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

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

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

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

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Publisher (other than as may be noted herein).

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

List of Contributors

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

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

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

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

v
vi List of Contributors

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

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

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

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

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

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

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

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

Yoshihiro Katsuura, MD Jason I. Liounakos, MD

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

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

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

Ahmad Nassr, MD Frank M. Phillips, MD

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

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

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

Zach Pennington, BS Mohamed Saleh, MD

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

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

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

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

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

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

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

Peter Shorten, MD Chun-Po Yen, MD

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

this book and keep it handy for review when a challenging

clinical situation presents itself.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1
2 C H AP T E R 1 Anatomy and Physiology/Biology of Bone
based on their morphological characteristics (Fig. 1.1). Type I
includes a dysplastic transverse process, either unilateral (Ia)
or bilateral (Ib), presenting as triangular in shape, and mea-
suring at least 19 mm in width. Type II exhibits incom-
plete lumbarization/sacralization, either unilateral (IIa)
(Fig. 1.2) or bilateral (IIb), with a large transverse process
that follows the contour of the sacral ala. These are recog-
nized as incomplete by the appearance of a diarthrodial joint
between the transverse process and the sacrum. Type II is
• Fig. 1.1 Castellvi classification system: Ia, Ib, IIa, IIb, IIIa, IIIb, IV.
most consistently associated with lower back and buttock
pain. Type III describes complete lumbarization/sacraliza-
tion, either unilateral (IIIa) or bilateral (IIIb), in which the
transverse process has made complete fusion to the sacrum.
Type IV is mixed, with these patients exhibiting characteris-
tics of type II on one side and type III on the other. This sys-
tem is useful in classifying the morphology of the transitional
segments, but it does not provide enough accurate informa-
tion for numbering the involved segments.4

• Fig. 1.2 Left Castellvi type IIa transitional vertebrae.
Lumbar Spine Alignment
Lumbar spine alignment is dependent upon the pelvic inci-
dence (PI). The PI is a parameter that assesses the depth of
the femoral head to the midpoint of the sacral endplate. First
described in 1992 by Madam Duval-Beaupère,5 the concept
of PI has been used extensively since that time. We have
learned over the decades that PI drives the lumbar lordosis
(LL).6 The LL should be no more than 9 degrees greater or
less than the PI.6,7 Perhaps this is slightly more complex, and
patients with low PI should probably have a LL of PI plus 9
degrees and those with a high PI should probably have a LL
of PI minus 9 degrees. Also of importance is the distribution
of lordosis along the lumbar vertebrae.8 This is called the LL
distribution index, which indicates that approximately two-
thirds of the lordosis should be located from L4 to S1.9 This
has been further developed by Roussouly et al.,9 who looked
at the overall sagittal alignment of the lumbar spine, not only
focusing on the LL and the PI but also considering the sacral
slope. They highlighted the importance of the sacral slope
and lower lumbar curve in determining the global lordosis
and sagittal alignment of the spine. These lumbar angles of
interest can be seen in Fig. 1.3.
Load Transmission
Under normal physiological conditions, axial spine load
transmission should be homogenous across intervertebral
segments. It has been shown, with a high degree of specific-
ity, that some forms of low back pain correlate with abnor-
mal load transmission across vertebral bodies.10 During
spinal fusion, the primary goal is to provide a solid and uni-
form bony mass across a segment that allows for stable load
transmission. By the same token, failure to restore physiolog-
ical stress patterns of load transmission across intervertebral
segments during spine fusion has been hypothesized as
explaining why some patients remain symptomatic despite
evident fusion.11
Balanced load transmission is important to ensure con-
struct stability and avoid graft subsidence. Closkey’s12 work
on load transmission in fusions showed that approximately
30% cross-sectional area during interbody fusion is needed
CHAPTER 1 Anatomy and Physiology/Biology of Bone 3
• Fig. 1.3 Lumbar angles of interest.
to handle adequate load transmission across an intervertebral
space. Below this number the pressure point on the caudal
vertebra is too high and the graft can subside through the
superior aspect of the vertebra, leading to motion and poor
stability, and is associated with a higher risk of pseudarthro-
sis.13 Closkey’s findings are most relevant in anterior fusions
where graft material is under direct axial load compression,
and adequate cross-sectional area facilitates load transmission
and solid fusion. This has not been well recognized by many
surgeons and as a result inadequate spot-welds often exist
that are incapable of transmitting the load. Load transmis-
sion differs in posterior fusions; loads are transmitted by can-
tilever forces, which require more robust bone cross-
sectional area to support a similar load.
Fusion Types and Area
Not uncommonly, treatment for spine pathology requires a
fusion. Multiple approaches have been developed over time
that best tailor the patient’s needs. These can be roughly
divided into anterior and posterior approaches, each of them
with their particular advantages and disadvantages. Spine
surgeons use and combine techniques as necessary to best
treat the pathology at hand.
Anteriorly Based Fusions and Approaches
The three ways to approach the spine anteriorly are direct
anterior, oblique, and lateral. They all provide excellent
access to the disc space and end-plate preparation, and, if
necessary, allow placement of implants with large footprints
that minimize the risk of subsidence.14 More importantly,
we know from biomechanical studies that the anterior and
middle columns carry about 80% of spinal loads.15 When
taking this into consideration along with Wolff’s law of bone
4 C H AP T E R 1 Anatomy and Physiology/Biology of Bone
remodeling in response to applied stress, a fusion mass has
better potential for healing if placed anteriorly, where it is
under direct compression.16 Not only is an anterior fusion
under direct compression, but the anterior and middle col-
umn provide 90% of osseous contact between vertebrae, as
well as a more vascular bed.16 18 Distraction with a large
interbody implant provides better neuroforaminal decom-
pression.16 Additionally, it can be very powerful in deformity
correction in the coronal and sagittal planes. These
approaches are not suitable for patients that have central
canal stenosis, bony lateral recess stenosis, or high-grade
spondylosis.19
Direct anterior: In the direct anterior approach, the patient is
positioned supine and this is followed by a median,
paramedian, or mini-Pfannenstiel incision. This provides a
retroperitoneal corridor with direct access to the disc space.
Presurgical advanced imaging is necessary, as it will
determine the limitations imposed by visceral structures.
Most often, the direct anterior approach is used to access
the L4 L5 and L5 S1 disc spaces, with higher levels
limited by the degree of retraction on the vascular and renal
structures. There are drawbacks associated with this
approach such need for an access surgeon, risk of vascular
injury, and the possibility of retrograde ejaculation
secondary to injury to the hypogastric plexus.20 Previous
abdominal surgeries are not an absolute contraindication to
this approach, but should be taken into consideration as
they might make the exposure more difficult. Placement of
a ureteral stent can aid in the approach, and with a skilled
approach, revision anterior surgery can be done.21
Oblique: For the oblique approach to the anterior spine, the
patient is placed in a lateral decubitus position. Along the
flank, the surgical corridor is between the retroperitoneum
and the psoas muscle. This approach does not require
retraction of vascular structures or violation of the psoas
muscle. As such, the levels accessible to this approach are
from L1 to S1. Although vascular structures are not
manipulated directly, they are still at risk given their
proximity with the surgical field. The risk of retrograde
ejaculation is still present. Because the approach involves
dissection through the abdominal musculature, patients
can develop hernias or pseudohernias secondary to
denervation of the flank musculature.18 Furthermore, the
approach requires experience to adequately assess its
obliquity without inadvertent entry into the canal or
violation of the lateral annulus. Clinical experience suggests
that this is more technically challenging than the standard
straight anterior approach and to date no current data is
available on revision oblique approaches.
Lateral: The patient is placed in the lateral decubitus position.
For this approach, the surgical corridor is retroperitoneal
but transpsoas. The disc spaces accessible through this
approach are T12 L1 to L4 L5. Preoperative images
need to be obtained to determine if the planned region of
the lumbar spine can be accessed through this corridor,
with particular attention to the relationship between the
top of the iliac crest and the level to be accessed. Care must
be taken at the L4 L5 level to avoid injuring the femoral
nerve. This approach allows bilateral access to the lumbar
spine, which is advantageous for coronal plane deformity
correction, as it is better managed from the convex side.
The lumbar plexus is at risk during a transpsoas approach,
its position drifting more anteriorly with more-caudal
levels.19 About 5% of patients complain of sensorimotor
disturbances post surgically.19 Because the approach is to
the lateral abdominal musculature, the possibility of hernia
and pseudohernia are also present, but are minimized with
careful dissection to prevent denervation. This approach
allows resection of the disc transversely all the way across,
but the risks of this are contralateral vessel or visceral injury.
Posteriorly Based Fusions and Approaches
Posterior: For this approach, the patient is positioned prone,
which is followed by a midline approach. The fusion
procedure involves decortication of the lamina, with or
without the spinous processes, and typically involves the
facet joints. This fusion mass is in the least advantageous
position biomechanically, as it must support all the loading
via a cantilever loading technique, thus experiencing minimal
compression compared with its anterior counterpart.22
Even with a solid posterior fusion, there have been
instances of persistent anterior column pain demonstrated
by discography and later confirmed by clinical improve-
ment after anterior interbody fusion.23 Although this
fusion has long been the workhorse of the available surgical
techniques, it is not without its problems. Revision surgery
through a posterior approach is common. The main
increased risks from this are bleeding of the scar bed,
distorted landmarks depending on the prior intervention,
and possible incidental durotomy in patients with significant
laminectomy defects.
Posterolateral: The posterolateral fusion is the more commonly
used posterior approach and involves not only the lamina
and facet, but also the transverse processes. This puts the
axis of loading closer to the fusion mass and in a more
biomechanically advantageous position. A drawback of this
technique is that it requires more stripping of the muscles to
gain access to the grafting area. A variation of this is the
paraspinal or Wiltse-type approach. This variation provides
similar access with less muscle disruption24 and for many
years was a mainstay for fusion in young adults with
spondylolysis. It has also been used in a minimally invasive
fashion as a way of accessing the paraspinal or Wiltse plane.
However, more typically, the minimally invasive approaches
have involved a transforaminal lumbar interbody fusion.
Interbody Fusion From a Posterior Approach
A number of techniques over the years have used this
method of obtaining interbody fusion.25 It began with the
posterior lumbar interbody fusion, which involves significant
lamina resection and side-to-side dural mobilization to access

the disc space and place bone graft into this area. The next
advancement was the so-called transforaminal lumbar inter-
body fusion, which was originally described as a single-sided
approach that allowed cleaning out of approximately two-
thirds of the disc space and obtained an interbody fusion
with bone graft and/or structural interbody support.26,27
These techniques use a working window in which the thecal
sac and traversing nerve root form the medial border and the
exiting nerve root of the proximal vertebra forms the lateral
border. This technique has subsequently been a workhorse
approach when done bilaterally and combined with Smith-
Peterson osteotomy for both extensive disc clean-out and
bone grafting structural interbody support, which allow sig-
nificant sagittal plane realignment.28
Basic Bone Biology
Cortical and cancellous bone are found in all types of osseous
tissue. Cortical bone is densely organized, which provides
maximum strength and the ability to bear heavy loads, in addi-
tion to being resistant to bending and torsion. Cancellous
bone is found where forces can be applied at variable angles,
specifically at the epiphysis, flat bones, and vertebral bodies.
Bone is an exceptionally well-organized tissue that undergoes
constant remodeling to maintain homeostasis. This dynamic
balance exists between the osteoclast and the osteoblast.29
Osteoclasts
Osteoclasts are specialized cells derived from the monocyte-
macrophage lineage; these cells degrade bone to allow for
normal and pathological bone remodeling.30 Differentiation
into an osteoclast requires receptor activator of nuclear factor
kappa-B ligand (RANK Ligand) although its function is regu-
lated by many other cytokines.31 Upon recruitment to areas
of bone targeted for resorption, precursor cells will fuse with
each other to form multinucleated cells. These cells have pow-
erful acid-producing and enzyme-secreting machinery to
resorb calcified bone and degrade the extracellular matrix.30
Bone mass and quality have been shown to be directly
related to osteoclast activity, with all acquired forms of osteo-
porosis resulting from increased activity of these cells relative
to osteoblasts.31 Bisphosphonates have been developed to mit-
igate osteoclast-mediated bone loss.32 Another therapy aimed
at slowing bone resorption by osteoclasts is calcitonin.
Normally, this peptide is closely linked to bone metabolism
and has been shown to reduce vertebral osteoporotic fractures
in postmenopausal women when administered on a daily
basis.33 Besides their role in bone health, osteoclasts have been
shown to be involved in osteoblast differentiation, mobiliza-
tion of hematopoietic cells from the bone marrow into the
bloodstream, and immune responses.30
Osteoblasts
Osteoblasts are mesenchymal cells involved in depositing
and maintaining bone architecture.34 They do so by
CHAPTER 1 Anatomy and Physiology/Biology of Bone 5
producing organic components, such as bone and collagen,
and the inorganic components of the calcium/phosphate
matrix. Additionally, they have an important role in main-
taining bone health by regulating osteoclast function
through the production of a decoy receptor for RANKL, the
osteoprotegerin molecule.35 Parathyroid hormone (PTH) is
closely linked to calcium metabolism and has been shown to
have anabolic effects on bone physiology. When adminis-
tered at low and intermittent doses, activation of the PTH
pathway, as shown with teriparatide,36 can act through
osteoblasts to improve bone mass and architecture,37 provid-
ing physicians with another tool to combat the deleterious
effects of osteoporosis. As bone matures, osteoblasts can
become trapped in the matrix they deposit, turning into
residing osteocytes. These osteocytes act as mechanorecep-
tors to orchestrate the appropriate balance between osteo-
blasts and osteoclasts as they function to maintain adequate
bone homeostasis.29
Wolff’s Law
Wolff’s law states that bone will remodel in respond to the
stresses applied to it.38 In this way, bone that is exposed to
higher loads will respond by increasing its mass to better
resist external pressures. The opposite is also true, where
bone that experiences decreased loads will adapt by reducing
its mass, such as in long-term bedridden patients.39 This
concept has important implications in spine fusion, where
increased loading can be helpful to promote bone formation
and improve the likelihood of arthrodesis. From previous
studies we know that 70% to 80% of axial loads through the
spine pass anteriorly through the vertebral bodies.40 Here
interbody fusion devices seem to have their best utility; the
compressive load that is applied across the device provides
optimal conditions for bone formation.19
Bone Grafting Area and Volume Available
in Different Approaches
A variety of bone graft materials are available and used in
conjunction with instrumentation. An iliac crest autograft is
the gold standard; however, donor site morbidity occurs,
especially if structural autograft is used. Other materials are
allogeneic graft, demineralized bone matrix bone graft exten-
ders, and true bone graft substitutes.41 Of the graft substi-
tutes, the most studied is rhBMP-2 because it has been
shown to be as effective in fusion rates and clinical outcomes
as iliac crest bone graft.42
Posterior midline and facet (Fig. 1.4A, B): Although Hibbs43
developed the posterior midline technique, it was Moe44
who modified it and began to insert blocks of graft material
into cut-out articular facets for the purpose of fusion. Today,
this technique may be done with or without posterior
decompression (laminectomy) and most commonly uses
instrumentation. The areas of the vertebrae that can be
used in this fusion are the lamina (if not removed in
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Muscular balance, lack of, 450.
rheumatism in cattle, 544.
rheumatism in the dog, 548.
rheumatism in horse, 540.
sense tract, 21.
Musty fodder in encephalitis, 97.
Mydriatics, 331.
Myelitis, 154.
chronic, 165.
in the dog, 161.
Myosin coagulated under heat, 41.
Myxoma of the brain, 131.

Nebula, 384.
Necrotic callosities, 455.
Neoplasms of brain, 128.
of the conjunctiva, 375.
Nephritis, 219.
acute, 220.
chronic, 234.
interstitial, 225.
purulent, 228.
suppurative, 225.
treatment, 225.
tubular, 225.
Nerve, optic, inflammation of the, 440.
optic, paralysis of the, 442.
Nerves, atrophy of, 189.
Nerve trunk, pressure on, 9.
Nervous centres, respiratory, 14.
disease, diagnosis of, 2.
disease, microbes in, 2.
disease, symptoms of, 2.
 disorders, diagnosis of, 12.
functional, 13.
structural, 12.
lesions, destructive, 12.
organs, irritation of, 12.
system, diseases of, 1.
Neuralgia, 184.
of ovary, 281.
Neurasthenia in pregnant ewes, 179.
Neuritis, 181.
ascendens, 441.
descendens, 441.
optic, retro-bulbar, 441.
Neurosis, 456.
Nictitans, membrana, lesions, 357.
Nigra, corpora, cysts of, 401.
Nitro-benzol poisoning, 149.
Nodules, 453.
Nose, rhythmic movements of, 68.
Nystagmus, 452.

Oblique focal illumination of the eye, 324.

Occluded pupil, 400.
Oöphoritis, 284.
Opacity of the cornea, 384.
of the lens or its capsule, 428.
of the vitreous, 437.
Ophthalmia, enzootic, 368.
internal, 390.
periodic, 404.
of solipeds, recurrent, 404.
Ophthalmoscope, 328.
Optic nerve, inflammation of the, 440.
paralysis of, 442.
Optic neuritis, retro-bulbar, 441.
Optic thalamus, 17.
Orbit, fracture of, 348.
periostitis of, 350.
tumors of, 350.
wounds of, 349.
Oscillatory movement of the eye, 452.
Osteomalacia, 573.
in pigs, dogs, goats and lambs, 489.
of the horse, 579.
Osteoporosis, 579.
treatment of, 587.
Ovarian cysts, 287.
tumors, 292.
Ovaries, absent, 280.
atrophy of, 280.
hernia of, 279.
supernumerary, 281.
undeveloped, 280.
Ovary and womb, malposition of, 279.
dermoid cysts of, 291.
hæmorrhage on, 282.
inflammation of, 284.
irritable, 281.
Oviduct, diseases of, 293.
egg impaction in, 293.
eversion of, 293.
imperforate, 293.
inflammation of, 295.
polypus of, 293.
Oxalic acid in rickets, 568.
in urine, 198.
test for, 198.
Ox, moist eczema of the pasterns, 486.
Oxytropis Lamberti, 135.

Pachydermia, 521.
elephantiasis, 456.
Pain, insensibility to, 10.
Palpebral fissure, widened, 338.
Panic, 23.
treatment, 24.
Panophthalmitis, 390, 403, 421.
enucleation, 422.
Papilloma of spine, 176.
Papulæ, papules, 453.
Paræsthesia, 9.
Paralysis, 2, 175.
local, 4.
of ocular muscles, 450.
of the optic nerve, 442.
sensory, 9.
Paraplegia, 3.
Parturient apoplexy, 299.
Parturition collapse, 299.
fever, 299.
Parturition fever, prevention, 311.
fever, treatment, 313.
paresis, 299.
Parasites, animal, 456.
of the bladder, 259.
 of the kidney, 248.
vegetable, 456.
Parasitic dermatosis, 460.
Paresis, 2.
Pasterns, moist eczema of, in the ox, 486.
Pemphigus, 507.
Pericarditis in rheumatism, 535.
Perinephritis, 230.
Perineuritis, 181.
Periodic ophthalmia, 404.
Perioöphoritis, 284.
Periostitis of orbit, 350.
Persistent arteria hyaloidea, 436.
pupillary membrane, 400.
Perspiratory centre, 16.
Phenol in urine, 198.
test for, 198.
Phlyctenæ, 454.
Phlyctenular conjunctivitis, 371.
Phosphates in rickets, 568.
in urine, 196.
in urine in osteoporosis, 587.
Phosphorus in rickets, 567.
Phymata, 455.
Phthiriasis, 460.
Phthisis bulbi, 446.
Physical properties of urine, 192.
Pigs, impetigo of, 491.
vesicular irruption in, 490.
Pilous cysts of ovary, 291.
Pimples, 453.
Pinguecula, 375.
Pitchy affection, 491.
Pituitary body, hypertrophy of, 133.
Pityriasis in dog and cat, 503.
in cattle, 503.
in horse, 501.
Pleuritic lesions in rheumatism, 535.
Plumbism, 141.
Podagra, 544.
Poisoning by aniline, 148.
by carbon disulphide, 150.
with cotton seed or cotton seed meal, 381.
by lead, 141.
by “loco”, 135.
by nitro-benzol, 149.
Poliomyelitis, 154.
Polypi of oviduct, 293.
Polyuria, of nervous origin, 8.
Pons, 16.
Prickly heat, 499.
Prolapse of the iris, 390.
Prostate, abscess of, 269.
cancer of, 278.
cysts of, 278.
hyperæmia of, 267.
hypertrophy of, 274.
tuberculosis of, 277.
Prostatic calculus, 278.
Prostatitis, acute, 267.
 chronic, 271.
follicular, 268.
interstitial, 269.
Pruritus, 9.
Psammomata of the brain, 131.
Pseudo-paralysis, 4.
Psychic peculiarities, 10.
symptoms, 10.
Pterygium, 376.
Ptosis, 337, 340.
Pupil dilatation, 21.
double, 399.
occluded, 400.
Pupillary membrane, persistent, 400.
Purkinje-Sanson images, 327.
Pus in urine, 201.
Pustulæ, pustules, 454, 474.
Pustular dermatitis, contagious, 504.
Pyelitis, 231.
Pyelonephritis, 231.
Pyometra, 296.

Quittor, 515.

Rachitis, 565.
from bran, 572.
Rain rot, 489.
Rarefaction of bone, 579.
Rarefying osteitis, 579.
Rash, 453.
Recto-vesical fistula, 261.
Recurrent ophthalmia, jurisprudence, 420.
microbiology, 410.
of solipeds, 404.
Red mange, 493.
Reflex action, 5.
increased, 6.
morbid, 5.
tonic spasm, 6.
Renal calculus, 247.
parasites, 248.
pelvis, inflammation of, 231.
tumors, 248.
Respiratory tract, 21.
inhibition, 15.
nerve centers, 14.
Restiveness, 26.
Retina, detachment of the, 439.
Retinal hemorrhage, 439.
Retina, tumors of, 439.
Retinitis, 438.
Retro-bulbar abscess, 350.
optic neuritis, 441.
Rheumatism, 528.
articular in cattle, 542.
in the dog, 547.
in horse, 536.
in sheep, 545.
in swine, 545.
blood changes in, 534.
cerebro-spinal lesions in, 536.
chronic articular, in horse, 540.
 heart lesions in, 534.
infection, theory of, 532.
lactic acid, theory of, 530.
muscular, in cattle, 544.
muscular, in dog, 548.
muscular, in the horse, 541.
neuropathic theory of, 531.
nodosities in, 538.
prevention and treatment of, 549.
theory of chill, 529.
Rickets, 565.
basement, stables in, 569.
confinement in, 569.
damp soils in, 569.
food experiments, 567.
infection in, 569.
lactic acid in, 568.
on poor soils, 567.
treatment of, 570.
Rimæ, 455.
Rocking hind quarters, 69.
Rodent eczema, 497.
Rouget, 460.
Rubrum, eczema, 493.
Rupture of the choroid, 403.

Sallenders, 480.
Salpingitis, 292.
Sarcoma of spine, 176.
Scabs, 454.
Scales, 454.
Scars, 455.
Sclera, ectasia (bulging) of the, 389.
inflammation of the, 389.
wounds of the, 389.
Scleroderma, 456.
Sclerosis, 5.
of spinal cord, 165.
Scorbutus, 557.
Scratches, 508.
Scurvy, 557.
Seborrhœa, 491.
of digital region, 512.
Secretions, modifications of, 7.
modified, skin, 456.
Sensory and motor tracts in brain, 14.
symptoms, 8.
Sheep, cutaneous eruptions in, 490.
eczema in, 489.
Shorts disease, 572.
Simple iritis, 395.
Sitfasts, 455.
Skin, discolorations of, 453.
diseases, diagnosis of, 458.
external causes of, 456.
internal causes of, 457.
general causes of, 456.
diseases of the, 453.
treatment of, general principles of, 461.
disease, white, 470.
gangrene of, 520.
hyperplasia of, 523.
hypertrophy, 521.
spots of, 453.
ulceration of, 520.
Softening of the brain, 84.
Solar erythema, 468.
Spasm, 4.
centre, 15.
clonic, 4.
of eyeballs, 4.
of sphincter vesicæ, 259.
paraplegic, 4.
tetanic, 4.
tonic, 4.
Spasms, 61.
general, 4.
local, 4.
Sphincter ani, centre, 21.
vesicæ, centre, 21.
Spina bifida, 171.
Spinal arteritis, 168.
caries, 172.
cord, congestion of, 153.
cord, cross hemi-section, 20.
cord, inflammation of, 154.
cord, lesions and phenomena, 22.
cord, longitudinal vertical section, 20.
hæmorrhage, 170.
hemiplegia, 3.
hyperæmia, 153.
lesions, 14.
lesions, localizations in, 20.
meningitis, 118, 160.
sclerosis, 165.
Spine, slow compression of, 175.
Squama, 454.
Squamæ in horse, 501.
Squinting, 450.
Squint, spasmodic or spastic, 451.
Staggering, 5.
Staggers, 69.
cerebral, 94.
Stalk disease, 482.
Stampede, 23.
Staphyloma, corneal, 387.
Starvation mange, 482.
Static refraction, 330.
Steatosis of the kidney, 244.
Stenosis of lachrymo-nasal duct, 355.
Stiffness, 573.
Strabismus, 450.
Streptococcic dermatitis, 512.
Streptococcus pneumoniæ equina, 397.
Stricture of the urethra, 264.
Structural alterations in glands and ducts, 456.
St. Vitus dance, 63.
Stye, 343.
Sun-stroke, 39.
Superior columns, 21.
transverse section of, 20.
Swine, eczema in, 490.
granular eruption in, 492.
Symblepharon, 339.
Symptomatic or metastatic iritis, 397.
Synechia, anterior, 392.
posterior, 392.
Syringomyelia, 178.

Tarsus, chronic eczema of, 480.

Tenderness, 10.
Tetany, 151.
Thalamus, 17.
Thermic fever, 39.
treatment of, 46.
Thrombosis of spinal cord, 168.
Thyroid enlargement, 560.
Timidity, 23.
Titubation, 5.
Tongue, abnormal movements of, 68.
Tonic spasm, 4.
Torpor, 11.
Toxic products of the system, maladies due to, 460.
Toxins in nervous disease, 2.
Traumas, 460.
Traumatica, dermatitis, 472.
Trembling, 4.
Tremor, 4.
Trichiasis, 344.
Trichorrhexis nodosa, 526.
Trophic spinal tract, 21.
symptoms, 6.
Tubercle of eyelid, 344.
of prostate, 277.
of womb, 298.
Tuberculæ, 453.
Tubercular disease of spine, 172.
meningitis, 127.
Tuberculosis of the iris, 401.
Tumor, dermoid of the conjunctiva, 375.
Tumors of eyelids, 348.
of kidney, 248.
of orbit, 350.
of ovary, 292.
of the brain, 128.
of the cornea, 388.
of the lachrymal caruncle, 356.
of the retina, 439.
of the vagina, 299.
Tyrosin in the urine, 199.
test for, 199.

Ulcer, 455.
of the cornea, 385.
Ulceration of the skin, 520.
Ulcerations of nervous origin, 7.
Urachus, persistent, 261.
Urea, 197.
test for, 197.
Ureteritis, 252.
Urethral anomalies, 261.
Urethra, foreign bodies in, 264.
imperforate, 261.
injuries of, 249.
stricture of, 264.
wounds of, 262.
Urethritis, acute catarrhal, 262.
Uric acid, 197.
test for, 197.
Urinary calculus, 247.
Urinary disease, general symptoms of, 202.
Urinary organs, diseases of, 190.
Urinary secretion, 190.
nervous control of, 191.
Urine, acetone in, 198.
albumen in, 199.
bile in, 200.
blood in, 200.
casts in, 201.
chemical changes in morbid, 196.
chemical reaction of, 196.
color of morbid, 193.
consistency, 195.
creatinin in, 198.
epithelium in, 200.
glucose in, 200.
indican in, 197.
odor of morbid, 195.
opacity of morbid, 195.
oxalic acid in, 198.
pathological, 193.
phenol in, 198.
phosphates in, 196.
physical properties, 192.
purulent, 224.
pus in, 201.
Urine, sodium chloride in, 196.
specific gravity of, 195.
translucency, 194.
viscid, 195.
Urticaria, 460.
Uterine tubercle, 298.
 tumors, 297.

Vagina, tumors of, 299.

Vaginitis, 298.
Variola, 460.
Variolous conjunctivitis, 370.
Vaso-motor nervous centre, 15.
spinal centre, 21.
tract, 21.
Vegetable parasites, 456.
Venenata, dermatitis, 473.
Vertigo, 69.
aural, 72.
cardiac, 71.
cerebral, 74.
embolic, 71.
essential, 75.
from venous obstruction, 71.
gastric, 71.
nasal, 75.
optic, 72.
Vertigo, pulmonary, 71.
toxic, 75.
treatment, 78.
Vesical parasites, 259.
Vesiculæ, 454.
Vesicular irruption in pigs, 491.
Vetch, action on dog, 23.
Vice, 11, 33.
constitutional, maladies due to a, 460.
jurisprudence of, 34.
treatment of, 35.
Violence, 11.
Vitreous, opacity of the, 437.

Watch eye, 399.

Weaving, 68.
White face and foot disease in horses, 468.
White skin disease, 470.
Womb, dropsy of, 296.
pus in, 296.
tumors in, 297.
Wounds of the cornea, 377.
of the sclera, 389.

Xanthin, 199.
Xerosis corneæ (epithelialis), 376.
 TRANSCRIBER’S NOTES
1. Added table of Contents.
2. Silently corrected obvious typographical errors and
variations in spelling.
3. Retained archaic, non-standard, and uncertain spellings
as printed.
4. Re-indexed footnotes using numbers.
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