Prelims

AO SPINE Textbook

AO SPINE Textbook: Comprehensive Overview on Surgical Management of the Spine

Editors Michael P Steinmetz MD William P and Amanda C Madar Endowed Professor and Chair Department of Neurological Surgery Cleveland Clinic Lerner College of Medicine Neurological Institute Cleveland, Ohio, USA Jeffrey C Wang MD Chief, Orthopedic Spine Service Co-Director, USC Spine Center Professor of Orthopedic Surgery and Neurosurgery, USC Spine Center Los Angeles, California, USA Thomas E Mroz MD Director, Center for Spine Health Director, Spine Research Lab Center for Spine Health Departments of Orthopedic and Neurological Surgery Cleveland Clinic Cleveland, Ohio, USA Forewords Edward C Benzel S Rajasekaran

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AO Spine Textbook: Comprehensive Overview on Surgical Management of the Spine

First Edition: 2020

9789386056955

Printed at

I would like to dedicate this book to my wife and two children. Editing such a text is a tireless and time consuming endeavor. Much of this time is taken away from family events. This is no lost on me as an editor and this finished product is a statements to their love and support.

Michael P Steinmetz

I would like to dedicate this book to my late father, who was an educator and a scholar in the area of political science. He lead, educated, and brought together stakeholders by being the prime example of being the best, and what we all should strive to be. He was the most amazing person to ever influence and guide my life.

Jeffrey C Wang

I would like to thank my family who has supported my career with love and inspiration over past 15 years.

Thomas E Mroz

Contributors

A Jay Khanna MD MBA
Vice Chair and Professor
Department of Orthopedic Surgery,
Neurosurgery and Biomedical Engineering
Johns Hopkins University
Bethesda, Maryland, USA

Abhishek Ray MD
Neurosurgeon
Department of Neurological Surgery
University Hospitals Cleveland Medical Center
Cleveland, Ohio, USA

Adam L Wollowick MD MBA
Senior Director
Business Development
Stryker Spine
New York City, New York, USA

Ahmet Alanay MD
Professor
Department of Orthopedics and Traumatology
Acibadem University School of Medicine
Istanbul, Turkey

Ajit A Krishnaney MD FAANS
Vice Chair
Department of Neurosurgery
Patient Safety Officer
Neurological Institute
Cleveland Clinic
Cleveland, Ohio, USA

Alexandra Paraskos MD
Physician
Cleveland Clinic
Columbus, Ohio, USA

Ankit I Mehta MD FAANS
Assistant Professor of Neurosurgery
Director of Spinal Oncology
University of Illinois at Chicago
Chicago, Illinois, USA

Anthony A Scaduto MD
Orthopedic Surgeon
UCLA Medical Center
Santa Monica
Los Angeles, California, USA

Brian K Kwon MD PhD FRCSC
Canada Research Chair in Spinal Cord Injury
Professor
Department of Orthopedics
University of British Columbia
Vancouver, British Columbia, Canada

Caglar Yilgor MD
Associate Professor
Department of Orthopedics and Traumatology
Acibadem University School of Medicine
Istanbul, Turkey

Casey Fisher MD
Interventional Pain Specialist
Pain Relief Solutions
San Diego, California, USA

Christopher Bonsignore MD
Spine Surgery Fellow
Texas Back Institute
Plano, Texas, USA

Christopher P Ames MD
Professor of Clinical Neurological Surgery
and Orthopedic Surgery
Director of Spinal Deformity and Spine Tumor Surgery
Co-Director, Spinal Surgery and UCSF Spine Center
Director, California Deformity Institute
Director, Spinal Biomechanics Laboratory
Department of Neurological Surgery
University of California, San Francisco
San Francisco, California, USA

Colin G Crosby MD
Orthopedic Spine Surgeon
Centennial Medical Center
St Thomas Hospital
Nashville, Tennessee, USA

Daniel G Hoernschemeyer MD
Chief of Pediatric Orthopedics
MU Women's and Children's Hospital
Associate Professor
Department of Orthopedic Surgery
University of Missouri
Columbia, Missouri, USA

Daniel K Resnick MD MS
Professor and Vice Chairman
Department of Neurosurgery
University of Wisconsin School of
Medicine and Public Health
Madison, Wisconsin, USA

Daniel Lubelski MD
Resident
Department of Neurosurgery
Johns Hopkins University
Baltimore, Maryland, USA

Darrel S Brodke MD
Louis and Janet Peery Presidential Endowed Chair
Professor and Executive Vice Chair
Department of Orthopedics
University of Utah
Salt Lake City, Utah, USA

David E Fish MD MPH
Associate Professor
Department of Orthopedics
Physical Medicine and Rehabilitation
The UCLA Spine Center
David Geffen School of Medicine at UCLA
Los Angeles, California, USA

David Gurd MD
Attending Pediatric Orthopedic Surgeon
Head, Pediatric Spinal Deformity Surgery
Cleveland Clinic Foundation
Cleveland, Ohio, USA

David T Anderson MD
Orthopedic Spine Surgeon
OrthoCarolina
Monroe, North Carolina, USA

Douglas Orr MD
Orthopedic Surgeon
Cleveland Clinic Spine Institute
Luthern Hospital
Cleveland, Ohio, USA

Edward C Benzel MD
Emeritus Chair of Neurosurgery
Cleveland Clinic
Cleveland, Ohio, USA

Emiliano Vialle MD
Spine Surgeon
Cajuru University Hospital
Catholic University of Parana
Curitiba, Parana, Brazil

Emmanuel Menga MD
Assistant Professor
Department of Orthopedics and Rehabilitation
University of Rochester Medical Center
Rochester, New York, USA

Faiz Ahmad MD MCh
Assistant Professor
Department of Neurosurgery
Emory University
Atlanta, Georgia, USA

Fernando Techy MD
Director of Spine Surgery
Department of Orthopedic Surgery
ClinTech Center for Orthopedics and Spine Health
Fort Collins, Colorado, USA

Gabriel Widi MD
Neurosurgeon
Miami Brain and Spine Center
Miami, Florida, USA

Geoffrey Stricsek MD
Neurosurgery Spine Fellow
Emory University
Atlanta, Georgia, USA

George Rymarczuk MD
Staff Neurosurgeon
Division of Neurosurgery
Landstuhl Regional Medical Center
Landstuhl, Germany
Assistant Professor of Surgery
Uniformed Services University
of the Health Sciences
Bethesda, Maryland, USA

Ghaith Habboub MD
Neurosurgery Resident
Cleveland Clinic
Cleveland, Ohio, USA

Graham C Calvert MD
Neck and Back Specialist
Mississippi Sports Medicine Orthopedic Center
Jackson, Mississippi, USA

Gregory R Trost MD
Professor, Vice Chair
Director, Spinal Surgery Program
Department of Neurological Surgery
University of Wisconsin School of
Medicine and Public Health
Madison, Wisconsin, USA

Haariss Ilyas MD
Resident Physician
Cleveland Clinic Foundation
Cleveland, Ohio, USA

Hillard T Spencer MD
Orthopedic Surgeon
Los Angeles, California, USA

Howard S An MD
The Morton International Endowed Chair
Professor of Orthopedic Surgery
Director, Spine Fellowship Program
Midwest Orthopedics at Rush University
Chicago, Illinois, USA

Isador H Lieberman MD MBA FRCSC
Orthopedic and Spinal Surgeon
Texas Back Institute
Plano, Texas, USA

Jacob Enders BS
Medical Student
Cleveland Clinic Lerner
College of Medicine
Cleveland, Ohio, USA

James D Kang MD
Chairman
Department of Orthopedic Surgery
Brigham and Women's Hospital
Boston, Massachusetts, USA

James S Harrop MD FACS
Professor
Department of Neurological and
Orthopedic Surgery
Director, Division of Spine and
Peripheral Nerve Surgery
Neurosurgery Director of Delaware Valley SCI Center
Thomas Jefferson University
Philadelphia, Pennsylvania, USA

Jason D Berk MD
Mid-Atlantic Permanente Medical Group
Rockville, Maryland, USA

Jason I Liounakos MD
Resident
Department of Neurological Surgery
University of Miami
Miami, Florida, USA

Jean Paul Wolinsky MD
Professor of Neurosurgery and
Orthopedic Surgery
Vice Chairman of Neurosurgery
Strategic Planning and Finance
Director of Spinal Oncology
Department of Neurosurgery
Northwestern University
Feinberg School of Medicine
Chicago, Illinois, USA

Jens R Chapman MD
Spine Surgeon
Swedish Neuroscience Institute
Seattle, Washington, USA

Jessica A Tang MD
Resident Physician
Department of Otolaryngology
Temple University
Philadelphia, Pennsylvania, USA

Joel Kolmodin MD
Resident
Cleveland Clinic Foundation
Cleveland, Ohio, USA

Juliann Kwak Lee MD
Assistant Professor
Department of Orthopedic Surgery
University of Southern California
Los Angeles, California, USA

Justin K Scheer MD
Resident Physician, PGY-4
Department of Neurological Surgery
University of California
San Francisco, California, USA

K Daniel Riew MD
Professor of Orthopedic Surgery
Columbia University
Chief, Cervical Spine Surgery and
Co-Director, Spine Division
Co-Director, Columbia University Spine Fellowship
New York City, New York, USA

Kaine C Onwuzulike MD PhD
Assistant Professor
Department of Neurological Surgery, CCLCM CCAG
Section Head
Pediatric Spine and Fetal Myelomeningocele Repair
Center of Pediatric Neurosciences S-60
Cleveland, Ohio, USA

Karthikeyan E Ponnusamy MD MSE
Orthopedic Surgeon
Pinnacle Orthopedics
Woodstock, Georgia, USA

Keith Bachmann MD
Resident
Cleveland Clinic Foundation
Cleveland, Ohio, USA

Kelly Krohn MD
Clinical Associate Professor
Department of Orthopedic Surgery
University of Arizona College of Medicine
Phoenix, Arizona, USA

Kevin Hines MD
Resident
Department of Neurosurgery
Thomas Jefferson University
Philadelphia, Pennsylvania, USA

Luiz Roberto Vialle MD PhD
Professor
Department of Orthopedics
School of Medicine
Pontifical Catholic University
Cajuru Hospital, Spine Group
Curitiba, Parana, Brazil

Mari L Groves MD
Neurosurgeon
Johns Hopkins Bayview Medical Center
Baltimore, Maryland, USA

Marzena Buzanowska MD
Physician
Cleveland Clinic
Cleveland, Ohio, USA

Mauricio Silva MD
Clinical Professor
Orthopedic Institute for Children
University of California, Los Angeles
Los Angeles, California, USA

Melissa Nadeau MD MPH FRCSC
Spine Surgeon
Surrey Comprehensive Orthopedics
Surrey, British Columbia, Canada

Michael D Daubs MD
Orthopedic Spine Surgeon
Professor and Chairman
Department of Orthopedic Surgery
University of Nevada, Las Vegas
Las Vegas, Nevada, USA

Michael G Fehlings MD PhD FRCSC FACS
Professor
Department of Neurosurgery
University of Toronto
Toronto, Ontario, Canada

Michael J Beebe MD
Orthopedic Trauma Surgeon
Campbell Clinic
Germantown, Tennessee, USA

Michael J Lee MD
Professor
Orthopedic Spine Surgery
University of Chicago
Chicago, Illinois, USA

Michael P Kelly MD MSc
Associate Professor
Department of Orthopedic and
Neurological Surgery
Director, Adult and Pediatric Spine Fellowship
Director, Spine Research
Washington University School of Medicine
St Louis, Missouri, USA

Michael P Steinmetz MD
William P and Amanda C Madar Endowed Professor and Chair
Department of Neurological Surgery
Cleveland Clinic Lerner College of Medicine
Neurological Institute
Cleveland, Ohio, USA

Michael T Modic MD FACR
Professor of Radiology and Radiologic Sciences
Senior VP Population Health
Vanderbilt University
Nashville, Tennessee, USA

Michael Y Wang MD FACS
Professor, Neurological Surgery and
Rehab Medicine
Spine Fellowship Director
Chief of Neurosurgery
University of Miami Hospital
University of Miami Miller School of Medicine
Miami, Florida, USA

Natalie L Leong MD
Assistant Professor
Department of Orthopedic Surgery
University of Maryland School of Medicine
Baltimore, Maryland, USA

Orlando Colina

Paul E Kaloostian MD FAANS FACS
Neurosurgeon
Riverside Community Hospital
Riverside, California, USA

Perry Dhaliwal MD MPH FRCSC
Assistant Professor of Neurosurgery
Section of Neurosurgery
Department of Surgery
University of Manitoba
Manitoba, Canada

Richard E Bowen MD
Co-Director, Spinal Deformity Center
Orthopedic Institute for Children
Clinical Professor
Department of Orthopedic Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California, USA

Robert A Hart MD
Spine Surgeon
Swedish Neuroscience Institute
Seattle, Washington, USA

Ryan Goodwin MD
Surgeon
Cleveland Clinic Foundation
Cleveland, Ohio, USA

S Tim Yoon MD PhD
Professor
Department of Orthopedic Surgery
Emory University
Atlanta, Georgia, USA

Safdar N Khan MD
The Benjamin R and Helen Slack Wiltberger Endowed Chair in
Orthopedic Spine Surgery
Associate Professor and Chief of Division of Spine
Department of Orthopedics
Adjunct Associate Professor
Department of Integrated Systems Engineering
Clinical Faculty, Spine Research Institute
The Ohio State University Wexner Medical Center
Columbus, Ohio, USA

Sajeel R Khan MD
Assistant Professor
Department of Neurosurgery
Marshall University
Huntington, West Virginia, USA

Sandeep N Gidvani MD
Orthopedic Spine Surgeon
OrthoNorcal
Los Gatos, California, USA

Scott D Daffner MD
Professor
Department of Orthopedics
West Virginia University
Morgantown, West Virginia, USA

Sean Barry MD MA FRCSC
Assistant Professor
Dalhousie University
Halifax, Nova Scotia, Canada

Shah-Nawaz M Dodwad MD
Assistant Professor
Division of Spine
Department of Orthopedics
University of Texas Health Science Center
Houston, Texas, USA

Shaleen Vira MD
Combined Neurological and
Orthopedic Spine Surgery Fellow
Cleveland Clinic
Cleveland, Ohio, USA

Siddharth A Badve MD MBBS MS(Orthopedics)
Attending Spine Surgeon
Carolina Pines Regional Medical Center
Hartsville, South Carolina, USA

Sohrab S Virk MD MBA
Spine Fellow
Division of Spine
Department of Orthopedics
Hospital for Special Surgery
New York City, New York, USA

Stephen Dechter DO
Benton Franklin Orthopedic Associates
Kennewick, Washington, USA

Sumit K Gupta MD
Associate Professor
Department of Orthopedic Surgery
University of Missouri
Columbia, Missouri, USA

Theodore J Choma MD
Professor of Orthopedic Surgery
Director, Spine Division
University of Missouri
Columbia, Missouri, USA

Todd M Emch MD
Staff Neuroradiologist
Cleveland Clinic
Cleveland, Ohio, USA

Tom D Cha MD MBA
Associate Professor
Chief of the Spine Section
Department of Orthopedics
Massachusetts General Hospital
Boston, Massachusetts, USA

Vikram Mehta MD MPH
Neurosurgery Resident Physician
Duke University Medical Center
Durham, North Carolina, USA

Vincent J Miele MD
Clinical Associate Professor
Department of Neurosurgery
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, USA

Wellington K Hsu MD
Clifford C Raisbeck Distinguished Professor of Orthopedic Surgery
Director of Research
Professor
Department of Orthopedic and Neurological Surgery
Northwestern University Feinberg School of Medicine
Chicago, Illinois, USA

Xiaobang Hu PhD
Research Director
Texas Back Institute
Plano, Texas, USA

Yi Lu MD PhD
Assistant Professor
Department of Neurosurgery
Harvard University
Boston, Massachusetts, USA

Yonatan G Keschner MD
Resident Physician
Massachusetts General Hospital–Brigham
and Women's Hospital
Boston, Massachusetts, USA

Yu-Po Lee MD
Clinical Professor
University of California, Irvine
Irvine, California, USA

Zachary L Gordon MD
Assistant Professor
Department of Orthopedics
Case Western Reserve University School of Medicine
Cleveland, Ohio, USA

Ziya L Gokaslan MD FAANS FACS
Julius Stoll, MD Professor and Chair
Department of Neurosurgery
The Warren Alpert Medical School of Brown University
Neurosurgeon-in-Chief
Rhode Island Hospital and the Miriam Hospital
Clinical Director
Norman Prince Neurosciences Institute
President
Brown Neurosurgery Foundation
Providence, Rhode Island, USA

Foreword

Within the pages that follow, lies a wonderful contribution to the spine literature—a contribution masterfully crafted by Drs Malhotra, Mroz, Wang, and Steinmetz. The editors of the AO Spine Textbook have gathered a who's who list of spine experts who collectively ‘blanket’ the field of spine care by addressing nearly all relevant aspects of the field. Such was eloquently accomplished, leaving very few, if any, gaps. They have, as would a conductor of an orchestra, played to the strengths of each of the chapter authors—leading them, in a way, to create a first class performance that leaves jaws dropping.

The book is beautifully illustrated. The illustrations are not only well-done, but are used in a manner that is very educational and enlightening. The chapters are placed in an orderly manner, with the book flowing nicely as one peruses the pages. The AO Spine Textbook can be used as a textbook to be read from cover to cover or as a reference for the busy spine practitioner. Though, once a reader initially thumbs through the text, he/she may be compelled to keep on reading. The book may indeed be very difficult to put aside for many of its readers.

Although the book covers many nonoperative topics, the focus in general is surgical. It is written, though, to be of interest and significant value to surgeons and nonsurgeons alike.

I am proud to have been a part of this project. The end result is truly remarkable. Please enjoy this well-orchestrated gem of a book. It will occupy a place on the book shelves of many for years to come.

Edward C Benzel MD

Emeritus Chair of Neurosurgery

Cleveland Clinic

Cleveland, Ohio, USA

Foreword

Spine surgery is not only one of the fastest growing subspecialties in orthopedic surgery but is also a very challenging one. Arriving at a perfect diagnosis, ordering and interpreting appropriate investigations, choosing the perfect management pathway without erring on over or undertreatment still remains a major challenge in the field of spine surgery. An error at any one of these decisions can lead to poor outcome commonly termed as ‘failed back syndrome’ the incidence of which is quoted from 3 to 18% in literature. In the event of such an unfortunate situation, it is a miserable scenario for the patient, his family members and the treating surgeon team.

The rapid progress that the last decade has witnessed a tremendous progress in all fields of spine surgery. The practising surgeon can often be confused with the numerous and often untested options in diagnostic techniques and surgical procedures. Often literature points to many successful methods to approach and manage a problem and the surgeon has to choose appropriately a solution suited for the patient from the large number of ‘arrows in the quiver’. This book will surely help the surgeon in this process as it is a comprehensive overview of the entire spectrum of spine surgery. There is a good focus on the physical examination, nonoperative and surgical treatment from leading orthopedic and neuro spine surgeons from international institutions. The contributors are renowned spine surgeons and the textbook naturally carries a huge amount of collective wisdom from all over the world. The book is also excellently illustrated to make reading and understanding easier.

I would like to congratulate the Editors, Michael P Steinmetz, Jeffrey C Wang and Thomas E Mroz for this outstanding textbook. The book will certainly help to achieve AOSpine's aim of improving spine surgery education throughout the world and I am confident that this will be a welcome addition to the library of all institutions and spine surgeons across the world.

S Rajasekaran MS FRCS MCh PhD

International Chair—AO Spine

Preface

We are proud to present the AO Spine Textbook: Comprehensive Overview on Surgical Management of the Spine. This comprehensive text covers the surgical treatment of the spine from ‘head-to-toe’. The text serves as a state-of-the-art one stop shop for the reader. It is appropriate for students, trainees or seasoned veterans.

The book begins in the cervical region, ends at the sacrum, while the last chapter focuses on the future of spine care and surgery. Each section begins with a discussion of pathology and pathophysiology. This is followed by diagnostic workup and then surgical management. Specialty chapters focus on disease specific issues such as scoliosis, deformity and oncology.

Each chapter is written by a true expert in the field. They are able to bring in up-to-date evidence and combine this with years of experience. Each section will provide a complete discussion of management of simple to the most complex pathologies.

Michael P Steinmetz

Jeffrey C Wang

Thomas E Mroz

Acknowledgments

We like to first thank the authors for taking this journey with us. It has been a long road, but we are very proud of the final product. We thank M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India. We thank Ms Nedup Denka Bhutia for her tireless efforts in the completion of this text as well as Ms Chetna Malhotra Vohra. We also thank the AO for support and aid in the completion of this text. Lastly, we would like to acknowledge our mentors, trainees and, present and past partners, and collaborators.

Chapter Notes