The Spine: Medical and Surgical Management (2 Volumes) S Rajasekaran, Alexander R Vaccaro, Marcel F Dvorak, Luiz R Vialle, Brian W Su, H Michael Mayer, Yan Wang, Kazuhiro Chiba, Magdy Gamal Youssef
INDEX
Page numbers followed by f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdominal cavity 787
Abdominal corsets 908
Abdominal injuries, concomitant 682
Abdominal muscle
closure of 1195f
layers 788, 791
Abdominal reflexes 66, 1140
abnormal 1121
Abdominal wall 733, 736f, 791
morbidity 818
Abdominis muscles 788
Abdominus myocutaneous flap 1352
Abducens 1507
Abductor digiti minimi 79, 80
Abductor hallucis 79, 80
Aberrant vertebral artery anatomy 1530
Abscess
epidural 191, 431, 856, 879, 1409, 1423f, 1440f, 1461, 1496, 1502
resolution of 1423f
Abundant cytoplasm 1418
Acadia facet replacement system 1039, 1039f
Acetaminophen 187
Acetylsalicylic acid 153
Achondroplasia 208, 210, 216, 338, 346
syndromes 230
Achondroplastic dwarf 232f
Acupuncture 910
massage 910
Adalimumab 359, 836
Adam's forward bending test 65, 1114
Adaptive spinal mechanism 1246
Adenoviral transfection 12
Adequate decompression 577
Adhesions, abdominal 1289
Adipocytes 242
Adipositas, severe 468
Adjacent segment
degeneration 638, 893, 1046, 1509
disease 466, 797, 1266
fracture 1309, 1318
pathology 48
Adjuvant radiation therapy 1346
Adolescence develop progressive spinal deformity 1154
Adolescent idiopathic scoliosis 103, 387, 767, 1100, 1163, 1164, 1181, 1186, 1254
nonoperative treatment of 1160
operative treatment of 1174
surgery for 104
treatment of 795, 1199
Adrenal suppression 116
Adriamycin-cisplatin, combinations of 1338
Adult deformity
management of 1265
nonoperative treatment of 1254
surgical treatment of 1261
Adult degenerative scoliosis 1254
Adult lumbar degenerative scoliosis 1285
surgical management of 1285
Adult scoliosis surgery 1280
Adult spinal deformity 766, 805, 1254, 1272, 1562
treatment of 1262
Adult thoracolumbar idiopathic scoliosis 1275
Advanced trauma life support 662, 949
Aggrecan 6, 10
molecules 5f, 6
production 6
Aggressive posterior osteotomy techniques 824
Air embolism 159, 1152
Airway 117
Alacrima 322
Alagille syndrome 202, 213
Alar ligaments 611
Albeit variable osteoinductive capability 388
Albumin 711, 1269
Aldosterone 708
Alendronate 1308
Alfacalcidol 1308
Alkaline phosphatase 509
Allen-Ferguson
classification 564, 651
system 628, 629
Allodynia 157
Allogeneic cell transplantation 394
Allogenic bone graft 372
Allograft 383, 386, 886
bone 924
matrix 893
structural 363
tricortical iliac crest 1410
Alpha fetoprotein 271
Alpha-amino-3-hydroxy-5-methylisoxazole propionate 692
Alprostadil 697
Alveolar concentration, minimum 160
Ambulation 113, 474
observation of 185
status 273
American Academy of Orthopaedic Surgeons 179, 1163
American Academy of Pediatrics 338, 1163
American Association of Anesthesiologists 105
American Association of Neurological Surgeons 153, 650
American Board of Orthopaedic Surgeons 177
American College of Cardiology 151, 152, 1267, 1449
American College of Chest Physicians 157, 1450
American College of Physicians Guidelines 154
American College of Surgeons National Surgical Quality Improvement Program 154, 1268
American Heart Association 151, 152, 1267, 1449
American Society for Parenteral and Enteral Nutrition 709
American Society of Anesthesiologists 114, 114t, 710, 1009, 1266, 1267
classification 154
American Spinal Injury Association 695, 717, 949, 960, 1410
Amino terminal sequence 411
Aminoglycoside 1431
Aminosteroid 656
Amniotic fluid 271
Amyotrophic lateral sclerosis, treatment of 696
Anal atresia 203
Analgesia
management 158
patient-controlled 115, 159
Analgesic medication 458
Anatomic facet replacement system 1039
Andersson lesion 359
Anesthesia 151
epidural 181, 856
transoral decompression, single 553
Anesthetic agents 118
Anesthetic equipment 1500
Anesthetic fade 160
Anesthetic regimen 160
Anesthetic technique 160
choice of 115
Aneurysmal bone cysts 1122, 1325, 1329, 1334, 1344, 1349, 1364, 1366
Angiogenesis 380, 1329
Angiographic procedure 1366
Angio-seal device 1403
Anhidrosis, severe 124
Ankylosing spondylitis 111, 358, 363, 364f, 571f, 572f, 856, 961, 962, 1114
Ankylosis 897, 951
severe 805
Annular disease 875
Annular tears 877
propagation of 876
types of 876, 876f
Annulectomy 1192f
Annuloplasty, types of 880
Annulotomy, small 869
Annulus
fibrosus 3, 18, 836, 879, 1476
margins of 877
ossification 897
peripheral lamellae of 876
preserving design 871
sealing 1031
methods of 1030
surgical treatment of 875
Anticatabolics 12
Anticholinergics 154
Anticonvulsant medications 188, 458
Antidepressant 458, 911
Antiepileptic drugs 833
Antiepileptic medications, use of 1151
Antiepileptic treatment 267
Antifibrinolytic medications 156
Anti-inflammatory drugs 113
nonsteroidal 118, 187, 359, 446, 477, 696, 726, 833, 863, 910, 1232, 1255, 1259, 1331
Anti-inflammatory therapies 836
Antilordotic bracing 1118
Antineuropathic medications 332
Anti-Nogo antibodies 665, 698
Antiperspirants, use of 122
Antiplatelet
agents 153
drugs 116
Antirheumatic drugs 359
Antirheumatoid drugs, disease-modifying 350
Antisclerostin antibody 714
Antiseizure medication 187
Antitubercular treatment 1423f, 1429
Antituberculous drugs 1430
Anular fiber strains 1041
Anxiety 1271
Aorta, abdominal 734, 787, 1469, 1470f
Aortic bifurcation 790
Aortitis 358
Aortogram 1403
Aperius 924
Apical ligament 611
Apical thoracic kyphosis 1482
Apnea 338
Apofix 537
Apophyseal endplate lesions, posterior 1232
Apophyseal ring fracture, posterior 1232
Apophyseal stage 1228f
Apophysis 1228
Apoptosis 139, 656, 664
Apoptotic pathways 664
Appendicitis 722, 1420
Appendicular musculoskeletal tumors 1326
Appendicular skeleton, tumor of 757
Arachnoid cysts
extradural 997
intradural 997
Arachnoidal prolongations, long 999
Arachnoiditis 1429, 1461
adhesive 805
Arcuate ligaments 787
Argon beam coagulation 1348
Arm abduction relief sign 62, 62f
Arm pain 453
anterior 453
superolateral 454
Arnold-Chiari deformity 1153
Arnold-Chiari malformation 208, 216, 239, 251, 268, 408, 528, 1153
classification of 209t
Arteria radicularis magna 96
Arterial embolization, selective 1366
Arterial pressure
maintenance of mean 663
mean 650
monitoring 154
Arterial vertebrospinal vascular unit 27
Arteriovenous
fistulas, dural 1393
malformations 128, 1379, 1392, 1402
Artery
Adamkiewicz 28, 96, 141, 1207, 1392, 1393
disease, peripheral 917, 918
peroneal 404f
radicular 27
radiculomedullary 1403
segmental 27
vertebromedullary 1392
Arthritis 1114
degenerative 42
juvenile idiopathic 1114
signs of 58
Arthrodesis 619, 817, 1218
single level anterior 633
Arthroplasty 863, 872, 1060
biomechanics of 1059
multilevel 1509
single level 1064, 1065, 1509
technology, uses of 1047
total posterior 1031
two-level 1055
Articular pillar, safe quadrant of 547f
Articular processes
inferior 30
superior and inferior 3
Artificial disc 1060
device 1064
implantation 1060
replacement 463, 469, 1065
Arylsulfatase B 343
Asdourian classification 1368
Asia impairment scale 717
Asia motor score 648
Aspiration pneumonia 1140
Aspirin 116, 153, 1271, 1330
Astrocytes 698
Astrocytoma 1379, 1389, 1532
genetic hallmark of 1379
Astroglial scar 694
Astrogliosis 648
Asymmetrical radiculomedullary signs, progressive 1395
Atelectasis 118, 710
Athletic injuries 1228
Atlantal arch defects, types of posterior 224f
Atlantal facets, superior 30
Atlantoaxial arthrodesis, anterior 423
Atlantoaxial disease 354
Atlantoaxial dislocation 553f
fixed 553f
Atlantoaxial fixation 43, 528
Atlantoaxial fusion 525
Harm's technique of 353
posterior 44
Atlantoaxial instability 111, 209f, 210, 346, 674
isolated 594
Atlantoaxial joint 19, 45, 528
bilateral anterior 423
congenital anomalies of 209, 216
Atlantoaxial junction 337
Atlantoaxial motion segment 52
Atlantoaxial pathology 353
Atlantoaxial rotatory fixation 421
fixed 428
Atlantoaxial spine 525
Atlantoaxial stabilization, pseudoarthrosis of 42
Atlantoaxial subluxation 352, 1507
irreducible 428
Atlanto-dens interval 616
Atlanto-occipital articulation 208, 613
Atlanto-occipital dissociation 614f, 670
Atlanto-occipital instability 613
Atlanto-occipital synostosis 1134f
Atlas
anterior arch of 614
embryology of 221
fractures 616
fractures of 170, 673
Atlas-dens interval 209
Atorvastatin 696
Atresia, esophageal 203
Atrophy 562
Auditory click stimuli 138
Auditory nerve, distal 138
Autocrine 395
Autograft bone chips grafted 1303f
Autologous macrophages, activated 657
Autonomic dysreflexia, causes of 722t
Autonomic nervous system function 112
Autosomal recessive disease 1154
Avascular necrosis 191, 1006
Axial neck pain 449, 450
classification of 443, 444
etiology 443
evaluation 443
physical examination 444
radiographic imaging 445
treatment 443, 445
injection therapy 446
nonoperative 445
Axial pain syndromes, source of 86
Azygos vein 1516
B
Babinski's reflex 65, 445
Babinski's signs 918
Back pain 822f, 974f, 1254, 1113, 1257, 1286, 1419
acute 1259
atypical 1482
chronic 1259
discogenic 99, 793, 1260
natural history of 1275
nocturnal 1360f
nonspecific 1113
sudden 1363f
Baclofen 188, 723
cessation of 1271
pump, intrathecal 1271
Bacteremia 1009
Bacteria, anaerobic 10
Bacterial infections 155
Bacteroides 1473, 1503
Ballistics 688
Balloon kyphoplasty 1592
procedure 1592
Bandemia 708
Bariatric surgery 1258, 1270, 1307
beneficial effect of 107
Barnet's classified syringomyelia 251
Barricaid implant 1030, 1031f
Basal metabolic rate 111
Basal plate 200
Basilar impression 207, 208
Basilar invagination 42, 111, 207, 225, 251, 557
Basilar venous sinuses 29
Basion plumbline 643
Basion-axis interval 614
Basion-dens interval 614
Basivertebral vein 29
Bath ankylosing spondylitis disease activity index 359
Batson's plexus 28, 29, 1518
Bauer classification 1368
Baxter health care corporation 1525
Bazedoxifene 1308
Bechterew's syndrome 358
Becker's muscular dystrophy 1155
Beevor's sign 66
Benzethonium chloride 422
Benzodiazepines 112, 113, 323, 723, 833, 1271, 1451, 1452
use of 911
Benzothiazole
anticonvulsant 664
sodium channel blocker 656
Beta blockade, perioperative 1449
Betamethasone 88
acetate 88
compounded 88
use of 461
Beta-tricalcium phosphate 404
Biceps function 61
Biceps reflex 61
Bicoxofemoral axis 1241
center of 1244
Biglycan 6
Bilaminar embryo 266
Bilaminotomy 748, 748f
Bioactive glass 383, 391
Bioengineered artificial disks 753
Biomechanical functional unit, part of 35
Biopsy 1365
Bioresorbable screws 44
Bipedicular fractures, angulated 619
Biphosphonates 1308
Bipolar cautery 1525
Bipolar radiofrequency energy 99
Biportal access, bilateral 878
Bisegmental fusion 1127
Bisphosphonate 305, 313, 1271, 1308, 1339, 1353
administration of 1472
several 725
therapy 313, 395, 714, 1142
use of 713
Bladder
distension 722
dysfunction 474, 918, 1002
functions 763
management 719
Blastic lesions 1330, 1360
Bleeding
hemorrhoidal 1338
intraoperative 1519
Blind dermal sinus 208
Blindness, cortical 160
Blood
clot 380
cultures 1474
flow, hepatic 112
loss 1411
management 155
pressure, elevation of 721
Blount's disease 1119
Blunt dissection 791
Blunt micronerve hook 1525
Body
casts 955
compression, anterior 961
lamina extension 1370
mass index 103, 468, 872, 1009, 1256
low 1309
Bohlman triple-wire technique 536
Bone
autologous 385, 394
biopsy 1365
debris 1418
deformation of 1418
diseases, infectious 1114, 1358
dysplastic disorders 915
dysregulated remodeling of 1359
healing 393
heterotopic 722
image quality 1579
implant interface integrity 1471
island 1329
loss, mechanism of 714
matrix, demineralized 382, 387, 388, 412
metastases 1369, 1372
mineral density 43, 1265, 1270, 1306, 1307
neoplasms 1334
on-bone technique 1196, 1202
removal 559, 1080f
resorption 725
scan 1214, 1429
scintigraphs 405, 993
sialoprotein 395
transplantation 538f, 1075f
union 1302
wax 375, 1492
Bone density 48, 1142
loss of 725
Bone formation
endochondral 380
essentials of 379
intramembranous 380
Bone graft 528, 538f, 1074, 1107, 1501
autologous 371, 736
donor site complications 408
extrusion 807
harvesting 371
intramedullary 373
incorporation 380
local 382, 1302
material 383
characteristics of 382
options 381
placement of 813
replacement 821
substitutes 379
technique 779
posterior lateral 275
types of 1303f
vascularized 400
Bone marrow
aspirate 383385
depletion of 1257
normal 1361
stromal cells 657, 697
transplantation 345
Bone morphogenetic protein 12, 381, 411, 485, 492, 638, 797, 994, 1311, 1510
recombinant 809
Bone tumor 537, 1121
benign 1330, 1331, 1593
of spine, primary 1358
primary 111, 1334, 1343
Bone-on-bone fusion, short segment 1199
Bony anatomy 19
Bony ankylosis 358
Bony development 17
Bony endplate 806, 864
injuries 897
Bony fusion 773, 779
solid 400, 943
Bony healing 1234
Bony resection, minimal 1107
Bony spike lies, median 245
Bony spinal
lesions, primary 1325
tumors
malignant primary 1325
primary 1327, 1339
Bony surfaces 21, 286
anterior surface 21
lateral surfaces 22
posterior surface 21
Bony tissue, removal of 745
Boston brace 172, 1165, 1165f, 1166, 1166f, 1167
Botox injection 122
Botulinum toxin 723
Bowel dysfunction 263, 474, 720
Bowel incontinence 764
Bowel injury 819, 1051
Bowel management 720
Bowel sounds 1152
Bowstring sign 69
Brace therapy 1235
Brace types 1165, 1167t
Brachial compression test 63f
Brachial plexopathy 638
Brachial plexus
compression 63f
test 63
neuritis, acute 456
sheath 1420
Brachioradialis 474
reflex tests 61
tendon 61
Bracing
complications of 172
spinal deformity, biomechanics of 172
Braden scale 725
Bradycardia 154, 691
Brain
derived neurotrophic factor 697, 698
suite intraoperative computed tomography 1578f
Brainstem 142, 190, 423, 719
auditory evoked potentials 138
compression 251, 269, 338
deformity 251
dysfunction syndrome, severe 269
herniation 295
infarct 138f
injury 670
lie 209
malfunction 251
nuclei changes 269
Branch blocks, medial 585
Breast
cancer, multiple metastases from 1361f
tumors, advanced 1364
Breathing 117
deep 154
positive pressure 154
Broken screw 539
Bronchoalveolar lavage 1448
Bronchoscope 1517
Bronchoscopy, fiberoptic 155
Brooks-Jenkins technique 44
Brown-Sequard syndrome 683, 1382
Brush-like border 1330
Buckled ligamentum flavum 818
Bulbocavernosus reflex 139, 960
Bupivacaine 89, 115
hydrochloride 95
Burners injuries 604, 606
Burst fracture 49f, 605, 950, 954, 954f, 955, 964f, 971
complete 975f
outcomes of 955
proper treatment of 954
stable 629
Buttock claudication, triad of 918
C
C1-C2 arthrodesis, technique for 528
Cadaveric allograft 386
Cadaveric models 1040, 1059
Cadaveric study 44
Café-au-lait spots 57
Cage 1192
device, intervertebral 886
insertion 1197
placement 1410
subsidence 1560
Calcium 1269, 1308
channel blockers 695
concentration activates destructive enzymes 693
phosphate ceramics 382
sulfate 383, 384, 391, 392
Calciuria 713
Canadian C-spine rule 627, 649
Canadian surgeons, majority of 664
Canal stenosis 1552
central 750
Cancellous bone graft, transplanted 385
Cancer, breast 1308, 1361f
Candida albicans 1503
Cannabinoids 719, 723
Cantilever correction 1146
Capillary hemangioma, flat 262
Capsulitis, adhesive 65
Captopril 722
Carbamazepine 1260
Carbon monoxide poisoning 203
Carbon table and carbon head clamp fixation 1579
Carcinoma
breast 1364
hepatocellular 1363f
Cardiac
arrest 1152
arrhythmias 113
biomarker 1448
death 151
disease 1140
function, impaired 1269
index 1449
risk index, revised 152
Cardiopulmonary disease, severe 122
Cardiovascular complications, management of 153
Cardiovascular disease 152fc, 153, 1258
Cardiovascular function 112
Cardiovascular instability 650
Cardiovascular surgeon 1519
Cardiovascular system 151
Cardioverter defibrillator 1060
Carisoprodol carries 911
Carotid artery
external 404, 526
injuries 92, 1503
internal 525
Carotid puncture 91
Carotid sheath 433, 1434
Carotid tubercle 431, 432f
Carpal tunnel syndrome 345, 456, 472
Cartilage capped bony growths 1333
Cartilage fails, ventral 18
Cartilaginous
debris 1050
endplates 483f
focus develops 380
joint 98
stage 197
synchondrosis 221
tumor, malignant 1336
Caspar-distractor 464
Catastrophic neurologic complications 1422
Catastrophic neurologic injury 592
Catastrophic spinal instability 1477
Catecholamines 708
Cauda equina 128, 132, 688, 1382, 1461
conduction 80f
conduction time 77, 80
level 1387
paragangliomas 1378
syndrome 855, 857, 857t, 860, 943, 1382
causes of 856t
complete 978
Caudad lamina 920
Caudal agenesis 212
Caudal axis 18
Caudal domains 18
Caudal endplate 876
Caudal ends, implantation of 537f
Caudal epidural block 1313
Caudal housings 1039
Caudal lumbar spine 3f
Caudal medulla 1486
Caudal neural tube 266
Caudal regression 240
syndrome 248, 249f
Caudal vertebra 1233
body 1546
Cavernomas 1379
Cavernous malformations 1392
Cavus foot deformity 1121
Cecin's sign 69
Cefazolin 844, 1476, 1478
Celecoxib 187
Celiac disease 1307
Cell
biphasic pattern of 1379
chondrocyte-like 876
density of 12
dorsolateral 220
engraftment 697
fibroblast like 875
genetic modification of 395
lung, small 130
salvage 156
signaling 17, 200
standing of 197
transfections of 12
transplantation 697
Cellular damage 693
Cellular death 1052
Cellular grafts 697
Cellular membrane lipid fatty acids, oxidation of 692
Cellular therapies 665
Cement augmentation 51, 1310
Central nervous system 25, 157, 665, 692
demyelinating disorders 476
dysfunction 322
Central stenosis 907, 916, 924, 1286
Central venous pressure 159
Cephal ends, implantation of 537f
Cephalad vertebra 1236
Cephalosporin 1476, 1478
Cephazolin 844
Ceramic 46, 390
Cerebellar
infarction 809
slump 300
tonsils 296f, 297f, 299f
herniation of 209
Cerebral
atrophy 112
effects 112
palsy 1140, 1152, 1153
spinal fluid leaks, management of 1456
Cerebrospinal fluid 269, 296, 647, 655, 686, 1378, 1458f, 1468, 1506, 1516
diversion 1083
drainage 657, 851
iatrogenic 511
leakage 518, 555, 809
outflow 208
Cerebrovascular accident 1091, 1451
Cerebrovascular disease 152
Cervical
alignment 627
anatomy 548
anomalies, congenital 233
approaches, anterior 430, 433, 527f, 1059
burst 599
collar 168
cord neurapraxia 674
curve 31
deformity, correction of 544
degenerative disc disease 430
dermatomal distribution 454f
dermatomes 474
discectomy 46, 387, 463, 465f, 469, 480, 495, 513, 1059, 1060, 1509, 1510, 1523
disconnection syndromes, congenital multilevel 232
dislocations, subaxial 597
dorsal pain 1361f
drill 544
encephalocele 250
epidural steroid injection 460
esophagus 1503
extension 600
facet cyst 493
fascia, deep 434f
fractures 605, 607, 682
hard collar 590f
hooks 537
injuries, upper 600
instability 1420f
instrumentation 536, 678
interbody fusion 390
interlaminar epidural injection 460
Kerrison rongeurs 1525
kyphotic deformity 1060
lamina, levels of 299f
laminar hooks 537
laminectomy, minimally invasive 1531
laminoforaminotomy, posterior 1525
lesion 1420
levels 576
lordosis 448f, 490f, 491, 637, 1246, 1247f
manipulation 477
neurology 61t
ossification 510f
periradicular injection 97
plating, anterior dynamic 52
procedures, anterior 1457f
roots 454f
sagittal balance 491
sclerotomes fuses 207
scoliosis 1134f
segmental motion 1060
selective nerve root block 89
spondylolysis 1229, 1229f
sympathetic chain injury 1505
syringomyelia 295, 554f
teardrop fractures, management of 630
total disc replacement 468t
transarticular screw fixation 546
transforaminal epidural technique 460
trauma classification methods 628
vertebral body 1525
wound, posterior 638f
Cervical arthroplasty 466, 1064, 1065
devices 1060
placement of 1062f
Cervical corpectomy
anterior 513, 515, 1506
minimally invasive anterior 1525
Cervical decompression
anterior 140
for spinal stenosis, microendoscopic 1529
multilevel anterior 1500
Cervical disc
arthroplasty 47, 608, 1059, 1509
disease 111, 1523
herniation 606, 607, 1523
replacement 1059
complications 1064
preoperative evaluation 1060
surgical technique 1061
Cervical fixation
anterior 46
posterior 47
Cervical foraminotomy
anterior 1523, 1533
minimally invasive 1524
posterior 1533
minimally invasive 1525
Cervical fusion 203
anterior 431, 1059
posterior 141
Cervical kyphosis 337, 338, 340, 570, 572f, 643, 1483, 1506
etiology of 570
iatrogenic 641
Cervical laminoplasty 1505
minimally invasive 1531
Cervical microendoscopic
decompression 1524, 1529
foraminotomy 1526
laminoforaminotomy 1526
Cervical myelopathy 64f, 345, 454, 468, 1505
compressive 80
Cervical nerve root
block 461f
compression, pathophysiology of 453f
Cervical orthoses 167, 168, 590, 629
role of 477
Cervical osteotomy 570, 578
complications 576
correction 571
postoperative management 575
technique 363
Cervical pedicle 1589f
screw 543, 543f, 1585
fixation 539
placement, complications of 548
subtraction osteotomy 362f
Cervical radiculopathy 452, 453t, 458, 459, 460, 463, 1064, 1524, 1526
differential diagnosis of 456t
natural history of 456
Cervical region 30
concomitant injuries of 682
Cervical spinal
canal, congenital stenosis of 210
cord 64f, 670, 1061f
radiculopathy 1060
stenosis, congenital 675f
Cervical spine 7, 27, 38, 404f, 430, 478, 483f, 493f, 555f, 557f, 570, 604, 1089, 1132, 1229f, 1409, 1420, 1421, 1508f
anatomy of 17
anterior exposure of high 142
congenital anomalies of 207, 219
deformities 1587
degenerative disease of 639
development of 220
different regions of 219
dislocation 597
embryology of 220
evaluation 59
flexion osteotomy of 575
fracture 171, 627, 1229
management of 171fc
subaxial 596
injury 651
closed management of 590
severity score 628
subaxial 600, 633, 651t, 674
instability 344
laminectomy, multilevel 1510
ligamentous structures of 23f
movement of 155
osteotomy of 573
pathologies of 140
radiographs 649
straightening of 491f
subaxial 19, 45, 47, 546, 1060
subluxation 344, 597
surgery 1510
anterior 46, 1500
general complications 1500
IONM during 140
posterior 1500
revision 636
single level 608
surgical complications of 469t
trauma
subaxial 626
upper 610
tumor of 468
upper 20f, 421, 526, 610, 1584
Cervical spondylosis 443
single level 1063
Cervical spondylotic myelopathy 472, 478, 490, 515, 1525
treatment of 480
Cervical stenosis
congenital 472
multilevel 476f
Cervical traction 459, 592, 600, 1507
local complications of 1507
Cervical tumor 1532
upper 1381
Cervical vertebrae 22, 35
anterior 435f
Cervicomedullary junction 552, 555
compression of 557f, 558f
Cervico-occipital region 430
Cervicothoracic
brace 169f
junction 439, 570, 584, 627, 1135f, 1147
deep dissection 441
preoperative planning 439
superficial approaches 440
X-ray of 245f
orthoses 168, 590, 619
spinal cord 209, 249
spine 1361f
Cethrin 647, 655657
Chance injuries 962
Charité disc 1045
Charite prostheses 897
Charleston bending brace 1166, 1166f
Charleston brace 172, 173f, 1167
Charlson comorbidity score 1567
Chemiadsorption 1115
Chemokines 876
Chemotherapy 1329
antitubercular 1422, 1431
Chest
pain 115, 453, 1448
anterior 453
tube placement 1541
wall 1420
development of 288
indrawing 155
muscles 1194
Chevron-shaped osteotomy 1296, 1296f, 1297
modification of 1297f
posterior 1295, 1296
Chiari decompression 298, 300
Chiari malformation 200, 249, 250, 250f, 251, 252, 252f, 269, 272, 295, 296, 553, 557, 1524
clinical presentation 250, 296
complications 300
decompression 299f
diagnosis 295
embryogenesis of 267
pathogenesis 297
prognosis 300
severe 269
treatment 250, 298
types of 249
Chiari syndrome 251
Child abuse 669
Chin brow 571
Chin-on-chest deformity 572f
Chin-on-pubis deformity 361f
Chiropractic care 863, 1259
Chiropractic manipulation 856, 1171
Chlorhexidine 1272
gluconate 1272
solution 422
Choanal stenosis 202
Cholecystitis 1420
Chondrification centers 197
Chondroblastoma 1329, 1334
Chondrocytes
exogenous 12
migration of 4f
proliferation of 508
Chondrodysplasia punctata 342, 346
Chondroitin sulfate 6, 696, 1271
Chondroitinase 696
Chondrosarcoma 421, 1336, 1344, 1364, 1517
Chordin 412
Chordoma 132, 421, 429, 1329, 1338, 1344, 1346, 1364
Chromaffin cells 121
Chromosome 321, 508
Chylorrhea 1504
Chylothorax 1518, 1520
Chylous fistula 1504
Circumspinal decompression 517
Cisplatin 1329, 1336
Claustrophobia 1060
Clavicle osteotomy 440
Clay-Shoveller's fracture 600
Cleft palate 202
Clivus, hypoplasia of 232f
Cloacal artesian 248
Cloacal folds 248
Clonus 64, 918, 1060
Clopidogrel 116, 153, 1271
Closed loop technique 762
Cobalt chromium 870
Cobb's angle 277, 1151, 1157, 1170, 1286, 1288, 1483, 1564, 1567
correction 1564
larger 1160
lumbar 1256
magnitude of 1285
measurement 961
Cobb's elevator 788, 821
Coblation technology 99
Coccyx 725
apex of 21
Cochlear
implants 1266
nucleus 138
Coconut condyle 223f
Cold abscess 1418
location of 1421t
Collagen 5, 412, 875
fibers 35, 1378
fibrils 4
resist tensile 875
matrix 1460
production of 6
sponges 526
synthesis 12
disorder of 313
Colliculus, inferior 138
Colloid administration 160
Colorectal tumor
invasive 1344
primary 1345
Colpocephaly 209
Column osteotomies, posterior 1282
Compartment syndrome 408
Complex deformities 823, 1126
Compound muscle action potential 77, 138, 1486
Compression
axial 962
cervicogenic 338
extradural 1429
fractures 111, 605
anterior 953, 957
Compressive thoracic myelopathy 80
Condylar emissary vein, posterior 534
Condyles, bilateral 610
Condyloid fossae 30
Congenital foramen magnum lesions, surgical treatment of 552
Congenital kyphosis, type of 215f
Congenital scoliosis, treatment of 1135
Congenital spinal
anomalies, types of 216
lesions
anatomy of 206
physiology of 206
Congenital spondylolisthesis, congenital 215, 216f
Connective tissue 197
Continuous positive airway pressure 154
Conus medullaris 25, 28, 139, 142, 143, 240, 652, 855, 970, 1382
complete 652
incomplete 652
injury 966f
lipoma of 242
syndrome 855, 857, 857t, 1382
terminates 1492
Conventional foraminotomy 748
Coralline hydroxyapatite 389
Cord atrophy 1429
Cord compression 344
kyphosis causing 1434f
Cord edema 1429
Cord injury 593
Cord signal change 445
Cord split 246
Cord syndrome
anterior 1381
central 111, 474, 1381
posterior 1381
tethered 252, 258, 262
Coronal
slices 843, 846
veins
anterior 28
posterior 28
Coronary artery disease 1266, 1308
Corpectomy 480, 483, 972, 1085, 1089, 1413, 1435, 1509, 1525, 1538, 1541
anterior 408, 1530
decompression 1492
defect, partial 1107
grafts 565
model 50
multilevel 566
anterior 516
multiple level 400
open-window 513
partial 1087
require access 737
technique
oblique 516
open-window 516
Correctable kyphosis, passively 565
Corridor, superior 441
Cortical screw fixation 779, 783, 784
Corticocancellous
allograft 46
use of 525
bone grafts, use of 525
graft 807
Corticospinal tract 1486
fibers 141
Corticosteroid 89, 187, 654, 831
injections, intramuscular 833
toxicity of 459
use of 647
Cortisol 708, 1152
Corynebacterium 1411
Cosmetic deformity, progressive 1254
Cosmic posterior dynamic system 1034
Costal bone 1073f
Costal head resection 1109
Costocervical trunk 27
Costopelvic impingement 1441
Costotransverse articulations 1288
Costotransversectomy 1089, 1436, 1535
Cotrel-Dubousset
hooks 1094
instrumentation 311, 766, 887, 1177f
set 557
Cottonoid patty 486
Cottonoid pledget 1460
Cox inhibitor 158, 446, 458
Cox pathway 458
Cox receptors 187
Cranial caudal plane 1530
Cranial endplate 876
Cranial nerve
injuries 1507
palsies 671
Cranial radiosurgery 126
Craniectomy 299f, 559
Craniocaudal axis 266
Craniocaudal exposure 554
Craniocaudal height, loss of 629
Craniocervical
deformity 310
dissociation, unstable 615f
junction 19, 306, 313, 338, 557, 559, 649
anomalies 233
dural surface of 559
settling 421, 428
stabilizers 594
Craniospinal pressure dissociation 297
Craniovertebral anomalies, classification of 208t
Craniovertebral junction 220, 297, 421, 552
malformations 555f
C-reactive protein 1011, 1409, 1474, 1518
Cricoid cartilage 431, 432f
Cricopharyngeal region 1503
Crockard retractors 422
Crockard transoral instruments 554
Crossed straight leg raise sign 69
Cruciate ligaments 594
Cruciform ligament 611
Crutchfield traction 477
Cryoablation 1348
Cryoneurolysis 94
Crystalloid 663
Culprits 1451, 1502
Cumbersome biplanar fluoroscopy 1585
Curettes 1107, 1301
Curve progression, predictors of 252
Cyclic loading test 1030f
Cyclical crisis patterns 325
Cyclooxygenase
receptors 187
selective agents 910
Cyclosporine 696
Cylindrical tubular retractor 841
Cyst
formation 694f
neck ligation 1001
Cysto-subarachnoid shunts 1000
Cytokine 395, 693, 876
inhibitors 877
leakage of 877
production of 708
D
Dandy-Walker syndrome 209, 251
Dantrolene 723
Davidson's shoulder abduction sign 455f
Debulking 1359, 1371, 1372
Decision tree 319fc
Decompression 932, 933, 1035, 1464
anterior 513
dural 559
foraminal 1559f
lumbar 1452
surgery 752
anterior 1516f
Decompressive procedures 1552
Decubitus position, lateral 122f, 1087, 1109
Decubitus ulcers 719
Deep tendon reflexes, asymmetric 1121
Deep vein thrombosis 118, 710, 721, 797, 973, 1156, 1449
risk of 352
Deformity 359
congenital 200, 201, 212
correction 439, 1193, 1194, 1465
pediatric 135
surgery 1291
degenerative 793
disorders 111
high grade 1288
post-traumatic 1589f
progression of 1288
surgery 1586
minimally invasive 1562
Degenerative cervical
disc disease 1060
spondylosis 1059
Degenerative diagnosis, spectrum of 1457
Degenerative disc disease 7, 85, 86f, 100, 737, 813, 821, 863, 882, 1044, 1060, 1257
management of 86
multilevel 822
treatment of 787
Degenerative disorders 111
Degenerative spinal stenosis, surgery for 104
Dehydration, chronic 324
Delirium 1451, 1451t
causes of 1451
risk of perioperative 116
Deltoids 459
Dementia 1381
Demyelinating diseases 1379
Demyelination 691
axonal 1396
Denervation techniques 94
Denis fractures 983
Denis zone III fracture, subclassification of 980
Denosumab 1351, 1353
Dens
anomalies of 226
hypoplasia of 232f
nerve fibers 876
quadriparesis 605
Dentinogenesis imperfecta 302
Dentocentral synchondrosis 221
Deoxyribonucleic acid 126
Depression 1010, 1271
cardiorespiratory 113
Dermal sinus 212, 240, 241f, 247, 261
congenital 248f
tract 247, 261-263
Dermatome 197, 454
Dermoid 1379
cysts 247
tumors 270
Dermomyotome 18, 220
Detrusor sphincter dyssynergia 722
Dexamethasone 88, 89, 1339, 1379
Diabetes mellitus 136, 1270, 1307
history of 1009
Diabetic peripheral neuropathy 917
Diamond burr 484f
Diaphragm, closure of 1195f
Diaphragmatic irritation 115
Diarthrodial synovial joint 990
Diastematomyelia 211, 212, 246, 270
Diazepam 113
Diclofenac 188
Digastric muscle 526
Dilators, serial 809
Diphtheroids 1502
Diplomyelia 212, 260
Dipyridamole 1271
Direct vertebral derotation techniques 1465
Directly observed treatment short course 1430
Disc 21, 35
arthroplasty 1047, 1053
partial 873
biomechanical function 1028
degeneration
adjacent level 1306
classification of 8t, 1116t
etiology of 8
grading 8f
multilevel 447
stages of 91t
dynamics 869f
erosion 1358
fragments 632, 1496
height, collapse of 882
herniation 85, 464f, 477, 608, 856, 1006, 1541, 1545
acute 1087
primary 842
single level 1552
level 454
nucleus 817
operations 1087
replacement 872
partial 863, 865, 872
strategies 865
surgery 1590
space
collapse, severe 805
narrowing 445
preparation 792
Discectomy 483f, 806, 841, 863, 1107, 1191, 1413, 1464, 1496, 1538, 1541, 1545
anterior 465, 1140
complete 1087
minimally invasive 1536, 1552
mini-open 1541
multilevel 566
open 1230, 1231
use of microscopy for 841
Discitis 793, 805, 879, 1120
clinical features of 1120
clinical presentation of 1121
diagnosis of 1120
early stages of 1121
treatments of 1121
Discogenic pain
chronic 879, 898
diagnosis of 92
Discogram, types of 91t
Discography 89, 878
contraindications 90
diagnostic tool 883
indications 90
Discoligamentous complex 628, 629
injury 596
Discovertebral junction 365
Disk osteophyte complexes, anterior 493
Dislocation, signs of 58
Displacement, minimal anterior 595f
Dissection, superficial 432
Disseminated intravascular coagulation 1152
Distal fixation 1279
Distraction 72
Dizocilpine 695
Dizziness 1259, 1260
Dobutamine stress echocardiography 152
Dominant anterior radicular artery 960
Dorsal annulus 100
Dorsal column
fibers 1381
mapping 137
Dorsal dermal appendage 262
Dorsal enteric fistula 212
Dorsal hypertrophic bone 245
Dorsal iliac crest 733
Dorsal lesions 1393
Dorsal midline defect 259
Dorsal ramus 25
Dorsal rhizotomy 719
Dorsal root
entry zone 719
ganglion 10, 76, 87, 876, 999
Dorsal sacral foramina 98
Dorsal spinal
column 562
dysraphism 241
Dorsiflexes 186
Double layer sign 511
Down's syndrome 209, 216, 230, 231f
Doxorubicin 1336
Drosophila melanogaster 17
Drug-resistant strains, suspicion of 1427
Dual therapy 153
Dual-energy radiograph absorptiometry 1270
Dual-energy X-ray absorptiometry 819, 1142, 1258
Dual-iliac screws technique 761f
Duchenne muscular dystrophy 1141, 1155, 1156, 1477
Dumbbell schwannoma 1384f
Dunn McCarthy presacral rods 285
Duodenal switch 108
Dural defect, repair of anterior 1518
Dural injuries, iatrogenic 1456
Dural tears 797, 809, 818, 973, 1009, 1461, 1494, 1502, 1506, 1541, 1551
intraoperative 1461
Dural tension signs 68
Durotomy
repair 1465
risk of 1506
Dynamic stabilization 51, 1290
systems 1023
Dynesys sleeves 1035
Dynesys spinal system 1024
Dynesys system 894, 1034, 1035, 1290
Dysautonomia, familial 321, 322
Dysesthesia 408
Dysphagia 485, 1502, 1523
iatrogenic 1503
incidence of 485
scores 1063
Dysphonia 1502, 1523
Dysplasia 1222t
campomelic 342, 343f
craniometaphyseal 208
diastrophic 337, 340, 346
disorder 337
fibrous 303, 1334
Dysplastic posterior elements, severely 279f
Dysplastic segment 1225
Dysraphic lesions, prevalence of 212
Dysraphism, manifestations of 261
Dysreflexia, autonomic 719, 721
Dysrhythmia 151
Dystrophin gene 1155
Dystrophin protein 1155
Dysuria 720
E
Ecchymoses 57, 627
Eccrine glands, idiopathic overproduction of 121
Ectodermal asymptomatic anomalies, minor 208
Ectodermal cells, mass of 17
Ectodermal symptomatic anomalies, minor 208
Ectopic bone formation 414
Edema 961
peripheral 1505
Edwin Smith surgical papyrus 951
Elastomeric devices, solid 870
Elastomeric nucleus replacement 869f
Elbow flexion 62
Electrical stimulation, functional 725
Electroacupuncture 910
Electrocardiogram 1448
monitoring 1579
Electromyographic
monitoring 1490f
technique 1489
Electromyography 137
Electrophysiological monitoring 272
Element replacement system, total posterior 1026
Embryo, rostral end of 220
Embryogenesis 203
Emery-Dreifuss muscular dystrophy 1155
Empty sac sign 1009
En bloc
excision 1330, 1335
resection 1371, 1372
spondylectomy 744
total 1519
vertebrectomy 1366
Endochondral bone formation, defective 338
Endochondral ossification 380
Endoderm 240
Endodermal-ectodermal adhesion 246
Endoneurial-perineurial junction 997
Endoscopic cervical foraminotomy
minimally invasive 1523
anterior approach 1524
posterior approach 1525
Endoscopic clip placement 123f
Endoscopic disc 752
Endoscopic foraminotomy, posterior 1526f
Endoscopic lumbar discectomy, posterolateral 1546
Endoscopic techniques 468, 790
Endoscopic visualization, under direct 1537
Endoscopy, fiberoptic 1500
Endothelin 509
Endotracheal tube 425f, 485, 1485, 1503
Endovascular
procedures 1400
treatment, risk of 1403
Endplate 807
chondroepiphyseal portions of 1228
curettage of 850
fragments 597
margin 749
remodeling 898
sclerosis 186, 882
Energy 688
loss of 1260
Enneking classification 757
Enneking principles 757
Enneking staging system 1326, 1326f, 1345
Enneking tumors 1335
Enostosis 1329
Enteral feeding 709
routes 1270
Enteral formulas 710
Enterobacter cloacae 1473
Ependymal cells 1379
Ependymoma 132, 1379, 1387, 1532
Epidermidis 1151
Epidermoid 262, 1379
cysts 247
Epidural
abscess, posterior 1419f
bleeding, control of 1516
hematoma
delayed 1519
postoperative 1519
Epinephrine 554, 708
Epithelial-mesenchymal transformation 18
Epithelioid cells 1417, 1418
Epsilon-aminocaproic acid 156
Erb's point 605
Erector spinae 734, 1343
aponeurosis 745
musculature 820
Erlotinib 1329, 1338
Erythrocyte sedimentation rate 1011, 1409, 1474
Erythropoietin 664, 696
Escherichia coli 1151, 1473, 1502
Esophageal
injury 436, 685, 1503, 1505
perforation 486, 1503
reflux 1448
retraction 485
Esophagitis 126
Esophagus 132
Estrogen agonists 1308
partial 1308
Estrogen antagonists, partial 1308
Estrogen receptors modulators, selective 1308
Etanercept 359, 836
Ethambutol 1430
Ethyl pyruvate 696
Etomidate 160
Euro-qol group index 104
Ewing's lymphoma 1349
Ewing's sarcoma 1122, 1329, 1338, 1344, 1349
Ewing's tumors 1325
Expedium system 1035
Extension osteotomy, posterior 573
Extensor hallucis longus 67, 68, 944
Extracavitary approach, lateral 1439, 1535
Extracavitary exposure, lateral 1087
Extracellular matrices 4, 508, 1337
Extraspinal bone metastases, number of 1369
F
Faces pain rating scale 1113
Facet arthritis 331
Facet arthrosis 882
Facet capsules 562, 950
Facet denervation 94
Facet disease 85
Facet dislocation 631
Facet hypertrophy 935
Facet joint 24, 40, 60, 216, 444, 468f, 817, 848, 907, 915, 1432f, 1530
adjoining 1235f
arthritis 1026, 1038
arthroplasty 52
articulating 806
bony ankylosis of 358
capsule 24, 562
dysfunction 187
hypertrophied 452
hypertrophy 331
injections 1260
pain 187
removal of bilateral 1038
separation of 1432f
sparing laminotomy 749
Facet replacement
system, posterior 1041f
total posterior 1041
Facet sparing decompression technique 922
Facet subluxation 631
bilateral 631, 632
unilateral 631
Facet syndrome 924
Facet violations 539
Facetectomy 382, 746, 1038, 1299f
complete 813
lateral 748f
medial 748f
unilateral 814
Facial dysmorphism 202
Facial trauma 600
Failed back surgery syndrome 794, 805, 1005, 1006
Fanconi anemia 201
Far lateral disc herniations 844
Fascia
endopleural 1106
endothoracic 1440
lumbodorsal 259, 1548
Fast motor testing 64
Fast-growing tumors, treatment of 1329
Fat tissue
epidural 847f
extraforaminal 846
Fatal bleeding 1504
Fatal pulmonary embolism 721
Fat-free body 712
Fatty
filum 244
mass 242
tumor 244
Fawn's tail 261
Fecal impaction 720
Feingold syndrome 201
Femoral artery 1519
Femoral cutaneous nerve
injury, lateral 1091
lateral 374
Femoral nerve 787
injury 1556
stretch test 69, 70f
Fetal surgery 270
Fever, low grade 725
Fiberoptic endoscopy, flexible 1503
Fibers bulging, peripheral 865
Fibrillar molecules 13
Fibrinogen 845
Fibrinolytic system 156
Fibroblast 321, 1378
growth factor
basic 381
receptor-3 338
Fibrocartilaginous tissue 944
Fibrolipoma 242
Fibromodulin 6
Fibromyalgia 910, 1086
Fibrosis 562, 1457
epidural 809, 1005
Fibrous histiocytoma, malignant 1336
Fibrovascular
invasion 390
tissue 1330
Fibula 371
graft, vascularized 1352f
Fibular allograft 47
Fibular autografts 482
Fick equation application 708
Figure-of-8 repair 1460
Filar lipoma 212
Filum
abnormal 240
ependymomas 1532
terminale 242, 248, 253, 254
lipoma of 240, 244
myxopapillary ependymoma 1384f
Finger
dissection 1189f
escape sign 64, 64f, 454
flexors hand intrinsics 61
Fistulas, arteriovenous 1392, 1395, 1398, 1400
Fixation
failure 775
loss of 771
technique 42, 539, 984
type of 44
Flatback deformity 1199
Flatback syndrome 1008, 1015
postoperative 1008, 1008f
Flavectomy, lateral 845
Flexible cable anterior implants 1199
Flexion distraction injuries 49f, 605
Flexion extension
films 627
views 1526
Flexion teardrop fracture 599, 630, 630f
Flexor digitorum
profundus 474
superficialis 61
Flexor hallucis longus 403
Fludrocortisone 722
Fluid retention 191
Fluoroscopic C-arm 96, 1536
Fluoroscopic time, total 1582
Fluoroscopically guided pedicle screw placement 1096
Fluoroscopy 530, 544, 741, 768, 788, 792, 945f
intraoperative 1572
lateral 792, 1536
Foley catheter 960
Folic acid 268
Follistatin 412
Food, thermic effect of 712
Foot
deformities 253
dorsiflexion weakness 843f
Footprint
cage, larger 818
surgical 752
Foramen magnum 27, 209, 225f, 249, 298, 526, 959
decompression 253f, 552
severe stenosis of 232f
small 338
stenosis 337, 338
Foramen transversarium 47, 1591
Foramina, intertransverse 430
Foraminal disc pathology 87
Foraminal entrapment, secondary 985
Foraminal height 1024
Foraminal patency 886
Foraminal slice 843
Foraminal space 945, 1550
Foraminal stenosis 186, 445, 447, 638, 748, 750, 813, 817, 907, 1007, 1287, 1306, 1525
iatrogenic 539, 638, 641
Foraminotomy 497, 641, 748750, 920, 1563
anterior 463, 466
endoscopic 1524
images of 1559f
minimally invasive 1533
posterior 466, 641
Forced vital capacity 1155, 1207, 1276
Forces, types of 36
Forearm
dorsum of 454
supination 604
Fossa
masses, posterior 296
tumors, posterior 251
Four-rod lumbopelvic reconstruction technique 762
Fractures 34
apophyseal ring 1232
development, iatrogenic 48
dislocation, type C 950f
intraoperative iatrogenic 1052
patterns 38
reduction of 955f
signs of 58
type B 950f
U-shaped 981
Fragmentation, axonal 691
Fragmentectomy 841
Frank myelopathy 509
Frankel B neurologic injuries 1101
Frankel grading system 1541
Frankel impairment scale 960
Free fatty acids 708
Free fibula graft 402
Free radical formation 648
Freehand technique 1178f
Friction massage 910
Friedreich ataxia 1141
Froin syndrome 1382
Fusion 499, 863, 1538
levels 277
posterolateral 384, 750, 884, 1222, 1235
procedures, posterior 1591
surgery, posterolateral 1475f
techniques, modern 794
G
Gaba aminobutyric acid 188
Gabapentin 158, 458
Gabapentinoids 719, 723
Gacyclidine 654, 695
Gadolinium 186, 850, 877
enhanced slices 843
Gaenslen's test 71, 71f, 992
Gaines procedure 1221
Gait
analysis studies 1248
disturbance 1381
instability 1060
Gallie fusion 525
Gallie technique 44
Galveston extension 1143
Galveston iliac rods 767
Galveston L-rod technique 760f
Galveston rods 49
Galveston technique 282, 766, 767, 768
modified 760, 761, 761f
Gangliogliomas 1379
Ganglion cyst 1330
Gangliosides 695
Gardner segmental deformity angle 961
Gardner-Wells
tongs 432, 591, 593, 654, 1501
traction 593f, 1524
Gastrocnemius 68
Gastroenteritis, infectious 710
Gastroesophageal reflux 324, 1139, 1140
rate of 324
Gastrointestinal
disorders 1309
malabsorption syndrome 1307
toxicity 1259
tract 688
tumors 128
Gastrojejunostomy 1152
Gastrostomy tube 1141
Gastrulation 197, 240
Gefitinib 1329, 1338
Gelfoam powder 1525
Gelfoam soaked thrombin 638
Gene 508, 657
expression 197
notable 508t
silencing 197
therapy 395, 415
Genetic hereditary lesions 1393
Genitofemoral
injury 819
nerve 735, 1207
injury 1556
Gentle intraoperative techniques 1469
Genu valgum 345
Gestational diabetes 248
Giant cell tumor 421, 424, 426f, 429, 1325, 1344, 1347
Gill laminectomy 1222
Gilles Dubois developed Dynesys system 1034
Gillet test 70, 70f
Ginkgo biloba 1271
Glasgow coma
scale 949
score 627
Glial cells 199, 1379
Glial fibrillary acidic protein, synthesis of 648
Glial scar 694f
Glial tumors 1532
Gliosis 694
process of 698
Global kyphotic deformities 286
Global spinal malalignment 1247
Global spinopelvic alignment relationships 1245, 1251
Globular radiodense shadow 1427
Glomus, intramedullary 1392
Glucagon, circulating levels of 708
Glucocorticoids 88, 1307
prolonged use of 1307
use of 1309
Glucosamine 1271
Glucose production, hepatic 708
Gluing annulus defect 1030
Glutamate 692
antagonists 695
intracellular 692
mediated excitotoxicity 648, 656
Gluteal arteries, superior 1469, 1501
Gluteus maximus 1343, 1420, 1501
Gluteus medius 68
Glycerin 189
Glycocalyx 1477
biofilm layer 1412
Glycosaminoglycans 4, 13, 864
Glycosphingolipids 656
Goldenhar's syndrome 231
Golgi tendon organs 322
Gore sign 877f
Gore-tex pericardial patch 1203
Graft
dislodgement of 427, 1509
harvesting 863
insertion 404
junction, lower 1509
material 384, 485, 814
migration, rate of 805
subsidence 1309
Gram stain 1447
Gram-negative
bacilli 1448
organisms 1408
Granuloma, eosinophilic 1335
Gravity pulls 570
Great distal fixation 286
Great vessels 132
Greater occipital nerve 525
Greater posterior cord drift 504
Greater trochanter 185
Gross tumor volume 127, 128
Growing cartilaginous endplates 1510
Growth cone 698
Growth deficit, minimal 1134
Growth factors 198, 698
alpha, transforming 698
autogenous 383
beta, transforming 12, 18
Growth guiding techniques 1132
Growth hormone deficiency 270
Growth plate, complete loss of 202
Guaiacol 189
Guidance reduces fluoroscopy, use of 1592
Guidewire, use of 1527
Gunshot
injuries 685, 963
to spine, surgical treatment of 686
wounds 680
H
Hair follicles 247
Hairy patch 262
Halifax clamps 537
Halo device 170
Halo ring 654, 1501
Halofemoral traction 1219
Halothoracic immobilization 674, 675
Halothoracic vest 590, 591, 591f, 598, 599
Halt inflammatory process 1216
Halter traction 477
Hand
clumsiness, tingling to 509
dysesthesia 509
intrinsics 61
Hangman's fracture 171, 596f, 621f, 1585f
Hard collar 169f, 590, 600
Hard disc prolapse, posterolateral 457f
Hardware complications 503
Hardware failure 973
Harm's technique 44, 449f
Harrington basic concept 277
Harrington classification 1367
Harrington instrumentation 311, 766, 1177f
distraction 1008
Harris classification 651
Harris-Benedict
equations, original 707
formulas 707
Hartshill-Ransford loop 557
Head injury 664
Headache 453, 1380, 1482
cervicogenic 1260
Headlamps, use of 736
Healed disease 1426
Health-related quality of life 1220, 1246, 1256
Heart
defective 202
disease, ischemic 113
failure, congestive 113, 152, 180
Hellum's study 896
Hemangioblastoma 132, 1379, 1383, 1386, 1387, 1532
Hemangioendothelioma 1364
Hemangioma 1327, 1335, 1364
capillary 241f
cutaneous 254
Hemangiopericytoma 1377, 1378
Hematocrit
levels 1151
low 277
Hematogenous seeding 1473
Hematologic diseases 1114
Hematoma 380, 383, 637, 797
epidural 191, 637, 856, 1506, 1519
expansile 682
extraosseous 1233
formation 1550
extradural 648
small amount of 1062
Hematopoietic stem cells 394
Hematoprogenitor cell populations 394
Hemicord 246
Hemicorporectomy 762
Hemiepiphysiodesis, convex anteroposterior 1127
Hemilamina 214
segmented 214
Hemilaminectomy 805, 889, 920
Hemimetameric segmental displacement 214
Hemimyelocele 212
Hemimyelomeningocele 212
Hemisacrectomy 1346
Hemivertebra 201, 203, 215, 1130, 1132, 1481
congenital 272
posterior 1126
resection 1127, 1132, 1135
surgical technique 1128
single 1130, 1135
types of 213f
Hemodynamic
instability, exacerbation of 652
state, unstable 116
Hemoglobin
levels 1448
recovery 156
Hemolytic reaction 155
Hemorrhage 139, 1395
epidural 717
subarachnoid 1395
Hemorrhagic complications, risk of 1403
Hemorrhoids 720
Hemostasis 637, 1062, 1387, 1470, 1551
Hemostat, use of 639
Hemostatic agent 486, 1386, 1387
collagen based 415
Hemothorax 973
Hernia
diaphragmatic 202
incisional 1051, 1091, 1289
Herniated lumbar
disc 747
intervertebral disc 1232
Herniated nucleus pulposus 1046
Herniations 885
Heterotopic ossification 725, 753, 897, 1064
development 1062
incidence of 1064
long-term complications 725
Hiccups 191
High cervical spine surgery, IONM during 142
High energy lower lumbar spinal traumas 971
Hindbrain herniation 554f
Hinge fracture after laminoplasty 1506f
Hinge joints 1026f
Hip
adductors 67, 68
arthritis 918
severe bilateral 333f
dysplasia 345
extension, maximum 944f
flexor weakness 1556
fractures, risk of 1269
joint
deformity 360
test 1114
osteoarthritis 917
Hippocrates’ traction 1164
Histone deacetylase 1337
Hitching sutures 1386
Hla-b27 test 1114
Hoarseness 1502
Hodgkin lymphoma 1339
Hoffman's reflex 82
Hoffman's sign 63f, 63, 454, 918, 1060
Holt-Oram syndrome 201
Homografts, use of 792
Honeycombed appearance 1335
Hooke's law 36
Hormonal therapy 395
Horn cells, anterior 1486
Horner's syndrome 122, 124
Hospital-acquired pneumonia 155
Host cells 415
Human
body, biomechanical properties of 36
embryology 17
embryonic stem cells 657, 697
lifespan, typical 112
sacrum 758
Hunter syndrome 343, 345
Huntington disease 476
Hurler's syndrome 343, 344, 345f
Hyaline cartilage 864
Hyaluronidase, infusion of 1012
Hybrid graft 391
Hybrid procedures 483, 480, 484
Hydrocephalus 209, 239, 268, 270
severity of 272
Hydrocephaly 1153
Hydrogels, injectable 899
Hydrogen peroxide 696
Hydromyelia 200, 270
Hydrostatic pressure 1030
Hydrostatic theory 297
Hydrosyringomyelia 1153
Hydroxyapatite 383, 389, 485
tricalcium phosphate 412
Hydroxyprolinuria 713
Hygiene-dietary rules 318
Hyoid bone 431, 432f
Hyperalgesia 157
Hyperalimentation 1152
Hyperextension injury comprises 363
Hyperglycemia 191, 708
Hyperhidrosis 121
Hyperintensity 1429
Hyperkyphosis 318, 1138, 1139, 1147, 1153, 1207, 1483
Hyperlordosis 185, 273, 311, 338, 1148, 1153
accentuate 1207
concurrent 1139
isolated 1138
lumbosacral 337, 340
severe 1139
Hyperlordotic cages 826
Hyperlumbar lordosis 276
Hypernephroma 1362f
Hyperosmolar dextrose 189
Hyperparathyroidism, primary 1307
Hyperplasia, erythroid 208
Hyperplastic unilateral occipital condyle 223f
Hyperreflexia
lower extremity 918
multiple areas of 72
Hypertension 113
Hypertrichosis 254
Hypertrophic degenerative disc disease 804
Hypesthesia lasting 1560
Hypnosis 113, 719
Hypoalbuminemia 724
Hypocaloric feeding 709
Hypochondroplasia 216
Hypodense mass 511
central 511
Hypofractionated stereotactic body radiotherapy 125
Hypogastric plexus, superior 735f, 736, 792, 797
Hypoglossal canal 534
Hypoglossal nerve 534
Hypoglycemia, risk of perioperative 116
Hypointensity, heterogeneous 1429
Hypokalemia, post-traumatic 650
Hypopharyngeal injury 683
Hypoplastic
atlas 208
posterior arches 226
Hyporeflexia 59
Hypotension 663
intraspinal 296
severe 722
Hypothesis 876
Hypovolemia 708
I
Iatrogenic problems, treatment of 794
Idiopathic curves, surgical management of 1276
Idiopathic scoliosis, treatment of 172
Ifosfamide-adriamycin-platinum 1338
Ileus 797, 1196
Iliac artery 404
external 1469
internal 1469
thrombosis 1469
Iliac circumflex artery, deep 1469
Iliac crest 97, 185, 373, 395, 736
arterial injury 373
autograft 400, 482, 892, 896
strips of 557
bone graft 371, 383, 415
anterior 375f, 389, 448f, 1501
autologous 821
harvest, posterior 1501
procedures 1501
nerve injury 374
pain 373
Iliac screw
safe placement of 768
technique and placement 768
Iliac spine
anterior inferior 767
anterior superior 49, 281, 374, 791, 1501
posterior superior 50f, 70f, 185, 767, 1144, 1145f, 1312, 1501
Iliac vein 404, 787, 797
Iliac vessels 789
Iliac wings, osteotomy of 1154
Iliopsoas 788
Ilium 978
anterior 372
posterior 373
posterolateral cortex of 1317
Imatinib 1329, 1338
Immune
diseases 1395
stimulant muramyl tripeptide phosphati-dylethanolamine 1336
Immunomodulation, transfusion-related 155
Implants
anterior 1027
posterior 1023
In situ arthrodesis 1218, 1219
In situ spinal fusion 943
In vitro studies 414
In vivo animal studies 835
In vivo resorption 384
Inadvertent durotomies
small 1529
treatment of 1531
Incidental durotomy
management of 1518
prevention of 1518
Incision
retroperitoneal approach, midline 789
single 284f
Incubated macrophages, autologous 665
Index finger proximal interphalangeal joint 63f
Indocyanine green, intraoperative 1396
Indwelling catheters 720
Infantile idiopathic scoliosis 1482
Infection 1310
acute 1502
chronic 1418
low grade 10
signs of 58
surgical site 106
Inflammation, attenuation of 663
Inflammatory cells, number of 1448
Inflammatory cytokines 876
Inflammatory disease 42
Inflammatory disorders 111
Infliximab 359
Inguinal ligament 375f
Injection
epidural 834, 835, 1260
techniques, host of 446
Insomnia 191
Instrumented pedicle screw trial 934
Instrumented vertebra, upper 1287
Insulin 708
growth factor-1 12
pumps 1266
requiring diabetes 152
Integrated rehabilitation program 727
Integrated scoliosis rehabilitation 1169
Integrity, structural 382
Interbody cage 46, 414, 795, 818, 943, 946
development of 795
insertion 1561
placement 52
Interbody correction, anterior 1199
Interbody fusion 393, 737, 814, 819, 884, 935, 1281
anterior 365, 792, 886, 892
cages 751
rest, lateral 826
lateral 742, 936, 1290, 1291, 1563
minimally invasive lateral 1570
multilevel 885
posterior 894
approach 1469
procedures, revision 1494
solid 805
technique 1465
anterior 792
lateral 825
types of anterior 792
Interbody graft 382, 565567, 1222
adjacent level 1247
device 809
use of 1291
Interbody implant placement, segmental 823
Intercostal muscles, closure of 1195f
Interdisciplinary rehabilitation team 716
Interlaminar
fusion 1570
route 94
scar tissue 850
space 844, 1502, 1527, 1548, 1550
window 746
International Standards for Neurological Classification of Spinal Cord Injury 649, 717
Interosseous nerve entrapment, anterior 456
Interphalangeal joint, distal 63f
Interspinous
distraction techniques 923
implant 1024, 1026f, 1031
ligament 24, 358, 950
process
devices 51
distance 51
distraction of 924
stabilization, use of 924
Interstitial lamellae 381
Interventional pain management 1012, 1260
procedures 1260
role of 1260
Interventional Pain Societies 94
Intervertebral disc 21f, 35, 86, 87, 188, 198, 206, 863, 876, 915, 1228, 1537
anterior 3
biochemistry of 5
bulging, cadaveric evaluation of 1041
degenerating 864, 876
development 18
disease 331
injury 581
innervation of 11f
lesions 885
physiology of normal 863
spaces 1346
Intervertebral wedge, osteotomy types of 1299
Intestinal dysfunction 907
Intestine, small 685
Intracellular messengers, secondary 692
Intracellular signaling mechanisms 693f
Intracranial tumors, benign 128
Intradiscal electrothermal therapy 99, 879, 879f
procedure 99
Intradiscal hydraulic pumping mechanism 898
Intradural
intramedullary tumors 1375, 1385t
lesions, benign 131t
tumor, asymptomatic 1384
Intralesional curettage 13331335
Intralesional excision 1327, 1328, 1369, 1371, 1372
Intramembranous ossification, process of 380
Intraoperative monitoring techniques 160
Intraoperative neurologic loss, management of 1481, 1492
Intraoperative systemic anaphylaxis, severe 270
Intraoperative wake-up test 160, 161
Intraosseous screw placement 1096
Intraspinous ligament 562
Intravenous anesthesia, total 139
Intubation, fiberoptic 140
Iohexol 461
Ion channel blockers 695
Ionotropic receptors 692
Iridocyclitis 358
Iris hamartomas 1382
Ischemia 142
management of 153
temporary period of 692
Ischemic heart disease, stable 152
Ischemic optic neuropathy, posterior 160
Ischiorectal fossa 1421
Ischium 725, 978
Isler system classify sacral fracture 981
Isoniazid 1430, 1431
Isotonic saline 1012
Isthmic spondylolisthesis, treatment of 794
J
Jackson table 1565, 1569
Jamshidi needle 775, 780, 1566
Japanese Orthopaedic Association 477, 493
Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire 179
Japanese Orthopaedic Association Scale 179
Jaw-jerk reflex 475
Jeanneret and Hacker's technique 543f
Jefferson fracture 616, 617f
Jejunal feeding tube 709
Jewett brace 174f, 952, 953f
Jewett hyperextension brace 590
Joint
anatomy 19
iliosacral 1471
Jugular vein 404
Junctional kyphosis, progressive 1306
Juxta-articular fluid 99
Juxtapedicular screw position 1098
K
Kainate 692
Kambin's triangle 95, 878, 1546, 1546f, 1557, 1557f, 1558, 1560, 1561
dimensions of 1560
Karnofsky performance status scale 1369t
Karnofsky score 1367
Katagiri classification 1368
Keratin sulfate 6
side chains 6
Kerrison bites injury 1468
Kerrison punch 464, 850, 921
image-guided 1591
Kerrison rongeur 361, 423, 559, 1296, 1301, 1351, 1457, 1506, 1527, 1529
Ketamine 158, 160, 719
potentiates 159
Keyhole hemilaminectomy technique 920
Kidney
injury, perioperative acute 155
lie beside 736
stones 722
Kinesiophobia 583
Kinetic energy 688
King classification 1174
Kirschner wire 740, 782, 1567
technique of placing 1178f
Klebsiella 1502
pneumonia 1473
Klippel-Feil
abnormalities 605, 606
anomaly 212, 250
classification 210
deformity 251
syndrome 201, 202, 208, 210, 228, 229f, 297
incidence of 220
Klopfenstein 822
Knee
jerk reflex 58
osteoarthritis 1249
Kniest dysplasia 346
Kniest syndrome 342
Knutsson, clinical signs of 317
Kocher camps 422
Kostuik's series 1562
Krebs cycle 696
Kurz's study 933
Kyphectomy 286
Kyphoplasty 332, 1591
technique 308, 1310
use of 309
Kyphoscoliosis
poses 1483
progressive 287
Kyphoscoliotic deformity, severe 285
Kyphosis 273, 641, 924, 955
acute 627
congenital 215
correction 1095
development of 1441
distal junctional 501, 643
flexible 1492
global rounded 1422
juvenile 316, 319
measurement of 961
pathological 316
postlaminectomy 563
postoperative 493
post-traumatic 564
progressive 973, 1306, 1318
Kyphotic alignment 493f
Kyphotic deformity 361f, 364f, 513, 970, 1422, 1442f
fracture 1413f
postoperative 514
post-tubercular 1442f
severe 279f, 359
Kyphotic segments 1108
Kyphotic spine 493f
Kyphus correction surgery 1441
L
Labiomandibuloglossotomy 423
Labral tears 1006
Laceration, dural 1456, 1457
Lactic acid 864
Laden macrophages, lipid 1448
Lambdoid synotosis types 297
Lamellar bone 1330
Lamina 3, 747, 845
contralateral 1529f
facet junction 497
removal of 493, 818
screws 45
Laminar defect 200
Laminar hooks 775
Laminectomy 332, 382, 493, 499, 638, 746, 848f, 920, 935, 1023, 1087, 1230, 1299f, 1365, 1435, 1545, 1563
bilateral 1398
defect 1302
multilevel 1532
procedures 430
total 748f
unilateral 745, 746
Laminoforaminotomy 467, 1590
endoscopic 1529f
lateral 1523
posterior 463, 1523
Laminoplasty 493
caudal end of 498
double door 1505
minimally invasive 1531
open-door 514, 1505
procedure 495
technique 514
Laminotomy 748, 748f, 1545
ipsilateral 750
modern unilateral 751f
multiple 748
Langdown's case series 1000
Langenbeck hooks 791
modified 791
Langer's lines, 432
Langerhans
cell histiocytosis 1335
giant cells 1418
Large lumbar lordosis 1247f
Larsen's syndromes 231
Laryngeal nerve
injury
recurrent superior 1502
superior 1503
recurrent 140
superior 435, 526, 639
Lasègue's sign 69, 69f
crossed 69
Lasegue's test 1114
Laser denervation 94
Latissimus dorsi 22, 122, 459, 733, 788, 1439
division of 1187
muscle 733
Le Fort osteotomy 552
Leg pain 822f
bilateral 9f, 1222
progressive 1286
Leg raise, straight 68, 1114
Lemniscus, lateral 138
Lenke classification 1175f, 1181
system 1200
Lenke curve 1095, 1280
pattern 1280
Leriche's syndrome 917, 918
Leucocyte cell adhesion molecule, activated 395
Leukopenia 708
Lhermitte's sign 64, 64f, 477, 1388
Lidocaine 89, 115, 188, 719
Ligament
anatomy of 22
intertransverse 24
ossified yellow 1483
structure, posterior 805
Ligamental laxity 1507
Ligamentoplasty 894, 1023
Ligamentous complex
integrity, posterior 963
posterior 651, 960, 970
Ligamentum flavum 24, 87, 358, 472, 493, 503, 508, 513, 562, 611, 749, 818, 915, 920, 924, 950, 1035, 1071, 1313, 1457, 1519, 1529, 1550
ossified 1464
resection of 632
Ligamentum nuchae 611
Light-emitting diodes 1573
Lignocaine 98
Limb
contractures, lower 270
girdle muscular dystrophy 1155
salvage 113
Linea alba 792
Lipid peroxidation 139, 648, 692
Lipid peroxidation inhibiting properties 656
Lipoma 241, 247, 258, 262, 1379
intradural 212, 242
intramedullary 243f
subcutaneous portion of 259
Lipomyelocele 212
Lipomyelomeningocele 201, 212, 240, 241f, 242, 243f, 244, 248, 258, 259, 262
type of 259
Lipomyeloschisis 240, 241
Lipoxygenases 693
Liquefied collagen 526
Liquid gelfoam 503, 539
Liquid polyurethane, prepared 869
Listhesis 963, 1277
Locomotor functions 697
Longissimus 747
thoracis muscles 745
Longitudinal ligament
anterior 433, 554, 818
ossification of
anterior 358
posterior 492, 507, 513, 1071, 1482, 1515, 1524
posterior 480, 510f, 512f, 818, 962, 1090, 1186, 1517f, 1525, 1538
Longus capitis 29
Longus colli 61, 435, 1524
muscle 22, 423f, 468f, 483f, 554, 639, 1061, 1435, 1502, 1524
medial part of 466
Loperoxidase levels 696
Lordosis 638, 641, 886
congenital 215
corrective 46
loss of 185
Lordotic 490, 870
cervical spine 1492
segments 963
Loupe magnification 464
Low back pain 5, 108, 190, 806f, 863, 910, 946, 946f, 1347f
acute 188, 189
axial 86, 882
causes of 331t
chronic 189191
discogenic 99, 813, 924
etiologies of 1114t
mild 843f
nonspecific 1114
Low grade lumbar degenerative spondylolisthesis
classification systems 931
clinical presentation 931
complications 938
costs 938
etiology 930
operative
approaches 932
indications 932
Low growth hormone levels 710
Low molecular weight heparin 157, 1449
Lowest cord-mediated reflex 960
Lucencies across interbody endplate 1510
Lumbar 25
Lumbar alignment 1244
Lumbar arthroplasty device, unconstrained 1045f
Lumbar burst fractures, lower 971
Lumbar canal stenosis 915
Lumbar curve 31, 1275
idiopathic like 273
progressive 275
secondary 1133f
Lumbar deformity correction places 144
Lumbar degenerative disc disease 886
diagnostic workup 882
nonoperative management 883
surgical management of 882
surgical treatment 884
Lumbar degenerative spondylolisthesis, operative treatment of 930
Lumbar disc
arthroplasty 52
prostheses 1590
disease 111
herniation 72, 452, 829, 830f, 1116, 1230
complications 851
critical evaluation 851
diagnosis of 1116
juvenile 1117
natural history of 829
nonoperative treatment of 829
open operative treatment of 841
postoperative care 851
surgical treatment of 841
replacement 1043
complications 1051
diagnostic evaluation 1046
postoperative care 1052
surgical technique 1048
surgery 1461, 844f
Lumbar discectomy 1010, 1469, 1549
laparoscopic 786
Lumbar dural tear, treatment strategies for 1460
Lumbar fractures, lower 970
Lumbar fusion 105, 412
anteroposterior 787
posterior 896, 935, 1556
surgeries 1588
Lumbar hyperextension 10
Lumbar hyperlordosis 338, 1153
Lumbar hypolordosis 365
Lumbar injuries, lower 970, 972, 975
Lumbar instrumentation procedures, posterior 750
Lumbar interbody
devices 1471
fusion 892
anterior 50, 781, 786, 793795, 798, 818, 885, 887f, 921, 935, 1007f, 1043, 1054, 1222, 1235, 1280, 1289
axial 752, 1290
lateral 818, 821, 822
posterior 50, 277, 750, 751f, 804, 809f, 810, 813, 888, 935, 1235, 1289, 1441, 1482
technique, lateral 819, 1556
Lumbar internal fixation, technique for posterior 775
Lumbar lordosis 31, 185, 972, 1143, 1241, 1245f, 1249
loss of 1285, 1286
maximum 1249
Lumbar lordotic curvature 1248
Lumbar neurology 68
Lumbar nucleus pulposus replacement 863
Lumbar osteotomy 360, 573
Lumbar pain
chronic 192
subacute 192
Lumbar paraspinal
muscles 1009
musculature 1547
Lumbar pedicle
insertion 777
screw 776
and iliac screw 984
insertion of 777
screw fixation 771
anatomy 771
complications 774
design and biomechanics 772
minimally invasive techniques of 775
surgical technique 773
subtraction osteotomy 360
Lumbar periradicular injection 96
Lumbar plexus 27
injury 822
representation of 735f
Lumbar posterior dynamic stabilization devices 1038
Lumbar preoperative pathology 1006
Lumbar psoas abscesses 1420
Lumbar puncture 697
Lumbar radiculitis 191
symptoms 191
Lumbar radiculopathy 458
Lumbar region 30, 908
Lumbar sacral junction 1249
Lumbar schwannoma 1381
Lumbar scoliosis 1330f
degenerative 739
Lumbar scoliotic stenosis 1260
Lumbar segmental
arteries 404, 1469
vessels, ligation of 1191f
Lumbar spinal
injections 190
pathology, evaluation of 68
stenosis 80, 907, 921, 1475f
clinical presentation 916
complications 922
decompression of 1550
degenerative 1545
imaging 918
indications 919
open operative treatment 915
pathophysiology 915
surgery for 922
treatment of 924
Lumbar spine 21, 38, 42, 188, 190f, 258f, 736f, 788, 831, 917f, 1044, 1048f, 1089, 1588
aging 3
anatomy of 17, 26f
anterior 788, 790, 888
concomitant injuries of 683
cortical screw fixation of 779
disorders 185
differential diagnosis 187
treatment 187
evaluation 66
failure of 38t
flexion 918
fractures 959, 1229
lower 970
fusion 106, 893
posterior 105
injury 675, 1229
levels of 1048f
ligamentous structures of 24f
lower 791, 813
mobile 1417
osteoblastoma of 1333f
surgery 1005
upper 788, 1189
Lumbar spondylolisthesis, operative treatment of 942
Lumbar spondylolysis 12321234
prevalence of 1232
Lumbar spondylosis 917
Lumbar stenosis 475, 917t, 918, 920
nonoperative treatment of 907
therapeutic options for 908
Lumbar surgery, minimally invasive 1545
Lumbar sympathectomy 121
Lumbar transfacet screw, ipsilateral 779
Lumbar tuberculosis, type of 1418f
Lumbar vascular complications 1469
Lumbar veins 28
Lumbar vertebra 35, 734, 787
Lumbar vertebral body 358
lower 1154f
Lumbar Z-joint 191
Lumbopelvic reconstruction techniques, multiple 760
Lumboperitoneal shunt 1000
Lumbosacral
angles 1225
deformity 943
fixation, types of 768
fractional curve 1282
fusion 1312
rates 767
junction 1132, 1312
orthotics 1259
plexus 25, 98
injury 820
lies 818
region 253, 259f
screws 1317
segment 1465
spinal lesion 753
Lumbosacral spine 244f, 737, 738f, 741, 744, 753, 1469
musculotendinous anatomy of 744
neuroskeletal anatomy of 745
posterior 747t
surgery
complications of 1464
surgery, IONM during 143
Lumbosacral surgery, minimally invasive 752
Lumbosacral transitional vertebra 1466
Lumbosacral trunk 27, 767
brace 1232
Lunatic fringe 202
Lung
cancer 1360f, 1364
function 1196
injury
acute 1448
transfusion-related acute 155, 1448
parenchyma 1082
ventilation, single 1109, 1535, 1537
Luque improved spinal fixation 766
Luque instrumentation 311, 1177f
Luque rectangle fixed 557
Luque rod instrumentation 1143
Luque system Galveston pelvic fixation 1156
Luque technique 767
Luque wires 1094
Luque-Galveston construct 281
Lymphatic system 734
Lymphocytes 1418
Lymphocytopenia, peripheral 1505
Lymphoma 130, 1339, 1344, 1364
Lysosomal enzyme iduronate-2-sulfatase 345
Lytic 1364
lesion 1364, 1365
tumors 1328
M
Macrofistulas 1393
Macrophage
autologous 665
transplantation 698
Macrosurgical exposure surgery 752
Magerl transarticular screw, posterior 529
Magerl's classification 951
Magerl's fixation 1507
Magerl's fusion 353
Magerl's screws 47, 1507
Magerl's technique 47
Magnesium 664, 708
Magnetic cortical stimulation 78
Magnetic neck stimulation 78
Magnetic resonance imaging 572, 845, 1115, 1121t, 1266, 1372, 1580
Malalignment, type of 642
Maldevelopment, partial unilateral 214
Malignancy
grade of 1369
hematologic 1339
Malignant tumor, primary 421, 1122, 1336, 1344
Mandibuloglossotomy 424
Mandibulotomy visualizes 423
Mantoux test 1426
Marchetti classification 1212t
Marchetti-Bartolozzi spondylolysis classification 1212
Marie-Strumpell disease 358
Maroteaux-Lamy syndrome 343, 345
Marrow infiltration 331
Mass fixation, lateral 538
Mass fracture, lateral 47, 633
Mass lesions, intracranial 296
Mass screw
fixation, lateral 538
lateral 47
Massage therapy 459
Massive edema 641
Matrix degrading enzymes 817
Matrix metalloproteinases 6
Matrix synthesis, rate of 10
Maxillotomy 423, 553
approach, open-door 552
Mayfield clamps 432
Mayfield skull clamp secures 1386
Mayfield tongs 496, 503, 1501
McCormack developed load 653
McGregor's line 208
Mechanistic classification scheme 628
Medial facetectomy, unilateral 805
Medulla spinalis 25
Membrane lipid peroxidation produces 692
Menigiomas 1382
Meningeal cysts 997
extradural 997
Meningeal diverticula 999
Meningioma 131, 1377, 1388, 1532
Meningitis 1461
Meningocele 212, 219, 239, 240, 254
intrasacral 240
Mental
disorders, statistical manual of 1451
planning 853
Meralgia paraesthetica 1556
Mesenchymal
cells 197, 892
pluripotential stem cells 394
somitocoele 18f
stem cells 394, 412, 893
stromal cells 386
Mesenteric artery
superior 1469
syndrome, superior 360
Mesoblastic cells 220
Mesoderm 240
Mesodermal asymptomatic anomalies, minor 208
Mesodermal defects 297
Mesodermal symptomatic anomalies, minor 208
Metabolic
derangements 647
diseases 337
equivalent task 152
terms of 152
syndrome 103, 105, 722
Metal artifact 1266, 1579
Metal endplates 1052
Metallic spacers 498
Metalloproteinases, tissue inhibitors of 6
Metastasis 1344, 1378
Metastatic cord compression 1361f
Metastatic disease 111, 132, 1089, 1348, 1370t
treatment of 126
Metastatic melanoma 129f
Metastatic neoplasm 1541
Metastatic tumors 130t, 544, 1364, 1535, 1592
of spine 1358
Metatropic dysplasia 342
Metaxalone 188
Methicillin-resistant staphylococcus aureus 1009, 1151, 1272
Methotrexate 359, 1336, 1379
Methylene blue 1503
Methylprednisolone 88, 663, 694, 695
acetate 88
bolus 695
sodium succinate 654, 655, 663
treatment 695
Meticulous hemostasis 788, 1080, 1525, 1550
Metzenbaum scissors 1187
Miaspas mini ALIF retractor 792
Microarchitecture of bone 1309
Microblade shaving system, flexible 922
Microbone saw 425f
Microcervical curette 1527
Microcysts 1379
Microdiscectomy 176, 1230
Microendoscopic cervical procedures 1523
Microendoscopic decompressive laminotomy 1550
Microendoscopic discectomy 1230, 1546
technique 841
Microendoscopic procedures 1526
Microendoscopic techniques 1524
minimally invasive 1552
Microfractures 331
Micrometastatic deposits, growth of 1358
Micronerve hook 497
Microsomal cytochrome p-450 system 692
Microsurgical discectomy 851, 1230, 1545
Microsurgical techniques 841
consist of 752
Midazolam 160
infusion 160
Midcervical pedicle screws 544
Midface hypoplasia 338
Midjugular veins 433
Midlumbar
curve 1563
spine 1563
Midodrine 722
Mid-thoracic back pain 1090f
Mifamurtide 1336
Migration, implant 1561
Milwaukee brace 172, 318f, 1165, 1165f
Mimic cervical radiculopathy 65
Minerals 389
Minerva casting 674
Minerva jackets 630
Minerva-type orthosis 309, 310
Miniaturized speculum-counter-retractor system 844
Minimally invasive
options, several 1570
spine surgery, evolution of 1546
techniques
goals of 775
posterior 889
Minneapolis 869
Minnesota multiphasic personality inventory, mean 1010
Minocycline 647, 655, 656, 664, 696
Miscarriage 271
Mitochondrial swelling 696
Mitogenic signaling 1334
Mitogens 12
Mitosis 1379
Monitoring corticospinal tract function, technique for 136
Mono radiculopathies, incomplete 978
Monoaxial screw systems 973
Monocyte coincubation 665
Monopolar cautery 789, 1083
Monopolar electrocautery 1579
Monopolar electrocoagulation, use of 797
Monosegmental fusion 946, 947
Monosegmental segmentation defect 1127
Monosialotetrahexosylganglioside 695
Mood 726
Morbid obesity 1060, 1258
Morel-Lavallee syndrome 979
Morphogens, chondrogenic 12
Morquio's mucopolysaccharidosis 216
Morquio's syndrome 232, 343, 344, 915
Morquio-Brailsford syndrome 208
Motion 29
preservation strategies, biomechanics of 1023
sparing technologies 925
Motion-tracking techniques 870
Motor axons 76
Motor column, median 199
Motor conduction time, central 77, 78
Motor deficits 453
distal 819
Motor denervation level 268
Motor evoked potential 945, 1396
Motor function 763, 960, 1541
Motor incomplete 717
Motor nerve emeres 1380
Motor neuron
gene 1154
lower 720
pathology, upper 57, 65
upper 720, 918
Motor testing grading 58t
Motor unit potential 77
Motor vehicle
accidents 678, 970
collision patients 582
crash 612
Motor weakness 454, 518, 1560
Motorcycle accident 617f
Motor-evoked potentials 78, 160, 360, 1483, 1486, 1490, 1487f
Mouth retractor 425f
Movement disorders 476
Mucin 1364
Mucolipidosis 345
Mucopolysaccharides 864, 1119
Mucopolysaccharidosis 343t, 344346
Multicenter spine fracture 952
Multidrug-resistant tuberculosis 1430
Multifidus 734, 747
lumborum fans 745
Multilevel injuries 1229
Multilevel laminoplasty, minimally invasive 1531
Multilocular cysts 1122
Multinucleated osteoclast-like giant cells 1334
Multiorgan disorder 213
Multiplanar fixation 1281
Multisegmentation defects 1132
Multivitamins 1271
Mupirocin 1272
Muscle 136
anatomy of 22
cells, death of 1155
deep 734
iliacus 375f, 734
iliocostal 788
imbalance 1139
injury 581
iatrogenic 1556
intercostal 1188f
proteins 1155
relaxants 187, 458, 833, 911, 1271
spasm 834
splitting techniques 745
sprain 911
strength, enhancement of 1216
stripping 1532
weakness 191, 351
Muscular avulsions 600
Muscular dystrophy 1152, 1155
congenital 1155
distal 1155
facioscapulohumeral 1155
Muscular fatigue, chronic 444
Muscular instability 744
Muscular pain 444
Muscular testing 58
Musculature development 18
Musculoligamentous element stretching 1507
Musculoskeletal pain, chronic 189
Musculoskeletal system 351
Musculoskeletal Tumor Society 1345
Mycobacterium
bacilli 1418
tuberculosis 1417
Mycosis 1395
Myelin proteins, leakage of 698
Myelin-associated protein 698
Myelocele 212, 240
Myelocystocele 212, 219, 248
terminal 212
Myelodysplasia 295
Myeloma 130, 1365
multiple 1339, 1344
Myelomalacia 1429
Myelomeningocele 17, 200, 212, 239, 240, 247, 254, 255f, 266, 269, 277, 1153
closure of 272
guiding principle of management of 271
incidence of 268
nonsurgical treatment of 266
pathogenesis 266
postnatal management 271
prenatal diagnosis 270
presentation 268
sac 254
spinal deformities 271
management of 272
surgical treatment of 266
treatment protocols of 266
Myelopathic symptoms 63
Myelopathy 447, 495f, 502f, 1064, 1483
grading 351
hand 473
manifestation of 1381
mild 1060
Myeloradiculopathy 472
Myelotomy 1386
Myocardial infarction 352, 1448, 1451
nonfatal 151
Myocardial ischemia, incidence of 1267
Myofascial pain 187
Myogenic motor responses 1487
Myogenic TCE-MEPs, loss of 142
Myotomal distribution 77, 82, 604
Myotomal weakness 1060
Myotomes 18, 197, 474
Myotonic muscular dystrophy 1155
Myxopapillary ependymoma 1344, 1378
N
N-acetyl-galactosamine-6-sulfate sulfatase 343
Naked facet sign 962f
Naloxone 654
Napoleon hat sign 1214f
Narcotic analgesics 1259
Nasojejunostomy tubes 1152
Nasotracheal intubation, fiberoptic 553
National Acute Spinal Cord Injury Studies 655, 663, 695
National Emergency X-Radiography Utilization Study 627, 649
National Health and Nutrition Examination Survey 1562
National Health Policies and Screening Programs 271
Navigated pedicle screw fixation, technique of 1580
Neck
disability index 48, 179, 1062
neutral fiberoptic intubation 432
pain 453, 473, 597
axial 444t
reveals pulsatile bleeding 682
soft tissues 1502
Necrotic tissue, Debridement of 1476
Needle
manipulation technique 89
types of 89
Nelaton's soft catheters 422, 425f
Neoadjuvant chemotherapy 1338
consist of 1349
Neoplasm 42
primary 1114
secondary 1114
Neoplastic disorders 1114
Nerve 735
coccygeal 25
compression syndromes 473
conduction
studies 76
velocity 1011
fibers 76
combinations of 1378
distribution of 877
nociceptive 865, 877
iliohypogastric 735
ilioinguinal 735, 1501
injury 191
permanent 797
risk of 805
intercostal 1439
irritation, signs of 1409
median 107f
plexus, hypogastric 1492
proximal auditory 138
pudendal 1317
root 128, 145, 430, 454, 875, 1359, 1464, 1506
block, selective 94, 460, 477
canal stenosis 748
damage, bilateral 805
diverticula 997
entrapment 1461
impairment 60
injection, selective 191, 460, 835f
injuries 140, 539, 879, 1551
irritation 638
lie 1465
selective 477
sleeve dilations 997
sacral 25
sheath tumors 1349, 1387
sinuvertebral 10, 11f, 876, 877
stimulation, median 80
zygomaticotemporal 592
Nervous system 25, 712
Nervus furcalis 27
Neural arches
absence of 18
duplicated 245, 245f
Neural crest 203
cells 197
Neural decompression, indirect 1556, 1563
Neural elements 39, 262, 475, 1493
decompression of 972
Neural foramen 87
encroachment 452
inferior 96
size of 924
Neural foraminal decompression 1496
Neural growth 877
Neural stem 692
Neural tube 203
closure 259
defect 200, 203, 266, 268
embryogenesis of 267
etiology of 267
prevention of 268
repair of 269
types of 266
fusion of 207
Neuralgia
ilioinguinal 1501
intercostal 973, 1083, 1535, 1541
Neuraxial analgesia, use of 159
Neurenteric cyst 212, 219, 240
Neuroaxis, dorsoventral differentiation of 199
Neuroblastoma 1122
Neurocentral synchodrosis 675
Neurodegenerative diseases 136
multiple 656
Neurodegenerative disorders 477
Neuroendocrine tumor 1378
Neurofibroma 131, 1344, 1378, 1532
Neurofibromatosis 208, 1383, 1483
Neuroforamen, posterior aspect of 921
Neuroforaminal compression 916
Neuroforaminal decompression 464
Neuroforaminal stenosis 805, 808, 916
causes of 916
Neurogenic bowel dysfunction 720
Neurogenic claudication 817, 916, 974f, 1254, 1261, 1285, 1306
symptoms of 916
Neurogenic D-wave 136
Neurogenic motor-evoked potential 1488
Neurogenic shock 691
Neurologic complications
incidence of 797
risks of 1482t
Neurologic compromise
absent 1371
present 1370
Neurologic decompression 565
Neurologic deficit 259, 518, 818, 938, 981, 1152, 1257, 1261, 1456
severity of 664
etiology of 638
Neurologic disturbances, majority of 1451
Neurologic dysfunction, mechanism of 1409
Neurologic impairment, severity of 1138
Neurologic injury 160, 605, 1464, 1477, 1492
mechanisms of 1484
secondary 597
Neurologic intraoperative monitoring 1484
Neurologic irritative signs 1222
Neurologic loss, intraoperative 1495fc
Neurologic signs 1046
Neurologic structure, anatomy of 25
Neurological complications 503, 939, 956
Neurological deficit 267, 633, 764, 1388, 1424, 1425, 1440f
progressive 351
Neurological examination 241, 1381
Neurological injury 1152
incomplete 686
risk of 631
Neurological signs 1381
Neurological success 1054
Neurological surgeons guidelines, congress of 650
Neurological symptoms 480, 1359
Neurolysis 850
Neuromonitoring
intraoperative 135, 575, 1177, 1494
modalities 139
techniques 135, 1465
Neuromuscular blockade 160, 1489
degree of 139
Neuromuscular disease 1138, 1140, 1141
consideration 1152
Neuromuscular disorder, prevalent 1152
Neuromuscular junction 59, 160
blockade 1489
Neuromuscular paralysis 709
Neuromuscular region 72
Neuromuscular scoliosis 172, 273, 1138, 1142, 1143, 1151, 1157
instrumentation 1143f
treatment of 1143
Neuronal apoptosis 698
inhibitory gene 1154
Neuronal cell 695
membranes 695
Neuronal necrosis 139
Neuronal plasticity 695, 697
Neuronal regeneration 698
Neurons synapse 121
Neuronspecific enolase 1379
Neurophysiologic monitoring, routine intraoperative 774
Neurophysiological monitoring 1386, 1500
intraoperative 135, 141
Neuropraxia 606, 827
injury 1507
stretch-induced 1502
Neuroprotection 657
agents 647, 656, 664, 694
Neuroprotective agents, numerous 654
Neuroprotective pharmacologic therapy 657
Neuroradiologists, armamentarium of 1396
Neuroskeletal anatomy 746
Neurotrophins 877
Neurovascular structures, adjacent 1465
Neurulation
primary 240, 266, 267
secondary 240, 259, 266
Neutral vertebra 1280
Neutropenia 708
Neutrophils 693
immature 708
Newton's first law 36
Newton's second law 36
Newton's third law 36
NEXUS clinical criteria 445t
NEXUS low-risk criteria 627t
Nicotine 1258
Nidus, angioarchitecture of 1399
Nifedipine 722
Night-time bracing 1166
Nimodipine 654, 695, 1403
treatment 696
Nitrous oxide 160
N-methyl D-aspartate 692
receptor antagonist 664
Noncardiac surgery 151
Noncardiogenic pulmonary edema 1448
Noncellular components 693
Nonclosure theory 267
Noncollagenous protein 863
carriers 412
Nondermatomal pain 253
Nonforaminotomy group 504
Nonfusion strategies 937
Nonfusion technique 1127, 1290
Non-Hodgkin lymphoma 1339
Nonincapacitating systemic disease, severe 114
Noninstrumented fusion 1221, 1235
Noninvasive orthoses 590
Nonkyphotic upper thoracic spine 517
Nonlethal congenital anomaly 271
Nonmicrosurgical techniques 841
Nonmissile mechanisms 681
Nonmissile penetrating injuries 687
Nonmissile penetrating spinal injuries, surgical treatment of 687
Non-narcotic analgesics 477
Nonopioid analgesics 158, 910
Nonpainful stimuli 157
Nonselective N-methyl-D-aspartate receptor antagonist 158
Nonsmall cell lung 130
carcinoma 128
Nonspinal pathology
treatment of 178
utility scores for 180
Nonsyndromic vertebral malformations 202
Nontraumatic origin 85
Nonvertebroplasty specimens 1271
Norepinephrine reuptake 1259
inhibitor, selective 187
Normal intervertebral disc, anatomy of 863
Normovolemic hemodilution, acute 156
North American Clinical Trials Network 655
North American Spine Society 190, 1062
Nortriptyline 911
Nosocomial pneumonia 1447, 1448
Notochord 17, 203
Notochordal cells proliferate 4
Notochordal induction 266
N-telopeptide 713
N-terminal propeptide 332
Nuchal lines, superior and inferior 559
Nuclear medicine studies 1474
Nucleoannular junction 99
Nucleoplasty 99
Nucleotide polymorphism, single 508
Nucleotide pyrophosphatase 508
Nucleus implant
concepts 1029f
extrusion 1030f
Nucleus pulposus 3, 21, 188, 197, 198, 836, 863, 876
extracellular matrix component of 5f
Nucleus replacement 872, 898, 1031
implant 1028, 1030f
Nucleus, removal of 872
Numeric pain score 1568
Numeric rating score 1261
Nurick's scale 496
Nursing care, postoperative 117
Nutrition 710, 1269
O
O-arm navigation system 1576, 1577f
Ober's test 1114
Obesity 103105, 187, 1258, 1551
prevalence of 103
related cancers 1258
Obstipation 1338
Obstructive pulmonary disease, chronic 154, 1267
Obstructive sleep apnea 154
development of 723
Occipital cervical
complex 669
instability 300
junction 610
Occipital condyle
embryology of 221
fractures 594, 613
malformations of 222
Occipital fixation points 534
Occipital headaches, posterior 454
Occipital plate 52
Occipital screw placement 42
Occipital vein 29
Occipital vertebrae 208
Occipitoaxial angle 534
Occipitocervical
alar ligaments 580
dislocation 592, 594, 613, 621f, 1507
Harborview classification of 614
fixation 42, 533, 555
fusion 309, 525, 672f
instability stems 42
instrumentation 1509
joint 532f
junction 614f
spine 206, 525
synostosis 208
Occlusal disharmony 427
Occult spinal dysraphism 258, 263
Oculopharyngeal muscular dystrophy 1155
Odontoid
agenesis 208
congenital anomalies of 210
dysplasia, congenital 528
fracture 44f, 595, 595f, 618, 619, 1507
nondisplaced type 2 fractures 595
old 528
pediatric 674
range 1510
hypoplasia 208, 345
process 19
fractures 674
screw fixation, anterior 43
Odontoideum 210
Olfactory ensheathing cells 657, 697
Olfactory system, glial cells of 697
Oligodendrocyte 698, 1379
progenitor cells 697
development of 199
Oliogendrogliomas 1379
Olisthesis 915
Olisthetic segment 1225
Olivary complex, superior 138
Omega-3 fatty acids 1271
Omni retractor system 788
Omphalocele 248
Ondra's technique 1247
Onlay local autologous bone 557
Opioid 113, 118, 160, 187, 446, 458, 911, 1259
analgesics 112, 113, 187, 833
antagonists 695
endogenous 190
medications 159
Oppenheim's sign 65
Optic nerve gliomas 1382
Optic neuropathy, anterior ischemic 160
Optimal annulus function in vivo 866
Optimize neuromonitoring 1493
Oral mucosa 424
Organ failure 415
Organic acid 696
Original surgical technique 804
Orthobiologics 863
Orthopedic
abnormalities 260
deformities 254, 259
deterioration 263
manifestations 323
procedures 119
surgery, computer-assisted 1572
Orthosis, lumbosacral 953f
Orthostatic hypotension 722
Os odontoideum 208, 210, 228, 674
Osmotics 189
Osseocartilaginous 245
Osseoligamentous injuries 676
Osseous
pathology 187
structures, posterior 528
tumors 186
union 863
Ossification
development, adjacent level 639
dural 511, 1519
stage 198
Ossified posterior longitudinal ligament, surgery for 1505
Osteoarthritis 114, 448f
Osteoarthrosis 1006
Osteobiologics 886, 892, 1570
Osteoblast 412
dysfunction 1307
Osteoblastoma 1120, 1121, 1329, 1331, 1344, 1364, 1573
Osteocalcin 509, 713
Osteocel plus 893
Osteochondrodysplasias 309, 310
Osteochondroma 1122, 1329, 1333
Osteochondrosis, juvenile 316
Osteoclast 412
activation of 1359
giant cells 1334
uncontrolled production of 1334
Osteoconduction 382, 383
Osteocutaneous flap 402
monitoring of 405
Osteodural craniocervical decompression, posterior 552
Osteogenesis 382
imperfecta 208, 302, 306f
spinal manifestations of 303f, 313
Osteogenic growth factors 395
Osteogenic protein-1 12
Osteogenic sarcoma 1122
exception of 1329
Osteogenin 411
Osteoid mineralization 302
Osteoid osteoma 1120, 1121, 1329, 1330, 1332f, 1344, 1573, 1593f
Osteoid tissue 1334
Osteoinduction 382, 383, 415
Osteoligamentous injury 584
Osteolysis 641
Osteolytic lesion, expansile 1334
Osteomalacia 1148, 1306
Osteomyelitis 1060, 1344, 1503, 1535
granulomatous vertebral 111
Osteopathic manipulation 1171
Osteopenia 8, 48, 351
Osteopenic bone 577
Osteopetrosis 208
Osteophyte 186, 472, 638, 817, 1059
compressive 1464
formation 3, 37, 882
upper vertebrae 484f
Osteopontin 509
Osteoporosis 114, 351, 468, 725, 898, 972, 1258, 1318
diagnosis of 1307
epidemiology of 1306
idiopathic juvenile 303
long-term complications 725
medical treatment of 1308
pathophysiological mechanism of 1307
pathophysiology of 1307
preoperative treatment of 1271
severe 805
Osteoporotic bone 1148
Osteoporotic spine 51
Osteoporotic vertebral compression fractures 959
Osteoprogenitor cells 637, 893
Osteopromotion 382, 383
Osteopromotive agents 383, 392
Osteopromotive growth factors 392
Osteoprotegerin levels 714
Osteosarcoma 1336, 1344, 1517
Osteotomes 1107
Osteotomized gap 1298
Osteotomy 360, 570
closure 576
correct level of 576
intravertebral wedge 1303f
involuntary 498f
levels of 577f
location of 1248
options 573
posterior 1149
procedures, applications of 1302
technique 363, 1295
types of 575, 1295
Oswestry disability 953
scores 1280
questionnaire scores 447, 1041
Oswestry score 898
Otorhinolaryngologists 422
Ovarian carcinoma 1364
Overt fractures 331
Oxidative stress 664, 692
Oxygen
carrying capacity 663
concentrations 112
deficit 692
saturation 789
Oxygenated hemoglobin plus deoxygenated hemoglobin 1483
P
Pacemakers 1266
Paget's disease 329, 333f, 334f, 915
Pain 1380, 1388
arthrogenic 98
chronic 876
claudication type 1545
discogenic 10, 185, 873
disorders, management of 88
dysesthetic 251
exacerbation 459
facetogenic 992, 1038
generator 10, 87f
inflammatory type of 1114
management 157, 350, 1271
provocation 1011
signs of 57
syndrome, chronic 883, 1009
Painless neck range of motion 606
Pain-related peptides, synthesis of 877
Palatotomy 423
Palliative procedures 1372
Palm beach gardens 1525
Pamidronate 1142, 1148
Pancreatitis 708, 721, 1420
Panhypopituitarism 1141
Panvertebral disease 1433
Paracervical muscle tenderness 60
Paracetamol, use of 350
Paracoxib 158
Paracrine stimuli 395
Paradiscal rami 87
Paradoxical motion 592
Paraganglioma 1378
Paralumbar muscle spasm 1046
Paralympic sports 279
Paralytic agents 1489
Paralytic kyphotic deformities 275
Paramedial incisions 280
Paramedian muscle-splitting approach 853
Paraparesis 576
Paraplegia 34, 691, 712
incomplete 1064
Paraspinal mass 1011
Paraspinal muscle 841, 842
attachments, stripping of 1545
fibers 1548, 1548f
function 1552
groups 775
posterior 580
spasm 458
splitting 841
Paraspinal musculature 786, 1436
Paraspinal tissue damage 752
Paraspinal veins 28
Paraspinous muscle atrophy 1524f
Parasurgical techniques 1359
Parathyroid hormone 395, 1308
Paravertebral ganglia 121
Paravertebral muscles 836
paramedian retraction of 844
Paravertebral psoas abscesses 1423f
Paraxial presomitic mesoderm 197
division of 198f
Paraxis deficient embryos 18
Parenteral nutrition 710
total 1518
Paresthesias 1121
Parietal pleura 1438
closure of 1195f
Parkinson disease 476
Pars defect 1235
Pars interarticularis 1233
defects 843
Pars lateralis 1313
Parsonage-Turner syndrome 456
Patellar height 185
Pathologic disc 885
Patrick test 71
Pectoralis stretching 324
Pedestrian accident 615f
Pediatric
and adolescent athletes 1229
cervical spine, hyperflexion of 673f
disc herniation, incidence of 1116
Orthopaedic Society of North America 1163
spine, disc of 670
Pedicle 3
based dynamic stabilization
of lumbar spine, posterior 1034
systems 894, 1035
breach, medial 1494
extension 1370
fractures 1318
instrumentation 897
unilateral 890
medial breach of 138
medial wall of 1464
morphology, abnormal 1464
screw 105, 771, 1024
based dynamic stabilization devices, posterior 1034
fixation 48, 538, 779, 784, 795, 821, 1302
instrumentation 813, 939, 1177f, 1586
malplacement 809
placement 1178f, 1592
rod systems 884
safe placement of 543
use, complications of 1519
subtraction osteotomy 567f, 573, 1247, 1249, 1298f, 1300f, 1442, 1568
extended 1299f
mini-open 1568, 1570
surgical technique of 361
types of 1297
use of 573
Pediculectomies 1301
Pediculofacetectomy 1087
Pelvic
alignment 1250, 1251
arches, bilateral 978
clamps 979
coronal malalignment 1251
curve 31
deformity 1242
fixation 281, 1154, 1282, 1312
biomechanics of 1313
types of 283f
fracture 987f
open book 979
growth-sparing fixation 286
incidence 31, 762, 1241, 1249
junction, lumbosacral 1314f
obliquity 282, 284, 1242, 1249, 1251
correct 1143
parameters 31, 288
retroversion 1247
ring 980
fracture, right anterior 985f
injury, treatment of unstable 982
stabilization of 978
tilt 31, 1222, 1241, 1242f
Pelvis 280, 734, 1143
ganglia 121
Penfield dissector 820, 1202, 1203
Penfield retractor 531
Penrose drains 638
Peptic ulcers 721
Percutaneous
ablations 1353
biopsy 1011
discectomies 1546
endoscopic discectomy 1117, 1230, 1231f
fixation 1359
interbody fixation 1592
intralesional injection 1329
lumbar pedicle 776f
pedicle screws 810f
polymethyl-metacrylate 973
sacroplasty 1348
screws 1566
stabilization 973
techniques 468, 777, 1340
therapy 1329
vertebroplasty 1329
Perianal numbness 1347f
Periapical multiple Chevron-shaped osteotomies 1301
Periconceptional supplementation 268
Peridural fibrosis 1010
Perimedullary arteries network 1392
Perimedullary veins 1393
Perineurial cerebrospinal fluid cyst 997
Perineurial cysts 999
Periodic neurologic evaluation 338
Periosteal stretching 331
Peripheral entrapment syndromes 476
Peripheral limb, compression of 1485
Peripheral nerve 59, 1486
blocks 112
distribution 473
functions 139
injury 143, 145, 1464
lesions 187
sheath tumors 1378, 1382, 1532
stimulation 80, 137
Peripheral nervous system 25, 197
tissue 665
Peripheral neural compromise, risk of 143
Peripheral neuropathy
idiopathic 918
treatment for 98
Peripheral nociceptors, activation of 157
Peripheral tear 876
Peripheral vascular disease 1006
Periradicular space 98
Periradicular spinal injections 95
Periscapular region 491
Peritoneal dialysis 180
Peritoneal sac 789
Perivertebral abscess formation 1428f
Peroneal nerve 107f
Peroneal veins 404f
Peroxidation inhibitor 695
Persistent terminal ventricle 212
Petechial hemorrhages 648
Petit's triangle 1421
Pfannenstiel incision 789
Phalen's maneuver 65
Pharmacologic neuroprotective therapies 662
Pharyngeal muscles 554
Pharyngocutaneous fistula 1505
Phenol 189, 723
Pheochromocytoma 122
Philadelphia collar 169f
Phosphate mixture 88
Phospholipases 693
Photometric image registration 1573
Photon emission computed tomography, single 1010, 1115, 1215, 1312
Physaliferous cells 1338
Physician's thumb 63f
Pilocytic astrocytomas 1379
Pilonidal sinus 240
Piriformis muscle 1317
Piriformis syndrome 1006
diagnostic of 1007
Placebo 159
Plane deformity, severe sagittal 825
Plantar hyperhidrosis 121
Plasma alkaline phosphatase 329
Plasma cell tumors 1339
Plasmacytoma 1325, 1339
Plasmin 156
Plasminogen, activation of 156
Platelet
concentrate, autologous 393
derived growth factor 382
rich plasma 382, 393, 880
Pleural cavity infection 1518
Pleural effusion 973, 1196, 1541
Plexiform neurofibromas 1382
Plexus of Batson 1089
Plumbline 642
Pluripotent mesenchymal cells 381
Pluripotent stem cells 657
Pneumatic compression
devices 979
intermittent 1449
Pneumonia 648, 1447, 1448
ventilator-associated 155
Pneumothorax 1152
iatrogenic 1541
Poikilothermia develops, partial 650
Poisson's ratio 866
Polyacrylamide core 870
Polyacrylonitrile, composed of 870
Polyaxial reduction screws 1146
Polyaxial screw, closed 1144
Polycarbonate urethane 869
spacers 1024
Polyetheretherketone 44, 485, 498, 641, 809, 870, 871, 924, 946
cages 47, 807f
spacer 641
Polyethylene terephthalate 866
cords 1024, 1026f
Polylactic acid polymer 412
Polymerase chain reaction 1427
Polymethylmethacrylate 485, 1028, 1090, 1100, 1310, 1334, 1348, 1366, 1411
augmentation 1310
bone cement 312
use of 465
Polymorphonuclear
cells 1417
leukocyte lysosomal enzyme release 89
Polysynaptic response 139
Polytrauma 591, 706, 951, 972
victims of 673
Polyurethane sleeves 1035
Ponte and Smith-Peterson osteotomies 1015
Ponte osteotomy 319f, 1296, 1296f, 1301
Pontomedullary junction 338
Popliteal fossae 1489
Positron emission tomography 1364
Postanesthesia care unit 117
Poster brace 170, 170f
Posterior cervical spine surgery, IONM during 141
Posterior lumbosacral spine surgery, IONM during 144
Posterior thoracic spine surgery, IONM during 142
Postganglionic axon lesions 82
Postganglionic neurons 121
Postinfectious deformity 570
Postlaminectomy kyphosis 494, 563, 568, 1510, 1510f
ankylosed 566
complications of 1500
hallmarks of 564
mild 565f
setting of 566
treatment of 495, 568
Postlumbar puncture syndrome, lower risk of 909
Postmenopausal osteoporosis 981
Postpartial discectomy 865
Postpyloric feeding tubes 155
Post-thoracotomy pain syndrome 1086, 1535
Post-tubercular kyphosis, correct severe 1442
Potassium 708
Pott's disease 430
Pott's spine 1419f
Prazosin 722
Prealbumin 711, 1269
Prebent rods 534
Precontoured rods 43
Predominant vertebral body destruction 1418
Pregabalin 158, 458, 1260
Preperitoneal fat 1187
Prerenal azotemia 324
Pressure
controlled manometric discography 91
hydrocephalus, normal 1381
intradiscal 7, 100, 1059
ulcers 724
long-term complications 724
Pretracheal fascia 433, 1434
Prevertebral
abscess 1438
cervical fascia overlying 482
fascia 1435
soft tissue 1427
Proatlantal sclerotome 221
Prodisc device 1045
Prodisc implant 1043
Progenitor cell 692, 697
Progressive action short brace 174
Proinflammatory cytokines 836, 877
levels of 836
Proinflammatory mediators, levels of 1257
Prolotherapy 189
Promote platelet aggregation 694
Prophylactic ceftriaxone 553
Propionibacterium 1502
acnes 10, 1411, 1473
Propofol 113, 160
Prostaglandin 693, 694
synthesis, inhibition of 187
Prostate
cancer 1330, 1359
carcinoma 1360f
Prosthetic disc
intervertebral 871
nucleus 870, 870f, 898
Prosthetic replacement 1038
Prosthetic titanium rib, vertical expandable 343f
Protein 508, 711
concomitant leakage of 876
enteral 709
intracellular 415
metabolism 708
Proteoglycans 4, 6, 344, 817, 864, 875, 876
attract 6
complex made of 875
content 6
hydrophilic 864
synthesis 12
Proteosome inhibitor bortezomib 1339
Proteus 1151, 1476
Prothrombin mutations 1449
Provocative cervical discography, technique of 91
Provocative lumbar discography, technique of 90
Provocative thoracic discography, technique of 91
Proximal junctional kyphosis 1095, 1258
Proximal tumors, eccentric 1348
Pseudarthrosis 365, 639, 766, 769, 795, 938, 1010, 1157, 1196, 1291, 1306, 1309, 1312, 1471
causes of 1309
development of 1008
high prevalence of 943
incidence of 576, 1510
posterior 819
postoperative 1310
surgical treatment of 365
Pseudoachondroplasia 337, 341, 346
Pseudoarthrosis 145, 325, 539, 886, 1005, 1010, 1015, 1266, 1570
rate of 46
Pseudoclaudication 908
Pseudogout granulation mass 1524
Pseudomeningocele 253f, 1005, 1009, 1506
formation of 1461, 1494
late 1458f
prevent formation of 1459
Pseudomonas 1502, 1503
aeruginosa 1151, 1473
Pseudospondylolisthesis 930
Pseudotumor 421, 422, 428
Psoas 787
abscess 1420, 1422f
bilateral 1421f
major 29
muscle 734, 734f, 735, 745f, 788, 818, 820, 821, 1189, 1280, 1556
Psychiatric disease 1269
Psychological testing, preoperative 1005
Psychosomatic pain 1123
Pubis 733, 978
Pudendal plexuses 25
Pudendal vessels, internal 1317
Pulley system 593
Pulmonary complications
majority of 1447
postoperative 154
Pulmonary disease 1267, 1448
Pulmonary dysfunction 647, 1160
Pulmonary edema 112
Pulmonary function test 1267
preoperative 1200
Pulmonary hypertension 154
Pure facet dislocation 593
Pyknotic nuclei of notochordal cells 4f
Pyogenic disc infection 1408, 1409
Pyogenic discitis pathogenesis 1408
Pyogenic spondylitis 421, 428, 1419
Pyogenic verterbral osteomyelitis 111
Pyrazinamide 1430
Pyrolytic carbon coat 871f
Q
Quadraplegia 691
Quadratus lumborum 25, 29, 734, 787, 788, 1189
Quadriceps weakness 819, 891
Quadriparesis 576, 605, 1425
Quadriplegia 92, 153
Quadriplegic cerebral palsy 1140f
Quality adjusted life year 938
Quality-associated life year 180
R
Rabbit intervertebral disc 4f
Rades classification 1368
Radial tears 876f
Radiation 1582
exposure 544, 1583
reduced 1577
induced meningiomas 1377
therapy 136, 1329
tolerance of normal tissues 126
Radical anterior excision 1432
Radicular artery, dural branch of 1394
Radicular injury 1502
Radicular pain 65, 96, 186, 808, 829, 1015, 1086, 1306, 1420
component of 472
severe 832
Radiculopathic pain, acute episode of 458
Radiculopathy 186, 187, 576, 637, 838, 1254, 1285
clinical symptoms of 1064
pathogenesis of 443
severe 1257
symptoms, severe 1261
unilateral 503
Radiobiology 126
Radiofrequency 1366
ablation 99, 191, 994, 1329, 1349, 1359
denervation techniques 192
neurotomy 585
Radionucleotide scan 1266
Radionuclide
bone scanning 1115
myocardial perfusion 152
scan images, functional 1115
Radioresistant tumors 128
Radiosensitive 130
structures 128
tumors 128
Radiotherapy
conventional 125
role of 125
types of 125t
Raloxifene 1308
Range of motion 29, 37, 496, 782, 795, 1040, 1055, 1220
Rapid cooling therapy, acute 655
Reactive airway disease 1140
Reamer-irrigator-aspirator system 372
Recess stenosis, lateral 817, 916
Rectus abdominis 29, 189, 733, 888, 1187
muscle 733, 787, 789
Rectus capitis 61
Rectus muscle denervation, risk of 789
Rectus sheath 792
Recurrent disc
herniation 737, 819, 848, 1014f
surgery 852f
Recurrent hypoglossal nerve injuries 1502
Recurrent laryngeal nerve 433, 485
injuries 1502
Recurrent lumbar disc herniation 813, 924
Red blood cell, intraoperative 156
Reed-Sternberg cells 1339
Reference system 1577
Reflex
arcs 77
deficits 453
disorders 454t
ileus 721
triceps 61
Regain lumbar implant 871f
Regional nervous sensory 58f
Regional spinal
disease 352
segments 1251
Remifentanil 160
infusion 161
Remyelination 697
Renal artery, segmental 404
Renal cell carcinoma 128, 1348
Renal defects 201
Renal diseases 1420
Renal dysplasias 213
Renal failure 719
aminoglycoside-induced 1259
Renal function
declines 114
impaired 1307
Renal insufficiency 152
Renal tubular acidosis 1307
Renal vein, segmental 404
Reoxygenation injury 203
Reproductive function 726
Rescue 1403
Resection technique 1386
Residual cosmetic deformity 943
Respiratory distress
syndrome, acute 1448
treatment of 657
Respiratory system 154
Restore trunk balance 1143, 1146
Restrictive lung disease, preoperative 1152
Restrictive pulmonary disease 1174
Resuscitation, cardiopulmonary 626
Retinal artery occlusion, central 160
Retractors 842
Retrograde ejaculation 789, 885
Retroperitoneal approach
anterior 742
anterolateral 787, 872
endoscopic 790
laparoscopic 790
mini-open 791
Retroperitoneal
space 737, 787, 820
structures 736
technique 737
veins 404
Retroperitoneum 888
Retropharyngeal
abscess 1420, 1422
hematoma 637, 1062
mucosa 423, 423f
space 436, 638
surgical field 422
tissue edema 485
wall 422, 424, 423f, 428
Retropleural approach 1106
lateral 1542t
Retropleural discectomy, lateral 1541
Retropulsed bony canal fragments 607
Rett syndrome 1156, 1157
Revision surgery 1505, 1552
Rhabdomyolysis 725
Rheumatoid
arthritis 111, 349, 421, 528, 856, 1473
spondylitis 358
Rhinolalia and nasal regurgitation 556
Rhizomelic limb shortening 338
Rhombencephalic anomalies 295
Rhomboids 459
Rhythmic oscillation 64
Rib 27
autograft 372
fractures 1086
graft 401
vascularized 401
head
complex 1098
excision of 1202f
removal 1107
interspaces 788
Rib-to-pelvis fixation, bilateral 288
Rifampicin 1430, 1431
Righting reflex 1140, 1145
Rigid pediatric cervical collar 671
Rigid scoliosis, severe 1301f
Rigid skeletal deformity 1562
Rigid spinal deformities, severe 285
Rigo Chêneau style brace 1166, 1166f, 1167
Riluzole 647, 655, 656, 664, 696
Rim of ilium 736
Ring apophysis 818, 823, 1228
Risser jacket 1164
Risser sign 1162f, 1169
Robust fixation, biomechanically 1313
Rodded connector, fixed lateral 1145
Roland Morris disability questionnaire scores 955, 956
Roof plate 203
Rosenthal fibers 1379
Rostral axis 18
Rostral vertebrae 1527
Rotator cuff tear 456
Rotatory atlantoaxial subluxation 618
Rotatory listhesis 1276, 1286
Roux-en-Y gastric bypass, laparoscopic 108
Rudimentary spinous process 1313
Rule of Spence 594
Ruptured tension band 950f
S
Sacral agenesis 248
Sacral alar
iliac 1312, 1313, 1315, 1317
fixation 1314f
screws 1312, 1314f, 1315, 1317, 1318
stress fractures 1352
Sacral aneurysmal bone cyst 1344, 1350f
Sacral anomaly, congenital 943
Sacral artery
lateral 28
median 28
Sacral chordoma 1347f
Sacral cornua 1313
Sacral crest
intermediate 1313
median 1313
Sacral cysts 240
Sacral foramina, posterior 1313
Sacral fractures 985
anatomy 978
assessment of 979
classification 980
Denis classification system of 980
epidemiology 978
nonoperative treatment 982
optimal management of 978
radiographical evaluation 980
surgical treatment for 978, 982
Sacral insufficiency fractures 981
Sacral metastases 1348
Sacral myelomeningocele, closure of 274f
Sacral neoplasm, primary 1344
Sacral osteoid osteoma, excision of 1593f
Sacral regions 25, 1229
benign tumor 757
malignant tumors 757
Sacral resection 764, 1345
bilateral 763
classification of 758
Sacral root 763
resection, unilateral 763
Sacral slope 31, 1222, 1241, 1242f
Sacral tumors 758, 1343, 1346, 1353
anatomy of 1343
benign 1350
clinical presentation 1343
complications 1352
diagnosis
biopsy 1344
imaging 1344
differential diagnosis of 1344t
epidemiology 1343
management of 757
primary 757, 1325, 1343, 1344
reconstruction techniques 1351
resection 763
techniques 1351
staging 1345
surgical planning 1345
treatment 1346
Sacral vertebral bodies 767
Sacrectomies, low 763
Sacrococcygeal area 1338
Sacroiliac 1006
dysfunction 70f
joint 86, 87, 98, 187, 190, 192f, 358, 990, 1344, 1346
anatomy 990
arthrodesis 994
biomechanics 991
block 98
diagnostic techniques 992
dysfunction 187, 990, 991, 994
imaging 992
injections 98, 192, 1260
nonoperative management 993
operative management 994
pain 192
physical examination 992
ligaments, posterior 978
pain 71f
screw 985
Sacroiliitis 358, 993
Sacropelvic
deformity 1242
dysmorphism 306
fixation 282, 769, 1309
morphology 1241
osteotomies, accurate 1351
Sacroplasty 982
Sacrospinalis muscle splitting
method 745
technique 749
Sacrovertebral
angle 31
articulation 31
Sacrum 21, 725, 733, 1282
anatomy 758
center of 1244
reconstruction of 757, 759, 760
rostral part of 981
surgical approach 758
tumor of 757, 1343
Salvage 156, 1403
techniques 1310
Sarcoma 132, 331
Scalp
hemorrhage 594
trauma 600
Scapular pain 453
Scapulohumeral reflex 475
Scar formation 691, 1505
Scar tissue 1552
epidural 852f
formation 879
Scarce bile ducts 202
Scheuermann's disease 316, 316f, 317f, 319fc, 1086, 1296
clinical aspects 316
etiology of 1119
imaging 317
treatment of 318, 319
Scheuermann's kyphosis 172, 1095, 1118, 1119, 1483
Schisis 1116
Schober's test 71
Schroth method 1169
Schroth program 1170
Schroth-based therapy 1169
Schwann cells 657, 697, 1378
Schwannoma 131, 1344, 1378, 1387, 1532
Sciatic nerve 1006, 1317
injury 192
Sciatic notch 185
Sclerosis, X-ray reveals 1431
Sclerotic metastasis 1360f
Sclerotic reactive bone formation 1360
Sclerotomal cells 18, 18f
migration of 18
Sclerotomal proliferation 197
Sclerotome 18, 197, 203, 207, 220
Scoliosis 202, 251, 252, 323, 337, 340, 678, 793, 872, 1120, 1151, 1169, 1276, 1483, 1588f
congenital 172, 202, 214, 1120, 1126, 1131f, 1483
correction 49, 1249
curve pattern 1153
deformity 338
degenerative 111, 819, 822, 823, 1291
forms of 172
idiopathic 202, 203, 1120, 1138, 1151
juvenile idiopathic 1482
natural history of 252, 1138
Orthopaedic and Rehabilitation Treatment, Society on 1164
pediatric 1157
prevalence of 1152
progression of 253
research society 1100, 1163, 1221, 1255, 1411, 1572
segment fusion for 1205t
specific exercises 1169
surgery 1187, 1482
Scoliotic deformity, progressive 284
Scoring system 1367
Scottish Dog's collar sign 1233f
Screw
avulsion 539
breakage 771
fixation 1026f, 1507
insertion technique 783
loosening 539
Scrotal compression 722
Sebaceous glands 247
Sebum, secretes 247
Sedative-hypnotics 113
Segmental deformity, treatment of 794
Segmentation
defect 214
failure of 201, 202, 214
Seizure disorders 1141
Seldinger technique, modified 1403
Self-illuminating retractors 736
Semen retrieval methods 726
Semicircular incision 792, 844
Semiconstrained plates, dynamic 485
Semiconstrained prostheses 47, 1028
Semicrystalline polymer 871
Seminoma 130
Semirigid system 884
Semisegmented hemilamina 214
Semispinalis cervicis 530
Sensory
axons 25
deficits 253, 453, 1060, 1451
evoked potential 945, 1485
examination of cervical spine 60
function, levels of 268
loss 251, 454
nerve action potentials 76
pathways, monitoring 1489
Sepsis 710
Septicemia 648
Serological tests 1426
Seroma formation 1501
Serotonergic systems 911
Serotonin reuptake inhibitor, selective 187
Serratus dorsalis caudalis muscle 733
Serum C-reactive protein 1114
Sevoflurane 160
Sexual dysfunction, history of 254
Sexually transmitted infections 722
Sharpy's fibers 436
Sheufler's series 1541
Shock 708
hemorrhagic 708
hypovolemic 1470f
Shockwave 688
lithotripsy 722
Short segment fusion, anterior 1201t
Shoulder clavicular complex 1109
Side-bending test 1140f
Sigmoid mesentary 791
Sigmoidoscopy 892
Signet ring cells 1338
Silicate-substituted calcium phosphates 384, 390
Simultaneous biplane fluoroscopic control 1403
Single endplate, fractures of 952f
Single layer
sign 511
tissue flap 554
SINS classification 1368t
Sioutos classification 1368
Skeletal dysplasia 337, 1483
spinal manifestations of 338
Skeletal hyperostosis, diffuse idiopathic 962
Skeletal immaturity 1160
Skeletal maturity 1138, 1275
Skeletal muscles 1486
Skeletal stabilization, satisfactory 987
Skeletal traction 592
Skeletogenesis, process of 380
Skin
appendages 247, 259, 263
flushing 191
hypopigmentation 191
incision, longitudinal 433f
lesions 1121
tags 57
Skip corpectomy 513
technique 516
Slipped capital femoral epiphysis 103
Smith-Petersen osteotomy 744, 1296, 1296f, 1301f
multiple 276
reverse 1299
surgical technique of 360
Smith-Robinson approach 433f, 574
Snaking phenomenon 598
Sodium channel
blocker 696
excessive activation of 696
Sodium morrhuate 189
Soft braces 1167
Soft collar 168f
Soft palate, retraction of 554f
Soft tissue
approach 844, 845, 848
dissection 557, 779
extraosseous 1345
injuries of cervical spine, management of 579
structure 724
tumors 1378
Solitary metastases 1362f
Somatic cells 18
Somatic mesoderm 19
Somatosensory-evoked potentials 136, 160, 360, 482, 544, 575, 966, 1181, 1351, 1483, 1485, 1486, 1493
cortical 1490
Somatotopy 1380
Somites 201, 203
formation of 1126
Somitocoele 18
Sonntag techniques 525
Spasm 188
Spastic diplegic cerebral palsy 1138
Spasticity 723, 724
Spatial information, accurate translation of 1577
Spear Tackler's spine 605
Spectacular success 1431
Spetzler's classification 1393, 1400
Sphenoid dysplasia 1382
Sphincter function 763
Spina bifida 200, 210, 214, 243f, 843
closed form of 239
history of 253
occulta 200, 239
Spinal accessory nerve 142
Spinal adhesiolysis 1012
Spinal alignment 1248
Spinal anatomy 34, 35
abnormal 1562
Spinal anesthesia 118
Spinal aneurysms 1393, 1395, 1400
Spinal ankylosis 358
Spinal arteriovenous malformations, classification of 1393
Spinal artery
anterior 81, 1392
posterior 1398
Spinal arthrodesis 385, 1015
Spinal balance 31, 1225
abnormal 1295
Spinal bifida cystica 200
Spinal bone tumor 1300
Spinal canal 3, 3f, 24, 211f, 630f, 1064, 1107, 1517
degenerative 1524
duplicate 245
growth of 675
portion of 510f
stenosis 344, 541f, 748
degenerative 915, 918
Spinal cavernous malformations 1395
Spinal claudication 1036f
Spinal column 96, 1114
anterior 430
dynamic instability of 648
ligaments, structure of 36f
pediatric 670
Spinal conditions, treatment of specific 821
Spinal cord 25, 28, 34, 112, 132, 139, 200, 695697, 1114, 1380f, 1392, 1395, 1398, 1506
anatomy of 26f
anomalies 240
arteriovenous malformations 1395, 1398
astrocytic glioma of 1376
atrophy 1483
blood volume 1483
cavernous malformations 1400
compression 82, 345, 663, 1477
direct 1493
congenital anomalies of 239
contusion 675f
defect impacts, levels of 1153
development of 199
drift 504
dysfunction, type of 473
embryology of 206
evoked potential 80, 1488f, 1490
method of recording 80
gliomas 1379
hemodynamics 1398
hemorrhage 961
iatrogenic 140
infarction 717
injury 122, 153, 539, 604, 655, 662, 669, 678, 682f, 691, 706, 711, 879, 956, 960, 1138, 1269, 1449, 1493, 1517, 1518
acute management of 647, 651t
diagnosis of 716
incidence of 662
management of acute 654t
medical complications of 151
nutritional management of chronic 711
penetrating 680, 688
professionals, multi-disciplinary association of 720
rehabilitation of 716
surgical timing in acute 652, 666
intermediolateral column of 121
interneurons 1486
ischemia 1493
lipomas 242, 260, 263
types of 258
malformations of 239
manipulation 1484
mediated function 960
monitoring 1152, 1484
intraoperative 1295
paralysis 1156
perfusion of 695
regeneration 692
signal hyperintensity of 511
stimulation 81, 1012
stroke 1395
symptoms, severity of 1369
terminates 855
tethered 258, 268
tissue of 27
trauma 70
tumors 141, 1375
dumbbell-shaped 1519
vascular malformation, endovascular treatment of 1400, 1404
ventricular zone of 199
Spinal coronal malalignment 1251
Spinal corrective surgery 1155
Spinal cutaneous fistulas, formation of 1459
Spinal cysts 999t
Spinal decompression, completion of 1074
Spinal deformity 171, 212, 288, 321, 323, 1140, 1279, 1282f
angular 1300
correction 1078
principles of 1143
surgeries 275
magnitude of 1295
orthotic treatment of ensuing 272
post-traumatic 676
prevalence of 1138
progressive 296
stiffness of 1142
study group 943, 1118, 1562
surgery 1151, 1265, 1482
surgical
intervention of 1141
management of 273, 324, 1272, 1465
treatment for 1295, 1306
Spinal development 198
Spinal disease 1417
Spinal disorder 111t, 337, 345
in common dysplasias 337t
management of 72, 338
treatment of 1523
Spinal dural arteriovenous fistula 1392, 1394, 1397
Spinal dysgenesis, segmental 212
Spinal dysraphism 200, 208, 211, 212, 212t, 239, 251, 266, 286
classification of 200, 240t
complex 267
form of 201, 260
incidence of 239
open 212, 266
repair of 254
segment of 275
Spinal elements, posterolateral involvement of 1368
Spinal epidural abscesses 1408
Spinal evoked potential 1488
Spinal exposure, open 544
Spinal fixation
biomechanics of 42
types of 281
Spinal focus, primary 1421t
Spinal fractures 978
incidence of 957, 959, 970
Spinal functional unit and curvature 35f
Spinal fusion 921, 1230
anterior 1196
phases of 381
posterior 306f, 307f, 516, 964f, 966f, 1153, 1181, 1186, 1196
single anterior 284
surgery 406t
Spinal headache 191
Spinal hemangioma 1335
Spinal image guidance systems 1573
Spinal imbalance 275, 277
Spinal immobilization 657
Spinal implants, cost of 182
Spinal infection 1089
classifications of postoperative 1472
postoperative 1472, 1477
prevention, pediatric 1272
risk factors for postoperative 1473t
Spinal injury 684, 687fc
category 39
causes of 970
pediatric 1228, 1229
Spinal instability 1359, 1433
Spinal instrumentation 766, 1151, 1386, 1477, 1481, 1584
complications 1471
evolution of 1177f
minimally invasive 752
posterior 287, 1410
single anterior 282
use of 933
Spinal integrity, loss of 1367
Spinal intradural
meningeal cysts 212, 997
tumor 1376f
Spinal intradural vascular malformations 1392, 1395
anatomy 1392
clinical features 1394
complications 1404
diagnosis 1395
epidemiological 1394
treatment 1396
Spinal intramedullary lipoma 243f
Spinal laminectomy 934
Spinal lesions, congenital 206
Spinal ligaments 24
Spinal line, posterior 490, 492f
Spinal lipoma 243f, 263
history of 260
intradural 240
Spinal malalignment, risk of 1241
Spinal manifestations 349
natural history of 306
Spinal manipulative therapy 189, 190
Spinal meningeal cyst 211, 1003
classification of 997
Spinal meningioma 1383f, 1387f
Spinal metastases
embolization of 1348
majority of 1359
treatment of 1365, 1371fc
Spinal misalignment, sagittal 1242
Spinal motor tracts 1489
Spinal muscular atrophy 1141, 1154
Spinal navigation 1580
evolution of 1573
operative time, use of 1581
principles of 1573
surgery, concerns of 1580
technique 1583
Spinal nerve 25
anatomy of 26f
root 139, 142
dermatomes 58
fibers 997
typical 25
Spinal neurological compressive symptoms 332
Spinal oncologic procedures 766
Spinal orthoses 167
Spinal osseoligamentous integrity, posterior 1552
Spinal osteoid osteomas, complete excision of 1593
Spinal osteosarcoma 1336
Spinal osteotomy 360
posterior surgical technique 1130
Spinal pain, biopsychosocial model of 188
Spinal pathology
accurate diagnosis of 57
utility scores for 180
Spinal pelvic fixation techniques 766
Spinal pelvic harmony 1248
Spinal procedure 805
interventional 85
Spinal pseudarthrosis 365
Spinal pseudomeningocele 1519f
Spinal reconstructive procedures 1247
Spinal segment 1250
instability of 932, 1552
operative 790
superimposed 25
Spinal shock 960
Spinal somatosensory-evoked potential 1490
Spinal stability 30, 962, 963, 1385
assessment of 684
structural 29
Spinal stabilization, nonoperative 685
Spinal stenosis 105, 108, 338, 339, 717, 856, 907, 910, 921f, 1452
acquired 605
congenital 215, 216, 468, 915
decompression of 1037f
treatment of 910
types of 907
Spinal stereotactic radiosurgery 130t, 131t
Spinal surgery 176, 182, 353, 1469t, 1552
minimally invasive 744, 747, 1105, 1546, 1579, 1583
revision 1590
step in image-guided 1574
technologies in 1024f
Spinal trauma 40
patterns of 676
Spinal treatment 1154
Spinal tuberculosis 1417, 1426f, 1426t
surgery in 1433t
Spinal tumor 400, 1089, 1518, 1532
benign primary 1325, 1327, 1329
malignant 1519
management of 1339
surgery 1592
treatment for 1350
Spinal unit, functional 29, 865, 1038, 1044
Spinal vascular malformations 1392, 1394
diagnosis of 1395
intradural 1404
Spinal vein, anterior median 28
Spinal vertebra, anatomy of 35f
Spine 103
advanced imaging of 831t
alignment of 490
anatomy 32, 34
functional 32
ankylosed 961f, 1507
ankylotic 972
biomechanical properties of 37
bony part of 35
center, tertiary 1256
chondrosarcoma of 1337f
clinical biomechanics of 34
congenital malformation of 200, 1127
development 4, 32, 198
failure of 201
dislocation, types of 215
disorders, treating 1088
dynamic 871f
electrodiagnostic studies of 76
embryology of 197, 206
extensors of 29
functional unit of 35, 40
immature 1228
infections, primary 1451
lower segments of 1392
malformations of 1126
maturation, failure of 202
multisegmental nature of 167
pain, management of 1260
pathologies, degenerative 106
pediatric 670f
physical examination of 57
posterior fixation of 766
postnatal maturation of 200
segments, adjacent 962
stability of neoplastic lesions 1367
stereotactic radiosurgery of 125
structure 35
surgeons 1520
surgery 135, 141, 151, 157, 159, 161, 182, 400, 1258, 1482
advantages of minimally invasive 107
computer-assisted 1572
elective 151
modern 1469f
outcomes of 104
procedures, minimally invasive 1551
type of minimally invasive 888
trauma 669
pediatric 669
study group 629, 951
tumor staging systems 1345t
vascular anatomy of 27
Spinopelvic alignment 1241, 1242
normal values of 1245
Spinopelvic balance 1221
Spinopelvic chain 1241
Spinopelvic dissociations 981
Spinopelvic fixation 281
Spinopelvic harmony, assessment of 1247
Spinopelvic instability 978, 980
treatment of 984
Spinopelvic integrity 978
Spinopelvic parameters 32f, 1241, 1246
Spinopelvic reconstruction
method of 761
techniques, multiple 764
Spinopelvic stability 762
Spinous process 20, 58, 600, 747, 920
avulsion 600
fractures 605
posterior 536
tuberculosis of 1419f
Spiral computed tomography 949, 957
angiography 1450
Split cord malformations 240, 245, 246, 246f, 258, 260, 261
types of 246t
Split fracture
anterior 952
of vertebral body 950
Spondylarthrosis, degenerative 782
Spondylectomy 1327
Spondyloarthritis International Society, assessment of 359
Spondyloarthropathies 570, 993
Spondylocostal dysostosis 202, 213
Spondylodiscitis 359, 365, 1535
diagnosis of 1364
Spondyloepimetaphyseal dysplasia 342
Spondyloepiphyseal dysplasia 210, 341
congenital 346
tarda 337, 341
Spondylolisthesis 58, 85, 180, 186, 737, 750, 793, 809f, 817, 822, 822f, 872, 907, 936, 1006, 1117, 1235, 1457
after surgery, progression of 943
degenerative 105, 111, 187, 815, 921, 930, 934, 939, 1034, 1035, 1277, 1290
develop isthmic 1235
diagnosis of 885
forms of 1235
high dysplastic developmental 1118
high grade 737, 819, 943f, 946f, 1118f, 1236
isthmic 942, 1236
isthmic 882, 1235
low grade 813, 821, 822, 942, 1118t, 1235
severe 1465
treatment of 1118
Spondylolisthetic segment 1035
Spondylolysis 331, 1006, 1117, 1232
bilateral 872
incidence of 1225
pain of 1117
suspected 1215t
terminal-stage 1234
Spondylometaphyseal dysplasia 346, 342
Spondyloptosis treatment 1221
Spondylosis 750, 1300
degenerative 570
Spondylotic
foraminal stenosis 463, 464f
motion segment 481
myelopathy 1060
Sponge retractors 122
Spontaneous curve correction 1120
Spontaneous electromyography 136
Sports injuries 970
Sprengel deformity 203, 210
Spring-back closure 1505
Spurling's test 61, 62, 455f
Sputum culture 1447
Stable internal fixators, angular 973
Stagnara wake-up test 1491, 1494
Stairmaster machine 459
Standard transoral approach 421
Staphylococcus 1473
aureus 247, 793, 1009, 1151, 1408, 1448, 1473, 1502
epidermidis 1473, 1502
Steinman pin 809
Stem cell 394
matrix 386
therapy 657
type of 697
Stenosis 605, 607, 920, 1545
adjacent multilevel 1551
anatomic areas of 915
congenital 216
extraforaminal 1285
multilevel 493
patterns with scoliosis 1277
source of 1277
Stenotic segments, decompression of 1035
Stereotactic body 1353
radiation therapy 1349, 1350
Stereotactic radiosurgery 125, 128t, 132
Sternal incision 440
Sternal occipital-mandibular immobilizer 168, 169f, 613
Sternal osteotomy 441
Sternocleidomastoid muscle 60, 1434
Sternotomy, median 440
Sternum-splitting approach 1516, 1516f
Steroid 834, 1012
dosage of 834
injection 477
epidural 88, 94, 1260
nonparticulate 88
particulate 88
treatment 685
Stigmata, cutaneous 259, 261, 263
Stimulate nerve fiber growth 656
Stingers injuries 604, 606
Stomach perforations 685
Streptomycin 1432
Stress
biomechanical 34, 894
disorder, post-traumatic 583
strain curve 36
Stroke 136
history of 152
Subarachnoid drainage 428
Subarachnoid lumbar catheter 719
Subarticular decompression 935
Subarticular stenosis 916
Subaxial cervical
injuries, management of 600
spine, embryology of 221
Subaxial disease 353, 354
Subaxial injury 598
Subaxial instability 111
Subaxial lateral mass screws 1507
Subaxial spine 536
abnormalities 228
secondary 432
Subaxial subluxation 353
Subcervical spine disease 353
Subchondral sclerosis 3, 805
Subcrestal window technique 372
Subcutaneous emphysema 124
Subcutaneous fat necrosis 191
Subcutaneous tissue 272
Subdental synchondrosis 210
Subdural hematoma 296, 856, 1461
Subependymal giant cell tumors 1345
Subfascial drain 1460
use of 1459
Subhyoid musculature 440
Sublaminar fixation 1271
Sublaminar wire 281, 312, 1094, 1142, 1143, 11461148, 1156, 1314
constructs 1095
fixation 1147, 1148
passage 1149
Sublesional osteoporosis 725
Subligamentous disc fragment 846
Sublingual nitrates 722
Suboccipital bony decompression 250
Subperiosteal dissection 1106f
Subsegmental clots 1450
Subtherapeutic levels 1269
Subtle foot deformities 268
Suction irrigation 122
Sulcus limitans 200
Sulfapyridine 359
Sulfasalazine 359
Sunitinib 1329
Supra-acetabular location 49
Supraclavicular fossa 60
Supraphysiologic translation 871
Suprascapular nerve entrapment 456
Supraspinous ligament 24, 562, 580
Swedish Spinal Stenosis Study 934
Swimming 908
Sympathectomy, bilateral 122
Sympathetic chain 121, 435
endoscopic exposure of 123f
Sympathetic nervous system, surgery to 121
Symptomatic disc degeneration 873
Symptomatic sacroiliac dysfunction 992
Symptomatic spinal vascular lesions 1400
Symptomatic thoracic disc herniations 1541
Syndromes spondyloepiphyseal dysplasia 232
Synostosis, congenital 208
Synovial joint, heterogeneous 990
Synthetic folic acid 268
Syringomyelia 209, 212, 249, 251, 252, 253f, 295, 719, 1429, 1481
development of 297
resolution of 252
Systematic disorders 208
Systemic congenital anomalies 267
Systemic disease, mild 114
Systemic hypotension 1464
Systemic inflammatory response syndrome 708
System-wide muscle atrophy 1154
Systolic blood pressure 153
T
Tachosil 851
Tacrolimus 696
Tanner-Whitehouse scale 1162
Tannic acid 189
Tantalum 46
Tanycytic variant 1379
Target sign 1344
Tarlov's cysts 212, 997
Tarlov's theory 997
Tarlov's classification 999t
Teardrop fractures, extension 600
Teardrop fragment 605
Technetium-99 982, 1362
Tectal beaking 209, 269
Tectorial membrane 611
Telangiectasia, hereditary hemorrhagic 1393
Temporomandibular
jaw mobility 553
joint dysfunction 351
Tenaculum 530
Tendon reflex
deep 474, 1163
latency 78
Tension band 950f, 951
Tensor fasciae latae 375f, 1501
Teratomas 262, 1379
Terminal spinal cord, formation of 259
Tetracycline antibiotic 664
Tetraplegia 712
Thalamic massa polimicrogyria 269
Thalidomide 1339
Thanatophoric dysplasia 342
Thecal sac 200, 813, 1108
Therapeutic hypothermia 655, 657
Thermocoagulation, intradiscal radiofrequency 879
Thermoluminescent dosimeter 1096
Thigh pain 946f
Thomas’ test 1114
Thoracic approaches, anterior 1105
Thoracic artery, internal 404
Thoracic cavity 1188f
Thoracic corpectomy 1085, 1089
indications 1089
operative treatment 1089
Thoracic curve 31, 1165f, 1275
right primary 1203f
Thoracic deformities 571
Thoracic disc
disease 1085
herniation 1071, 1078, 1086f, 1591
management of acute 1087
Thoracic discectomy 1085, 1087, 1202, 1541, 1591
anterior approaches 1087
complications 1090
contraindications 1087
indications 1087
minimally invasive techniques 1089
posterior approaches 1087
posterolateral approaches 1088
surgical approach 1087
transpedicular approach 1088
Thoracic duct injury 1504
Thoracic enlargement, artery of 27
Thoracic fusion, selective 1179f
Thoracic hyperkyphosis 337, 1153
Thoracic injury 675, 1229
Thoracic insufficiency syndrome 1153
Thoracic interbody fusion, direct lateral 890, 1105
Thoracic kyphosis 31, 57, 276, 341, 491, 1143, 1147, 1149f, 1241, 1245f, 1247f, 1249, 1282
maximum 1249
Thoracic kyphotic curvature 1248
Thoracic laminoplasty 517
Thoracic level, upper 1109
Thoracic longissimus muscle 849f, 850f
Thoracic myelopathy 1086
Thoracic nerve roots 323
Thoracic outlet syndrome 65, 456
Thoracic pedicle 1097, 1587
anatomy 1098
classification of 1099f
screw 52, 1101t, 1520f
placemen, technique for 10961098
Thoracic radiculopathy 1086
Thoracic reciprocal changes 1248
Thoracic region 30, 1260
concomitant injuries of 683
Thoracic scoliosis 1135f, 1148f
Thoracic spinal
cord 142
fractures, pediatric 675
roots 1519
tuberculosis 1428f
tumors, epidural 143
Thoracic spine 20, 38, 142, 1087, 1088f, 1089, 1097f, 1108, 1332f, 1409, 1419f, 1515, 1518
anatomy of 17
ankylosed 964
anterior 143, 1535
deformities 1586
development of 288
disease 1535
evaluation 65
sensation 65
fractures of 959, 1229
indications, minimally invasive techniques of 1535
instrumentation 1586
ligamentous structures of 23f
minimally invasive
surgery of 1543
techniques of 1535
positioning, minimally invasive techniques of 1536
stable 1417
surgery 142
anterior 1515
IONM during anterior 143
posterior 1515
Thoracic transpedicular approach 1089
Thoracic tubercular spondylosis 1440f
Thoracic vertebra 35, 1075f, 1288
anterior 1541
lower 1071, 1073f
middle 1073f
multiple 1439f
third 22
Thoracoabdominal aortic aneurysm 657
Thoracoabdominal approach, long anterior 1197
Thoracoabdominal musculature 734f
Thoracodorsal fascia 733
Thoracolumbar burst fractures 956, 1541
nonoperative management of 956
Thoracolumbar constructs 1312
Thoracolumbar correction, anterior 1197
Thoracolumbar curves 1165f, 1275
Thoracolumbar deformity 312, 1295
post-traumatic 1589f
sagittal plane 1295
Thoracolumbar fascia 950
Thoracolumbar fixation 48
Thoracolumbar fracture 953
concomitant 979
management of 959
surgical indications of 959
treatment 964, 968
Thoracolumbar fusion 1180f, 1197, 1309
Thoracolumbar injury 675
classification 652t-964t
management of 959
Thoracolumbar junction 279f, 610, 787, 788, 954, 959, 1517f
Thoracolumbar kyphoscoliosis 307f
Thoracolumbar kyphosis 337339, 344, 345, 1244
Thoracolumbar orthosis 955
Thoracolumbar scoliosis 1108, 1276f, 1332f
Thoracolumbar segment 365
kyphosis of 1119f
Thoracolumbar spine 1330f, 1421, 1425f
fusions, multilevel 1448
nonoperative treatment of fractures of 949
Thoracolumbar trauma 174, 970
Thoracolumbar tuberculosis 1421f
Thoracolumbar vertebral collapse 1591
Thoracolumbosacral orthosis 171, 172, 1142, 1165, 1230, 1234
Thoraco-osteotomy 360
Thoracoscopic approach
advantages of 1077
anterolateral 1535
for spinal disorders 1077
Thoracoscopic discectomy 1078, 1592
Thoracoscopic instruments 1538
Thoracoscopic ports, placement of 1083
Thoracoscopic single-level discectomy 1541
Thoracoscopic spine surgery
image-guided 1592
procedures 1080
Thoracoscopic surgery 124, 1079f
video-assisted 1330
Thoracoscopic sympathectomy 121, 122
Thoracoscopic technique 1078
Thoracoscopy
complications of 1537
considerations of 1537
Thoracotomy 122
anterolateral 143
double 284f
Thorny radiations 1329
Threshold technique 144
Thromboembolism, risk of 1308
Thrombophlebitis 1051
Thromboxanes 694
Thumb interphalangeal joint 63f
Thyroid
artery, superior 404
cartilage 60, 431, 432f
gland 1434
stimulating hormone 1307
Thyrotropin releasing hormone 654, 655, 695
Tibial nerve-innervated muscles 77
Tibial torsion 323
Tibial vessels, anterior 403
Tibialis anterior 68, 944
Tight filum terminale 212, 240
Tinel's sign 65
Tirilazad mesylate 654, 656, 695
Tissue 203
damage 688
amount of 38
death of 1155
derived adult neural stem cells 657
destruction 688
grafts, ex vivo adenoviral transduction of 395
hypoxia 708
injury 580
deep 724
massage, deep 910
tolerance, adjacent 132t
Titanium mesh cage 813
Titanium, cage composed of 886
Tizanidine 188, 723
T-myelotomy 719
Tokuhashi classification 1368
Tongue 425f
maceration, self-injury 322
Tonsillar ectopia 209
Tonsillar herniation 1461
Tonsillar ptosis 553
Tonsils 250f
Torque wrenches 1507
Torticollis, congenital 170
Total disc arthroplasty 895, 1027, 1031, 1062
Total disc prostheses 1027
classification of 1028f
Total disc replacement 466, 863, 872, 895, 1038, 1043, 1054
Total facet
arthroplasty system 1039, 1040f
replacement 1038, 1039
Total facetectomy, bilateral 1041
Toxicity 131, 415
Trabecular thickening 331
Tracheal injury 1504
Tracheoesophageal
fascia inferior 433
fistula 201, 203, 213, 248
groove 1502
Tracheostomy 287, 425f
Tracking system 1579
Tramadol 187
Tranexamic acid 156, 1151
Transarticular facet fixation 546
Transarticular screw 547, 674
fixation 547
use of 546
placement 547, 618
Transarticular technique, posterior 529
Transcranial electric motor 138f, 142
evoked potential 136, 145f
Transcranial electrical
stimulation 136
stimulus, high voltage 1486
Transcranial magnetic stimulation 78
Transcranial motor-evoked potentials 573, 1181, 1486
spinal monitoring of 482
Transcutaneous electrical nerve stimulation 459, 910
Transexamic acid 1151
Transfacet 779, 784
fixation
adjunctive 781
ipsilateral 779
Transferrin 711, 1269
Transforaminal cage insertion 1471
Transforaminal endoscopic treatment 879
Transforaminal epidural injections 192, 460
Transforaminal interbody fusion 921, 1411
Transforaminal lumbar interbody fusion 50, 277, 414, 747, 775, 782, 795, 813, 815, 818, 885, 935, 1235, 1289, 1441, 1482, 1492, 1563, 1591
minimally invasive 745, 1556
technique, minimally invasive 1557
Transforaminal nerve block, selective 1260
Transforaminal route 94, 835
Transforaminal steroid injections 191, 817
Transforaminal surgery 878
Transforaminal technique, endoscopic 752
Transgastrointestinal gunshot wounds 685
Transient hip flexor weakness 819
Transient hypoxia 203
Transient inflammatory reaction 1334
Transient intraoperative hypotension 308
Transient ischemic attack 152
Transient neuropraxia, episode of 606
Transient paraplegia 1091
Transient quadriparesis 605, 606, 609
episode of 606, 607
Transient ulnar neuropathy 638
Transitional lipomas 259
Translaminar facet
fixation 779
screws, percutaneous placement of 1591
Translaminar fixation, adjunctive 782
Translaminar hole 845
Translaminar injection 909
Translaminar screw 52, 787
fixation 782
placement of 782
Transmaxillary procedure 553
Transmembrane metalloenzyme 508
Transmuscular route 848
Transnasal endoscopy 422
Transoral approach 421, 552, 1502
Transoral atlantoaxial reduction 528
Transoral decompression 557, 559
Transoral decortication 528
Transoral intubation 422
Transoral surgery 553, 557
Transoral-transpalatopharyngeal exposures 309
Transpedicular approach 965, 1436, 1533
bilateral 1436
unilateral 1436
Transpedicular biopsy 332
Transpedicular decancellation osteotomy 1297, 1298f
Transpedicular fixation 774, 775, 1565
Transpedicular instrumentation 807, 810
Transpedicular screw
fixation 1572
placement 675
Transperitoneal access approach 872
Transperitoneal approach 733
endoscopic 791
laparoscopic 791, 797, 889
Transperitoneal technique 738
Transpleural dissection 1435
Transpleural technique splits 1106
Transpsoas approach 741
Transpsoas technique 739
Trans-sacral arthrodesis, computer-aided 1592
Transthoracic approach 818
Transversalis muscles 733
Transverse abdominis 29, 733, 737
muscles 1190f, 1194
Transverse apophyses 430
Transverse atlantal ligament 611
Transverse atlantoaxial 580
Transverse ligament rupture 616
Transvertebral approach 513
Trapdoor technique 372
Trapezius 58, 459, 1439
Trauma 38
acute 39
cumulative 39
disorders 111
induced canal compromise 607
instability 40
mechanical 40
signs of 57
Traumatic atlanto-axial instability 674
Traumatic brain injury 153, 648
Traumatic cord edema 630f
Traumatic delivery system 1556
Traumatic facet subluxation, operative management of 631
Traumatic nerve root cysts 997
Traumatic pain 90
Traumatic rotatory atlantoaxial dislocation 618
Traumatic spinal cord injury 662
Traumatic spondylolisthesis of axis 619
Traumatic spondylolysis 633, 633f
Trendelenburg gait 1502
Trendelenburg test 1114
Trephine
curettage 372
method 372
Triamcinolone 88, 98
acetonide 88, 95
diacetate 88
Triangular osteosynthesis technique 984
Triaxial potentiometric systems 66
Tricortical graft 372
Tricortical interbody bone grafts 311
Tricortical purchase 944, 1471
Tricyclic antidepressants 187, 833, 911
Trigeminal neuralgia 128
Trigger point injections 1260
Triggered electromyography 819
Trilogy system, treatment on 127f
Tripod sign 1420
Trochanters 725
True radiculopathy 447
Truebeam linear accelerators 127
Tubercle
adjacent 1418
bacilli 1418
Tubercular kyphosis 1422
Tubercular spondylodiscitis 1423f
Tuberculin skin test, role of 1426
Tuberculosis
antigens 1426
first-line drug regime 1430
multidrug-resistant 1431
posterior element 1419f
Tuberculous bacilli 1418
Tuberculous infection, extrapulmonary 1427
Tuberculous paraplegia, stages of 1425t
Tuberculous sinus, healing of 1424f
Tuberculous spondylitis 421
Tubular retractors 752, 1549
Tumors 1089
ablation 1366
benign 1326f, 1329
border 1328
cell
access of 1358
death 132
classification of 1377fc
disorders 111
dissemination 1358
encapsulated 1326f
excision 1592
extradural 1376f
extramedullary 1375, 1376f, 1377, 1381t, 1383t, 1387, 1532
free survival 757
high grade 1336
histotype 1371
incidence of 1376f
infiltration 1359
intramedullary 143, 1376f, 1379, 1382, 1385, 1389, 1532
intraspinal 212
localization 1385
low grade 1336
malignant 1329, 1336, 1346
markers 1364
mass 1359
necrosis factor 350, 359
alpha antagonists 358
pathology 1376
pseudocapsule 1338
replacing bone, mechanism of 1359
resection 400, 421
completion of 424
intramedullary 1386
minimally invasive 1532
surgery 1593
with radiosurgery 131
Tuohy needle 191
Tyrosine kinase inhibitors 1329
U
Ulnar fingers, adduction of 64f
Ulnar nerve 107f, 473
entrapment 456
stimulation 79f
Uncinate process 1524
Uncovertebral joint 20, 466, 468f
bilateral 482, 483f
hypertrophy 452, 1062
Unicortical grafts 1501
Unicortical screws 47
Universal donor blood group 663
Universal spine system, posterior 392
Upper cervical spine
injuries of 594
ligamentous anatomy of 611f
Ureter injury 1051
Uribe's series 1564
Urinary dysfunction 1121
Urinary incontinence 1347f, 1381
Urinary metanephrine, measurement of 712
Urinary retention 1060
Urinary tract infection 710, 720, 726, 1121, 1451
Urogenital sinus 248
Urological dysfunction 254, 259
Uvula 425f
V
Vacterl/vater association 201
Vacuum devices 726
Valgus deformity, risk of 408
Valproic acid 203, 267
Valsalva maneuver 62, 249, 1002, 1387, 1459, 1460, 1495
Vancomycin
powder 641
resistant enterococci 1476
Vascular and neurological anatomy 32
Vascular claudication 917, 918, 1005
Vascular complication 1469, 1477, 1516
Vascular damage 691
Vascular disease 918
Vascular endothelial growth factor 381
Vascular engorgement 331
Vascular injuries 678, 1470
life-threatening 683
major 1207, 1520
spectrum of 1469f
Vascular lesions 1379
Vascular stiffening 112
Vascularized fibrous tissue ingrowth 882
Vasculitis 1395
Vasculogenesis result 380
Vasoactive drugs, use of 153
Vasoconstriction, distraction induced 1493
Vasogenic edema 657
Vasopressin 708
Vasopressors, administration of 140
Vasospasm 139
Vein
azygos system of 29
brachiocephalic 1516f
iliolumbar 789, 1469
intraosseous 28
Vena cava, inferior 734, 1516, 1536
Venous air embolism 159
Venous hematogenous spread 1089
Venous thromboembolism 1449
prophylaxis 156, 721
risk of 1308
Ventral debridement 1410
Ventral somites 198
Ventral spine surgery 1591
Ventral tumors 431
Ventricular hypertrophy 112
Ventriculoatrial shunt treatment 269
Ventriculoperitoneal shunt 201, 269, 298, 310
Ventromedial extradural lesions 421
Ventromedial somite cells 220
Versican 6
Vertebra
coccygeal 35
superior 597
venous system of 28f
wedge-shaped 214
Vertebral apophyseal ring fracture 1228
Vertebral artery 29f, 430, 526f, 527f, 529f, 534, 539, 570, 1505, 1524, 1530
anomalous 45f
course, abnormal 528
injury 142, 469, 539, 682, 1523
ranges 1503
Vertebral axis, sagittal 1249
Vertebral body 3, 27, 221, 286, 395, 574, 738, 771, 774, 871, 962, 973, 1119, 1228, 1327, 1359, 1370, 1427, 1536
anomalies 260, 261
anteroinferior 605
biopsy of 431
burst fracture 629
chondrification centers 216
collapse 1368, 1418
expansion 331
formation of 198f
fractures of 954f
growth of 1136f
listhesis 963
loss 1433
maturity stage of 1228f
paradiscalmargin of 1427
posterior 1050f
resection 1494
resorption 414
small 1195
Vertebral bone window 871
Vertebral collapse 1359, 1427
Vertebral column 17, 19, 22, 25, 31
development of 199
fractures 1114
lower 203
malalignment 1477
posterior margins of 1536
resection 286, 1295, 1300, 1483
osteotomy types of 1300
stability 1477
Vertebral disc, removal of 1074f
Vertebral dysmorphology, types of 212
Vertebral endplate 316, 814, 815, 864
deficient 1471
Vertebral foramina from c6 to c1 27
Vertebral formation 202
Vertebral fracture 40, 713
Vertebral growth 1135
Vertebral infection 1417, 1516
Vertebral interbody cages 50
Vertebral level 1536
Vertebral metastases, incidence of 1358
Vertebral osteomyelitis 1408
Vertebral osteotomies 1302, 1303f
types of 1295
Vertebral plexus, external 28
Vertebral subluxation, degrees of 219
Vertebral tumors, classification of 1327f
Vertebral wedge osteotomies 1302
Vertebrectomy 382, 752, 1327, 1328f
Vertebrobasilar ischemia 1504
Vertebroplasty 1366, 1372
specimen 1271
Vertebrospinal arterial system 27
Vessel
injury, large 1289
intercostal 1439
Vicryl stitches 272
Vimentin 1379
Viral infections 155
Virgin translaminar route 850
Virtual fluoroscopy 1574
Visceral metastases 1369
Visceral organs 439
Visceral pain 187
Viscoelastic biomechanical properties 12
Viscoelastic matrix 876
Viscoelastic properties 864
Viscous semi-fluid 7
Vision impairment 1451
Visual analog scale 815, 953, 1044, 1054, 1062
Visual analog score 130, 934, 1561
Visual imagery 719
Visual loss, postoperative 160
Volatile agents 113, 160
Volatile anesthesia 160
Volkmann canals 381
von Hippel-Lindau disease 1379
von Hippel-Lindau syndrome 1383
von Mises stress distribution 1233f
W
Wackenheim clival line 614, 614f
Waddell's signs 72
Water-Laden glycosaminoglycans 35
Wedge fractures, anterior 952
Wedge osteotomy
osteotomy types of 1297
posterior 1302
Wedge vertebra 201, 203
Weinstein-Boriani-Biagini system 1345
Whiplash injury 444, 579
transition from acute 582
Whiplash-associated disorder 444, 579, 582
White blood
cell 1518
count 1474
Wilmington brace 1165
Wiltse-Newman anatomic classification 1211t
Wiltse-Newman spondylolysis classification 1211
Winkling owl sign 1362f
Wisconsin segmental spinal instrumentation 1177f
Woodsen elevator 497
Wound
closure 1187
multilayer 851
complications 1352
dehiscence and sepsis 555
healing, poor 408
hematoma 485, 637, 643
infection 108, 277, 973, 1502
Wrist flexors, triceps 61
Wrong level surgery 1465, 1515
X
Xenopus 266
Xylocaine 98
Y
Yeoman's test 71
Young myelomeningocele patient 286
Z
Zellballen cells 1378
Zimmer spine 869, 1043
Zinc 708
sulfate 189
Zoledronic acid 332
Zozulya's classification 1394
Zozulya's paper 1394
Zurich claudication
questionnaire 925
scale 179
Zygapophyseal joint 20, 86, 87, 188, 444, 749, 992
articular surfaces 30
capsular ligaments 580
damage 581
denervation 94
injury 581
innervation of 87f
pain 188, 585, 586, 990, 1012
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Chapter Notes

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1General
Magdy Gamal Youssef2

The Aging Lumbar SpineCHAPTER 1

Isaac L Moss,
Howard S An,
Stephen P Banco
Snapshot
  • » Etiology of Disc Degeneration
 
INTRODUCTION
The lumbar spine is composed of the five caudal-most fully segmented vertebrae of the spine. Each vertebra is a complex bone composed of several parts (Fig. 1.1). The vertebral body serves as the primary weight-bearing structure of the spine. The lamina and pedicles form the spinal canal that contains and protects the neural elements. A central spinous process and two lateral transverse processes protrude from the vertebrae and serve as attachment points for the paravertebral muscles and ligaments. The superior and inferior articular processes form synovial joints with the adjacent vertebrae known as the facet joints. Multiaxial motion between the vertebrae is achieved through a three-joint complex composed of an anterior intervertebral disc (IVD) separating two vertebral bodies and two posterior facet joints.
The facet joints are lined with articular cartilage and are surrounded by a capsule, typical of synovial joints elsewhere in the body. The IVD, however, has a unique structure consisting of an inner proteoglycan-rich gelatinous nucleus pulposus (NP), surrounded by the annulus fibrosus (AF), an organized fibrous ring with abundant type I collagen content. The entire structure is confined cranially and caudally by cartilaginous end plates.
With age, both the IVD and facet joints can degenerate displaying morphologic changes similar to other articulations in the skeleton, including joint space narrowing, subchondral sclerosis, and osteophyte formation (Figs. 1.2A and B).1 In a segment of the population, this process can lead to a variety of clinical presentations including debilitating back pain, a common condition with enormous psychosocial and economic ramifications. It has been estimated that approximately 85% of individuals in the United States suffer from back pain at some point in their lifetime, with an annual prevalence of 15–45%.2 The resulting direct and indirect economic costs have been estimated to be between 14 and 90 billion dollars per year.3 Despite the enormous clinical problem it represents, there is a lack of consensus as to how lumbar degeneration should be defined and which changes, particularly within the IVD, should be considered pathologic or just a normal part of aging.
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Fig. 1.1: Mid-sagittal crytome section of the caudal lumbar spine demonstrating the relationship between the vertebrae, intervertebral discs, and the spinal canal.
4
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Figs. 1.2A and B: Lateral X-ray of a normal lumbar spine (A) and a lumbar spine with advanced degenerative changes (B) including disc space narrowing (arrowheads), osteophyte formation (arrow), and spondylolisthesis (*).
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Fig. 1.3: Histologic section of rabbit intervertebral disc demonstrating migration of chondrocytes from the end plate into the nucleus pulposus (arrows). The pyknotic nuclei of notochordal cells undergoing apoptosis are visible in the center of the nucleus.
This chapter will describe the development of the lumbar spine, the morphologic and biochemical features of the normal IVD and vertebrae, as well as the changes that occur with aging and pathologic degeneration. A better understanding of these processes is the first essential step in the development of novel therapies to treat and even potentially reverse the degenerative process and its consequence.
 
Development of the Spine
The axial skeleton is formed by condensation of mesenchymal cells in somites and their aggregation around the notochord. The segmentation of this perichordal tube results in condensed regions that form the vertebral bodies and noncondensed regions that form the IVDs.4,5 The notochordal cells proliferate within the IVD and synthesize an extracellular matrix rich in glycosaminoglycans, forming the original embryonic structure of the NP. The AF, on the other hand, is derived from the surrounding mesenchymal tissue. This gives rise to a distinct border between these two IVD components as well as very different tissue composition and properties.6,7 In the NP, the negatively charged aggregating proteoglycans produced by the notochordal cells generate an osmotic gradient that both attracts and holds waters within the IVD. At birth, the population of notochordal cells within the IVD is estimated to be 2,000 cells/mm3.8 Shortly afterward, Fas-mediated mitochondrial caspase-9 activation9 results in notochordal cell apoptosis with a resulting cell density of 100 cells/mm3 at 1 year of age and almost none identifiable by late childhood. As the notochordal cell population dwindles, chondrocytic cells migrate from the cartilaginous end plate to repopulate the NP (Fig. 1.3). These cells synthesize both proteoglycan and type II collagen in an effort to maintain extracellular matrix homeostasis.10 Since these migrated chondrocytes are believed to be the major NP cell type in the adult IVD, NP and articular cartilage biology share many similar features.
The AF, derived from the mesoderm, is composed primarily of type I collagen organized into concentric lamellae synthesized by a fibrocyte-like cell population (Fig. 1.4). The collagen fibrils within the annulus are oriented approximately 30° from the long axis of the spine. Fibrils within each layer are parallel and run in opposing directions to adjacent layers. This organization confers significant tensile strength to AF tissue, which is responsible for resistance to tensile and shearing loads placed on the IVD. Only a small percentage of the dry weight of the AF is made up of proteoglycans. With aging, the distinct border characteristic of the developing NP and AF is lost, resulting in fibrous and highly organized outer AF, and an inner AF with mixed fibrocartilaginous characteristics.5
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Fig. 1.4: The intervertebral disc composed of a gelatinous nucleus pulposus, surrounded by a fibrous annulus fibrosus. The annulus is composed of concentric lamellae with collagen fibers running in alternating directions, angles approximately 30° from the vertical axis of the spine.
The bony vertebral bodies and cartilaginous end plates are formed by mesenchymal cells above and below the IVD. In early life, blood vessels permeate through these structures providing the disc with nutrients.11
By the third decade of life, the blood vessels that supply the center of the disc have receded. As a result, nutritional support to the IVD comes from diffusion through the end plate and outer AF.12 The cell density within the IVD decreases to a level lower than almost any other tissue in the body as the disc grows with age and more extracellular matrix (ECM) is laid down.13 Much of this sparse cell population is found in the regions closest to the source of nutrition near the periphery of the IVD.
When development is complete, the IVD is a relatively acellular, avascular tissue with little potential for self-repair. As a consequence of this process and the constant biomechanical demands placed on the spine, the balance in production and degradation of extracellular matrix components within the NP and AF becomes disturbed with aging. This can give rise to the morphologic appearance of IVD degeneration, and sometimes, symptomatic discogenic low back pain (LBP).
 
Biochemistry of the Intervertebral Disc
The biochemical composition of the individual components of the spine dictates the biomechanical behavior of the various structures of the spinal motion segment. Biochemical changes within the IVD are considered the primary drivers of the degenerative process and therefore will be the focus in this section.
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Fig. 1.5: Schematic drawing of the major extracellular matrix component of the nucleus pulposus. Large, predominantly type 2 collagen fibers (pink) are randomly arranged throughout the matrix. Aggrecan molecules (circular inset), composed of highly charged chondroitin sulfate and keratin sulfate monomers connected to a core protein, surround the collagen fibers. Multiple aggrecan molecules are connected to long hyaluronan backbones (green) via link protein to form large proteoglycan aggregates.
The IVD and hyaline cartilage share a similar extracellular matrix molecule profile, likely due to the similar cell type populating both tissues (Fig. 1.5). It is estimated that 60% of the dry weight of the AF and 20% of the dry weight of the NP is made up of various collagen types, making it the most abundant protein in the disc. Both fibril forming (collagen I, II, III, V, XI) and short helical forming (collagen VI, IX, XII) collagen types are present in the disc.14 Type II collagen is the predominant type within the NP, creating a disordered fibrillar framework for other matrix molecules and cell attachment. There is a shift to a predominance of organized type I collagen with progression from the center of the NP toward the AF. Approximately 80% of the collagen molecules in the outer AF are type I.
The structure and distribution of collagen molecules within the IVD change in at least three significant ways as degeneration progresses.1 The AF and the NP become more fibrous tissues as a result of an increase in the ratio of type I to type II collagen in both structures. Advanced 6glycation end products are formed and accumulate due to the nonenzymatic cross-linking of collagen molecules. Production of collagenases by disc cells is also augmented, leading to enzyme-mediated proteolytic cleavage of collagen fibers. The consequence of these events is a buildup of incompetent fibrous collagen that decreases the compliance of the NP, limits its overall swelling ability, and impairs resistance to compressive loading.15
Up to 50% of the dry weight of the NP and 20% of the dry weight of the AF is made up of proteoglycans. After collagen, these are the second most abundant group of extracellular matrix molecules within the IVD. Versican, lumican, decorin, biglycan, and fibromodulin are all found in measurable quantities within the IVD; however, aggrecan is by far the most abundant proteoglycan.1 The NP's ability to attract and bind water is largely due to the highly charged nature of this molecule consisting of chondroitin-6 sulfate and keratin sulfate side chains bound to a core protein. The aggrecan of the IVD also forms large proteoglycan aggregates by binding to hyaluronan through interaction with link protein, further augmenting its ability of attracting water and maintaining disc hydration.
As the disc ages, there is a change in both the amount and character of aggrecan within the IVD. A reduction in both cell numbers and the rate of proteoglycan synthesis per cell leads to a decrease in overall aggrecan production. At birth, chondroitin sulfate is the most abundant glycosaminoglycan side chain present within aggrecan molecules. With age, however, there is a shift to a predominance of keratin sulfate side chains.16 Water-binding capacity and efficiency is diminished as both aggrecan and aggrecan-hyaluronan aggregates are subject to proteolytic degradation. Additionally, due to the large size of these molecules, the partially digested proteoglycans are not easily scavenged from the disc. Similar to the collagens, these molecules amass within the IVD and are subject to nonenzymatic cross-linking further contributing to the accumulation of advanced glycation end products.15
The principal proteolytic enzymes produced by native disc cells are a disintegrin and metalloprotease with thrombospondin motifs and matrix metalloproteinases (MMPs).17 The cells also produce natural antagonists to MMPs, namely, tissue inhibitors of metalloproteinases. These enzymes and enzymatic inhibitors, which are modulated by a number of biochemical stimuli including expression of growth factors and cytokines, are responsible for remodeling and maintenance of IVD matrix homeostasis. Clearly, a certain amount of tissue turnover is required to clear damaged molecules. However, the balance between anabolic and catabolic metabolism within the IVD can be altered due to age-related metabolic changes, genetic predisposition, and biomechanical dysfunction. This balance is generally shifted toward intensified catabolism, thus producing the biochemical changes typical of degeneration.
The consequence of these biochemical changes in collagen and proteoglycan content and enzymatic activity within the disc is a limited ability to adequately dissipate both compressive loads and progressive mechanical incompetence. Additionally, the impaired swelling pressure within the degenerated disc leads to a reduction in exchange of waste and nutrients, further starving the few remaining disc cells, which are diffusion dependent. The progressively fibrous matrix also places increased stress on the mechanically sensitive disc cells. The intracellular response to this microenvironment can lead to increased cell death and/or further upregulation of type I collagen and proteolytic enzyme synthesis, possibly contributing to downward degenerative spiral.18
 
Biomechanics
Two adjacent vertebrae, the facets joints, an intervening IVD, and the various connecting ligaments form the functional spinal unit. The AF and end plates enclose the relatively incompressible hydrated NP. Both axial compression and eccentric loading result in even stress distribution across the cartilaginous end plate in nondegenerated IVD.19 In the unloaded condition, proteoglycans attract and hold water within the NP generating positive intradiscal hydrostatic pressure. When the spine is loaded, stress is transmitted through the compact subchondral bone of the end plate to the NP. This leads to an increase in pressure within the NP that, in turn, is transmitted to the organized lamellar structure of the AF and converted into tensile hoop stress resulting in altered spatial arrangement of the collagen network and a small amount of immediate decrease in disc height. If the load applied to the spine remains constant, slow outflow of fluid through the AF and end plates results in a viscoelastic creep phenomenon with the IVD continuing to lose height over time. When the load is eventually removed, the osmotic pressure generated by the proteoglycans within the healthy NP will cause an influx of fluid from the surrounding tissue to slowly recover the lost height.20 There is, therefore, a regular diurnal variation in IVD height with progressive loss of height during the day when upright, and recovery when supine at night.7
Many rehabilitation regimes designed for patients with discogenic back pain are based on the in vivo intradiscal pressure measurements in various functional positions reported by Nachemson and Morris.21 In their study of undegenerated human discs, the unsupported sitting position resulted in the highest recorded intradiscal pressure (0.8–1.5 MPa). Conversely, the lowest pressures were measured in the discs of relaxed, supine subjects (0.1–0.2 MPa). Lifting, especially with an anterior positioned load, and other strenuous activities resulted in a significant increase in intradiscal pressure. These general trends observed by Nachemson were confirmed in two more recent studies.22,23 These studies also found a significant decrease in intradiscal pressure in degenerated IVDs (see Fig. 1.3).
The mechanical properties of the IVD change from those of a viscous semi-fluid to properties closer to those of a solid as the nucleus degenerates and becomes fibrous with decreased proteoglycan and increased collagen content.1 Stress distribution across the spinal motion segment becomes uneven as the more fibrous NP has a diminished overall swelling capacity and is unable to adequately conform to and transmit applied loads.24 The AF becomes overloaded and structurally damaged, especially when eccentric loads are applied to the IVD. Nucleus pulposus containment eventually fails, often through the development of fissures within the AF, as the degenerative process proceeds. Degenerated IVDs demonstrate altered creep characteristics with larger and more rapid deformation with any given load, and slower recovery when the load is removed.25 As the main load-bearing structure of the functional spinal unit fails, a higher portion of load bearing is transferred to the posterior elements. Osteoarthritic changes similar to other cartilaginous synovial articulations begin to manifest within the overloaded facet joints. While facet joint degeneration does not always progress in parallel to IVD degeneration, facet degeneration is not found in the absence of a degenerated IVD.26
The degenerative cascade proposed by Kirkaldy-Willis and Farfan explains the pathogenesis of spinal motion segment degeneration through three progressive phases.27 In the first “dysfunctional” stage, acute or repetitive injury can lead to the accumulation of microscopic damage within the disc and synovitis within facet joint. In the second “unstable” phase, diminished IVD height, in addition to facet capsule laxity and subluxation, leads to pathologic and potentially painful hypermobility of the degenerated spinal motion segment. Eventually, severe degenerative changes inducing disc osteophyte formation and facet enlargement lead to the third “stabilization” phase with resolution of the hypermobility present in stage two. The majority of back pain episodes are thought to occur during the first two stages of degeneration. In the third stage, discogenic back pain is relatively uncommon; however, patients may remain or become symptomatic from spinal stenosis due to hypertrophy of the facet joint and disc bulging. Recent cadaveric studies in both the lumbar28 and cervical spine29 have supported this observation, reaffirming the relationship between spinal motion and disc degeneration.
 
Macroscopic and Radiographic Changes
The biochemical and biomechanical alterations within the IVD result in well-described macroscopic changes. This progressive deterioration is the basis of the grading system proposed by Thompson et al. based on gross pathologic changes visible as the disc degenerates.30
As pathologic examination is not usually practical, clinicians rely on radiographic imaging to diagnose degenerative disc disease. On plain X-ray, disc space narrowing, end plate sclerosis, and osteophyte formation at the margins of the affected level characterize degeneration. In more severe cases, gas collections can be visible within the disc. Degenerative changes on magnetic resonance imaging (MRI) provide a more detailed assessment of the state of the IVD. However, clinical correlation with the radiologic finding is always important, as MRI abnormalities are found in a large percentage of asymptomatic individuals.31,32 On T2-weighted sequences, loss of NP hydration results in progressive loss of signal intensity. Pfirrmann et al.33 described an MRI grading scale of degenerative changes, similar to the pathologic Thompson scale (Table 1.1 and Fig. 1.6). Tears within the AF are often visible,34 as well as end plate signal changes, both of which can be indicative of degenerative disc disease (DDD). Modic et al.35 classified end plate signal changes into two types: Modic type I changes, indicative of augmented marrow fibrovascularity, demonstrate decreased signal intensity on T1-weighted sequences and increased signal intensity on T2-weighted sequences; whereas, Modic type II changes are characterized by increased signal intensity on T1-weighted sequences and isointense or slightly increased signal on T2-weighted sequence. The correlation of these changes with back pain is still the subject of debate.3639
As degeneration within the disc progresses, arthritic changes in other parts of the spinal motion segment become evident on imaging. Degenerative changes within the facet joint can become clinically important, and severity can be graded with either computed tomography scans or MRI.26,408
Table 1.1   MRI classification of disc degeneration.
Grade
Structure
Distinction between AF and NP
Signal intensity
IVD height
I
Homogenous, bright white
Clear
Hyperintense, isointense to CSF
Normal
II
Inhomogenous with or without horizontal bands
Clear
Hyperintense, isointense to CSF
Normal
II
Inhomogenous, gray
Unclear
Intermediate
Normal to slightly decreased
IV
Inhomogenous, gray to black
Lost
Intermediate to hypointense
Normal to moderately decreased
V
Inhomogenous, black
Lost
Hypointense
Collapsed disc space
(MRI: Magnetic resonance imaging; AF: Annulus fibrosus; NP: Nucleus pulposus; IVD: Intervertebral disc; CSF: Cerebrospinal fluid).
Source: Adapted from Pfirrmann CW, Metzdorf A, Zanetti M, et al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976). 2001;26(17):1873-8.
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Fig. 1.6: Grading disc degeneration: T2-weighted magnetic resonance images (left panel) and gross pathology mid-sagittal sections (right panel) of intervertebral discs demonstrating progression of degenerative changes from Pfirmmann/Thompson Grade I, with no degeneration to Pfirmmann/Thompson Grade V, with severe degeneration and disc space collapse.
The combination of both IVD and facet degeneration can lead to spinal stenosis and segmental instability, known as spondylolisthesis (Fig. 1.7). If degeneration progresses over multiple levels, alteration in both coronal and sagittal alignment can occur resulting in degenerative lumbar scoliosis or kyphosis. When asymmetric degeneration of the IVD and/or the facet joints occurs, the spinal motion segment is loaded unevenly. Over several years, an asymmetric deformity (i.e. scoliosis and/or kyphosis) can develop. The developing deformity further alters the load distribution, setting up a cycle, with the deformity again triggering additional asymmetric degeneration and inducing more asymmetric loading.41 These changes often occur in postmenopausal females or older men who have altered bone metabolism and some osteopenia.42 These patients may experience collapse of weak osteoporotic vertebrae and develop asymmetric bony deformity, which can contribute to further progression of either scoliosis or kyphosis. At each level, translational dislocations in either the coronal plane alone or three-dimensionally can occur in addition to spondylolisthesis, leading to rotational subluxation.43
The degenerative changes not only lead to spinal deformity, but are also likely to result in the development of spinal canal narrowing, known as spinal stenosis. This stenosis, a result of disc narrowing, disc bulging, facet hypertrophy, and vertebral translation, can impinge on the neural elements in the spinal canal or neural foramen. Clinically, patients with stenosis can experience back pain and/or leg pain in the form of radiculopathy or neurogenic claudication.
 
ETIOLOGY OF DISC DEGENERATION
Lumbar spine degeneration is considered an unavoidable consequence of aging. In one anatomic study, macroscopic disc degeneration was found in 98% of specimens above the age of 70 years, and in only 16% of specimens below the age 20 years.44 Fortunately, while extremely common on pathologic examination and imaging, spinal degeneration is frequently asymptomatic.31,32 In patients with back pain, it can be a clinical challenge to determine which degenerated structures are the pain generators and which are incidental findings.9
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Fig. 1.7: Mid-sagittal (left panel) and axial (right panel) T2-weighted magnetic resonance imaging of the lumbar spine of a 64-year-old woman who presented with both low back and bilateral leg pain. The hallmarks of disc degeneration are apparent at the L4-5 level (arrow head) on the sagittal including loss of nucleus pulposus hydration and disc space narrowing. Facet joint hypertrophic osteophyte formation is evident on the axial images (arrows). These degenerative changes have resulted in spondylolisthesis, with L4 slipped forward on L5 (left panel), and severe spinal stenosis (*, right panel).
There are many etiologic factors that have been linked to the development of spinal degeneration. As discussed previously, the disc cells are responsible for maintenance of homeostasis within the IVD. Therefore, anything that impacts the microenvironment within the NP or alters disc cell metabolism and synthetic rate can accelerate the degenerative process. These factors can be environmental, mechanical, and/or genetic.
Intervertebral disc nutrition has been implicated as a major contributor to degeneration.45 As detailed above, the blood vessels supplying the NP recede in the first two decades of life leaving the disc cells largely dependent on diffusion through the end plates and outer AF for nutrition.12 As the end plates calcify with age, diffusion into the IVD is impeded further. The cells at the center of the mature NP can be several millimeters from the nearest blood supply, severely limiting nutrient diffusion.12 Viability of these cells is significantly impacted by the loss of nutritional support, leading to a decreased number of cells over time.46 Lack of nutrients and low oxygen tension shift the metabolism of the remaining cells to the anaerobic pathway, leading to lactate production and lowered tissue pH. In these conditions, the rate of matrix synthesis by disc cells drops off further.47,48 The combination of a low number of viable cells and less matrix synthesis per cell shifts the balance of homeostasis within the disc to one of net catabolism. Systemic diseases that can alter vertebral blood supply, such as atherosclerosis,49 have been associated with higher rates of disc degeneration. Smoking has also been linked to the development disc degeneration and back pain in several epidemiologic studies.50,51 The negative effects of smoking on the disc are thought to be mediated both through nutritional restriction52,53 and direct nicotine toxicity to disc cells.54,55
Alteration in mechanical loading has also been implicated as a cause of disc degeneration, with changes 10in the biomechanical environment leading to biochemical changes within the tissue.56,57 Excess, or asymmetric mechanical loading of the disc can lead to localized tissue trauma. Tissue repair will be minimal due to slow turnover of the disc matrix.58 Prolonged mechanical loading can lead to a higher rate of apoptosis of IVD cells.59 Additionally, excessive hydration or dehydration of the disc has been shown to significantly decrease the rate of matrix synthesis.60,61 The combination of repetitive microtraumas and the decreased turnover and synthetic rate of disc cells and matrix, ultimately leads to progressive structural failure of the disc, making it more susceptible to further injury.
Genetic susceptibility has also been implicated as major contributing factor to disc degeneration. The so-called “Twin Spine Study”62 compared the rates of IVD degenerative changes in monozygotic twins in three countries with discordant exposure to occupational or sport-related spinal loading. The data demonstrated that genetic factors are the primary predictor of disc degeneration, with heredity accounting for up to 74% of the variance present in the adult population. This dispelled the previously held belief that mechanical injury was the strongest driver of degeneration. Further work by Videman et al.63 demonstrated that polymorphism within vitamin D receptor gene was associated with disc degeneration. Other gene polymorphisms including aggrecan,63 interleukin-1 and COL9A3,64,65 COL9A2,66 collagen IX and XI,67 and MMPs-368 have been linked to the development of disc degeneration.
Chronic low-grade infection has recently received some attention as a potential contributor to disc degeneration and LBP. Albert et al.64 cultured herniated disc material from patients undergoing discectomy. The study found microorganisms to be present in 46% of herniations, with the anaerobic bacteria Propionibacterium acnes being the most common isolate detected. The study further demonstrated a statistically significant higher rate of type 1 Modic changes in patients with disc material infected with anaerobic bacteria. A follow-up randomized controlled trial demonstrated improved clinical outcomes in patients with chronic back and previous herniated discs after 100 days of antibiotic therapy.65 The generalizability of these exciting findings to the general population of LBP patients has yet to be determined.
 
Pain Generators
An understanding of the biomechanical and biochemical processes as well as the etiologic factors leading to spinal degeneration is important. However, from a clinical perspective, an essential question remains to be answered—what is the source of pain in the degenerating spinal motion segment? This is especially relevant as there is a poor correlation between the morphologic signs of degeneration and back pain.66 No single answer to these questions has emerged; however, it has become clear that several sources of pain exist.
Pain originating from the IVD, termed discogenic pain, has long been implicated as a major player in the process; however, its etiology is not well understood. The central end plate and the periannular tissues have the most abundant nerve supply of the IVD.67 The outer rim of the AF is thought to contain the bulk of IVD nociceptive fibers arising from the sinuvertebral nerve, a meningeal branch of the spinal nerve originating from the dorsal root ganglia (Figs. 1.8A and B). It has been demonstrated in animal models that the caudal IVDs may be innervated by the L1 or L2 dorsal root ganglia through the sympathetic trunk.6871 Thus, discogenic back pain may be referred to the groin (i.e. the L2 dermatome). There is currently debate in the literature as to whether or not this finding may be of diagnostic or therapeutic value.72,73
Discography, injection of fluid into the IVD, has been used as a provocative test for discogenic pain; however, its accuracy in predicting the source of pain in response to treatment is still quite controversial.74 Stretch of an abnormal AF, extravasation of foreign tissue into the peridural space, and pressure on adjacent nervous structures are thought to be mechanism for pain generation. In vitro experiments have demonstrated that human IVD cells increase production of nerve growth factor when exposed to interleukin-1β and tumor necrosis factor-α, both important proinflammatory cytokines.75 This may promote infiltration of nociceptive nerve fibers into the disc and lead to back pain. Other authors have attempted to find differences in morphologically degenerate discs with varying degrees of clinical symptoms. Keshari et al. found that proteoglycan, lactic acid, and collagen ratio as measured by nuclear magnetic resonance spectroscopy differed in symptomatic and nonsymptomatic abnormal IVDs.66 These findings may serve as the basis for a diagnostic test at some point in the future.
The facet joints have been noted to be a major source of pain since early in the 20th century.76,77 The load to the facets is maximal with lumbar hyperextension, and is further increased when disc height is lost as a result of degeneration.78 Experiments using both provocative and therapeutic intra-articular injections confirmed the facets joints to be a significant pain generator in patients with LBP.79,8011
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Figs. 1.8A and B: Innervation of the intervertebral disc. (A) Ascending and descending branch of the sinuvertebral nerve shown arising from the dorsal root ganglion (DRG). (B) Course of the recurrent sinuvertebral nerve from the DRG through the vertebral foramen innervating the outer annulus fibrosus.Source: Raj PP. Intervertebral disc: anatomy-physiology-pathophysiology-treatment. Pain Pract. 2008;8(1):18-44.
Additionally, both sensory and autonomic nerve fibers as well as neurotransmitters have been shown to be present in the facet capsule.81 The lumbar facet joints are segmentally innervated by the medial branch of the dorsal rami.82 Thus, intra-articular facet joint injections, and medial branch block or ablation is a commonly employed treatment for chronic LBP. Evidence for the efficacy of these treatments remains unclear, especially in the long term.8385
Nerve root compression or irritation can also be a mechanism for pain production in lumbar degeneration. While this most often presents as radiculopathy, with pain radiation to the dermatomes of the lower extremities, nerve compression can also cause isolated back pain. The pathophysiologic basis for neurogenic pain is a subject of debate; however, recent studies have demonstrated increased neuropathy, ectopic discharge, and mechano-sensitization of nerve roots when exposed to NP tissue, a situation commonly found in the degenerated lumbar spine.86
As more information emerges in the literature, it is clear that the area of pain generation deserves further study both mechanistically and diagnostically in order to enable researchers and clinicians to develop and plan appropriate therapies.
 
Biologic Therapy for Lumbar Degeneration
Although our understanding of the mechanisms of spinal degeneration has advanced significantly, the current standard of care for patients with lumbar degeneration is aimed at symptomatic control rather than reversal of the disease process. Nonsurgical therapeutic modalities including patient education, medications, exercise therapy, and occasionally various types of injections are commonly employed. In a small number of patients with unrelenting symptoms, surgical intervention to decompress, stabilize, or even replace the affected motion segments is recommended. While these interventions can be effective, they come at a high cost and put patients at risk of complications. As discussed previously, spinal degeneration is believed to begin with changes in the NP of the IVD. Thus, biologic repair to slow or reverse the early nucleus degenerative process is an attractive alternative to the current 12end-stage mechanical treatment approaches. Successful biologic repair strategies require a consideration of one or all of the following components: delivery of cells, the application of therapeutic molecules, and the supplementation of matrix.11
The density of cells present in the NP decreases significantly with aging and degeneration.13 In order for tissue repair to be possible, a new population of cells is necessary to produce appropriate extracellular matrix molecules and supplement the existing population. This can be achieved by implantation of new healthy cells into the disc, and/or by stimulation of native cell proliferation with bioactive molecules. A small clinical study examined the utility of autologous disc cell harvest, followed by ex vivo expansion and subsequent reimplantation.87 While the possibility of supplementation with autologous cells is attractive, concerns with the practical application of this strategy and the infrastructure necessary to harvest and expand the cells ex-vivo have prompted the investigation of other source of cells. Pluripotent cells, such as mesenchymal stem cells, are interesting candidates for cell supplementation as they can be harvested from several sources and are highly metabolically active in the proper environment. They have thus become the focus of many studies. Experiments conducted both in vitro and in vivo have demonstrated that mesenchymal stem cells can be successfully differentiated into chondrocyte-like cell populations. Under appropriate conditions, these cells can express IVD matrix proteins and cell surface markers.8899 Based on successful recent in vivo work with an ovine model of disc degeneration,100 a phase 2 human clinical trial using cell-based therapy is currently underway. The study is designed to determine the safety and initial efficacy of injecting mesenchymal precursor cells in a hyaluronic acid carrier into the degenerating IVDs. Results of this study have yet to be released; however, this represents an important step in the translation of this technology from the laboratory to clinical application.
The delivery of bioactive molecules to alter the catabolic environment of the degenerating NP is another cornerstone of a successful regenerative strategy. There are four basic categories of potentially therapeutic bioactive molecules: anticatabolics, mitogens, chondrogenic morphogens, and intracellular regulators.11 The chondrogenic morphogens, which include transforming growth factor-β and the bone morphogenetic protein (BMP) family, have been the focus of much investigation in this field. Proteoglycan and collagen synthesis is increased in response to transforming growth factor-β treatment of both healthy and degenerated IVD cells in vitro.101103 The BMP family of growth factors is currently used clinically to promote fracture healing and spinal fusion as they have been shown to induce osteogenesis. Interestingly, disc cells treated with BMP-2 and BMP-7 (osteogenic protein-1) show increased production of collagen type II and proteoglycans, without osteogenic effects seen in other environments.104107 In preclinical animal experiments, direct injection of a single dose of BMP-7 into degenerating discs resulted in improved disc height, restoration of viscoelastic biomechanical properties, and healthier functional metabolism.108,109 Another member of the BMP family, growth differentiation factor-5, was found to improve IVD cell viability and extracellular matrix production in vitro, and to curb progression of degeneration in a preclinical model.110 Several other potentially therapeutic molecules, including interleukin-1 receptor antagonist, platelet-derived growth factor, and insulin growth factor-1, are currently being investigated for their effects on IVD cells and disc degeneration.
Despite encouraging in vitro and in vivo studies, there is some concern that a single direct injection of a therapeutic molecule into the IVD may not be sufficient to stimulate and maintain the repair process. Gene therapy has been proposed as a method to achieve long-term sustained expression of stimulatory molecules from cells within the IVD. The potential for immune reaction and the spread of disease have raised safety concerns with the employment of viral vectors to deliver gene therapy elsewhere in the body. Due to its relative avascularity, cells of the immune system have limited access to the IVD and it is considered to be an immune-privileged environment. Thus, viral transfection of both native disc cells and exogenous chondrocytes with vectors to promote expression of several therapeutic factors has been attempted. The genes of interest include both intracellular regulatory proteins and growth factors. Both cell culture work and in vivo experiments examining the delivery of the transcription factor Sox-9, known to be an important regulator of the chondrocytic phenotype, to nucleus cells via a recombinant adenovirus have demonstrated upregulation of proteoglycan synthesis and reversal of early degeneration.111,112 Increased cell viability and augmented production of extracellular matrix molecules have also been demonstrated with adenoviral transfection of both animal and human NP cells with several growth factors including transforming growth factor-β1, BMP-2, BMP-7, and insulin growth factor-1.112114 Data from these experiments have served as a proof of principle that transfections of cells with stimulatory genes and subsequent implantation of 13these altered cells into the degenerating disc may represent an effective strategy for cell therapy and the delivery therapeutic molecules in a single treatment.
Scaffolds to serve as cell or drug carriers and supplement the degenerating extracellular matrix are the final component of a successful IVD tissue-engineering strategy. A wide variety of candidate materials have been investigated. A scaffold must provide a favorable microenvironment for cell growth, migration, and synthesis of extracellular matrix in order to be successful. Ideally, constructs must have mechanical properties capable of withstanding the loads within the IVD in the short term, and then incorporate and remodel as the disc regenerates.115 Many of the scaffolds studied are designed by combining fibrillar molecules and glycosaminoglycans in an attempt to re-create the normal matrix components of the IVD.116120 This aspect of regenerative therapies continues to be the subject of active investigation.
 
SUMMARY
The lumbar spine is a complex structure elegantly designed to support upright posture and protect the neural elements. Lumbar degeneration occurs as an inevitable part of aging and results in altered biochemical and biomechanical function as well as anatomic abnormalities. These changes result in a wide spectrum of symptoms, from completely asymptomatic to debilitating pain and functional decline. As our understanding of the makeup and function of the various components of the lumbar spine advances, opportunities for interventions to halt or reverse this process at early stages are evolving. In the future, these interventions may allow the next generation of physicians to change, for the better, the way we treat the aging lumbar spine.
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