. This is normalized to 0 for water and
21000 for air, and is called the Hounsfield unit (HU). HUs
can easily be obtained from any picture archiving and com-
munication system (PACS) tool using the elliptical tool.28 An
ellipse is drawn at the ROI and the mean HU is reported (see
Fig. 2.1C). Correlations between HU and DXA-based BMD
are moderate.28 However, HU can be used to establish a
threshold to determine who does or does not require DXA
testing. Pickhardt et al.29 and others have established an HU
threshold at L1 of under 110 as indicating likely osteoporosis.
Similarly, an HU threshold of greater than 150 indicated nor-
mal bone. Patients having HU under 135 should undergo a
DXA examination to evaluate bone quality status.
Low HU has been predictive of pseudarthrosis, cage sub-
sidence, pedicle screw loosening, and junctional failure
because of fractures (see Figs. 2.1 and 2.2). Nguyen et al.30
found that patients with pseudarthrosis had HU values 30
points lower than patients whose fusion was successful.
Meredith et al.17 found that patients having multilevel
fusions with HU ,145 had significantly increased likeli-
hood of junctional fractures. Uei et al.9 assessed HU in
deformity patients with proximal junctional fracture and
those without fracture. At T8 and T9, the mean HU was
102 with fractures, compared with 145 without fractures.
Patients needing revision surgery who have had a CT
should be assessed by HU. Using accepted thresholds of
,110 identifies patients likely to have osteoporosis.
22 C H AP T E R 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery

Evaluation of the proximal and distal site of fixation is
important. Proximal junctional fracture has been shown to
occur at levels with HU under 145 and global HU under
135. Furthermore, the sacrum and ilium should be assessed,
although criteria have not yet been established for either. In
the author’s opinion, pedicle screws inserted at sites where
the HU is under 80 are likely to fail. Other techniques such
as preoperative optimization and cement augmentation
should be considered in these cases.
Preoperative Bone Health Optimization
Bone health optimization should be considered for both pri-
mary and revision surgery patients. The goal of preoperative
optimization is to prepare the patient and spinal column for
rapid healing and the avoidance of complications (see
Table 2.1). A systems-based approach using an organized
checklist will aid in obtaining a thorough process (Table 2.5).
All patients 50 years and older who are undergoing tho-
racolumbar spine surgery should be assessed to determine if
they need to have a DXA before surgery. Because many of
the revision surgeries may be associated with osteoporosis,
screening in this group is of particular importance. The
screening process can be performed by the surgeon or nurs-
ing personnel. We use a checklist consistent with the current
guidelines (see Table 2.5).
In the case of revision surgery, one should attempt to
identify potential causes of failure of the index surgery. One
such cause can be poor bone mass. Findings that support this
would include any postoperative fracture, screw loosening,
cage subsidence, increased spondylolisthesis or deformity,
insufficiency fracture, or proximal junctional kyphosis. In
addition, patients are assessed for fall risk, given recommen-
dations for nutritional supplementation, examined for mal-
nourishment and sarcopenia, and educated regarding the
risk of complications from poor bone health, if warranted.

Preoperative Screening for Osteoporosis

Identification of patients with osteoporosis has proven difficult,
especially by surgeons who are not familiar with the indications
for and interpretations of DXA screening. Furthermore, there
is a false expectation that bone health evaluation should be per-
formed by primary care physicians; unfortunately, less than
10% of patients who should be screened according to current
guidelines undergo screening in such a way. Therefore the sur-
geon must assume the responsibility of applying the presurgical
screening process and interpreting DXA results. If there is low
bone mass, then a referral to a specialist or fracture liaison ser-
vice (FLS) should be considered.
Nutritional Supplementation
Vitamin D and Calcium
The active form of vitamin D is important to allow osteo-
blastic differentiation, mineralization of osteoid matrix,
absorption of calcium from the gut, calcium regulation, and
collagen crosslinking. Ultraviolet radiation from the sun con-
verts 7-dehydrocholesterol to cholecalciferol (vitamin D3).
It is then hydroxylated in the liver and kidney to the active
form 1 25(OH) vitamin D. Serum levels are measured by
the inactive metabolite 25(OH) vitamin D. Normal 25
(OH)D in adults is over 30 ng/mL, insufficiency is 20 to

TABLE
2.5 Bone Health Optimization

Checklist Goals Timing

Screening
Nutritional supplements
Fall risk assessment
Patient education
DXA/opportunistic CT
Referral to bone health
specialist/fracture liaison
service
Treatment of osteoporosis
Surgical delay
Identify patients who need further BMD screening
Replace calcium/vitamin D/protein as needed
Nutritional assessment, TUG, and grip strength
Inform patients of association with fall risk poor
outcomes and future fractures related to
osteoporosis
Measure bone mineral density/estimate risk of
osteoporosis
Screen for secondary causes/assess 25(OH)D
levels/recommend medications as needed
Anabolic agents if possible
Discuss between surgeon and bone health
specialist regarding efficacy of delay until bone
health optimized
At initial surgery scheduling or first office visit
At initial surgery scheduling or first office visit
At initial surgery scheduling or first office visit
At all stages of preoperative evaluation
At initial surgery scheduling
Patients with abnormal bone mineral density
should have assessment for bone health
Start before surgery and continue for full
treatment
Ranges from 3 months for simple surgery to 9
months for complex multilevel or osteotomy or
revision

BMD, Bone mineral density; CT, computed tomography; DXA, dual energy bone densitometry; TUG, timed up and go.
 CHAPTER 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery
30 ng/mL, and deficiency is under 20 ng/mL. The majority
of patients undergoing spine surgery (and likely even more
among patients undergoing revision surgery) are vitamin D
deficient or insufficient.31 33
Vitamin D deficiency is easily corrected by administration
of oral vitamin D supplements. The author recommends
2000 to 5000 IU of vitamin D3 daily at the time patients are
scheduled for surgery. Serum 25(OH)D levels are not rou-
tinely tested unless the patient has osteoporosis proven by
DXA. In general, 4 weeks is enough time to correct these
levels in the majority of patients, with the risk of toxicity at
this dose being extremely unlikely.
Calcium
Calcium, in addition to vitamin D, is required for bone min-
eralization and to maintain bone stock. The adult daily
recommended dose is 1200 mg and is best obtained from
diet alone. Dairy products and leafy vegetables are calcium
rich. Eight ounces of a dairy product (or its equivalent) pro-
vides approximately 250 mg of calcium. Supplements are
often needed, and calcium citrate is the most tolerated sup-
plement in patients with gastrointestinal disease. Fear of cor-
onary artery disease from calcium use has been dispelled,
based on a meta-analysis that showed no risk from calcium
supplementation.34
Sarcopenia and Fall Risk
Revision spine surgery often involves patients with extremes
of weight: low body mass and the morbidly obese. An assess-
ment of nutritional status is important as malnutrition is
associated with osteoporosis and is a risk factor for complica-
tions. Optimization before surgery should be considered. To
address bone health, it is recommended that patients con-
sume 0.8 to 1.2 mg/kg/day of protein.24
Sarcopenia is a term describing both a loss of muscle from
atrophy and fatty replacement and a functional deficit.
Sarcopenia and similar conditions such as frailty are strongly
associated with surgical morbidity and mortality in spine
patients. Furthermore, sarcopenia is linked to fall risk which
often leads to revision surgery and poor outcomes after revi-
sion surgery. There is a link between sarcopenia and osteopo-
rosis that has been termed dysmobility syndrome.35 This
syndrome can ultimately result in falls, fractures, and (in the
spine surgery patient) failure of the procedure. Assessing fall
risk and nutritional status is an essential component of bone
health assessment. Optimization as needed and referral to
physical therapy may be indicated preoperatively.
To assess fall risk, the Centers for Disease Control and
Prevention (CDC) recommends asking three questions: (1) do
you feel unsteady when standing or walking, (2) do you worry
about falling, and (3) have you fallen in past year?36 Also, sev-
eral tests of fall risk can be performed in the surgeon’s office.
The timed up and go (TUG) test measures the time to rise
from a seated position, walk 3 m, turn around and sit down.
Fall risk is associated with a TUG greater than 12 seconds.37
Grip strength can be measured by a dynamometer; males
23
should have grip strength greater than 32 kg and females
greater than 22 kg.38 Shen et al.39 has demonstrated that
increased grip strength is a positive predictor of outcome of
spine surgery. Patients with these functional deficits should
undergo a nutritional assessment, and address fall risk with
perioperative rehabilitation. Also, knowledge of the fall risk
may aid in determining postoperative rehabilitation goals such
as the need for disposition to a skilled nursing facility.
Patient Education
Education is an important aspect of care as primary care
practitioners and patients themselves are reluctant to take
osteoporotic medications, and often deny that osteoporosis
exists (largely because it remains silent until a patient sustains
a fracture). Patients are counseled as to why surgery may be
delayed to optimize bone health and how adverse events/
poor outcomes are linked to osteoporosis. Most patients are
grateful, and are surprised when osteoporosis is identified
and treatment is recommended.
Bone Densitometry and Medical Treatment
For cases that screen positive as described earlier, DXA of the
proximal femur and spine is obtained. In cases where the
hips are not available (surgery), a distal forearm DXA is also
ordered. If available, a VFA should be obtained to determine
the presence of occult fractures and TBS to determine if
degraded microarchitecture is present.
Patients who have a diagnosis of osteoporosis based on
the NOF criteria: T-score less than 22.5; history of hip or
spine fracture, osteopenia and other fracture; and more than
3% 10-year risk of hip fracture or more than 20% risk of
major osteoporotic fracture are referred for bone health opti-
mization. It is not uncommon, however, that patients will
have osteopenia (but do not meet osteoporosis criteria) and
will be undergoing complex procedures associated with an
increased risk of failure. At this time there is no indication to
treat these patients with pharmaceutical agents, although all
other bone health optimization measures should be consid-
ered. The use of bisphosphonates might be an alternative,
although evidence for their effectiveness in the osteopenic
surgical patient is lacking.
Referral to Bone Health Specialist
Bone health specialists include endocrinologists, rheumatol-
ogists, and gerontologists. More often than not, there is a sig-
nificant waiting time for referral to these specialists that is
suboptimal in the preoperative period. The use of an FLS is
an alternative and has proven effective at the author’s
institution.
Screening for Secondary Osteoporosis
The bone health specialist will screen patients for a secondary
cause of osteoporosis, which occurs in 35% of cases. Most
common secondary causes are vitamin D deficiency, chronic
24 C H AP T E R 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery
renal disease (stage $ 3), hyperparathyroidism, monoclonal
gammopathy of unknown significance, gastrointestinal mal-
absorption, and medications.24 In patients with a diagnosis
of osteoporosis, 25(OH) vitamin D is measured. For patients
with vitamin D deficiency, 50,000 U vitamin D3, weekly
for 6 weeks, is prescribed. In addition, 5000 U vitamin D3
daily is started. After 6 to 8 weeks 25(OH) vitamin D is
remeasured. For patients with vitamin D3 insufficiency,
5000 U vitamin D3 daily is recommended. In addition, cal-
cium supplementation is recommended as needed (depend-
ing on diet).
Pharmaceutical Treatment
Pharmaceutical treatment is indicated when patients meet
NOF criteria for diagnosis of osteoporosis (see Table 2.2). In
addition, patients with osteopenia undergoing multilevel
fusions with osteotomy or who have failed previous surgery are
considered candidates for drug therapy. Gaining authorization
for medications in this subset of patients can be difficult.
Two classes of medications for the treatment of
osteoporosis are available: antiresorptive and anabolic.
Antiresorptive drugs prevent osteoclastic-mediated bone
resorption. Bisphosphonates bind to the hydroxyapatite
surface, prevent osteoclastic resorption, and induce osteo-
clastic apoptosis. Denosumab is an antiresorptive drug
that is a monoclonal antibody to Rank ligand, which also
prevents osteoclastic activation. These antiresorptive drugs
reduce fracture risk by 40% to 60% in osteoporotic
patients. Long-term use greater than 5 years is associated
with development of atypical femur fractures and osteone-
crosis of the jaw; therefore it is common to offer patients a
drug holiday after 5 years of treatment.
Liu et al.40 reported a meta-analysis of seven spinal fusion
trials on osteoporotic patients comparing the use of bisphos-
phonates to controls and showing improved fusion success
rates, decreased time to fusion, better clinical outcomes, and
lower complication rates in the former group. Despite a con-
cern regarding a possible negative effect of bisphosphonates on
bone healing, the opposite, in fact, was observed. In another
meta-analysis, Kates and Ackert-Bicknell41 evaluated bone
healing in patients receiving bisphosphonates and found no
negative effects.
Three anabolic agents have been approved. Two of these
agents are recombinant parathyroid (PTH) analogs, teripara-
tide and abaloparatide, which increase osteoblastic function,
increase bone remodeling, and promote bone formation.
Both PTH analogs reduce vertebral fractures up to 80%.
Romosozumab is a monoclonal antibody against the protein
sclerostin, which, when blocked, increases osteoblastic func-
tion and bone formation. This drug also has antiresorptive as
well as anabolic effects. Encouraging results with the use of
teriparatide in spinal fusion patients have been reported.
Ebata et al.41a demonstrated higher fusion success rates as
well as faster rates of fusion in an RCT using controls,
although no clinical differences were seen. Other cohort
studies comparing teriparatide with controls have shown
lower complication rates and better fusion success rates. Seki
et al.42 performed a cohort study comparing teriparatide
with bisphosphonates and found reduced complications and
better clinical outcomes with teriparatide. In a systematic
review, Stone et al.43 found that clinical benefits appeared
greater with the use of anabolic agents compared with
bisphosphonates in osteoporotic spine surgery patients.
Surgical Delay for Bone Health Optimization
A delay in surgery may be warranted for bone health optimi-
zation. This is a shared decision process between the sur-
geon, bone health specialist, and patient. Patients with
urgent conditions such as neurological deficits should rarely
have delays to optimize bone health. In these cases, postoper-
ative care can be instituted.
If a delay is possible then the duration of the delay is
dependent on the severity of bone disease, the need for bony
fusion in that patient, and the relative risks of surgery. No
data are available that provide an indication as to the opti-
mum number of months of treatment before surgery can take
place. Current recommendations are based on the known
mechanisms of action of the available medications, evidence
from treatment of fractures, and biomechanical studies.
Treatment with both antiresorptive and anabolic agents
result in skeletal changes that can be measured within 3
months including increased BMD and lower fracture rates
between placebo controls and treatment groups.24 By 12
weeks, bone turnover markers have optimized indicating that
the desired response to treatment has occurred.24 In addition,
Inoue et al.44 have shown in an RCT that pedicle screw inser-
tional torque was significantly better in osteoporotic patients
given teriparatide compared with placebo controls after only
2 months of treatment. Furthermore, finite element studies
based on spinal CT scanning show a 10% increase in bending
strength at 3 months with romosozumab.45
No Surgical Delay
Delay of surgery is not indicated when there are urgent indi-
cations such as neurological deterioration, rapid progressive
deformity, and presence of fractures. In addition, simpler
cases such as laminotomy without significant removal of
bone and discectomy likely do not need surgical delay.
Short-Term Delay—3 Months
The author recommends 2 to 3 months of pretreatment of
osteoporotic patients before undergoing wide decompression
for spinal stenosis and one- to two-level posterior fusions.
Treatment will be continued after surgery.
Long Delays—6 to 9 Months
Osteoporotic patients having revision surgery and those
undergoing multilevel arthrodesis or spinal osteotomy
should be more aggressively treated before surgery. Six to 9
months of pretreatment maximizes increases in BMD and
strength, and creates a more receptive bone milieu that may
enhance healing. In addition, correction of nutritional and
vitamin deficits promotes bone healing and may help to pre-
vent postoperative falls.
 CHAPTER 2 The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery
Conclusion
The assessment of potential revision surgery patients requires
careful determination of the cause for failure. One modifiable
cause often overlooked is poor bone health. Surgeons should
introduce into their practice a method, such as that described
in this chapter, to screen patients for osteoporosis and, if indi-
cated, to obtain a DXA scan in patients at risk. Any nutritional
deficits should be corrected and the fall risk should be assessed.
In patients with inadequate bone health, referral to a bone
health specialist is recommended. Pharmaceutical treatment
using antiresorptive or anabolic agents can improve BMD and
promote biological activity of osteoblasts, thereby improving
surgical outcomes. This, however, may come at the expense of
having to delay surgery in a subset of patients.
References
1. Bjerke BT, Zarrabian M, Aleem IS, et al. Incidence of
osteoporosis-related complications following posterior lumbar
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osteoporosis on the clinical and radiological outcomes following
one-level posterior lumbar interbody fusion. J Orthop Sci.
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3. Sakai Y, Takenaka S, Matsuo Y, et al. Hounsfield unit of screw tra-
jectory as a predictor of pedicle screw loosening after single level
lumbar interbody fusion. J Orthop Sci. 2018;23:734 738.
4. Bredow J, Boese CK, Werner CM, et al. Predictive validity of pre-
operative CT scans and the risk of pedicle screw loosening in spi-
nal surgery. Arch Orthop Trauma Surg. 2016;136:1063 1067.
5. Bernstein DN, Kurucan E, Menga EN, Molinari RW, Rubery
PT, Mesfin A. Comparison of adult spinal deformity patients with
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cervical spinal fusion surgery: a nationwide analysis of 52,818
patients. Spine J. 2018;18:1861 1866.
6. Formby PM, Kang DG, Helgeson MD, Wagner SC. Clinical and
radiographic outcomes of transforaminal lumbar interbody fusion
in patients with osteoporosis. Global Spine J. 2016;6:660 664.
7. Tempel ZJ, Gandhoke GS, Okonkwo DO, Kanter AS. Impaired
bone mineral density as a predictor of graft subsidence following
minimally invasive transpsoas lateral lumbar interbody fusion. Eur
Spine J. 2015;24(suppl 3):414 419.
8. Tempel ZJ, McDowell MM, Panczykowski DM, et al. Graft sub-
sidence as a predictor of revision surgery following stand-alone lat-
eral lumbar interbody fusion. J Neurosurg Spine. 2018;28:50 56.
9. Uei H, Tokuhashi Y, Maseda M, et al. Exploratory analysis of pre-
dictors of revision surgery for proximal junctional kyphosis or
additional postoperative vertebral fracture following adult spinal
deformity surgery in elderly patients: a retrospective cohort study.
J Orthop Surg Res. 2018;13:252.
10. Meredith DS, Schreiber JJ, Taher F, Cammisa Jr FP, Girardi FP.
Lower preoperative Hounsfield unit measurements are associated
with adjacent segment fracture after spinal fusion. Spine. 2013;38:
415 418.
11. Yagi M, Fujita N, Tsuji O, et al. Low bone-mineral density is a sig-
nificant risk for proximal junctional failure after surgical correction
of adult spinal deformity: a propensity score-matched analysis.
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12. Wang P, Wang F, Gao YL, et al. Lumbar spondylolisthesis is a risk
factor for osteoporotic vertebral fractures: a case-control study.
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13. Andersen T, Christensen FB, Langdahl BL, et al. Degenerative
spondylolisthesis is associated with low spinal bone density: a com-
parative study between spinal stenosis and degenerative spondylo-
listhesis. BioMed Res Int. 2013;2013:123847.
14. Yu WS, Chan KY, Yu FW, et al. Abnormal bone quality versus
low bone mineral density in adolescent idiopathic scoliosis: a case-
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15. Sheu H, Liao JC, Lin YC. The fate of thoracolumbar surgeries in
patients with Parkinson’s disease, and analysis of risk factors for
revision surgeries. BMC Musculoskeletl Disord. 2019;20:106.
16. Puvanesarajah V, Shen FH, Cancienne JM, et al. Risk factors for
revision surgery following primary adult spinal deformity surgery in
patients 65 years and older. J Neurosurg Spine. 2016;25:486 493.
17. Meredith DS, Taher F, Cammisa Jr FP, Girardi FP. Incidence,
diagnosis, and management of sacral fractures following multilevel
spinal arthrodesis. Spine J. 2013;13:1464 1469.
18. Papadopoulos EC, Cammisa Jr FP, Girardi FP. Sacral fractures
complicating thoracolumbar fusion to the sacrum. Spine. 2008;33:
E699 E707.
19. Odate S, Shikata J, Kimura H, Soeda T. Sacral fracture after
instrumented lumbosacral fusion: analysis of risk factors from spi-
nopelvic parameters. Spine. 2013;38:E223 E229.
20. Klineberg E, McHenry T, Bellabarba C, Wagner T, Chapman J.
Sacral insufficiency fractures caudal to instrumented posterior
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vention and treatment of osteoporosis. Osteoporosis Int. 2014;25:
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25. Siris ES, Adler R, Bilezikian J, et al. The clinical diagnosis of osteo-
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27. Schousboe JT, Shepherd JA, Bilezikian JP, Baim S. Executive
summary of the 2013 International Society for Clinical
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28. Anderson PA, Polly DW, Binkley NC, Pickhardt PJ. Clinical use
of opportunistic computed tomography screening for osteoporo-
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29. Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ,
Binkley N. Opportunistic screening for osteoporosis using
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abdominal computed tomography scans obtained for other indica-
tions. Ann Intl Med. 2013;158:588 595.
30. Nguyen HS, Shabani S, Patel M, Maiman D. Posterolateral lumbar
fusion: relationship between computed tomography Hounsfield
units and symptomatic pseudoarthrosis. Surg Neurol Int. 2015;6:
S611 S614.
31. Ravindra VM, Godzik J, Guan J, et al. Prevalence of vitamin D
deficiency in patients undergoing elective spine surgery: a cross-
sectional analysis. World Neurosurg. 2015;83:1114 1119.
32. Stoker GE, Buchowski JM, Bridwell KH, Lenke LG, Riew KD,
Zebala LP. Preoperative vitamin D status of adults undergoing
surgical spinal fusion. Spine. 2013;38:507 515.
33. Ravindra VM, Guan J, Holland CM, et al. Vitamin D status in
cervical spondylotic myelopathy: comparison of fusion rates and
patient outcome measures. A preliminary experience. J Neurosurg
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34. Kopecky SL, Bauer DC, Gulati M, et al. Lack of evidence linking
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36. Centers for Disease Control and Prevention. National Center for
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37. Centers for Disease Control and Prevention. Assessment: Timed
Up & Go (TUG). 2019. https://www.cdc.gov/steadi/pdf/STEADI-
Assessment-TUG-508.pdf.
38. Bahat G, Tufan A, Tufan F, et al. Cut-off points to identify sarcope-
nia according to European Working Group on Sarcopenia in Older
People (EWGSOP) definition. Clin Nutr. 2016;35:1557 1563.
39. Shen F, Kim HJ, Lee NK, et al. The influence of hand grip
strength on surgical outcomes after surgery for degenerative lumbar
spinal stenosis: a preliminary result. Spine J. 2018;18:2018 2024.
40. Liu WB, Zhao WT, Shen P, Zhang FJ. The effects of bisphospho-
nates on osteoporotic patients after lumbar fusion: a meta-analysis.
Drug Des Devel Ther. 2018;12:2233 2240.
41. Kates SL, Ackert-Bicknell CL. How do bisphosphonates affect
fracture healing? Injury. 2016;47(suppl 1):S65 S68.
41a. Ebata S, Takahashi J, Hasegawa T, et al. Role of weekly teri-
paratide administration in osseous union enhancement within
six months after posterior or transforaminal lumbar interbody
fusion for osteoporosis-associated lumbar degenerative disor-
ders: a multicenter, prospective randomized study. J Bone Joint
Surg. 2017;99(5):365 372.
42. Seki S, Hirano N, Kawaguchi Y, et al. Teriparatide versus low-
dose bisphosphonates before and after surgery for adult spinal
deformity in female Japanese patients with osteoporosis. Europ
Spine J. 2017;26:2121 2127.
43. Stone MA, Jakoi AM, Iorio JA, et al. Bisphosphonate’s and intermit-
tent parathyroid hormone’s effect on human spinal fusion: a system-
atic review of the literature. Asian Spine J. 2017;11:484 493.
44. Inoue G, Ueno M, Nakazawa T, et al. Teriparatide increases the
insertional torque of pedicle screws during fusion surgery in
patients with postmenopausal osteoporosis. J. Neurosurg Spine.
2014;21:425 431.
45. Keaveny TM, Crittenden DB, Bolognese MA, et al. Greater gains
in spine and hip strength for romosozumab compared with teri-
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Min Res. 2017;32:1956 1962.
3
Medical Fitness Evaluation
SHELLY K. SCHMOLLER, NATHANIEL P. BROOKS, AND DANIEL K. RESNICK
CHAPTER OUTLINE
Introduction 27
Overall Wellness 27
Age 27
Frailty 27
Affective Disorder 28
Smoking 30
Obesity 31
Carriers of Methicillin-Resistant Staphylococcus aureus 31
Comorbidities 31
Cardiovascular 31
Pulmonary Diseases 32
Diabetes 33
Osteoporosis 33
Conclusion 33
References 34
Introduction
One major issue when considering reconstructive spinal sur-
gery is medical fitness for surgery. This is defined as an indi-
vidual’s ability to sustain the physiological stress of surgery
and recovery. Medical fitness is related to the overall wellness
of the patient and accumulated comorbidities.
Although some assessment of medical fitness can be done
during initial evaluations for spine care, work-flow and staff-
ing issues may make a full assessment during the spine surgi-
cal consult not feasible. Patients with significant medical
issues are often brought back for a more thorough evalua-
tion, optimally with cooperation and communications with
other caregivers. There is a lot of debate about what provider
is best able to perform a complete evaluation of medical fit-
ness. Ultimately, the best provider to perform medical fitness
is one who understands the risks of anesthesia, knows the
surgery, and is able to assess comorbidities and determine
strategies for risk reduction. The goals and outcomes of a
quality evaluation of medical fitness include: 1,2
1. Educated patient
2. Unify patients with the surgeon’s anticipated outcomes
3. Reduce operating room delays and cancellations
4. Decreased postoperative complications
5. Improve overall health of the patient.
Overall Wellness
Age
There is no age that is an absolute contraindication to sur-
gery. Many studies have indicated that age increases mortal-
ity and complication rates.3 Advancing age is often
accompanied by an accumulation of comorbidities and
decreased postoperative resilience, which can drastically
affect surgical outcomes.4 Life expectancy is considered
when planning for a surgical procedure that requires exten-
sive healing time. This is appropriate but it is important to
remember that life expectancy depends most heavily on
comorbidities rather than age. The chronological age on a
chart should not be use as a main decision-making tool when
evaluating a patient for surgery.
Frailty
Lack of postoperative resilience, or the physiological reserve
to heal from surgery, is termed frailty.5 Frailty scores do not
worsen at the same rate between patients and are not linked
to chronological age.3,6 Frail patients have increased postop-
erative mortality across all surgical fields, with odds ratios
(ORs) ranging from 1.1 to 4.97, and are at higher risk for
falls, skilled nursing home placement, and readmissions.4,5
Although there is no universally accepted rating scale for
frailty, several key components are measured.
1. Weakness, also referred to as sarcopenia, is defined as
progressive loss of skeletal muscle mass. Often this is
assessed by grip strength with cutoff values based on
body mass index (BMI) and sex (men: BMI above 28,
cutoff of # 32 kg; women: BMI above 29, # 21 kg).
Calculations of the psoas muscle area in the abdominal
region based on magnetic resonance imaging (MRI) have
been proposed to be helpful in determining sarcopenia
but standard cutoff values have not been established.6
The use of MRI as an objective measure of sarcopenia
will likely be particularly useful in spine surgery as
lumbar MRI is often available.
27
28 C H AP T E R 3 Medical Fitness Evaluation
2. Functional status is the ability to independently complete
activities of daily living (ADL).4 This can be assessed
through patient and caregiver questioning about ADL
and falls. In spine patients, the ability to ambulate
independently and the absences of any falls in the 6
months before surgery have been linked to decreased
length of stay and decreased readmission rates.7,8
3. Nutritional assessment should be conducted before
surgery. Malnutrition impairs wound healing and increases
the propensity for infections.3 Mini nutritional assessment,
which evaluates BMI and unintentional weight loss, can be
completed but this takes 10 to 15 minutes. An alternative
to this is a laboratory test for albumin. Nutritionally
deficient patients, as defined by a serum albumin of less
than 36 g/L, showed 27.6% higher risk of postoperative
pulmonary complications compared with patients with
normal serum albumin levels.9
4. Dementia screening. This can be efficiently done through
Mini-Cog 3 screening which assesses short-term recall and
spatial recognition.4 Preoperative dementia is associated
with increased postoperative cognitive dysfunction and
postoperative delirium.5
Although increased frailty is predictive of overall compli-
cations, it most strongly corresponds to increased rates of dis-
charge to skilled nursing facilities. Increased frailty has also
been linked to increased length of hospital stay and increased
readmission rates.
If patients are found to have a high frailty index, several
interventions are recommended (Table 3.1). Patients should
be evaluated for polypharmacy to ensure that medication
use is optimized.4 Patients with nutritional deficiency may
be supplemented with protein-rich enrichment formulas.
If functional limitations are severe, “pre-habbing” therapy
for ambulation and strengthening should be considered
before surgery when possible. Such therapies can also work
on strengthening the muscles involved in inspiration to
decrease pulmonary risk.9 Modifications in surgical planning
for frail patients should include consideration of regional
anesthesia, shorter operating room time, and less invasive
procedures.
TABLE
3.1 Strategies for Mitigation of Frailty
Factor Evaluation Concern
Sarcopenia Circumferential muscle Score .2
measurement
Get-up-and-go test, history
Activities of daily History Dependent ADL
living (ADL)
Nutrition Mini nutritional evaluation, Albumin ,36 g/L
albumin
Dementia Mini-Cog Score ,3
Affective Disorder
It is becoming increasing clear that mental well-being or the
absence of psychological disorders affect surgical outcomes.
This has been discussed for decades but continues to be sup-
ported by literature. The most common psychological disor-
ders seen in the spine surgical population are anxiety and
depression. Current rates of anxiety and depression in the
general population are approximately 6% to 10% and 7.3%,
respectively, and these numbers continue to increase.10
Often, anxiety and depression are present concurrently,
which is termed affective disorder.
Depression has been strongly correlated with chronic pain
and disability.11 14 The US Preventative Service Task Force
(USPSTF) states that depression is the leading cause of dis-
ability.14 In the spine patient population, chronic pain and
health-related disability are always present. Therefore, unsur-
prisingly, a large percentage of spine surgery patients experi-
ence depression. A cyclic depression model for spine-related
disability was first described decades ago and continues to
gain support in the literature (Fig. 3.1).13 This model begins
with a back injury and pain resulting in patient disability. In
some patients, depression can occur during this time. Patients
more commonly experience depression during this time if
they have a history of depression. Regardless of depression sta-
tus, the patient goes on to seek medical care, which can prog-
ress to surgery. If the surgery is not successful at relieving all of
the symptoms of their pain condition, the patient may rapidly
spiral into increased disability progressing to unemployment,
making them very vulnerable to depression.11,13 Depression
decreases the ability to deal with chronic pain, driving the
patient to once again seek medical care and surgery. This
cyclic progression needs to be carefully considered when mak-
ing decisions about revision spine surgery. In some cases, a
successful initial surgery can improve depression attributed to
relief of back and leg pain and decreased disability.15 This is
less common in revision cases because patients have already
experienced one surgery that failed to relieve pain.13
Psychological distress is a predictor of poor outcomes fol-
lowing spinal surgery. Multiple studies have shown that the
Modification
Consider preoperative physical therapy
Discuss skilled nursing facility after surgery
Supplement with protein enrichment
Assess polypharmacy preoperatively and decrease
length of surgery; decrease psychotropic
medications postoperatively
 CHAPTER 3 Medical Fitness Evaluation 29

improvement in depressed patients compared with nonde-

Pain pressed patients.18 Depressed patients are more likely to
report poor patient-to-provider communication.19
Lower pain Preoperative screening for depression is easily done.
Back surgery
tolerance There are multiple validated depression scales including the
Patient Health Questionnaire 9 (PHQ-9), Hospital Anxiety
and Depression Scale (HADS), Zung Self Rating Depression
Scale (SDS), and Becks Depression Index (BHI). All these
studies have been used in the spine literature. The USPSTF
recommends general depression screening using the PHQ-9
Depression Residual pain or HADS (Tables 3.2 and 3.3).14 Both of these studies
are patient questionnaires. HADS has the advantage of also
screening for anxiety. For geriatric patients, screening for
depression with the single question “Do you think you suffer
from depression?” has been suggested.20 Spine-specific stud-
Unemployment Disability ies favor the Hamilton Rating Scale for Depression (HRSD).
The drawback to HRSD is that it is a clinician-administered
• Fig. 3.1 Cyclic nature of depression as it relates to revision spine screening which can be difficult to complete owing to staff-
surgery. (From Walid MS, Zaytseva N. The relationship of unemployment ing and time constraints.21 In these spine-specific studies,
and depression with history of spine surgery. Perm J. 2011;15:19 22.) the BDI and PHQ-9 were only mildly inferior to HRSD and
may be easier to administer.
patient-reported disability, as measured by the Oswestry The mainstays of treatment for depression are cognitive
Disability Index (ODI), shows a more substantial decrease in behavioral therapy (CBT) and antidepressants. These treat-
patients who are not depressed compared with depressed ments are not entirely successful because remission rates at
patients, regardless of preoperative disability.15 17 Patient- 10 to 16 weeks after treatment are 48% with antidepressants
reported outcomes of spine surgery also show less and 46% with CBT.14 Treating depression before spine

TABLE
3.2 Patient Health Questionnaire 9 and Patient Health Questionnaire 2

Over the Last 2 Weeks, How Often Have You Been Several More Than Nearly
Bothered By Any of the Following Problems? Not At All Days Half the Days Every Day
1. Little interest or pleasure in doing thingsa 0 1 2 3
a
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself, or that you are a failure, or 0 1 2 3
have let yourself or your family down
7. Trouble concentrating on things, such as reading the 0 1 2 3
newspaper or watching television
8. Moving or speaking so slowly that other people could 0 1 2 3
have noticed, or the opposite—being so fidgety or
restless you have been moving around a lot more
than usual
9. Thoughts that you would be better off dead or of hurting 0 1 2 3
yourself in some way
Total the scores from all answers.
No depression: 0a4
Mild depression: 5a9
Moderate depression: 10a14
Moderately severe depression: 15a19
Severe depression: 20a27
a
Patient Health Questionnaire 2 questions.
From Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606 613.
30 C H AP T E R 3 Medical Fitness Evaluation

TABLE
3.3 Hospital Anxiety and Depression Scale

From Time A Lot of Most of

Hospital Anxiety and Depression Scale Anxiety Not At All to Time the Time the Time
1. I feel tense and wound up 0 1 2 3
2. I still enjoy the things I used to enjoy 0 1 2 3
3. I get sort of frightened as if something awful is about to 0 1 2 3
happen
4. I can laugh and see the funny side of things 0 1 2 3
5. Worrying thoughts go through my mind 0 1 2 3
6. I feel cheerful 0 1 2 3
7. I can’t sit at ease and feel relaxed 0 1 2 3
8. I feel as if I have slowed down 0 1 2 3
9. I get sort of frightened feeling like “butterflies in the 0 1 2 3
stomach”
10. I have lost interest in my appearance 0 1 2 3
11. I feel restless as if I have to be on the move 0 1 2 3
12. I look forward with joy to things 0 1 2 3
13. I get sudden feelings of panic 0 1 2 3
14. I can enjoy a good book, or radio or TV program 0 1 2 3
Total the scores for the even number questions (anxiety-related questions).
Total the scores for odd number questions (depression-related questions).
For each category:
Absence of condition: 0a7
Borderline/possible condition: 8a10
Presence of condition: 11a21

From Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361 370.

surgery has not been clearly linked to changes in outcomes.12
Practitioners are often caught in a “Catch-22 situation,”
where a patient who is clearly depressed has an anatomically
and physiologically obvious reason for pain. In these cases,
most practitioners treat what they can treat and manage what
they cannot cure. As a side note, the dual nature of tricyclic
antidepressants and selective serotonin and norepinephrine
reuptake inhibitors started preoperatively does have the
advantage of also treating neuropathic pain, while possibly
controlling mood. A referral to a health psychologist is useful
in teaching pain management techniques and a psychiatric
consultation to assure best possible management preopera-
tively are often the best options for these patients.
Smoking
Tobacco use affects all body systems and increases patient
risk of other diseases such as coronary artery disease,
obstructive sleep apnea, and chronic obstructive pulmonary
disease. Smokers also have higher rates of anxiety and
depression and increased pain complaints.22 Higher
patient-reported pain and smoking could both be owing to
depression, as discussed in the previous section. Smoking
has been found to negatively affect patient-reported out-
comes, similar to depression.22,23
Smoking has other physiological concerns. A major con-
cern in smokers undergoing spine fusion is the occurrence of
pseudarthrosis. This has been written about since the 1970s
and still is discussed and generally upheld for larger fusion
segments and revision cases.24,25 Surgery patients who
smoke are believed to have higher postoperative pulmonary
risk although these risks are modest (OR 1.26) and have not
been demonstrated within the spinal surgery population.9,26
Smoking has been linked with slight increase in surgical site
infection (SSI) in spine surgery (OR 1.17), although study
results vary.27,28
Smoking cessation can be difficult for the patient and dif-
ficult to assess for the provider. Abstaining from nicotine can
result in pain sensitization.22 Increased pain causes increased
anxiety and depression, driving the patient to smoke again.
Another random document with
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 Fig. 23.—Skeleton of the Perch.

Fig. 24.—Skeleton of a Perch’s Skull.

Fig. 25.—Hyoid arch, branchial apparatus, and scapulary arch of the Perch.
Fig. 26.—Lower view of Skull of Perch.
 Fig. 27.—Hyoid bone of the Perch.
The formation of the posterior part of the side of the skull is completed by the
mastoid and parietal bones. The former (12) projects outwards and backwards
farther than the paroccipital, forming the outer strong process of the side of the
cranium. This process lodges on its upper surface one of the main ducts of the
muciferous system, and affords the base of articulation to a part of the
hyomandibular. Its extremity gives attachment to the strong tendon of the dorso-
lateral muscles of the trunk. The parietals (7) are flat bones, of comparatively
much smaller extent than in higher Vertebrates, and separated from each other
by the anterior prolongation of the supraoccipital.
The anterior wall of the brain-capsule (or the posterior of the orbit) is formed
by the orbitosphenoids (14), between which, superiorly, the olfactory nerves, and
inferiorly, the optic, pass out of the cranium. In addition to this paired bone, the
Perch and many other fishes possess another single bone (15),—the os
sphenoideum anterius of Cuvier, ethmoid of Owen, and basisphenoid of Huxley; it
is Y-shaped, each lateral branch being connected with an orbito-sphenoid, whilst
the lower branch rests upon the long basal bone.
A cartilage, the substance of which is thickest above the vomer, and which
extends as a narrow stripe along the interorbital septum, represents the ethmoid
of higher Vertebrata; the olfactory nerves run along, and finally perforate it.
There remain, finally, the bones distinguishable on the upper surface of the
skull; the largest, extending from the nasal cavities to the occipital, are the frontal
bones (1), which also form the upper margin of the orbit. The postfrontals (4) are
small bones placed on the supero-posterior angle of the orbit, and serving as the
point from which the infraorbital ring is suspended. The pre-frontals (2), also
small, occupy the anterior margin of the orbit. A pair of small tubiform bones (20),
the turbinals, occupy the foremost part of the snout, in front of the frontals, and
are separated from each other by intervening cartilage.
After removal of the gill-cover and mandibulary suspensorium, the hyoid arch,
which encloses the branchial apparatus, and farther behind, the humeral arch are
laid open to view (Fig. 25). These parts can be readily separated from the
cranium proper.
The hyoid arch is suspended by a slender styliform bone, the stylohyal (29),
from the hyomandibulars; it consists of three segments, the epihyal (37),
ceratohyal (38), which is the longest and strongest piece, and the basihyal, which
is formed by two juxtaposed pieces (39, 40). Between the latter there is a median
styliform ossicle (41), extending forwards into the substance of the tongue, called
glossohyal or os linguale; and below the junction of the two hyoid branches there
is a vertical single bone (42), expanded along its lower edge, which, connected
by ligament with the anterior extremity of the humeral arch, forms the isthmus
separating the two gill-openings. This bone is called the urohyal. Articulated or
attached by ligaments to the epihyal and ceratohyal are a number of sword-
shaped bones or rays (43), the branchiostegals, between which the
branchiostegal membrane is extended.
The branchial arches (Figs. 25 and 27) are enclosed within the hyoid arch,
with which they are closely connected at the base. They are five in number, of
which four bear gills, whilst the fifth (56) remains dwarfed, is beset with teeth, and
called the lower pharyngeal bone. The arches adhere by their lower extremities to
a chain of ossicles (53, 54, 55), basibranchials, and, curving as they ascend,
nearly meet at the base of the cranium, to which they are attached by a layer of
ligamentous and cellular tissue. Each of the first three branchial arches consists
of four pieces movably connected with one another. The lowest is the
hypobranchial (57), the next much longer one (58) the cerato-branchial, and,
above this, a slender and a short irregularly-shaped epibranchial (61). In the
fourth arch the hypobranchial is absent. The uppermost of these segments (62),
especially of the fourth arch, are dilated, and more or less confluent; they are
beset with fine teeth, and generally distinguished as the upper pharyngeal bones.
Only the cerato-branchial is represented in the fifth arch or lower pharyngeal. On
their outer convex side the branchial segments are grooved for the reception of
large blood-vessels and nerves; on the inner side they support horny processes
(63), called the gill-rakers, which do not form part of the skeleton.
The scapular or humeral arch is suspended from the skull by the
(suprascapula) post-temporal (46), which, in the Perch, is attached by a triple
prong to the occipital and mastoid bones. Then follows the (scapula)
supraclavicula (47), and the arch is completed below by the union of the large
(coracoid) clavicula (48) with its fellow. Two flat bones (51, 52), each with a
vacuity, attached to the clavicle have been determined as the (radius and ulna)
coracoid and scapula of higher vertebrates, and the two series of small bones
(53) intervening between the forearm and the fin as carpals and metacarpals. A
two-jointed appendage the (epicoracoid) postclavicula, is attached to the clavicle:
its upper piece (49) is broad and lamelliform, its lower (50) styliform and pointed.
The ventral fins are articulated to a pair of flat triangular bones, the pubic
bones (80).
The bones of the skull of the fish have received so many different
interpretations that no two accounts agree in their nomenclature, so that their
study is a matter of considerable difficulty to the beginner. The following
synonymic table will tend to overcome difficulties arising from this cause; it
contains the terms used by Cuvier, those introduced by Owen, and finally the
nomenclature of Stannius, Huxley, and Parker. Those adopted in the present
work are printed in italics. The numbers refer to the figures in the accompanying
woodcuts (Figs. 23–27).
Cuvier. Owen. Stannius. Huxley, Parker, etc.
1. Frontal principal Frontal Os frontale
2. Frontal Prefrontal Os frontale Lateral ethmoid
antérieur anterius (Parker)
3. Ethmoid Nasal Os ethmoideum
4. Frontal Postfrontal Os frontale Sphenotic (Parker)
postérieur posterius
5. Basilaire Basioccipital Os basilare
6. Sphénoide Basisphenoid Os sphenoideum Sometimes referred
basilare to as “Basal”
7. Pariétal Parietal Os parietale
8. Interpariétal or Supraoccipital Os occipitale
occipital superius
supérieure
9. Occipital Paroccipital Os occipitale Epioticum (Huxley)
externe externum
10. Occipital lateral Exoccipital Os occipitale
laterale
11. Grande aile du Alisphenoid Ala temporalis Prooticum (Huxley)
sphénoide
12. Mastoidien Mastoid Os mastoideum + Opisthoticum[5]
 os +Squamosal
extrascapulare (Huxley)
13. Rocher Petrosal and Oberflächliche
Otosteal Knochen-
lamelle
14. Aile orbitaire Orbitosphenoid Ala orbitalis Alisphenoid (Huxley)
15. Sphenoide Ethmoid and Os sphenoideum Basisphenoid
antérieur Ethmoturbinal anterius (Huxley)
16. Vomer Vomer Vomer
17. Intermaxillaire Inter- or Pre- Os intermaxillare
maxillary
18. Maxillaire Maxillary Os maxillare
supérieur
19. Sousorbitaires Infraorbital ring Ossa infraorbitalia
20. Nasal Turbinal Os terminale
22. Palatine Palatin Os palatinum
23. Temporal Epitympanic Os temporale Hyomandibular
(Huxley)
24. Transverse Pterygoid Os transversum s.
pterygoideum
externum
25. Ptérygoidien Entopterygoid Os pterygoideum Mesopterygoid
interne (Parker)
26. Jugal Hypotympanic Os quadratojugale Quadrate (Huxley)
27. Tympanal Pretympanic Os tympanicum Metapterygoid
(Huxley)
28. Operculaire Operculum Operculum
29. Styloide Stylohyal Os styloideum
30. Préopercule Præoperculum Præoperculum
31. Symplectique Mesotympanic Os symplecticum
32. Sousopercule Suboperculum Suboperculum
33. Interopercule Interoperculum Interoperculum
34. Dentaire Dentary Os dentale
35. Articulaire Articulary Os articulare
36. Angulaire Angular Os angulare
37. Grandes pièces Epihyal Segmente der
latérales Zungenbein-
Schenkel
38. Ceratohyal
39. Petites pièces Basihyal
laterales
40.
41. Os lingual Glossohyal Os linguale s.
entoglossum
42. Queue de l’os Urohyal Basibranchiostegal
hyoide (Parker)
43. Rayon Branchiostegal Radii
branchiostège branchiostegi
46. Surscapulaire Suprascapula Omolita Post-temporal
(Parker)
 47. Scapulaire Scapula Scapula Supraclavicula
(Parker)
48. Humeral Coracoid Clavicula Clavicula (Parker)
49.
Postclavicula
Coracoid Epicoracoid
50. (Parker)
51. Cubital Radius Coracoid (Parker)
Ossa carpi
52. Radial Ulna Scapula (Parker)
Basalia (Huxley),
53. Os du carpe Carpals Ossa metacarpi
Brachials (Parker)
53 bis.
Chaine
55. Basibranchials Copula
intermédiaire
54.
56. Pharyngiens Lower Ossa pharyngea
inférieurs Pharyngeals inferiora
57. Pièce interne de Hypobranchial
partie
inférieure de
l’arceau
branchiale
58. Pièce externe „ Ceratobranchial
Segmente der
59. Stylet de Upper
Kiemenbogen-
prémière epibranchial of
Schenkel
arceau first branchial
branchiale arch
61. Partie Epibranchials
supérieure de
l’arceau
branchiale
62. Os pharyngian Pharyngobranchial Os pharyngeum Upper pharyngeals
supérieur superius
63. Gill-rakers
65. Rayons de la Pectoral rays Brustflossen-
pectorale Strablen
67, 68. Vertèbres Abdominal Bauchwirbel
abdominales vertebræ
69. Vertèbres Caudal vertebræ Schwanzwirbel
caudales
70. Plaque [Aggregated Verticale Platte Hypural (Huxley)
triangulaire et interhæmals]
verticale
71. Caudal rays Schwanzflossen
Strahlen
72. Côte Rib Rippen
73. Appendices or Epipleural spines Muskel-Gräthen
stylets
74. Interépineux Interneural spines Ossa interspinalia
s. obere
Flossentræger
75. Épines et Dorsal rays and Rückenflossen-
rayons spines Strablen u.
dorsales Stacheln
76. First interneural
78. Rudimentary
caudal rays
79. Apophyses Interhæmal spines Untere
épineuses Flossentræger
inférieures
80. Pubic Becken
81. Ventral spine Bauchflossen-
Stachel
 CHAPTER IV.

MODIFICATIONS OF THE SKELETON.

The lowermost sub-class of fishes, which comprises one form

only, the Lancelet (Branchiostoma [s. Amphioxus] lanceolatum),
possesses the skeleton of the most primitive type.

Fig. 28.—Branchiostoma lanceolatum. a, Mouth; b, Vent; c, abdominal porus.

Fig. 29.—Anterior end of body of Branchiostoma (magn.) d, Chorda dorsalis; e,

Spinal chord; f, Cartilaginous rods; g, Eye; h, Branchial rods; i, Labial
cartilage; k, Oral cirrhi.
The vertebral column is represented by a simple chorda dorsalis
or notochord only, which extends from one extremity of the fish to the
other, and, so far from being expanded into a cranial cavity, it is
pointed at its anterior end as well as at its posterior. It is enveloped in
a simple membrane like the spinal chord and the abdominal organs,
and there is no trace of vertebral segments or ribs; however, a series
of short cartilaginous rods above the spine evidently represent
apophyses. A maxillary or hyoid apparatus, or elements representing
limbs, are entirely absent.
[J. Müller, Ueber den Bau und die Lebenserscheinungen des
Branchiostoma lubricum, in Abhandl. Ak. Wiss. Berlin, 1844.]
The skeleton of the Cyclostomata (or Marsipobranchii) (Lampreys
and Sea-hags) shows a considerable advance of development. It
consists of a notochord, the anterior pointed end of which is wedged
into the base of a cranial capsule, partly membranous partly
cartilaginous. This skull, therefore, is not movable upon the spinal
column. No vertebral segmentation can be observed in the
notochord, but neural arches are represented by a series of
cartilages on each side of the spinal chord. In Petromyzon (Fig. 30)
the basis cranii emits two prolongations on each side: an inferior,
extending for some distance along the lower side of the spinal
column, and a lateral, which is ramified into a skeleton supporting
the branchial apparatus. A stylohyal process and a subocular arch
with a palato-pterygoid portion may be distinguished. The roof of the
cranial capsule is membranous in Myxine and in the larvæ of
Petromyzon, but more or less cartilaginous in the adult Petromyzon
and in Bdellostoma. A cartilaginous capsule on each side of the
hinder part of the skull contains the auditory organ, whilst the
olfactory capsule occupies the anterior upper part of the roof. A
broad cartilaginous lamina, starting from the cranium and overlying
part of the snout, has been determined as representing the ethmo-
vomerine elements, whilst the oral organs are supported by large,
very peculiar cartilages (labials), greatly differing in general
configuration and arrangement in the various Cyclostomes. There
are three in the Sea-lamprey, of which the middle one is joined to the
palate by an intermediate smaller one; the foremost is ring-like,
tooth-bearing, emitting on each side a styliform process. The lingual
cartilage is large in all Cyclostomes.
There is no trace of ribs or limbs.
 [J. Müller, Vergleichende Anatomie der Myxinoiden. Erster Theil.
Osteologie und Myologie, in Abhandl. Ak. Wiss. Berlin, 1835.]

Fig. 30.—Upper (A) and side (B) views, and vertical section (C) of the skull
of Petromyzon marinus.
a, Notochord; b, Basis cranii; c, Inferior, and d, Lateral process of basis; e,
Auditory capsule; f, Subocular arch; g, Stylohyal process; h, Olfactory
capsule; i, Ethmo-vomerine plate; k, Palato-pterygoid portion of subocular
arch; l-n, Accessory labial or rostral cartilages; with o, appendage; p,
lingual cartilage; q, neural arches; r, Branchial skeleton; s, Blind
termination of the nasal duct between the notochord and œsophagus.
 Fig. 31.—Heterocercal Tail of Centrina salviani.
a, Vertebræ; b, Neurapophyses; c, Hæmapophyses.
The Chondropterygians exhibit a most extraordinary diversity in
the development of their vertebral column; almost every degree of
ossification, from a notochord without a trace of annular structure to
a series of completely ossified vertebræ being found in this order.
Sharks, in which the notochord is persistent, are the Holocephali (if
they be reckoned to this order, and the genera Notidanus and
Echinorhinus). Among the first, Chimæra monstrosa begins to show
traces of segmentation; but they are limited to the outer sheath of the
notochord, in which slender subossified rings appear. In Notidanus
membranous septa, with a central vacuity, cross the substance of
the gelatinous notochord. In the other Sharks the segmentation is
complete, each vertebra having a deep conical excavation in front
and behind, with a central canal through which the notochord is
continued; but the degree in which the primitive cartilage is replaced
by concentric or radiating lamellæ of bone varies greatly in the
various genera, and according to the age of the individuals. In the
Rays all the vertebræ are completely ossified, and the anterior ones
confluent into one continuous mass.
In the majority of Chondropterygians the extremity of the
vertebral column shows a decidedly heterocercal condition (Fig. 31),
and only a few, like Squatina and some Rays, possess a diphycercal
tail
The advance in the development of the skeleton of the
Chondropterygians beyond the primitive condition of the previous
sub-classes, manifests itself further by the presence of neural and
hæmal elements, which extend to the foremost part of the axial
column, but of which the hæmal form a closed arch in the caudal
region only, whilst on the trunk they appear merely as a lateral
longitudinal ridge.

Fig. 32.—Lateral view.

Fig. 33.—Longitudinal section.
 Fig. 34.—Transverse section of Caudal
vertebra of Basking Shark (Selache
maxima). (After Hasse.) a, Centrum; b,
Neurapophysis; c, Intercrural cartilage; d,
Hæmapophysis; e, Spinal canal; f,
Intervertebral cavity; g, Central canal for
persistent portion of notochord; h, Hæmal
canals for blood-vessels.
The neural and hæmal apophyses are either merely attached to
the axis, as in Chondropterygians with persistent notochord, the
Rays and some Sharks; or their basal portions penetrate like wedges
into the substance of the centrum, so that, in a transverse section, in
consequence of the difference in their texture, they appear in the
form of an X.[6] The interspaces between the neurapophyses of the
vertebræ are not filled by fibrous membrane, as in other fishes, but
by separate cartilages, laminæ or cartilagines intercrurales, to which
frequently a series of terminal pieces is superadded, which must be
regarded as the first appearance of the interneural spines of the
Teleostei and many Ganoids. Similar terminal pieces are sometimes
observed on the hæmal arches. Ribs are either absent or but
imperfectly represented (Carcharias).
The substance of the skull of the Chondropterygians is cartilage,
interrupted especially on its upper surface by more or less extensive
fibro-membranous fontanelles. Superficially it is covered by a more
or less thick chagreen-like osseous deposit. The articulation with the
vertebral column is effected by a pair of lateral condyles. In the
Sharks, besides, a central conical excavation corresponds to that of
the centrum of the foremost vertebral segment, whilst in the Rays
this central excavation of the skull receives a condyle of the axis of
the spinous column.
The cranium itself is a continuous undivided cartilage, in which
the limits of the orbit are well marked by an anterior and posterior
protuberance. The ethmoidal region sends horizontal plates over the
nasal sacs, the apertures of which retain their embryonic situation
upon the under surface of the skull. In the majority of
Chondropterygians these plates are conically produced, forming the
base of the soft projecting snout; and in some forms, especially in
the long-snouted Rays and the Saw-fishes (Pristis) this prolongation
appears in the form of three or more tubiform rods.
As separate cartilages there are appended to the skull a
suspensorium, a palatine, mandible, hyoid, and rudimentary
maxillary elements.
The suspensorium is movably attached to the side of the skull. It
generally consists of one piece only, but in some Rays of two. In the
Rays it is articulated with the mandible only, their hyoid possessing a
distinct point of attachment to the skull. In the Sharks the hyoid is
suspended from the lower end of the suspensorium together with the
mandible.
What is generally called the upper jaw of a Shark is, as Cuvier
has already stated, not the maxillary, but palatine. It consists of two
simple lateral halves, each of which articulates with the
corresponding half of the lower jaw, which is formed by the simple
representative of Meckel’s cartilage.
 Some cartilages of various sizes are generally developed on
each side of the palatine, and one on each side of the mandible.
They are called labial cartilages, and seem to represent maxillary
elements.
The hyoid consists generally of a pair of long and strong lateral
pieces, and a single mesial piece. From the former cartilaginous
filaments (representing branchiostegals) pass directly outwards.
Branchial arches, varying in number, and similar to the hyoid,
succeed it. They are suspended from the side of the foremost part of
the spinous column, and, like the hyoid, bear a number of filaments.
The vertical fins are supported by interneural and interhæmal
cartilages, each of which consists of two and more pieces, and to
which the fin-rays are attached without articulation.
The scapular arch of the Sharks is formed by a single coracoid
cartilage bent from the dorsal region downwards and forwards. In
some genera (Scyllium, Squatina) a small separate scapular
cartilage is attached to the dorsal extremities of the coracoid; but in
none of the Elasmobranchs is the scapular arch suspended from the
skull or vertebral column; it is merely sunk, and fixed in the
substance of the muscles. Behind, at the point of its greatest
curvature, three carpal cartilages are joined to the coracoid, which
Gegenbaur has distinguished as propterygium, mesopterygium, and
metapterygium, the former occupying the front, the latter the hind
margin of the fin. Several more or less regular transverse series of
styliform cartilages follow. They represent the phalanges, to which
the horny filaments which are imbedded in the skin of the fin are
attached.
In the Rays, with the exception of Torpedo, the scapular arch is
intimately connected with the confluent anterior portion of the
vertebral column. The anterior and posterior carpal cartilages are
followed by a series of similar pieces, which extend like an arch
forwards to the rostral portion of the skull, and backwards to the
pubic region. Extremely numerous phalangeal elements, longest in
the middle, are supported by the carpals, and form the skeleton of
the lateral expansion of the so-called disk of the Ray’s body, which
thus, in fact, is nothing but the enormously enlarged pectoral fin.
The pubic is represented by a single median transverse cartilage,
with which a tarsal cartilage articulates. The latter supports the fin-
rays. To the end of this cartilage is also attached, in the male
Chondropterygians, a peculiar accessory generative organ or
clasper.
The Holocephali differ from the other Chondropterygians in
several important points of the structure of their skeleton, and
approach unmistakably certain Ganoids. That their spinal column is
persistently notochordal has been mentioned already. Their palatal
apparatus, with the suspensorium, coalesces with the skull, the
mandible articulating with a short apophysis of the cranial cartilage.
The mandible is simple, without anterior symphysis. The spine with
which the dorsal fin is armed articulates with a neural apophysis, and
is not immovably attached to it, as in the Sharks. The pubic consists
of two lateral halves, with a short, rounded, tarsal cartilage.
The skeleton of the Ganoid Fishes offers extreme variations with
regard to the degree in which ossifications replace the primordial
cartilage. Whilst some exhibit scarcely any advance beyond the
Plagiostomes with persistent cartilage, others approach, as regards
the development and specialisation of the several parts of their
osseous framework, the Teleosteans so closely that their Ganoid
nature can be demonstrated by, or inferred from, other
considerations only. All Ganoids possess a separate gill-cover.[7]
The diversity in the development of the Ganoid skeleton is well
exemplified by the few representatives of the order in the existing
Fish-fauna. Lowest in the scale (in this respect) are those with a
persistent notochord, and an autostylic skull, that is, a skull without
separate suspensorium—the fishes constituting the suborder Dipnoi,
of which the existing representatives are Lepidosiren, Protopterus,
and Ceratodus, and the extinct (as far as demonstrated at present)
Dipterus, Chirodus (and Phaneropleuron?). In these fishes the
notochord is persistent, passing uninterruptedly into the cartilaginous
base of the skull. Only now and then a distinct vertical segmentation