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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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Publisher (other than as may be noted herein).

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

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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 The main interest, however, of pragmatists in their somewhat
tiresome insistence upon the truism that all truth is made truth is their
hostility (Locke had it in his day) to the supposed rationalist position
that there is an “a priori” and “objective” truth independent altogether
113
of human activities and human purposes. The particular object of
114
their aversion is what Dewey talks of as “that dishonesty, that
insincerity, characteristic of philosophical discussion, that is
manifested in speaking and writing as if certain ultimate abstractions
or concepts could be more real than human purposes and human
beings, and as if there could be any contradiction between truth and
115
purpose.” As we shall reflect at a later stage upon the rationalist
theory of truth, we may, meantime, pass over this hostility with the
remark that it is, after all, only owing to certain peculiar
circumstances (those, say, of its conflict with religion and science
and custom) in the development of philosophy that its first principles
have been regarded by its votaries as the most real of all realities.
These devotees tend to forget in their zeal that the pragmatist way of
looking upon all supposed first principles—that of the consideration
of their utility in and necessity as explanations of our common
experience and its realities—is the only way of explaining their
reality, even as conceptions.
It requires to be added—so much may, indeed, have already
been inferred from the preceding chapter—that, apart from their hint
about the highest truth being necessarily inclusive of the highest
human purposes, it is by no means easy to find out from the
pragmatists what they mean by truth, or how they would define it.
When the matter is pressed home, they generally confess that their
attitude is in the main “psychological” rather than philosophical, that
it is the “making” of truth rather than its “nature” or its “contents” or its
systematic character that interests them. It is the “dynamical” point of
view, as they put it, that is essential to them. And out of the sphere
and the associations of this contention they do not really travel. They
will tell you what it means to hit upon this particular way of looking
upon truth, and how stimulating it is to attempt to do so. And they will
give you many more or less artificial and tentative, external,
descriptions of their philosophy by saying that ideas are “made for
man,” and “not man for ideas,” and so on. But, although they deny
both the common-sense view that truth is a “correspondence” with
external reality, and the rationalist view that truth is a “coherent
system” on its own account, they never define truth any more than
do their opponents the rationalists. It is a “commerce” and not a
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“correspondence,” they contend, a commerce between certain
parts of our experience and certain other parts, or a commerce
between our ideas and our purposes, but not a commerce with
reality, for the making of truth is itself, in their eyes, the making of
reality.
Secondly, it is another familiar characteristic of Pragmatism that,
although it fails to give a satisfying account either of truth or reality,
the one thing of which it is for ever talking of, as fundamental to our
117
entire life as men, is belief. This is the one thing upon which it
makes everything else to hang—all knowledge and all action and all
theory. And it is, of course, its manifest acceptance of belief as a
fundamental principle of our human life, and as a true measure of
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reality, that has given to Pragmatism its religious atmosphere. It is
this that has made it such a welcome and such a credible creed to
so many disillusioned and free-thinking people to-day, as well as to
so many of the faithful and the orthodox. “For, in principle,
Pragmatism overcomes the old antithesis of Faith and Reason. It
shows, on the one hand, that faith must underlie all reason and
pervade it, nay, that at bottom rationality itself is the supremest
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postulate of Faith.” “Truth,” again, as James reminds us, “lives in
fact for the most part on a credit system. Our thoughts and beliefs
[how literally true this is!] pass so long as nobody challenges them,
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just as bank-notes pass so long as nobody refuses them.”
Now it requires but the reflection of a moment to see that the
various facts and considerations upon which the two last quotations,
and the general devotion of Pragmatism to “belief,” both repose, are
all distinctly in favour of the acceptability of Pragmatism at the
present time. There is nothing in which people in general are more
interested at the beginning of this twentieth century than in belief. It
is this, for example, that explains such a thing as the great success
to-day in our English-speaking world of such an enterprise as the
Hibbert Journal of Philosophy and Religion, or the still greater
phenomenon of the world-wide interest of the hour in the subject of
comparative religion. Most modern men, the writer is inclined to
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think, believe a great deal more than they know, the chief difficulty
about this fact being that there is no recognized way of expressing it
in our science or in our philosophy, or of acting upon it in our
behaviour in society. It is, however, only the undue prominence of
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mathematical and physical science since the time of Descartes
that has made evidence and demonstration the main consideration
of philosophy instead of belief, man’s true and fundamental estimate
of reality.
123
We have already pointed out that one of the main results of
Pragmatism is the acceptance on the part of its leading upholders of
our fundamental beliefs about the ultimately real and about the
realization of our most deeply cherished purposes. In fact, reality in
general is for them, we may say—in the absence from their writings
of any better description,—simply that which we can “will,” or
“believe in,” as the basis for action and for conscious “creative”
effort, or constructive effort. As James himself puts it in his book on
The Meaning of Truth: “Since the only realities we can talk about are
objects believed in, the pragmatist, whenever he says ‘reality,’
means in the first instance what may count for the man himself as a
reality, what he believes at the moment to be such. Sometimes the
reality is a concrete sensible presence.... Or his idea may be that of
an abstract relation, say of that between the sides and the
hypotenuse of a triangle.... Each reality verifies and validates its own
idea exclusively; and in each case the verification consists in the
satisfactorily-ending consequences, mental or physical, which the
idea was to set up.”
We shall later have to refer to the absence from Pragmatism of a
criterion for achievement and for “consequences.” And, as far as
philosophical theories are concerned, these are all, to the
pragmatists, true or false simply in so far as they are practically
credible or not. James is quite explicit, for example, about
Pragmatism itself in this regard. “No pragmatist,” he holds, “can
warrant the objective truth of what he says about the universe; he
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can only believe it.” There is faith, in short, for the pragmatist, in
every act, in every phase of thought, the faith that is implied in the
realization of the purposes that underlie our attempted acts and
thoughts. They eagerly accept, for example, the important doctrine of
the modern logician, and the modern psychologist, as to the
presence of volition in all “affirmation” and “judgment,” seeing that in
every case of affirmation there is a more or less active readjustment
of our minds (or our bodies) to what either stimulates or impedes our
activity.
A third outstanding characteristic of Pragmatism is the “deeper”
view of human nature upon which, in contrast to Rationalism, it
supposes itself to rest, and which it seeks to vindicate. It is this
supposedly deeper view of human nature for which it is confessedly
pleading when it insists, as it is fond of doing, upon the connexion of
philosophy with the various theoretical and practical pursuits of
mankind, with sciences like biology and psychology, and with social
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reform, and so on. We have, it may be remembered, already
intimated that even in practical America men have had their doubts
about the depth of a philosophy that looks upon man as made in the
main for action and achievement instead of, let us say, the
realization of his higher nature. Still, few of the readers of James can
have altogether failed to appreciate the significance of some of the
many eloquent and suggestive paragraphs he has written upon the
limitations of the rationalistic “temperament” and of its unblushing
sacrifice of the entire wealth of human nature and of the various
pulsating interests of men to the imaginary exigencies of abstract
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logic and “system.” To him and to his colleagues (as to Socrates,
for that part of it) man is firstly a being who has habits and purposes,
and who can, to some extent, control the various forces of his nature
through true knowledge, and in this very discrepancy between the
real and the ideal does there lie for the pragmatists the entire
problem of philosophy—the problem of Plato, that of the attainment
of true virtue through true knowledge.
Deferring, however, the question of the success of the
pragmatists in this matter of the unfolding of the true relation
between philosophy and human nature, let us think of a few of the
teachings of experience upon this truly important and inevitable
relation, which no philosophy indeed can for one moment afford to
neglect. Insistence upon these facts or teachings and upon the
reflections and criticisms to which they naturally give rise is certainly
a deeply marked characteristic of Pragmatism.
Man, as has often been pointed out, is endowed with the power
of reflection, not so much to enable him to understand the world
either as a whole or in its detailed workings as to assist him in the
further evolution of his life. His beliefs and choices and his spiritual
culture are all, as it were, forces and influences in this direction.
Indeed, it is always the soul or the life principle that is the important
thing in any individual or any people, so far as a place in the world
(or in “history”) is concerned.
Philosophers, as well as other men, often exchange (in the
words of Lecky) the “love of truth” as such for the love of “the truth,”
that is to say, for the love of the system and the social arrangements
that best suit their interests as thinkers. And they too are just as
eager as other men for discipleship and influence and honour.
Knowledge with them, in other words, means, as Bacon put it,
“control”; and even with them it does not, and cannot, remain at the
stage of mere cognition. It becomes in the end a conviction or a
belief. And thus the philosopher with his system (even a Plato, or a
Hegel) is after all but a part of the universe, to be judged as such,
along with other lives and other systems—a circumstance hit off
early in the nineteenth century by German students when they used
to talk of one’s being able (in Berlin) to see the Welt-Geist (Hegel)
“taking a walk” in the Thiergarten.
Reality again, so far as either life or science is concerned,
means for every man that in which he is most fundamentally
interested—ions and radium to the physicist of the hour, life to the
biologist, God to the theologian, progress to the philanthropist, and
so on.
Further, mankind in general is not likely to abandon its habit of
estimating all systems of thought and philosophy from the point of
view of their value as keys, or aids, to the problem of the meaning
and the development of life as a whole. There is no abstract “truth”
or “good” or “beauty” apart from the lives of beings who contemplate,
and who seek to create, such things as truth and goodness and
beauty.
To understand knowledge and intellect, again, we must indeed
look at them in their actual development in connexion with the total
vital or personal activity either of the average or even of the
exceptional individual. And instead of regarding the affections and
the emotions as inimical to knowledge, or as secondary and inferior
to it, we ought to remember that they rest in general upon a broader
and deeper attitude to reality than does either the perception of the
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senses or the critical analysis of the understanding. In both of
these cases is the knowledge that we attain to limited in the main
either to what is before us under the conditions of time and space, or
to particular aspects of things that we mark off, or separate, from the
totality of things. As Bergson reminds us, we “desire” and “will” with
the “whole” of our past, but “think” only with “part” of it. Small wonder
then that James seeks to connect such a broad phenomenon as
religion with many of the unconscious factors (they are not all merely
“biological”) in the depth of our personality. Some of the instincts and
the phenomena that we encounter there are things that transcend
altogether the world that is within the scope of our senses or the
reasoning faculties.
Truth, too, grows from age to age, and is simply the formulated
knowledge humanity has of itself and its environment. And errors
disappear, not so much in consequence of their logical refutation, as
in consequence of their inutility and of their inability to control the life
and thought of the free man. Readers of Schopenhauer will
remember his frequent insistence upon this point of the gradual
dissidence and disappearance of error, in place of its summary
refutation.
Our “reactions” upon reality are certainly part of what we mean
by “reality,” and our philosophy is only too truly “the history of our
heart and life” as well as that of our intellectual activity. The historian
of philosophy invariably acts upon a recognition of the personal and
the national and the epochal influence in the evolution of every
philosophical system. And even the new, or the fuller conception of
life to which a given genius may attain at some stage or other of
human civilization will still inevitably, in its turn, give place to a newer
or a more perfect system.
Now Pragmatism is doubtless at fault in seeking to create the
impression that Rationalism would seek to deny any, or all, of those
characteristic facts of human nature. Still, it is to some extent
justified in insisting upon their importance in view of the sharp
conflict (we shall later refer to it) that is often supposed to exist
between the theoretical and the practical interests of mankind, and
that Rationalism sometimes seems to accept with comparative
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equanimity. What Pragmatism is itself most of all seeking after is
a view of human nature, and of things generally, in which the fullest
129
justice is done to the facts upon which this very real conflict of
modern times may be said to rest.
A fourth characteristic of Pragmatism is its notorious “anti-
130
intellectualism,” its hostility to the merely dialectical use of terms
131
and concepts and categories, to argumentation that is unduly
detached from the facts and the needs of our concrete human
experience. This anti-intellectualism we prefer meantime to consider
not so much in itself and on its own account (if this be possible with a
negative creed) as in the light of the results it has had upon
philosophy. There is, for example, the general clearing of the ground
that has undoubtedly taken place as to the actual or the possible
meaning of many terms or conceptions that have long been current
with the transcendentalists, such as “pure thought,” the “Absolute,”
“truth” in and for itself, philosophy as the “completely rational”
interpretation of experience, and so on. And along with this clearing
of the ground there are (and also in consequence of the pragmatist
movement) a great many recent, striking concessions of Rationalism
to practical, and to common-sense, ways of looking at things, the
very existence of which cannot but have an important effect upon the
philosophy of the near future. Among some of the more typical of
these are the following:
From Mr. F. H. Bradley we have the emphatic declarations that
the principle of dialectical opposition or the principle of “Non-
Contradiction” (formerly, to himself and his followers, the “rule of the
game” in philosophy) “does not settle anything about the nature of
reality”; that “truth” is an “hypothesis,” and that “except as a means
to a foreign end it is useless and impossible”; and “when we judge
truth by its own standard it is defective because it fails to include all
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the facts,” and because its contents “cannot be made intelligible
throughout and entirely”; that “no truth is idle,” and that “all truth” has
“practical” and æsthetic “consequences”; that there is “no such
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existing thing as pure thought”; that we cannot separate truth and
practice; that “absolute certainty is not requisite for working
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purposes”; that it is a “superstition to think that the intellect is the
highest part of us,” and that it is well to attack a one-sided
“intellectualism”; that both “intellectualism” and “voluntarism” are
“one-sided,” and that he has no “objection to identifying reality with
goodness or satisfaction, so long as this does not mean merely
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practical satisfaction.” Then from this same author comes the
following familiar statement about philosophy as a whole:
“Philosophy always will be hard, and what it promises in the end is
no clear vision nor any complete understanding or vision, but its
certain reward is a continual and a heightened appreciation [this is
the result of science as well as of philosophy] of the ineffable
mystery of life, of life in all its complexities and all its unity and all its
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worth.”
Equally typical and equally important is the following concession
from Professor Taylor, although, of course, to many people it would
seem no concession at all, but rather the mere statement of a fact,
which our Neo-Hegelians have only made themselves ridiculous by
seeming to have so long overlooked: “Mere truth for the intellect can
never be quite the same as ultimate reality. For in mere truth we get
reality only in its intellectual aspect, as that which affords a higher
satisfaction to thought’s demand for consistency and systematic
unity in its object. And as we have seen, this demand can never be
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quite satisfied by thought itself. For thought, to remain thought,
must always be something less than the whole reality which it
138
knows.”
And we may add also from Professor Taylor the following
declaration in respect of the notorious inability of Neo-Hegelian
Rationalism to furnish the average man with a theory of reality in the
contemplation of which he can find at least an adequate motive to
conscious effort and achievement: “Quite apart from the facts, due to
personal shortcomings and confusions, it is inherent in the nature of
metaphysical study that it can make no positive addition to our
information, and can itself supply no motive for practical
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endeavour.”
Many of those findings are obviously so harmonious with some
of the more familiar formulas of the pragmatists that there would
seem to be ample warrant for associating them with the results of the
pragmatist movement. This is particularly the case, it would seem,
with the concession of Mr. Bradley with respect of the “practical” or
“hypothetical” conception that we ought to entertain of “truth” and
“thinking,” and also with the strictures passed by him upon “mere
truth” and “mere intellectualism,” and with Professor Taylor’s position
in respect of the inadequacy of the rationalist theory of reality, as in
no sense a “dynamic” or an “incentive” for action. And we might well
regard Professor Taylor’s finding in respect of mere systematic truth
or the “Absolute” (for they are the same thing to him) as confirmatory
of Dr. Schiller’s important contention that “in Absolutism” the two
“poles” of the “moral” and the “intellectual” character of the Deity “fall
apart.” This means, we will remember, that the truth of abstract
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intellectualism is not the truth for action, that absolutism is not
able to effect or harmonize between the truth of systematic
knowledge and moral truth—if, indeed, there be any such thing as
moral truth on the basis of a pure Rationalism.
To be sure, both the extent and even the reality of all this
supposed cession of ground in philosophy to the pragmatists has
been doubted and denied by the representatives of Rationalism.
They would be questioned, too, by many sober thinkers and scholars
who have long regarded Hegelian intellectualism and pragmatist
“voluntarism” as extremes in philosophy, as inimical, both of them, to
the interests of a true and catholic conception of philosophy. The
latter, as we know from Aristotle, should be inclusive of the realities
both of the intellectual and the practical life.
Pragmatist criticisms of Rationalism, again, may fairly be claimed
to have been to a large extent anticipated by the independent
findings of living idealist thinkers like Professors Pringle-Pattison,
Baillie, Jones, and others, in respect of the supposed extreme claims
of Hegelianism, as well as by similar findings and independent
constructive efforts on the part of the recent group of the Oxford
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Personal Idealists. That there is still a place for pragmatist anti-
intellectualism is evidently the conclusion to be drawn from such
things as the present wide acceptance of the philosophy of Bergson,
or the recent declarations of Mr. Bradley that we are justified “in the
intelligent refusal to accept as final an theoretical criterion which
actually so far exists,” and that the “action of narrow consistency
must be definitely given up.”
The reflection ought, moreover, to be inserted here that even if
Pragmatism has been of some possible service in bringing forth from
rationalists some of their many recent confessions of the limitations
of an abstract intellectualism, it is not at all unlikely that Rationalism
in its turn may succeed in convicting Pragmatism of an undue
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emphasis upon volition and action and upon merely practical
truth.
We shall now terminate the foregoing characterization of
Pragmatism by a reference to two or three other specific things for
which it may, with more or less justice, be supposed to stand in
philosophy. These are (1) the repudiation of the “correspondence
143
view” of the relation of truth to reality, (2) the rejection of the idea
of there being any ultimate or rigid distinction between “appearance”
and “reality,” and (3) the reaffirmation of the “teleological” point of
view as characteristic of philosophy in distinction from science.
As for (1) it has already been pointed out that this idea of the
misleading character of the ordinary “correspondence notion” of truth
is claimed by pragmatists as an important result of their proposal to
test truth by the standard of the consequences involved in its
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acceptance. The ordinary reader may not, to be sure, be aware of
the many difficulties that are apt to arise in philosophy from an
apparent acceptance of the common-sense notion of truth as
somehow simply a duplicate or a “copy” of external reality. There is
the difficulty, say, of our ever being able to prove such a
correspondence without being (or “going”) somehow beyond both
the truth and the reality in question, so as to be able to detect either
coincidence or discrepancy. Or, we might again require some bridge
between the ideas in our minds and the supposed reality outside
them—“sensations” say, or “experiences,” something, in other words,
that would be accepted as “given” and indubitable both by idealists
and realists. And there would be the difficulty, too, of saying whether
we have to begin for the purposes of all reflective study with what is
within consciousness or with what is outside it—in matter say, or in
things. And if the former, how we can ever get to the latter, and vice
versa. And so on with the many kindred subtleties that have divided
thinkers into idealists and realists and conceptualists, monists,
dualists, parallelists, and so on.
Now Pragmatism certainly does well in proposing to steer clear
of all such difficulties and pitfalls of the ordinary “correspondence
notion.” And as we shall immediately refer to its own working
philosophy in the matter, we shall meantime pass over this mere
point of its rejection of the “correspondence notion” with one or two
remarks of a critical nature, (1) Unfortunately for the pragmatists the
rejection of the correspondence notion is just as important a feature
145
of Idealism as it is of Pragmatism. The latter system therefore can
lay no claim to any uniqueness or superiority in this connexion. (2)
Pragmatism, as we may perhaps see, cannot maintain its position
that the distinction between “idea” and “object” is one “within
experience itself” (rather than a distinction between experience and
something supposedly outside it) without travelling further in the
146
direction of Idealism than it has hitherto been prepared to do. By
such a travelling in the direction of Idealism we mean a far more
thorough-going recognition of the part played in the making of reality
by the “personal” factor, than it has as yet contemplated either in its
“instrumentalism” or in its “radical empiricism.” (3) There is, after all,
an element of truth in the correspondence notion to which
Pragmatism fails to do justice. We shall refer to this failure in a
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subsequent chapter when again looking into its theory of truth
and reality.
Despite these objections there is, however, at least one
particular respect in regard to which Pragmatism may legitimately
claim some credit for its rejection of the correspondence notion. This
is its insistence that the truth is not (as it must be on the
correspondence theory) a “datum” or a “presentation,” not something
given to us by the various objects and things without us, or by their
supposed effects upon our senses and our memory and our
understanding. It rather, on the contrary, maintains Pragmatism, a
“construction” on the part of the mind, an attitude of our “expectant”
(or “believing”) consciousness, into which our own reactions upon
things enter at least as much as do their supposed effects and
impressions upon us. Of course the many difficulties of this thorny
subject are by no means cleared up by this mere indication of the
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attitude of Pragmatism, and we shall return in a later chapter to
this idea of truth as a construction of the mind instead of a datum,
taking care at the same time, however, to refer to the failure of which
we have spoken on the part of Pragmatism to recognize the element
of truth that is still contained in the correspondence notion.
(2) The rejection of the idea of any rigid, or ultimate distinction
between “appearance” and “reality.” This is a still broader rejection
than the one to which we have just referred, and may, therefore, be
thought of as another more or less fundamental reason for the
rejection either of the copy or of the correspondence theory of truth.
The reality of things, as Pragmatism conceives it, is not something
already “fixed” and “determined,” but rather, something that is
“plastic” and “modifiable,” something that is, in fact, undergoing a
continuous process of modification, or development, of one kind or
another. It must always, therefore, the pragmatist would hold, be
defined in terms of the experiences and the activities through which
it is known and revealed and through which it is, to some extent,
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even modified.
Pragmatism, as we may remember, has been called by James
“immediate” or “radical” empiricism, although in one of his last books
he seeks to give an independent development to these two
doctrines. The cardinal principle of this philosophy is that “things are
what they are experienced as being, or that to give a just account of
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anything is to tell what that thing is experienced to be.” And it is
perhaps this aspect of the new philosophy of Pragmatism that is
most amply and most attractively exhibited in the books of James. It
is presented, too, with much freshness and skill in Professor
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Bawden’s book upon Pragmatism, which is an attempt, he says,
“to set forth the necessary assumptions of a philosophy in which
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experience becomes self-conscious as a method.”
153
“The new philosophy,” proceeds Bawden, “is a pragmatic
idealism. Its method is at once intrinsic and immanent and organic or
functional. By saying that its method is functional, we mean that its
experience must be interpreted from within. We cannot jump out of
our skins ... we cannot pull ourselves up by our own bootstraps. We
find ourselves in mid-stream of the Niagara of experience, and may
define what it is by working back and forth within the current.” “We
do not know where we are going, but we are on the way” [the
contradiction is surely apparent]. Then, like James, Bawden goes on
to interpret Pragmatism by showing what things like self-
consciousness, experience, science, social consciousness, space,
time, and causation are by showing how they “appear,” and how they
“function”—“experience” itself being simply, to him and to his friends,
a “dynamic system,” “self-sustaining,” a “whole leaning on nothing.”
The extremes of this “immediate” or “radical” philosophy appear
to non-pragmatists to be reached when we read words like those just
quoted about the Niagara stream of our experience, and about our
life as simply movement and acceleration, or about the celebrated “I
think” of Descartes as equally well [!] set forth under the form “It
thinks,” or “thinking is going on,” or about the “being” of the individual
person as consisting simply in a “doing.” “All this we hold,” says
Bawden, “to be not materialism but simply energism.” “There is no
‘truth,’ only ‘truths’—this is another way of putting it—and the only
criterion of truth is the changing one of the image or the idea which
comes out of our impulses or of the conflict of our habits.” The end of
all this modern flowing philosophy is, of course, the “Pluralism” of
James, the universe as a society of functioning selves in which
reality “may exist in a distributive form, or in the shape, not of an All,
but of a set of eaches.” “The essence of life,” as he puts it in his
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famous essay on Bergson, “is its continually changing character,”
and we only call it a “confusion” sometimes because we have grown
accustomed in our sciences and philosophies to isolate “elements”
155
and “differents” which in reality are “all dissolved in one another.”
“Relations of every sort, of time, space, difference, likeness, change,
rate, cause, or what not, are just as integral members of the
sensational flux as terms are.” “Pluralism lets things really exist in
the each form, or distributively. Its type of union ... is different from
the monistic type of all-einheit. It is what I call the strung-along type,
the type of continuity, contiguity, or concatenation.” And so on.
(3) The reaffirmation of the teleological point of view. After the
many illustrations and references that have already been given in
respect of the tendencies of Pragmatism, it is perhaps hardly
necessary to point out that an insistence upon the necessity to
philosophy of the “teleological” point of view, of the consideration of
both thoughts and things from the point of view of their purpose or
utility, is a deeply-marked characteristic of Pragmatism. In itself this
demand can hardly be thought of as altogether new, for the idea of
considering the nature of anything in the light of its final purpose or
end is really as old in our European thought as the philosophy of
Aristotle or Anaxagoras. Almost equally familiar is the kindred idea
upon which Pragmatism is inclined to felicitate itself, of finding the
roots of metaphysic “in ethics,” in the facts of conduct, in the facts of
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the “ideal” or the “personal” order which we tend in human
civilization to impose upon what is otherwise thought of by science
as the natural order. The form, however, of the teleological argument
to which Pragmatism may legitimately be thought to have directed
our attention is that of the possible place in the world of reality, and
in the world of thought, of the effort and the free initiative of the
individual. This place, unfortunately (the case is quite different with
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Bergson ), Pragmatism has been able, up to the present time, to
define, in the main, only negatively—by means of its polemic against
the completed and the self-completing “Absolute” of the Neo-
Hegelian Rationalists. What this polemic is we can best indicate by
quoting from Hegel himself a passage or a line of the reflection
against which it is seeking to enter an emphatic and a reasoned
protest, and then after this a passage or two from some of our Anglo-
Hegelians in the same connexion.
“The consummation,” says Hegel, in a familiar and often-quoted
passage, “of the Infinite aim (i.e. of the purpose of God as
omniscient and almighty) consists merely in removing the illusion
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which makes it seem unaccomplished.” Now although there is a
sense in which this great saying must for ever be maintained to
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contain an element of profound truth, the attitude of Pragmatism
in regard to it would be, firstly, that of a rooted objection to its
outspoken intellectualism. How can the chief work of the Almighty be
conceived to be merely that of getting rid somehow from our minds,
or from his, of our mental confusions? And then, secondly, an equally
rooted objection is taken to the implication that the individual human
being should allow himself to entertain, as possibly true, a view of
the general trend of things that renders any notion of his playing an
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appreciable part therein a theoretical and a practical absurdity.
This notion (or “conceit,” if you will) he can surrender only by ceasing
to think of his own consciousness of “effort” and of the part played by
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“effort” and “invention” in the entire animal and human world, and
also of his consciousness of duty and of the ideal in general. This
latter consciousness of itself bids him to realize certain “norms” or
regulative prescripts simply because they are consonant with that
higher will which is to him the very truth of his own nature. He
cannot, in other words, believe that he is consciously obliged to work
and to realize his higher nature for nothing. The accomplishment of
ends and of the right must, in other words, be rationally believed by
him to be part of the nature of things. It is this conviction, we feel
sure, that animates Pragmatism in the opposition it shares both with
common sense and with the radical thought of our time against the
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meaninglessness to Hegelianism, or to Absolutism, many of the
hopes and many of the convictions that we feel to be so necessary
and so real in the life of mankind generally.
And there are other lines of reflection among Neo-Hegelians
against which Pragmatism is equally determined to make a more or
less definite protest, in the interest, as before, of our practical and of
our moral activity. We may recall, to begin with, the memorable
words of Mr. Bradley, in his would-be refutation of the charge that the
ideals of Absolutism “to some people” fail to “satisfy our nature’s
demands.” “Am I,” he indignantly asks, “to understand that we are to
have all we want, and have it just as we want it?” adding (almost in
the next line) that he “understands,” of course, that the “views” of
Absolutism, or those of any other philosophy, are to be compared
“only with views” that aim at “theoretical consistency” and not with
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mere practical beliefs. Now, speaking for the moment for
Pragmatism, can it be truly philosophical to contemplate with
equanimity the idea of any such ultimate conflict as is implied in
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these words between the demands of the intellect and the
demands of emotion—to use the term most definitely expressive of a
personal, as distinct from a merely intellectual satisfaction?
Then again there is, for example, the dictum of Dr. McTaggart,
that there is “no reason to trust God’s goodness without a
demonstration which removes the matter from the sphere of
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faith.” May there not, we would ask, be a view of things according
to the truth of which the confidence of the dying Socrates in the
reasonableness and the goodness of God are at least as reasonable
as his confession, at the same time, of his ignorance of the precise,
or the particular, fate both of the just and of the unjust? And is not,
too, such a position as that expressed in these words of Dr.
McTaggart’s about a logically complete reason for believing in the
essential righteousness of things now ruled out of court by some of
the concessions of his brother rationalists to Pragmatism, to which
reference has already been made? It is so ruled out, for example,
even by Mr. Bradley’s condemnation as a “pernicious prejudice” of
the idea that “what is wanted for working purpose is the last
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theoretical certainty about things.”
 CHAPTER IV
PRAGMATISM AND HUMAN ACTIVITY

It requires now but a slight degree of penetration to see that beneath

this entire matter of an apparent opposition between our “theoretical”
and our “practical” satisfaction, and beneath much of the pragmatist
insistence upon the “consequences” of ideas and of systems of
thought, there is the great question of the simple fact of human
action and of its significance for philosophy. And it might truly be said
that the raising of this question is not merely another of the more or
less definitely marked features of Pragmatism, but in some respects
it is one outstanding characteristic.
For some reason or other, or for some strange combination of
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reasons, the phenomenon that we call “action” (the activity of
man as an agent) and the apparently simple facts of the reality and
the intelligibility of action have long been regarded as matters of
altogether secondary or subordinate importance by the rationalism of
philosophy and by the mechanical philosophy of science. This
Rationalism and this ostensibly certain and demonstrable
mechanical philosophy of science suppose that the one problem of
human thought is simply that of the nature of truth or of the nature of
reality (the reality of the “physical” world) as if either (or each) of
these things were an entity on its own account, an absolutely final
finding or consideration. That this has really been the case so far as
philosophy is concerned is proved by the fact even of the existence
of the many characteristic deliverances and concessions of
Rationalism in respect of Pragmatism to which reference has already
been made in the preceding chapter. And that it has also been the
case so far as science is concerned is proved by the existence of the
many dogmatic attempts of many natural philosophers from Holbach
to Haeckel to apply the “iron laws” of matter and motion to the reality
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of everything else under heaven, and of everything in the
heavens in spite of the frequent confessions of their own colleagues
with regard to the actual and the necessary limits and limitations of
science and of the scientific outlook.
Only slowly and gradually, as it were, has the consideration
come into the very forefront of our speculative horizon that there is
for man as a thinking being no rigid separation between theory and
practice, between intellect and volition, between action and thought,
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between fact and act, between truth and reality. There is clearly
volition or aim, for example, in the search after truth. And there is
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certainly purpose in the attention that is involved even in the
simplest piece of perception, the selection of what interests and
affects us out of the total field of vision or experience. And it is
equally certain that there is thought in action—so long, that is to say,
as action is regarded as action and not as impulse. Again, the man
who wills the truth submits himself to an imperative just as surely as
does the man who explicitly obeys the law of duty. It is thus
impossible, as it were, even in the so-called intellectual life, to
distinguish absolutely between theoretical and practical
considerations—“truth” meaning invariably the relations obtaining in
some “sphere,” or order, of fact which we separate off for some
purpose or other from the infinite whole of reality. Equally impossible
is it to distinguish absolutely between the theoretical and the
practical in the case of the highest theoretical activity, in the case,
say, of the “contemplation” that Aristotle talks of as the most
“godlike” activity of man. This very contemplation, as our Neo-
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Hegelian friends are always reminding us, is an activity that is just
as much a characteristic of man, as is his power of setting his limbs
in motion.
We have referred to the desire of the pragmatists to represent,
and to discover, a supposedly deeper or more comprehensive view
of human nature than that implicitly acted upon by Intellectualism—a
view that should provide, as they think, for the organic unity of our
active and our so-called reflective tendencies. This desire is surely
eminently typical of what we would like to think of as the rediscovery
by Pragmatism for philosophy, of the active, or the volitional, aspects
of the conscious life of man, and along with this important side of our
human nature, the reality also of the activities and the purposes that
are revealed in what we sometimes speak of as unconscious nature.
The world we know, it would hold, in the spirit and almost in the letter
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of Bergson, lives and grows by experiment, and by activities and
processes and adjustments. Pragmatism has doubtless, as we
pointed out, been prone to think of itself as the only philosophy that
can bake bread, that can speak to man in terms of the actual life of
effort and struggle that he seems called upon to live in the
environment in which he finds himself. And, as we have just been
insisting, the main ground of its hostility to Rationalism is the
apparent tendency of the latter to treat the various concepts and
hypotheses that have been devised to explain the world, and to
render it intelligible, as if they were themselves of more importance
than the real persons and the real happenings that constitute the
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world of our experience.
If it were at all desirable to recapitulate to any extent those
phenomena connected with Pragmatism that seem to indicate its
rediscovery of the fact of action, and of the fact of its meaning for
philosophy, as its one outstanding characteristic, we may point to
such considerations as the following: (1) The fact of its having
sought to advance from the stage of a mere “instrumentalist” view of
human thought to that of an outspoken “humanism” or a socialized
utilitarianism. (2) The fact of its seeking to leave us (as the outcome
of philosophy) with all our more important “beliefs,” with a general
“working” view of the world in which such things as religion and
ideals and enthusiasm are adequately recognized. Pragmatism is
really, as we have put it, more interested in belief than in knowledge,
the former being to it the characteristic, the conquering attitude of
man to the world in which he finds himself. (3) Its main object is to
establish a dynamical view of reality, as that which is “everywhere in
the making,” as that which signifies to every person firstly that aspect
of the life of things in which he is for the time being most vitally