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

AND MANAGEMENT, FIFTH EDITION ISBN: 978-0-323-63668-1
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies, and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website:
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
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or contributors for any injury and/or damage to persons or property as a matter of products liability,
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contained in the material herein.
Previous editions copyrighted 2017, 2012, 2005, 1999.
Library of Congress Control Number: 2020951843
Content Strategist: Humayra Khan

Senior Content Development Manager: Luke Held
Senior Content Development Specialist: Rae Robertson
Publishing Services Manager: Shereen Jameel
Project Manager: Manikandan Chandrasekaran
Cover Design and Design Direction: Ryan Cook
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedication
This book is dedicated to our families and to the

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

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

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

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

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

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

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

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

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

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

Sait Naderi, Edward C. Benzel
SUMMARY OF KEY POINTS

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

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

Gradually, the intellectual doldrums of the Dark Ages in
Europe evolved into the Renaissance. Academic centers were
established in Europe, as well as centers for the translation of
documents, similar to centers established in Islamic regions.
Thus the classics from the antique age were translated into
Latin from Arabic, making their scientific information avail-
able to the scholars and physicians of the Renaissance. During
this time, the Western world spawned disciplines, including
art, medicine, physics, and mathematics.
The works of Leonardo da Vinci (1452–1519 ce) are of
importance in this regard. Da Vinci worked on the philosophy
of mechanics and on anatomy in De Figura Humana. He
described spine anatomy, the number of vertebrae, and
the joints in detail. By studying anatomy in the context of
Fig. 1.1. Avicenna. mechanics, da Vinci gained some insight into biomechanics.
He considered the importance of the muscles for stability
in the cervical spine. However, his work was unpublished
Oribasius (325–400 ce), another physician of the antique for centuries, and his brilliant daydreaming had a limited
period, added a bar to the Hippocratic reduction device and scientific influence on biomechanics.16,17
used it to treat both spinal trauma and spinal deformity.8,9 Andreas Vesalius (1514–1564 ce), an anatomist and
One of the most important figures dealing with spinal physician, wrote his famous anatomy book, De Humani
disorders during the end of this period was Paulus of Aegina Corporis Fabrica Liberi Septum, which changed several
(625–690 ce). He collected what was known from the previous doctrines described by Galen. Actually, it took several
1000 years in a seven-volume encyclopedia. Paulus of Aegina centuries for the world to accept that Galen had made errors
not only used the Hippocratic bed, but also worked with a that Vesalius corrected. Because he described and defined
red-hot iron. He is credited with performing the first known modern anatomy, he is commonly accepted as the “father of
laminectomy. This was performed for a case of spinal fracture anatomy.” He described the spine, intervertebral discs, and
resulting in spinal cord compression. He emphasized the use intervertebral foramina. His biomechanical point of view
of orthoses in spinal trauma cases.6,10 regarding the flexion extension of the head was similar to
that of Avicenna.18
The early anatomic studies and observations were followed
MEDIEVAL PERIOD AND SPINE SURGERY by biomechanical advancements. Prominent among the
The studies and reports of Paulus of Aegina are the most contributors to those advancements was Giovanni Alfonso
important sources of information regarding this period of Borelli (1608–1679 ce), who described the biomechanical
medicine.11 This age was followed by the Dark Ages (ca. 500– aspects of living tissue. He is the founder of the “iatrophysics”
1000 ce) in Europe. Although Western medicine showed no concept—a term that subsequently became known as
progress during the Dark Ages, the Eastern world developed biomechanics. He is accepted as the “father of spinal
the science. The early Islamic civilizations realized the impor- biomechanics.” His book, De Motu Animalium, describes the
tance of science and scientific investigation. The most impor- movements of animals. He wrote that the intervertebral disc
tant books of the antique age were translated into Arabic and is a viscoelastic material that carries loads; he observed that
Persian. Therefore using the Western doctrines, the Islamic muscles could not bear the loads alone, so he concluded that
civilizations discovered new information and were able to the intervertebral discs had a function in load-bearing. He
contribute further. In terms of spine medicine, several impor- was the first scientist to describe the human weight center
tant contributors, including Avicenna and Abulcasis, added to (center of gravity).19,20
this movement. The studies and accomplishments of the Renaissance
Avicenna (981–1037 ce), a famous physician from present- period were not limited to the aforementioned. Many scientists
day Uzbekistan, worked in all areas of medicine (Fig. 1.1). contributed to the body of the literature in this period. The
His famous book, the Canon of Medicine, was a seminal advancements from this period resulted in the formation of
textbook until the 17th century in Europe. He described the early modern surgery, beginning in the 19th century.
biomechanics-related anatomy of the spine, as well as flexion,
extension, lateral bending, and axial rotation of the spine.12
Avicenna also used a traction system similar to the system
EARLY MODERN PERIOD AND SPINE SURGERY
described by Hippocrates.13 Many developments and inventions contributed to the prog-
Abulcasis (936–1013 ce), a famous Arabian surgeon of the ress and evolution of spine surgery (Box 1.1). Each of these
11th century, wrote a surgery treatise, “At-Tasnif.” He described steps had an important impact on the improvement of spine
several surgical disorders, including low back pain, sciatica, health care and inspired other developments. Advances in
scoliosis, and spinal trauma. He recommended the use of nursing care, anesthesiology, and asepsis and antisepsis, as
chemical or thermal cauterization for several spinal disorders. well as the development of antibiotics, increased the braveness
He also developed a device to reduce the dislocated spine.14 of surgeons to do surgery. The improvement of spine imaging
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The Project Gutenberg eBook of In Korea with
Marquis Ito
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Title: In Korea with Marquis Ito
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1908
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*** START OF THE PROJECT GUTENBERG EBOOK IN KOREA

WITH MARQUIS ITO ***
IN KOREA
WITH
MARQUIS ITO
Marquis Ito
IN KOREA
WITH
MARQUIS ITO
Part I
A NARRATIVE OF PERSONAL EXPERIENCES
Part II
A CRITICAL AND HISTORICAL INQUIRY
BY
GEORGE TRUMBULL LADD, LL.D.
CHARLES SCRIBNER’S SONS

NEW YORK: 1908
Copyright, 1908, by
CHARLES SCRIBNER’S SONS
Published February, 1908
TO THE
DEAR COMPANION
OF ITS EXPERIENCES AND THE
READY SCRIBE OF MUCH OF ITS MANUSCRIPT
THIS BOOK IS GRATEFULLY
AND AFFECTIONATELY
DEDICATED
PREFACE
The contents and purposes of this volume may be conveniently
classified under three heads; for here are statements of fact,
expressions of opinion, and certain ventures into the realm of
conjecture. The statements of fact are, almost without exception,
made on grounds of personal observation, or on the authority of the
most competent and trustworthy first-hand witnesses. For the earlier
periods of the history of the relations, friendly or hostile, between
Japan and Korea, these authorities are indeed no longer living, and
they cannot be subjected to cross-questioning. But the choice
between the truth they told and the mistakes and falsehoods of a
contradictory character is in most cases not difficult to make. For
events of the present generation the reader will find the statements
of the witnesses quoted, and of the documents cited, to be in general
unimpeachable. I believe, then, that what is claimed to be truth of
fact in this book is as nearly exact and worthy of implicit confidence
as it is ordinarily given to human beings to be in matters pertaining to
the history of human affairs.
In expressing my own opinions as to the truth or untruth of certain
contentions, and as to the merit or demerit of certain transactions, I
have uniformly tried to base these opinions upon the fullest
obtainable knowledge of the facts. In some cases the judgments at
which I have been compelled to arrive contradict those which have
been and still are widely current; in some cases they can scarcely
fail to be interpreted as an impeachment of other writers who have
had either a narrator’s interest only in the same events or even a
more substantial concernment. I have no wish to deny the apologetic
character of this book. But at every point the charge of being
swerved from the truth by prejudice may be met with these replies:
First, very unusual opportunities were afforded the author for
ascertaining the truth; and, second, in almost every case where the
evidence brought forward seems insufficient there is much more of
the same sort of evidence already in his possession, and still more to
be had for the asking. But in these days one must limit the size of
such undertakings. Few readers wish to wade through a long stretch
of shoals in order to reach the firm ground of historical verity.
As to the ventures at conjecture which are sparingly put forth, let
them be rated at their seeming worth, after the facts have been
carefully studied and the opinions weighed, which have called out
these ventures. They are confessedly only entitled to a claim for a
certain degree, higher or lower, of probability. The status of all things
in the Far East—and for the matter of that, all over the civilized world
—is just now so unstable and loaded with uncertainties that no
human insight can penetrate to the centre of the forces at work, and
no human foresight can look far into the future.
The division of the book into two parts may seem at first sight to
injure its unity. Such a division has for its result, as a matter of
course, a somewhat abrupt change in the character of the material
employed and in the style of its handling. The First Part is a narrative
of personal observations and experiences. It gives the results,
however, of a serious study of a complicated situation; and it
pronounces more or less confident judgments upon a number of
subordinate questions involved in the general problem of
establishing satisfactory relations between two nations which are
inseparably bound together—physically, socially, politically—whether
for the weal or for the woe of both. In the Second Part the attempt is
made to submit these judgments to the tests of history. But what is
history? Of no other civilized country than Korea is the truth of the
cynical saying more obvious that much of what has been written as
history is lies, and that most of real history is unwritten. All of which
has tended to make the writer duly appreciate the unspeakable
advantage of having access to authentic information which, for
diplomatic and other sufficient reasons, has not hitherto been made
public.
The underlying literary and logical unity which binds together the
two seemingly diverse Parts of the one book is made clear by stating
in general terms the problem upon which it aims to throw light. This
problem concerns the relations to be established between Japan and
Korea—a question which has for centuries been proposed in various
imperative and even affective ways to both these nations. It is also a
question which has several times disturbed greatly the entire Orient,
and the recent phases of which have come near to upsetting the
expectations and more deliberate plans of the entire civilized world.
To lay the foundations, under greatly and suddenly changed
conditions, of a satisfactory and permanent peace, one of the
greatest statesmen of the Orient is giving—with all his mind and
heart—the later years of his eventful life. I hope that this book may
make its readers know somewhat better what the problem has been
and is; and what Prince Ito, as Japanese Resident-General in Korea,
is trying to accomplish for its solution.
It remains for the Preface only to acknowledge the author’s
obligations. These are so special to one person—namely, Mr. D. W.
Stevens, who has been for some time official “Adviser to the Korean
Council of State and Counsellor to the Resident-General”—that
without his generous and painstaking assistance in varied ways the
Second Part of the book could never have appeared in its present
form. It is hoped that this general acknowledgment will serve to
cover many cases where Mr. Stevens’ name is not especially
mentioned in connection with the text. Grateful acknowledgment is
also made to Mr. Furuya, the private secretary of the Resident-
General, for his painstaking translation from the original Japanese or
Chinese official documents; to Mr. M. Zumoto, editor of the Seoul
Press, for varied information on many subjects; and to Dr. George
Heber Jones for facts and suggestions imparted in conversation and
embodied in writings of his. My obligations to the Resident-General
himself, for the perfectly untrammelled and unprejudiced opportunity,
with its complete freedom to ask all manner of questions, which his
invitation afforded, are, I trust, sufficiently emphasized in the title of
the book. Other debts to writers upon any part of the field are
acknowledged in their proper connections.
George Trumbull Ladd.
Hayama, Japan, September, 1907.
CONTENTS
CONTENTS OF PART I
CHAPTER PAGE
I. The Invitation 1
II. First Glimpses of Korea 15
III. Life in Seoul 37
IV. Life in Seoul (Continued) 65
V. The Visit To Pyeng-yang 90
VI. Chemulpo and Other Places 112
VII. The Departure 139
VIII. Personal Reminiscences and Impressions 148
CONTENTS OF PART II
IX. The Problem: Historical 179
X. The Problem: Historical (Continued) 222
XI. The Compact 252
XII. Rulers and People 280
XIII. Resources and Finance 300
XIV. Education and the Public Justice 326
XV. Foreigners and Foreign Relations 352
XVI. Wrongs: Real and Fancied 367
XVII. Missions and Missionaries 388
XVIII. July, 1907, and After 414
XIX. The Solution of the Problem 444
ILLUSTRATIONS
Portrait of Marquis Ito Frontispiece
TO FACE PAGE
Bird’s-Eye View of the Capital City 22
Going to the Lecture at Independence Hall 52
Water-gate at Pyeng-yang 100
West Gate or “Gate of Generous
Righteousness” 132
Peony Point at Pyeng-yang 184
The Tong-Kwan Tai-Kwol Palace 206
The Ex-Emperor and Present Emperor 284
The Hall of Congratulations 306
Street Scene in Seoul 330
The Stone-Turtle Monument 384
Funeral Procession in Seoul 408
PART I
A NARRATIVE OF PERSONAL EXPERIENCES
CHAPTER I
THE INVITATION
It was in early August of 1906 that I left New Haven for a third visit
to Japan. Travelling by the way of the Great Lakes through Duluth
and St. Paul, after a stay of two weeks in Seattle, we took the
Japanese ship Aki Maru for Yokohama, where we arrived just before
the port was closed for the night of September 20. Since this ship
was making its first trip after being released from transport service in
conveying the Japanese troops home from Manchuria, and was
manned by officers who had personal experiences of the war to
narrate, the voyage was one of uncommon interest. Captain Yagi
had been in command of the transport ship Kinshu Maru when it was
sunk by the Russians, off the northeastern coast of Korea. He had
then been carried to Vladivostok, and subsequently to Russia, where
he remained in prison until the end of the war. Among the various
narratives to which I listened with interest were the two following;
they are repeated here because they illustrate the code of honor
whose spirit so generally pervaded the army and navy of Japan
during their contest with their formidable enemy. It is in reliance on
the triumph of this code that those who know the nation best are
hopeful of its ability to overcome the difficulties which are being
encountered in the effort to establish a condition favorable to safety,
peace, and prosperity by a Japanese Protectorate over Korea.
At Vladivostok the American Consul pressed upon Captain Yagi a
sum of money sufficient to provide a more suitable supply of food
during his journey by rail to Russia. This kindly offer was respectfully
declined on the sentimental ground that, as an officer of Japan, he
could not honorably receive from a stranger a loan which it was
altogether likely he would never be able to repay. But when still
further urged, although he continued to decline the money, he
begged only the Consul’s card, “lest he might himself forget the
name or die,” and so his Government would be unable to
acknowledge the kindness shown to one of its officers. The card was
given, sent to Tokyo, and—as the Captain supposed—the Consul
was “thanked officially.” The first officer, an Englishman, who had
been in the service of Japan on the Aki Maru, while it was used for
transporting troops to Manchuria and prisoners on its return, told this
equally significant story. His ship had brought to Japan as prisoner
the Russian officer second in command at the battle of Nan-san.
Having been wounded in the foot, the Russian was, after his capture,
carried for a long distance by Japanese soldiers, to whom, when
they reached the hospital tent, he offered a $20 gold-piece. But they
all refused to receive money from a wounded foe. “If it had been
Russian soldiers,” said this officer of his own countrymen, “they
would not only have taken this money but would have gone through
my pockets besides.”
Before leaving home only two official invitations had been
received, namely, to lecture on Education before the teachers in the
Tokyo branch of the Imperial Educational Society; and to give a
course in the Imperial University of Kyoto, on a topic which it was
afterward decided should be the “Philosophy of Religion.” This
university was to open in the following autumn a Department of
Philosophy (such a forward movement having been delayed by the
war with Russia). Almost immediately on our arrival, a multitude of
requests for courses of lectures and public addresses came to the
committee in charge of the arrangements, with the result that the six
months from October 1, 1906, to April 1, 1907, were crowded full of
interesting and enjoyable work. In the intervals of work, however,
there was opportunity left for much valuable social intercourse and
for meeting with men like Togo, Oyama, Noghi, and others in military
and business, as well as educational circles, whose names and
deeds are well known all over the civilized world. But it is not the
narrative of these six months which is before us at the present time,
although doubtless they had a somewhat important influence in
securing the opportunity and providing the preparation for the
subsequent visit to Korea.
The thought of seeing something of the “Hermit Kingdom” (a title,
by the way, which is no longer appropriate) had been in our minds
before leaving America, only as a somewhat remote possibility. Not
long after our arrival in Japan the hint was several times given by an
intimate friend, who is also in the confidence of Marquis Ito, that the
latter intended, on his return in mid-winter from Seoul, to invite us to
be his guests in his Korean residence. It was not, however, until the
afternoon of December 5 that the invitation was first received. This
was at the garden-party given by Marquis Nabeshima on his sixty-
first birthday. It should be explained that every Japanese is born
under one of the twelve signs—corresponding to our signs of the
Zodiac. When five of these periods have been completed the total of
sixty years corresponds with the end of six periods of ten years each
—a reckoning which is, I believe, of Chinese origin. The fortunate
man, therefore, may be said to begin life over again; and presents
such as are ordinarily appropriate only to childhood are entirely in
order on such a festal occasion. While walking in the beautiful
garden, which is of Japanese style but much modified by Italian
ideals, the private secretary of Marquis Ito, Mr. Furuya, came to us
and announced that his chief, who had recently returned from Seoul
to Japan, was near and wished to see me. After an exchange of
friendly greetings almost immediately the Marquis said: “I am
expecting to see you in my own land, which is now Korea”; and when
I jestingly asked, “But is it safe to be in Korea?” (implying some fear
of a Russian invasion under his protectorate) he shook his fist
playfully in the air and answered: “But I will protect you.” To this he
added, pointing to his sword: “You see, I am half-military now.” The
significance of the last remark will be the better understood when it is
remembered that from the days of his young manhood to the present
hour, Ito has always stood for the peaceful policy and the cultivation
of friendly relations between Japan and all the rest of the world. For
this reason he has never been the favorite of the military party; and
he is to-day opposed in his administration of Korean affairs by those
who would apply to them the mailed hand of punishment and
suppression rather than hold out the friendly but firm hand of
guidance and help.
Even after this interview the real purpose of the invitation to visit
Korea was not evident. A week later, however, it was disclosed by a
visit from Mr. Yamada of the Japan Times, who came from Marquis
Ito to present his request more fully and to arrange for a subsequent
extended conference upon the subject. I was then informed, in a
general way, how it was thought by the Resident-General I might be
of help to him and to Japan in solving the difficult problem of
furthering for the Koreans themselves the benefits which the existing
relations of the two countries made it desirable for both to secure.
Complaints of various sorts were constantly being made, not only
against individual Japanese, but also against the Japanese
administration, as unjust and oppressive to the Koreans, and as
selfish and exclusive toward other foreigners than its own
countrymen. Especially had such complaints of late been propagated
by American missionaries, either directly by letters and newspaper
articles, or more indirectly by tales told to travellers who, since they
were only passing a few days in Korea, had neither desire nor
opportunity to investigate their accuracy. In this way, exaggerations
and falsehoods were spread abroad as freely as one-sided or half-
truths. In the office of Resident-General the Marquis greatly desired
to be absolutely just and fair, and to prevent the mistakes, so harmful
both to Korea and to Japan, which followed the Japanese occupation
of Korea at the close of the Chino-Japan war. But it was difficult, and
in most cases impossible, for him even to find out what the
complaints were; they came to the public ear in America and
England before he was able to get any indication of their existence
even. And when his attention was called to them in this roundabout
fashion, further difficulties, almost insuperable, intervened between
him and the authors of these complaints; for in most cases it turned
out that the foreign plaintiffs had no first-hand information regarding
the truth of the Korean stories. They would not themselves take the
pains to investigate the complaints, much less would they go to the
trouble to bring the attention of the Resident-General to the matters
complained of in order that he might use his magisterial authority to
remedy them. In respect to these, and certain other difficulties,
Marquis Ito thought that I might assist his administration if I would
spend some time upon the ground as his guest.
The nature of this invitation put upon me the responsibility of
answering two questions which were by no means altogether easy of
solution; and on which it was, from their very nature, impossible to
get much trustworthy advice. The first of these concerned my own
fitness for so delicate and difficult but altogether unaccustomed
work. The second raised the doubt whether I could in this way be
more useful to Japan and to humanity than by carrying out the
original plan of spending the spring months lecturing in Kiushu. After
consulting with the few friends to whom I could properly mention the
subject, and reflecting that the judgment of His Imperial Majesty, with
whom Marquis Ito would doubtless confer, as well as of the
Resident-General himself, might fairly be considered conclusive, I
accepted the invitation; but it was with mingled feelings of pleasure
and of somewhat painful hesitation as to how I should be able to
succeed.
The illness of Marquis Ito which, though not serious, compelled
him to retire from the exciting life of the capital city to the seaside,
and then to the hills, prevented my meeting him before I left Tokyo
for Kyoto to fulfil my engagements in the latter city. But, by
correspondence with a friend, I was kept informed of the Marquis’
plans for his return to Korea, and thus could govern my
engagements so as to be in the vicinity of some point on his route
thither, at which the meeting with him might take place.
The expected conference followed immediately after our return
from one of the most delightful of the many gratifying experiences
which came to us during our year in Japan. We had taken a trip to
the village of Hiro Mura, where formerly lived Hamaguchi Goryo, the
benevolent patron of his village, whose act of self-sacrifice in burning
his rice straw in order to guide the bewildered villagers to a place of
safety when they were being overwhelmed by a tidal wave in the
darkness of midnight, has been made the theme of one of Lafcadio
Hearn’s interesting tales. Mr. Hearn, it appears, had never visited the
locality; and, indeed, we were assured that we were the first
foreigners who had ever been seen in the village streets. A former
pupil of mine is at the head of a flourishing school patronized by the
Hamaguchi family; and having accepted his invitation, in the name of
the entire region, to visit them and speak to the school and to the
teachers of the Prefecture, the cordial greeting, hospitable
entertainment, and the surpassingly beautiful scenery, afforded a
rich reward for the three or four days of time required. For, as to the
scenery, not the drive around the Bay of Naples or along the

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BENZEL’S SPINE SURGERY: TECHNIQUES, COMPLICATION AVOIDANCE,

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Sigurd Berven joined us as an editor for this

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1 History of Spine Surgery

SUMMARY OF KEY POINTS

Serefeddin Sabuncuoglu (1385–1468 ce), a Turkish

RENAISSANCE AND SPINE SURGERY

Title: In Korea with Marquis Ito

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