Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 1 pot

Norbert Boos · Max Aebi EditorsSpinal Disorders Fundamentals of Diagnosis and Treatment... Norbert Boos · Max Aebi EditorsSpinal Disorders Fundamentals of Diagnosis and Treatment With 27

Norbert Boos · Max Aebi (Editors)

Spinal Disorders

Fundamentals of Diagnosis and Treatment

Norbert Boos · Max Aebi (Editors)

Spinal Disorders Fundamentals of Diagnosis and Treatment

With 274 Figures in 1290 Parts

and 190 Tables

Prof Dr Norbert Boos

Zentrum für Wirbelsäulen- und Rückenmarkchirurgie

Universität Zürich

Universitätsklinik Balgrist

Forchstraße 340, 8008 Zürich

Switzerland

Prof Dr Max Aebi

Institut für Evaluative Forschung in Orthopädischer Chirurgie

MEM Forschungszentrum, Universität Bern

Stauffacherstraße 78, 3014 Bern

Switzerland

ISBN 978-3-540-40511-5 Springer-Verlag Berlin Heidelberg New York

Library of Congress Control Number: 2006927571

ˇ 2008 Springer-Verlag Berlin Heidelberg

This work is subject to copyright All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks Duplication of this publication or parts thereof is permitted only under the provisions

of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag Violations are liable to prosecution under the German Copyright Law.

Printed in Germany

The use of general descriptive names, registered names, trademarks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book In every individual case the user must check such information by consulting the relevant literature.

Cover design: eStudio Calamar, Spain

Illustrations: Alain Blank, Zürich, Switzerland

Printed on acid-free paper

9 8 7 6 5 4 3 2 1

springer.com

To Christa, Anna, Lisa and Sarah N.B.

To Christine, Eva and Samuel M.A.

For their love, understanding, encouragement and tolerance, without which this book would not have been possible

Form Follows Function

Congratulations to the editors and authors on a truly outstanding book Most

books recapitulate what many already know, and leave one seeking more This

book is unique in its content and format “Form follows function”, popularized

by the great American architect Frank Lloyd Wright, is a principle associated

with modern architecture and industrial design in the 20th century Simply

stated, the shape of a building or object should be predicated by or based upon its

intended function or purpose Like this phrase there is often a history that is

important to recognize and understand if we are to truly understand its meaning

The origin of the phrase “Form follows function” can be traced back to the

American sculptor Horatio Greenough, but it was American architectural giant

Louis Sullivan who adopted it and made it famous Sullivan actually said, “form

ever follows function”, but the simpler (and less emphatic) phrase is the one

usu-ally remembered Sullivan’s student and assistant Frank Lloyd Wright adopted

this principle in slightly different form – perhaps because shaking off the old

styles gave them more freedom and latitude

Drs Boos and Aebi have adopted a particular form, in this book, in order to

give the reader a thorough grounding in the basic knowledge and general

princi-ples of spinal disorders The didactic concept (form) of all the chapters is based

on a consistent style and layout, and follows three basic principles of sustainable

learning (functions), i.e.: (1) less is more, (2) repetition enhances sustained

learning, and (3) case studies are an efficient and complementary means of

learn-ing

The book utilizes learning aids to highlight and repeat core messages

through-out all chapters, and visual aids facilitate a repetition-based learning approach,

starting with the core messages, leading to an in-depth reading of each chapter

Marginal notes allow for effective repetition of material to facilitate the learning

process, and outstanding graphics with pictorial and anecdotal learning

meth-ods are used to complement the many detailed case studies to exemplify the core

messages Finally, the use of important references and landmark articles makes

this a prized book for everyone’s shelf

Congratulations to Norbert and Max on a fantastic contribution This book

will help those most in need, our patients “Form and function” are the most

important outcomes of this work, especially for those of us who work everyday to

care for people with these various spinal disorders Thank you

James N Weinstein

Director, The Dartmouth Institute for Health Policy and Clinical Practice

Professor & Chairman, The Department of Orthopaedics

Editor-in-Chief – Spine

Dartmouth College and Medical School

Dartmouth Hitchcock Medical Center

Lebanon, New Hampshire, USA

VII

Dinosaur or State of the Art?

Long ago, medical observations, advances, innovations and reviews were first

presented at meetings and published in books With the introduction of scientific

medical journals, two things happened First publication time was cut down

dra-matically compared to books and dissemination of knowledge became faster

Secondly a new approach to scientific publication was introduced in the form of

peer review This again lengthened publication time, yet benefited quality Some

argued that scientific journals would herald the slow death of books History

proved them wrong

The advent of the internet again mixed up all the cards Would scientific

jour-nals survive the internet? Initially the peer review aspect was lost and the quality

of available knowledge suffered Yet, sites like Wikipedia introduced the very

concept of peer review online So, would the internet kill peer review journals let

alone books? Well, here again history demonstrates that both journals and books

remain alive and well

This book on spinal disorders edited by Norbert Boos and Max Aebi is a

typi-cal example of the kind of textbook anybody involved with matters regarding the

spine wants on her or his desk Moreover, this work is unique because it is not a

classic multi-author textbook The editors have approached chapter authors with

whom they personally collaborated and share a common philosophy on the

diag-nosis and treatment approach to spinal disorders By an intensive editing

pro-cess, the different chapters have been woven into a homogeneous book

combin-ing personal experience with evidence based knowledge

Editors of scientific journals know that so-called “review articles” are very

popular, more referenced than other articles and thus excellent for boosting a

journal’s Impact Factor Well, this book consists of a succession of reviews

bring-ing us a real “state of the art” regardbring-ing the spine but put into perspective through

personal experience This work is truly pluri-disciplinary and reflects the

com-plex and difficult nature of the human spine Among the authors we find

clini-cians as well as scientists

The editors tackle every aspect of the spine in a well balanced way No topic is

superfluous or perceived as more important than another and the book reads as

one continuous flow, one topic logically leading to the next This book can be

rec-ommended to anyone involved in clinical or research aspects of the spine It

sim-ply has to lie on the desk of doctors, scientists, physiotherapists and

chiroprac-tors, psychologists and health-care specialists interested in the spine

Robert Gunzburg

President 2007–2008

EuroSpine, the Spine Society of Europe

Cavell Spine Center

Brussels, Belgium

IX

Spinal disorders are among the most common medical conditions, having a

sig-nificant impact on health-related quality of life, use of health care resources and

socioeconomic costs As a therapeutic measure, spinal surgery is still one of the

most rapidly growing areas in clinical medicine, and is a major contributor to the

continuously increasing costs of modern-day medicine Similarly, the

increas-ingly aging population will have a greater need for the treatment of degenerative

spinal disorders, particularly secondary spinal deformities and stenosis

How-ever, at the same time limited health care resources will mean difficult choices in

the allocation of treatment modalities Therefore, a basic knowledge of the state

of the art of the diagnosis and treatment of spinal disorders is required, not only

for spine specialists but also for general orthopedic surgeons, rheumatologists,

neurologists, rehabilitation doctors, psychiatrists, chiropractors,

physiothera-pists, basic scientists and health care executives, to enable them to choose and/or

evaluate appropriate diagnostic and therapeutic approaches

Owing to the rapid development of knowledge of spinal disorders over the

past 20 years, a comprehensive new textbook which incorporates all the latest

knowledge has become necessary, and we have become aware again and again of

innumerable residents, fellows and colleagues searching for a comprehensive

introductory learning tool for the study of spinal disorders Although excellent

textbooks on specific issues of the spine and specifically spinal surgery are

already available, none fulfills the criterion of being an easily readable teaching

tool that focuses systematically on the fundamentals and basic principles in a

standardized manner Strongly encouraged by our residents and fellows, we have

designed a textbook on spinal disorders which is an integration of the

evidence-based knowledge in the up-to-date literature and our decade-long personal

expe-rience at the source of research and treatment of spinal disorders

With Springer, we found a dedicated publisher willing to give our book project

strong support, and with carefully selected chapter authors we have hopefully

succeeded in creating a consistent message throughout the book Unlike many

other spinal textbooks, the editors did not want simply to collect and edit

chap-ters from many different authors, which often leads to an inhomogeneous book

with overlapping, redundant and incoherent chapters We rather aimed to

pro-vide a homogeneous syllabus with a consistent didactic strategy to teach the

fun-damentals and general principles

Although we have based the information in this book on an extensive survey

of the peer-reviewed literature, we have moderated this information in a

synthe-sis with research and clinical experience We have, however, refrained specifically

from an in-depth description of sophisticated surgical procedures For this field

of expertise, there are already a number of excellent manuals and textbooks

available

Although we recognize the difficulty and challenge of our task, we feel that we

have fulfilled our goal by choosing authors with whom we have collaborated for

a long time and who concur with our own philosophy The didactic concept is

XI

presented in every single chapter in a consistent manner and is based on three principles:

1 Less is more when concisely written

2 Repetition enhances sustained learning

3 Case studies are an invaluable means of exemplifying important principles

We hope that we have met our objective in providing a modern, up-to-date and easy to read textbook on spinal disorders with an appealing layout, and that the book will inspire and stimulate the reader in the study of spinal disorders It is our hope that this book may become the standard basic textbook for spinal disor-ders if you, the reader, decides to make this happen

We would like to thank all the contributing authors for their major commit-ment and hard work We would also like to thank our students, fellows and col-leagues for critically proof-reading the chapters and their constructive and encouraging feedback We owe many thanks to Doris Stettler and Grit Gagel-mann for their support and help with the editing process We further thank Wil-liam Shufflebotham in the UK for copy-editing the book We also want to acknowledge the Medical Pictorial Documentation team of the University Hospi-tal Balgrist (Heidi Wylenmann, Helene Uhlmann and Christian Streng) for their invaluable help with the editorial preparation of the medical images and figures

We are particularly indebted to Alain Blank, who created the unique illustra-tions with his meticulous and careful attention to the anatomical and surgical details The major book sections are separated by the paintings of Arnaldo Ricci-ardi, who perfectly understood how to transform his inspirations of spinal disor-ders into works of art We also thank Springer, the publisher, and specifically Gabriele Schröder for making this book happen

Zürich and Bern, March 2008

Centre for Spinal Surgery MEM Research Centre for University Hospital Balgrist Orthopaedic Surgery University of Zürich University of Bern

XII Preface

1 History of Spinal Disorders

Philipp Gruber, Thomas Boeni

Core Messages 1

A Brief Etymology 1

Historical Case Introduction 2

Spinal Anatomy and Physiology 4

Anesthesia and Supportive Techniques 6

Laughing Gas, Chloroform and Cocaine 6

Antisepsis and Antibiotics 6

Diagnostic Imaging 8

Scoliosis 8

Pathogenesis 9

Assessment 9

Non-operative Treatment 11

Scoliosis Surgery 13

Juvenile Kyphosis 13

Spondylolisthesis 14

An Obstetrical Problem 14

Surgery 14

Back Pain and Sciatica 15

A Wrong Mixture of Fluids 15

Disc Herniation 17

Historical Case Study 19

The Facet Syndrome 21

Spinal Stenosis 21

Spinal Infections 22

Egyptian Mummies and Sir Percival Pott 22

Treatment 24

Ankylosing Spondylitis 24

Discovery of a New Disease 25

Spinal Injuries 27

First Reports 27

Spinal Injuries as a Socioeconomic Problem 28

Traction Table and Laminectomy 29

The Advent of Internal Spinal Fixation 29

Recapitulation 30

Appendix: History of spinal disorders 31

Key Articles 33

References 34

Basic Science 2 Biomechanics of the Spine Stephen Ferguson Core Messages 41

The Human Spine 41

The Motion Segment 42

Anterior Structures 42

Posterior Elements 46

Ligaments of the Spine 47

Motion Segment Stiffness 48

Muscles 48

Spinal Stability Through Muscular Activity 52

Muscle Activity During Flexion and Extension 54 Muscle Activity During Lateral Flexion and Rotation 54

Spine Kinematics 54

Range of Motion 55

Mechanical Response of the Spinal Motion Segment 55

Clinical Instability 57

Kinetics (Spinal Loading) 58

Static Loading 58

Loads During Lifting 59

Dynamic Loading 60

Recapitulation 61

Key Articles 62

References 63

3 Spinal Instrumentation Daniel Haschtmann, Stephen J Ferguson Core Messages 67

Goals of Spinal Instrumentation 67

Basic Biomechanics of Spinal Instrumentation 69

Loading and Load Sharing Characteristics 69

Posterior Stabilization Principles 71

Anterior Stabilization Principles 74

Anterior Tension Band Technique 78

Biomechanics of the “Adjacent Segment” 79

Non-Fusion Principles 80

Disc Arthroplasty 80

Nucleoplasty 82

Posterior Dynamic Stabilization Technique 82

XIII