Lower Back Pain and Disorders

C H A P T E R
39
Lower Back Pain and Disorders

of Intervertebral Discs
Keith D. Williams Ashley L. Park
Epidemiology,
General disc and spine anatomy,
Neural elements,
Anatomical proportions,
Natural history of disc disease,
Nonspecific lumbar pain,
Diagnostic studies,
Roentgenography,
Myelography,
Computed tomography,
Magnetic resonance imaging,
Positron emission tomography,
Other diagnostic tests,
Injection studies,
Epidural cortisone injections,
Cervical epidural injection,
Thoracic epidural injection,
Lumbar epidural injection,
Zygapophyseal (facet) joint injections,
Cervical facet joint,
Lumbar facet joint,
Sacroiliac joint,
Discography,
Lumbar discography,
Thoracic discography,
Cervical discography,
Psychological testing,
Cervical disc disease,
Signs and symptoms,
Differential diagnosis,
Confirmatory testing,
Myelography,
Nonoperative treatment,
Operative treatment,
Removal of posterolateral herniations
by posterior approach (posterior
cervical foraminotomy),
Anterior approach to cervical disc,
Thoracic disc disease,
Signs and symptoms,
Confirmatory testing,
Treatment results,
Costotransversectomy,
Anterior approach for thoracic disc
excision,
Thoracic endoscopic disc excision,
Lumbar disc disease,
Signs and symptoms,
Physical findings,
Differential diagnosis,
Confirmatory imaging,
Humans have been plagued by back and leg pain since the
beginning of recorded history. Primitive cultures attributed
such pain to the work of demons. The early Greeks recognized
the symptoms as a disease and prescribed rest and massage for
the ailment. The Edwin Smith papyrus, the oldest surgical text
dating to 1500 BC, includes a case of back strain. Unfortunately,
the text does not include the treatment rendered by the ancient
Egyptians. In the fifth century AD, Aurelianus clearly described
the symptoms of sciatica. He noted that sciatica arose from
either hidden causes or observable causes, such as a fall, a
violent blow, pulling, or straining. In the eighteenth century
Cotugnio (Cotunnius) attributed the pain to the sciatic nerve.
Gradually, as medicine advanced as a science, the number of
specific diagnoses capable of causing back and leg pain
increased dramatically.
Nonoperative treatment,
Epidural steroids,
General principles for open disc
surgery,
Ruptured lumbar disc excision,
Microlumbar disc excision,
Endoscopic techniques,
Additional exposure techniques,
Lumbar root anomalies,
Results of open (micro or standard)
surgery for disc herniation,
Complications of open disc
excision,
Dural repair augmented with fibrin
glue,
Free fat grafting,
Chemonucleolysis,
Spinal instability from degenerative disc
disease,
Disc excision and fusion,
Lumbar vertebral interbody fusion,
Anterior lumbar interbody fusion,
Posterior lumbar interbody fusion,
Failed spine surgery,
Repeat lumbar disc surgery,
Several physical maneuvers were devised to isolate the true

problem in each patient. The most notable of these is the
Lase`gue sign, or straight leg raising test, described by Forst in
1881 but attributed to Lase`gue, his teacher. This test was
devised to distinguish hip disease from sciatica. Although
sciatica was widespread as an ailment, little was known about
it because only rarely did it result in death, allowing
examination at autopsy. Virchow (1857), Kocher (1896), and
Middleton and Teacher (1911) described acute traumatic
ruptures of the intervertebral disc that resulted in death. The
correlation between the disc rupture and sciatica was not
appreciated by these examiners. Goldthwait in 1911 attributed
back pain to posterior displacement of the disc. Oppenheim and
Krause in 1909 performed the first successful surgical excision
of a herniated intervertebral disc. Unfortunately, they did not
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P A R T X I I The Spine
recognize the excised tissue as disc material and interpreted it

as an enchondroma. Oil-contrast myelography was serendipitously introduced when iodized poppy seed oil, injected to treat
sciatica in 1922, was inadvertently injected intradurally and
was noted to flow freely. Dandy in 1929 and Alajouanine in the
same year reported removal of a disc tumor, or chondroma,
from patients with sciatica. The commonly held opinion of that
time was that the disc hernia was a neoplasm. Mixter and Barr
in their classic paper published in 1934 attributed sciatica to
lumbar disc herniation. This report also included a series of
four patients with thoracic disc herniations, and four patients
with cervical disc herniations. They suggested surgical treatment. Myelography was not used for confirmation of disc
disease because of toxicity of the agents used in the years that
followed. Myelography was refined with the development of
nonionic contrast media, and the test was combined with CT;
however, even this appears to have been supplanted by MRI of
the spine.
The standard procedure for disc removal was a total
laminectomy followed by a transdural approach to the disc. In
1939 Semmes presented a new procedure to remove the
ruptured intervertebral disc that included subtotal laminectomy
and retraction of the dural sac to expose and remove the
ruptured disc with the patient under local anesthesia. Love in
the same year also described this same technique independently. This procedure, now the classic approach for the
removal of an intervertebral disc, has been improved with the
use of microscopic and video imaging. Kambin, Onik, and
Helms and others have popularized minimally invasive
techniques for selected disc hernias.
As more people were treated for herniated lumbar discs, it
became obvious that surgery was not universally successful.
Over the past several decades, studies of patients with back or
leg pain have led to improved treatment of those in whom a
specific diagnosis was possible. Unfortunately, this group
remains the minority of patients who are evaluated for low back
or leg pain. Complex psychosocial issues, depression, and
secondary gain are but a few of the nonanatomical problems
that must be considered when evaluating these patients. In
addition, the number of anatomical causes for these symptoms
has increased as our understanding and diagnostic capabilities
have increased. In an attempt to identify other causes of back
pain Mooney and Robertson popularized facet injections, thus
resurrecting an idea proposed originally in 1911 by Goldthwait.
Smith et al. in 1963 approached the problem by suggesting a
radical departure in treatmentenzymatic dissolution of the
disc by injection of chymopapain. Although this technique is
still used in Europe, it rarely is used in the United States
because of medicolegal concerns.
The anatomical dissections and clinical observations of
Kirkaldy-Willis and associates identified pathological processes associated with or complicating the process of spinal
aging as primary causes of disc disease. Additional information
about this process and its treatment continues to be collected.
A thorough and complete history of all aspects of lumbar
spinal surgery was compiled by Wiltse in 1987.
Epidemiology
Back pain, the ancient curse, is now an international health
issue of major significance. Hult estimated that up to 80% of
people are affected by this symptom at some time in their lives.
Impairments of the back and spine are ranked as the most
frequent cause of limitation of activity in people younger than
45 years by the National Center for Health Statistics.
Physicians who treat patients with spinal disorders and
spine-related complaints must distinguish the complaint of
back pain, which several epidemiological studies reveal to be
relatively constant, from disability attributed to back pain. In
1984, disability was noted by Waddell to be exponentially
increasing in the United Kingdom (Fig. 39-1). Conversely, an
insurance industry study revealed a trend toward decreasing
claim rates for low back pain in the United States from 1987 to
1995.
Although back pain as a presenting complaint may account
for only 2% of the patients seen by a general practitioner,
Dillane, Fry, and Kalton reported that in 79% of men and 89%
of women the specific cause was unknown. Svensson and
Andersson noted the lifetime incidence of low back pain to be
61% and the prevalence to be 31% in a random sample of 40to 47-year-old men. They noted that 40% of those reporting
back pain also reported sciatica. In women 38 to 64 years of age
the lifetime incidence of low back pain was 66% with a
prevalence of 35%. Svensson and Anderson noted psychological variables associated with low back pain to be dissatisfaction with the work environment and a higher degree of worry
and fatigue at the end of the workday. The cost to society and
the patient in the form of lost work time, compensation, and
treatment is staggering. Snook reported that Liberty Mutual
Insurance Company paid $247 million for compensable back
105
95
85
Million days (per year)
1956
75
65
55
45
35
25
15
5
55 60 65 70 75 80 85 90 95
Year
Fig. 39-1 Forty-year trends in chronic low back disability.

United Kingdom statistics for sickness and invalidity benefits for
back incapacities from 1953-1954 to 1993-1994 (based on
statistics supplied by the Department of Social Security). (From
Waddell G: Spine 21:2820, 1996.)
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C H A P T E R 3 9 Lower Back Pain and Disorders of Intervertebral Discs
pain in 1980. Because this company represents only 9% of the

insured workers compensation market, Webster and Snook
estimated the compensable costs of low back pain in the United
States to be $11.1 billion in 1989. They reported that the mean
cost of each reported claim of low back pain at Liberty Mutual
had increased from $6807 in 1986 to $8321 in 1989, although
they suggested that an increase in premiums sold, not an
increase in low back pain claims, was the reason for this rise.
More recent data from Liberty Mutual estimates that $8.8
billion was paid annually in the United States for claims related
to low back pain. Of the billions of dollars spent annually in the
United States because of back complaints, it was estimated that
only about 39% was spent for medical treatment; the remaining
costs were for disability payments. This did not include the
losses from absenteeism. Although absenteeism because of
back pain varies with the type of work, it rivals the common
cold in total workdays lost.
Saal and Saal noted an 18% incidence of chronic back pain
in 1135 adults; 80% of those reporting chronic pain did not
report limitation of activity, and fewer than 4% reported
significant limitation of activity. Females reported back pain
more frequently than males. There were no racial differences,
but the lower the educational level of those interviewed the
greater the proportion of those reporting back pain. In 1992
Carey et al. interviewed 4437 North Carolinians by telephone
and noted an incidence of 3.9% chronic low back pain. Of those
who reported having chronic low back pain, 34% said that they
were permanently disabled. These authors concluded that
chronic back pain is common and associated with high costs.
In the Netherlands van Doorn noted that the low back pain
disability claims for self-employed dentists, veterinarians,
physicians, and physical therapists increased 211% from 1977
to 1989, and the cost increased 13% over that same time period.
Frymoyer and Cats-Baril noted an increase of 2500% in awards
for back pain disability by the Social Security Disability
Insurance from 1957 to 1976. They estimated that the total cost
of low back pain was $25 billion to $100 billion per year, with
75% of those costs attributed to the 5% who became
permanently disabled.
Multiple factors affect the development of back pain.
Frymoyer et al. noted that risk factors associated with severe
lower back pain include jobs requiring heavy and repetitive
lifting, the use of jackhammers and machine tools, and the
operation of motor vehicles. They also noted that patients with
severe pain were more likely to be cigarette smokers and had
a greater tobacco consumption. In an earlier study Frymoyer
et al. noted that patients complaining of back pain reported
more episodes of anxiety and depression; they also had more
stressful occupations. Women with back pain had a greater
number of pregnancies than those who did not. Jackson,
Simmons, and Stripinis noted that adult patients with scoliosis
are more likely to have back pain and that the pain persists and
progresses. Deyo and Bass noted a strong relationship between
smoking and back pain in patients younger than 45 years of
age. They also noted a greater tendency for back pain in those
patients who were the most obese. Other investigators, how-
1957
ever, have found no relationship between obesity and back

pain. Svensson and Anderson associated low back pain with
cardiovascular risk factors, including calf pain on exertion,
high physical activity at work, smoking, frequent worry,
tension, and monotonous work.
The incidence of back pain appears to be constant. Efforts
are being made to decrease the physical risk factors that may
lead to low back pain. However, as shown by Boos et al.,
nonanatomical factors, specifically work perception and psychosocial factors, are intimately intertwined with physical
complaints. Compounding diagnostic and treatment difficulties
is the high incidence of significant abnormalities demonstrated
by imaging studies, which in asymptomatic matched controls is
as high as 76%.
General Disc and Spine Anatomy

General Disc and Spine Anatomy
The development of the spine begins in the third week of
gestation and continues until the third decade of life. Formation of the primitive streak marks the beginning of spinal
development, which is followed by the formation of the
notochordal process. This process induces neurectodermal,
ectodermal, and mesodermal differentiation.
Somites form in the mesodermal tissue adjacent to the
neural tube (neurectoderm) and notochord. They number 42 to
44 in humans. The somites begin to migrate in preparation for
the formation of skeletal structures. At the same time, the
portion of the somites around the notochord separates into a
sclerotome with loosely packed cells cephalad and densely
packed cells caudally. Each sclerotome then separates at the
junction of the loose and densely packed cells. The caudal
dense cells migrate to the cephalad loose cells of the next more
caudal sclerotome (Fig. 39-2).
The space where the sclerotome separates eventually forms
the intervertebral disc. Vessels that originally were positioned
between the somites now overlie the middle of the vertebral
body. As the vertebral bodies form, the notochord that is in the
center degenerates. The only remaining notochordal remnant
forms the nucleus pulposus. Pazzaglia, Salisbury, and Byers
reviewed the involution of the notochord in fetal and
embryonic spines by several histological methods and concluded that all chordal cells disappear by early childhood.
Notochordal remnants usually are not distinguishable in the
adult nucleus pulposus.
The intervertebral disc in adults is composed of the annulus
fibrosus and the nucleus pulposus. The annulus fibrosus is
composed of numerous concentric rings or layers of fibrocartilaginous tissue. Fibers in each ring cross diagonally, and the
rings attach to each other with additional radial fibers. The rings
are thicker anteriorly (ventrally) than posteriorly (dorsally).
The nucleus pulposus, a gelatinous material, forms the center of
the disc. Because of the structural imbalance of the annulus, the
nucleus is slightly posterior (dorsal) in relation to the disc as a
whole. The discs vary in size and shape with their position in
the spine. Discs also decrease in volume, resulting in a 16% to
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Fig. 39-2 Schematic representation of

development of vertebrae and discs. (From
Rothman RH, Simeone FA: The spine, vol 1,
Philadelphia, 1982, WB Saunders.)
21% loss in disc height after 6 hours of standing or sitting.

T2-weighted MRI signals increase as much as 25% after a night
of bed rest. This diurnal variation has been substantiated by
Botsford et al. and Paajanen et al.
The nucleus pulposus is composed of a loose, nonoriented,
collagen fibril framework supporting a network of cells
resembling fibrocytes and chondrocytes. This entire structure is
embedded in a gelatinous matrix of various glucosaminoglycans, water, and salts. This material usually is under considerable pressure and is restrained by the crucible-like
annulus. Inoue demonstrated that the cartilage endplate contains no fibrillar connection with the collagen of the subchondral bone of the vertebra. This lack of interconnection
between the endplate and the vertebra may render the disc
biomechanically weak against horizontal shearing forces. Inoue
also demonstrated that the collagen fibrils in the outer two
thirds of the annulus fibrosus are firmly anchored into the
vertebral bodies (Fig. 39-3).
The intervertebral disc in the adult is avascular. Rudert and
Tillmann were able to demonstrate blood vessels in the annulus
until the age of 20 years and within the cartilage endplates until
the age of 7 years. The cells within the disc are sustained by
diffusion of nutrients into the disc through the porous central
concavity of the vertebral endplate. Histological studies have
shown regions where the marrow spaces are in direct contact
with the cartilage and that the central portion of the endplate is
permeable to dye. Motion and weight-bearing are believed to
be helpful in maintaining this diffusion. The metabolic turnover
Fig. 39-3 Schematic representation of orientation of fibers in

disc and endplate. AF, Annulus fibrosus; NP, nucleus pulposus;
CP, cartilaginous plate. (From Inoue H: Spine 6:139, 1981.)
of the disc is relatively high when its avascularity is considered

but slow compared with other tissues. The glycosaminoglycan
turnover in the disc is quite slow, requiring 500 days. Inoue
postulated that the degeneration of the disc may be prompted
by decreased permeability of the cartilage endplate, which is
normally dense.
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C6
Dorsal root
ganglion
C5
Dorsal
ramus
Ventral
ramus
C6
C7
C8
1959
C7
L4
L4
L5
T1
L5
Fig. 39-4 Discs are named for vertebral

level immediately cephalad. Pathology
most commonly affects nerve root one
segment caudal.
T1
S1
NEURAL
NEURAL ELEMENTS
ELEMENTS
The organization of the neural elements is strictly maintained
throughout the entire neural system, even within the conus
medullaris and cauda equina distally. Wall et al. noted that the
orientation of the nerve roots in the dural sac and at the conus
medullaris follows a highly organized pattern, with the most
cephalad roots lying lateral and the most caudal lying centrally.
The motor roots are ventral to the sensory roots at all levels.
The arachnoid mater holds the roots in these positions.
The pedicle is the key to understanding surgical spinal
anatomy. The relation of the pedicle to the neural elements
varies by region within the spinal column. In the cervical
region, there are seven vertebrae but eight cervical roots.
Therefore, accepted nomenclature allows each cervical root to
exit cephalad to the pedicle of the vertebra for which it is
named (e.g., the C6 nerve root exits above or cephalad to the C6
pedicle). This relationship changes in the thoracic spine
because the eighth cervical root exits between the C7 and T1
pedicles, requiring the T1 root to exit caudal or below the
pedicle for which it is named. This relationship is maintained
throughout the remaining more caudal segments. Of importance, the naming of the disc levels is different, in that all levels
where discs are present are named for the vertebral level
immediately cephalad (i.e., the C6 disc is immediately caudal
to the C6 vertebra and disc pathology at that level typically
would involve the C7 nerve root). In the lumbar spine
classically a similar relationship exists in that disc pathology
most commonly affects the nerve root one segment caudal (e.g.,
an L4 disc herniation would be expected to cause L5 root
symptoms and findings) (Fig. 39-4).
At the level of the intervertebral foramen is the dorsal root
ganglion. The ganglion lies within the outer confines of the
foramen. Distal to the ganglion three distinct branches arise; the
most prominent and important is the ventral ramus, which
supplies all structures ventral to the neural canal. The second
branch, the sinu-vertebral nerve, is a small filamentous nerve
that originates from the ventral ramus and progresses medially
over the posterior aspect of the disc and vertebral bodies,
innervating these structures and the posterior longitudinal
ligament. The third branch is the dorsal ramus. This branch
courses dorsally, piercing the intertransverse ligament near the
pars interarticularis. Three branches from the dorsal ramus

innervate the structures dorsal to the neural canal. The lateral
and intermediate branches provide innervation to the posterior
musculature and skin. The medial branch separates into three
branches to innervate the facet joint at that level and the
adjacent levels above and below (Fig. 39-5).
Pedersen, Blunck, and Gardner noted that the clinically
significant function of the sinu-vertebral nerves and the
posterior rami is the transmission of pain. The proprioceptive
functions of these nerves are not known but assumed.
Studies by Bogduk and others demonstrated neural fibers in
the outer layers of the annulus. These fibers are branches of the
sinu-vertebral nerve dorsally. Ventral branches arise from
the sympathetic chain that courses anterolaterally over the
vertebral bodies. Rhalmi et al., using histological methods,
demonstrated neural elements in all spinal ligaments. In the
ligamentum flavum the nerve fibers are close to blood vessels
and fat globules.
ANATOMICAL PROPORTIONS
ANATOMICAL PROPORTIONS
Variation in the ratio of the cross-sectional area of the neural
elements to the cross-sectional area of the spinal canal at
various levels is relatively large. This is particularly true in
patients with developmental stenosis in whom otherwise
relatively minor intrusion into the spinal canal by pathological
anatomy may cause compression of the neural structures. Many
studies have documented that the changes in the foraminal
dimensions increase with flexion and decrease with extension.
Also, disc space narrowing causes significant volumetric
decreases in the neural foramen at all levels.
Natural History of Disc Disease

Natural History of Disc Disease
The natural process of spinal aging has been studied by
Kirkaldy-Willis and Hill and by others through observation of
clinical and anatomical data. One theory of spinal degeneration
assumes that all spines degenerate and that our current methods
of treatment are for symptomatic relief, not for a cure.
The degenerative process has been divided into three
separate stages with relatively distinct findings. The first stage
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Fig. 39-5 A, Dorsal view of lumbar spinal segment with lamina and facets removed. On left side,
dura and root exiting at that level remain. On right side, dura has been resected and root is elevated.
Sinu-vertebral nerve with its course and innervation of posterior longitudinal ligament is usually
obscured by nerve root and dura. B, Cross-sectional view of spine at level of endplate and disc. Note
that sinu-vertebral nerve innervates dorsal surface of disc and posterior longitudinal ligament.
Additional nerve branches from ventral ramus innervate more ventral surface of disc and anterior
longitudinal ligament. Dorsal ramus arises from root immediately on leaving foramen. This ramus
divides into lateral, intermediate, and medial branches. Medial branch supplies primary innervation
to facet joints dorsally.
is dysfunction, which is seen in those 15 to 45 years of age. It

is characterized by circumferential and radial tears in the disc
annulus and localized synovitis of the facet joints. Varlotta et al.
noted a familial predisposition to lumbar disc herniation in
patients who had disc herniation before the age of 21 years. In
this group the familial incidence was 32% compared with a
matched control group of asymptomatic individuals in whom
the rate was only 7%. A case control study of familial
degenerative disc disease revealed a similar incidence of
degenerative changes between first-order relatives of those with
documented lumbar disc herniations and those without such a
family history. However, the first-order relatives did have
statistically significant more severe degenerative change.
The next stage is instability. This stage, found in 35- to
70-year-old patients, is characterized by internal disruption of
the disc, progressive disc resorption, degeneration of the facet
joints with capsular laxity, subluxation, and joint erosion. The
final stage, present in patients older than 60 years, is
stabilization. In this stage the progressive development of
hypertrophic bone about the disc and facet joints leads to
segmental stiffening or frank ankylosis (Table 39-1).
Each spinal segment degenerates at a different rate. As one
level is in the dysfunction stage, another may be entering the
stabilization stage. Disc herniation in this scheme is considered
a complication of disc degeneration in the dysfunction and
instability stages. Spinal stenosis from degenerative arthritis in
this scheme is a complication of bony overgrowth compromis-
ing neural tissue in the late instability and early stabilization

stages. Mayoux-Benhamou et al. noted that a 4-mm collapse of
the disc produces sufficient narrowing of the foramen to
threaten the nerve.
The stages and progression of degeneration have been
confirmed by histological studies. Miller, Schmatz, and Schultz
noted that disc degeneration progresses histologically as age
increases. Males were found to have more degeneration than
females. L4-5 and L3-4 disc levels showed the greatest degree
of disc degeneration. Urban and McMullin noted that the
hydration of disc material decreased with age. The relationship
between the change in hydration and swelling pressure was
dependent on the composition of the disc rather than on the age
of the patient or the degree of degeneration. In their study L1-2
and L5-S1 discs had the lowest hydration. Yasuma et al. noted
progressive histological changes in the prolapsed discs when
compared with protruded discs. Urovitz and Fornasier were
unable to detect any evidence of autoimmune reaction in
human disc tissue, but they did detect evidence of the response
to mechanical injury. Using postmyelogram CT scans, Takata
et al. found that the cauda equina and affected nerve roots were
swollen in 17 of 28 patients studied. The affected roots returned
to normal size after disc excision. Ziv et al. reported coarsely
fibrillated and ulcerated spinal facet joints in young patients,
and this finding continued through progressive aging. The
cartilage of the superior facets is thicker and has a higher water
content than the inferior facets, indicating more frequent
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Table 39-1
Spectrum of Pathological Changes in Facet Joints and Discs and the Interaction
of These Changes
Phases of Spinal Degeneration
Dysfunction
Instability
Stabilization
1961
Facet Joints
Synovitis
Hypermobility
Continuing degeneration
Capsular laxity
Subluxation
Enlargement of articular
processes
Pathological Result
Dysfunction
&
Herniation
Instability
Lateral nerve entrapment
One-level stenosis
Multilevel spondylosis and
stenosis
Intervertebral Disc
Circumferential tears
Radial tears
Internal disruption
Disc resorption
Osteophytes
Modified from Kirkaldy-Willis WH, ed: Managing low back pain, New York, 1983, Churchill Livingstone.
damage. Neumann et al. suggested that the amount of bone

tissue in the spine may be functionally related to the structural
properties of the spinal ligaments.
Long-term follow-up studies of lumbar disc herniations by
Hakilius in 1970, Weber in 1983, and Seal in 1996 consistently
documented several principles, the foremost being that
generally symptomatic lumbar disc herniation (which is only
one of the consequences of disc degeneration) has a favorable
outcome in most patients. This was pointed out by Weber, who
noted that the primary benefit of surgery was early on in the
first year, but that with time the statistical significance of
the improvement was lost. In addition, the review by Saal
supported an active care approach, minimizing centrally acting
medications. The judicious use of epidural steroids also is
supported. Nonprogressive neurological deficits (except cauda
equina syndrome) can be treated nonoperatively with expected
improvement clinically. If surgery is necessary, it usually can
be delayed 6 to 12 weeks to allow adequate opportunity for
improvement. These principles are consistent with clinical
findings and treatment practices at this clinic. Clearly, some
patients are best treated surgically, and this is discussed in the
section dealing specifically with lumbar disc herniation.
Similar principles are valid regarding cervical disc herniations,
which also generally can be treated nonoperatively. The
important exceptions are patients with cervical myelopathy,
who are best treated surgically.
The natural history of disc disease is one of recurrent
episodes of pain followed by periods of significant or complete
relief. Biering-Srensen and Hilden noted that the memory of
painful low back episodes was short. At initial evaluation and
at 6 months follow-up the question of ever having had low
back pain was answered by patients with a yes or no and 84%
answered consistently on the two occasions. However, in a
questionnaire at 12 months only two fifths of those interviewed
answered consistently. They questioned the long-term analysis
of data from this standpoint and noted that the clinician should
be aware of the potential vagueness and unreliability of a
history of previous back injury.
Before a discussion of diagnostic studies, axial spine pain
with radiation to one or more extremity must be considered.
Also, our understanding of certain pathophysiological entities

must be juxtaposed to other entities of which we have only a
rudimentary understanding. It is doubtful if there is any other
area of orthopaedics in which accurate diagnosis is as difficult
or the proper treatment as challenging as in patients with
persistent neck and arm or low back and leg pain, despite
appropriate evaluation and care. Although there are many
patients with clear diagnoses properly arrived at by careful
history and physical examination with confirmatory imaging
studies, more patients with pain have absent neurological
findings other than sensory changes and have normal imaging
studies or studies that do not support the clinical complaints
and findings. Inability to easily demonstrate an appropriate
diagnosis in a patient does not relieve the physician of the
obligation to recommend treatment or to direct the patient to a
setting where such treatment is available. Careful assessment of
these patients to determine if they have problems that can be
orthopaedically treated (nonsurgically or surgically) is imperative to avoid overtreatment as well as undertreatment. Surgical
treatment can benefit a patient if it corrects a deformity, corrects
instability, or relieves neural compression, or treats a combination of these problems. Obtaining a history and completing a
physical examination to determine a diagnosis that should be
supported by other diagnostic studies is a very useful approach;
conversely, matching the diagnosis and treatment to the results
of diagnostic studies, as is done in other subspecialties of
orthopaedics, is fraught with difficulty.
As pointed out by Waddell, most patients with nonspecific
complaints and findings are best treated by their primary care
physicians. For those with significant findings, evaluation and
treatment by a specialist is appropriate. For a small minority of
patients (although they are responsible for a much more
significant portion of health care utilization) a multidisciplinary
approach is best.
NONSPECIFIC LUMBAR PAIN

NONSPECIFIC LUMBAR PAIN
Nonspecific low back pain occurs at some point in the lives of
most people. In Western societies a lifetime incidence of
approximately 80% has been documented. A study of 1389
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Table 39-2
100
Selective Indications for

Roentgenography in Acute Low
Back Pain
Age >50 years

Significant trauma
Neuromuscular deficits
Unexplained weight loss (10 pounds in 6 months)
Suspicion of ankylosing spondylitis
Drug or alcohol abuse
History of cancer
Use of corticosteroids
Temperature 37.8 C (100.0 F)
Recent visit (within 1 month) for same problem and no
improvement
Patient seeking compensation for back pain
90
80
70
Percentage
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60
50
40
30
20
10
0
Adapted from Deyo RA, Diehl AK: J Gen Intern Med 1:20, 1986.
adolescents aged 13 to 16 years recorded low back pain in

nearly 60%. The incidence and severity of this problem has
remained fairly constant since the early 1980s. Appropriate
treatment for what can be at times excruciating pain generally
should begin with evaluation for significant spinal pathology.
This being absent, a brief (1 to 3 days) period of bed rest with
institution of an antiinflammatory regimen and rapid progression to an active exercise regimen with an anticipated return to
full activity should be expected and encouraged. Diagnostic
studies, including roentgenograms, often are unnecessary
because they add little information. More sophisticated
imaging with CT scans and MRI or other studies have even less
utility initially. An overdependence on the diagnosis of disc
herniation occurred with early use of these diagnostic studies
that show disc herniations in 20% to 36% of normal volunteers.
This incidence increased to 76% of asymptomatic controls
when they were matched to a population at risk for workrelated lumbar pain complaints. Imaging guidelines have been
set forth by Bigos et al. (Table 39-2). Generally, patients treated
in this manner improve significantly in 4 to 8 weeks. Patients
should understand that persistence of some pain is not
indicative of treatment failure, necessitating further measures;
however, it is important for treating physicians to recognize that
the longer a person is limited by pain, the less likely is a return
to full activity. Once a patient is out of work for 6 months, there
is only a 50% chance that he will return to his previous job
(Fig. 39-6).
For patients who do not respond to treatment regimens,
early recognition that other issues may be involved is essential.
Careful reassessment of complaints and reexamination for new
information or findings as well as inconsistencies are necessary.
Many studies of occupational back pain have revealed that
depression, occupational mental stress, job satisfaction, intensity of concentration, anxiety, and marital status can be related
to complaints of pain and disability. The role of these factors as
causal or consequential of the symptoms remains an area of
continued study; however, there is certainly some evidence that
the psychological stresses occur before complaints of pain in
1
Time off work (yr)
Fig. 39-6 Diminishing chance of return to work with increasing

time out of work resulting from low back pain (based on data from
Clinic Standards Advisory Group). (From Waddell G: Spine
21:2820, 1996.)
some patients. Another finding that is evident from the

literature is the inability of physicians to detect psychosocial
factors adequately without using specific instruments designed
for this purpose in patients with back pain. In one particular
study by Grevitt et al. experienced spinal surgeons were able to
identify distressed patients only 26% of the time based on
patient interviews. Given the difficulty of identifying patients
with psychosocial distress, being aware of the high incidence of
incidental abnormal findings on imaging studies underscores
the need for critical individual review of these studies by
treating physicians. Severe nerve compression demonstrated by
MRI or CT correlates with symptoms of distal leg pain;
however, mild to moderate nerve compression (Table 39-3),
disc degeneration or bulging, and central stenosis do not
significantly correlate with specific pain patterns.
A review of the pertinent literature reveals that similar
psychological factors are important in patients with neck pain.
As confounding as these psychological risk factors are,
reasonable and logical measures are available that assist in
evaluation and treatment.
Diagnostic Studies
ROENTGENOGRAPHY
Diagnostic Studies
ROENTGENOGRAPHY
The simplest and most readily available diagnostic tests for
back or neck pain are anteroposterior and lateral roentgenograms of the involved spinal segment. These simple roentgenograms show a relatively high incidence of abnormal findings.
Ford and Goodman reported only 7.3% normal spine roentgenograms in a group of 1614 patients evaluated for back pain.
Scavone, Latshaw, and Rohrer reported a 46% incidence of
abnormal incidental findings in lumbar spine films taken over
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Table 39-3
Classification for Spinal Nerve

and Thecal Sac Deformation
SPINAL NERVE DEFORMATION IN LATERAL RECESS

OR INTERVERTEBRAL FORAMEN
0Absent
No visible disc material contacting or
deforming nerve
IMinimal
Contact with disc material deforming nerve
but displacement less than 2 mm
IIModerate
Contact with disc material displacing 2 or
more mm. The nerve is still visible and
not obscured by disc material
IIISevere
Contact with disc material completely
obscuring the nerve
THECAL SAC DEFORMATION IN VERTEBRAL CANAL
0Absent
No visible disc material contacting or
deforming thecal sac
IMinimal
Disc material in contact with thecal sac
IIModerate
Disc material deforming thecal sac, anteroposterior distance of thecal sac 7 mm
IIISevere
Disc material deforming thecal sac, anteroposterior distance of thecal sac <7 mm
From Beattie PF, Meyers SP, Strafford P, et al: Spine 25:819, 2000.
1 year in a university hospital. Unfortunately, when these

roentgenographic abnormalities are critically evaluated with
respect to the patients complaints and physical findings, the
correlation is very low. Fullenlove and Williams clearly
identified the lack of definition between roentgenographic
findings in symptomatic, asymptomatic, and operated patients.
Rockey et al. and Liang and Komaroff concluded that spinal
roentgenograms on the initial visit for acute low back pain do
not contribute to patient care and are not cost effective. They
recommended that plain roentgenograms be taken only after the
initial therapy fails, especially in patients younger than 45 years
of age.
There is insignificant correlation between back pain and the
roentgenographic findings of lumbar lordosis, transitional
vertebra, disc space narrowing, disc vacuum sign, and claw
spurs. In addition, the entity of disc space narrowing is
extremely difficult to quantify in all but the operated backs or
in obviously abnormal circumstances. Frymoyer et al. in a
study of 321 patients found that only when traction spurs or
obvious disc space narrowing or both were present did the
incidence of severe back and leg pain, leg weakness, and
numbness increase. These positive findings had no relationship
to heavy lifting, vehicular exposure, or exposure to vibrating
equipment. Other studies have shown some relationship between back pain and the findings of spondylolysis, spondylolisthesis, and adult scoliosis, but these findings also can be
observed in spine roentgenograms of asymptomatic patients.
Special roentgenographic views can be helpful in further
defining or disproving the initial clinical roentgenographic
impression. Oblique views are useful in further defining
spondylolisthesis and spondylolysis but are of limited use in
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facet syndrome and hypertrophic arthritis of the lumbar spine.

Conversely, in the cervical spine hypertrophic changes about
the foramina are easily outlined. Lateral flexion and extension
roentgenograms may reveal segmental instability. Hayes et al.
attempted to identify the pathological level of abnormal lumbar
spine flexion, but they found a wide range of motion in
asymptomatic patients. They also found that translational
movements of 2 to 3 mm were frequent, which means that there
is little correlation between abnormal motion and pathological
instability. No standards are available to make this distinction.
Unfortunately, the interpretation of these views depends on
patient cooperation, patient positioning, and reproducible
technique. Knutsson, Farfan, Kirkaldy-Willis, Stokes et al.,
Macnab, and Bigos are excellent references on this topic. The
Ferguson view (20-degree caudocephalic anteroposterior roentgenogram) has been shown by Wiltse et al. to be of value in
the diagnosis of the far out syndrome, that is, fifth root
compression produced by a large transverse process of the fifth
lumbar vertebra against the ala of the sacrum. Abel, Smith, and
Allen note that angled caudal views localized to areas of
concern may show evidence of facet or laminar pathological
conditions.
MYELOGRAPHY
MYELOGRAPHY
The value of myelography is the ability to check all disc levels
for abnormality and to define intraspinal lesions; it may be
unnecessary if clinical and CT findings are in complete
agreement. The primary indications for myelography are
suspicion of an intraspinal lesion or questionable diagnosis
resulting from conflicting clinical findings and other studies. In
addition, myelography is of value in a previously operated
spine and in patients with marked bony degenerative change
that may be underestimated on MRI. Myelography is improved
by the use of postmyelography CT scanning in this setting,
as well as in evaluating spinal stenosis. Bell et al. found
myelography more accurate than CT scanning for identifying
herniated nucleus pulposus and only slightly more accurate
than CT scanning in the detection of spinal stenosis. Szypryt
et al. found myelography slightly less accurate than MRI in
detecting spinal abnormalities.
Several contrast agents have been used for myelography: air,
oil contrast, and water-soluble (absorbable) contrast including
metrizamide (Amipaque), iohexol (Omnipaque), and iopamidol
(Isovue-M). Since these nonionic agents are absorbable, the
discomfort of removing them and the severity of the postmyelographic headache have been decreased.
Isophendylate (Pantopaque) was the contrast agent of choice
from 1944 to the late 1970s (Fig. 39-7). This agent required
aspiration at the conclusion of the study and was more of a
meningeal irritant than the nonionic materials currently
available. Occasionally, older patients are seen with small
amounts of residual Pantopaque within the subarachnoid space.
Rarely, patients have severe reactions such as transient
paralysis, cauda equina syndrome, or focal neurological
deficits.
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B
B
Fig. 39-7 A, Anteroposterior roentgenogram of iophendylate (Pantopaque) myelogram showing lumbar disc herniation.
B, Oblique roentgenogram showing large L4-5 disc herniation.
Fig. 39-8 A, Anteroposterior roentgenogram of metrizamide

lumbar myelogram showing lumbar disc herniation. B, Oblique
roentgenogram showing large L4-5 disc herniation.
Arachnoiditis is a severe complication that has been

attributed on occasion to the combination of isophendylate and
blood in the cerebrospinal fluid (CSF). Unfortunately, this
diagnosis usually is confirmed only by repeat myelography.
Attempts at surgical neurolysis have resulted in only short-term
relief and a return of symptoms within 6 to 12 months after the
procedure. Fortunately, time may decrease the effects of this
serious problem in some patients, but progressive paralysis
has been reported in rare instances. Arachnoiditis also can
be caused by tuberculosis and other types of meningitis.
Arachnoiditis has not been noted to be related to the use of
water-soluble contrast, with or without injection, in the
presence of a bloody tap. Myelography remains the best
diagnostic study to evaluate arachnoiditis.
Water-soluble contrast media are now the standard agents
for myelography (Fig. 39-8). Their advantages include
absorption by the body, enhanced definition of structures,
tolerance, absorption from other soft tissues, and the ability to
vary the dosage for different contrasts. Like isophendylate they
are meningeal irritants, but they have not been associated with
arachnoiditis. The complications of these agents include
nausea, vomiting, confusion, and seizures. Rare complications
include stroke, paralysis, and death. Iohexol and iopamidol
have significantly lower complication rates than metrizamide.
The more common complications appear to be related to patient
hydration, phenothiazines, tricyclics, and migration of contrast
into the cranial vault. Many of the reported complications can
be prevented or minimized by using the lowest possible dose to
achieve the desired degree of contrast. Adequate hydration and
discontinuation of phenothiazines and tricyclic drugs before,
during, and after the procedure should also minimize the
incidence of the more common reactions. Likewise, maintenance of at least a 30-degree elevation of the patients head
until the contrast is absorbed also should help prevent reactions.
Complete information about these agents and the dosages
required is found in their package inserts.
Iohexol (Omnipaque) is a nonionic contrast medium
approved for thoracic and lumbar myelography. The incidence
of reactions to this medium is low. The most common reactions
are headache (less than 20%), pain (8%), nausea (6%), and
vomiting (3%). Serious reactions are very rare and include
mental disturbances and aseptic meningitis (0.01%). Good
hydration is essential to minimize the common reactions. The
use of phenothiazine antinauseants is contraindicated when this
medium is employed. Management before and after the
procedure is the same as for metrizamide.
Air contrast is used rarely and probably should be used only
in situations in which myelography is mandatory and the
patient is extremely allergic to iodized materials. The resolution
from such a procedure is poor. Air epidurography in conjunction with CT has been suggested in patients in whom
further definition between postoperative scar and recurrent disc
material is required.
Myelographic technique begins with a careful explanation
of the procedure to the patient before its initiation. Hydration of
the patient before the procedure may minimize postmyelographic complaints. Heavy sedation rarely is needed. Proper
equipment, including a fluoroscopic unit with a spot film
device, image intensification, tiltable table, and television
monitoring, is useful. The type of needle selected also
influences the risk of postdural puncture headaches (PDPH),
which can be severe. Smaller gauge needles (22 or 25 gauge)
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have been found to result in a lower incidence of PDPH. Also,

use of a Whitacre-type needle with a more blunt tip and side
port opening results in fewer PDPH complaints.
TECHNIQUE 39-1
Place the patient prone on the fluoroscopic table. Use of an
abdominal pillow is optional. Prepare the back in the usual
surgical fashion. Determine needle placement by the
suspected pathological level. Placement of the needle
cephalad to L2-3 is more dangerous because of the risk of
damaging the conus medullaris.
Infiltrate the selected area of injection with a local
anesthetic. Use the smallest-gauge needle that can be well
placed. If a Whitacre-type needle is used, a 19-gauge needle
may be placed through the skin, subcutaneous tissue, and
fascia to form a track, since this relatively blunt needle may
not penetrate these structures well. Midline needle placement usually minimizes lateral nerve root irritation and
epidural injection. Advance the needle with the bevel
parallel to the long axis of the body. Subarachnoid
placement can be enhanced by tilting the patient up to
increase intraspinal pressure and minimize the epidural
space.
Once the dura and arachnoid have been punctured, turn
the bevel of the needle cephalad. A clear continuous flow of
CSF should continue with the patient prone. Manometric
studies can be performed at this time if desired or indicated.
Remove a volume of CSF equal to the planned injection
volume for laboratory evaluation as indicated by the clinical
suspicions. In most patients a cell count, differential white
cell count, and protein analysis are performed.
Inject a test dose of the contrast material under
fluoroscopic control to confirm a subarachnoid injection. If
a mixed subdural-subarachnoid injection is suspected,
change the needle depth; occasionally a lateral roentgenogram may be required to confirm the proper depth. If flow
is good, inject the contrast material slowly.
Be certain of continued subarachnoid injection by
occasionally aspirating as the injection continues. The usual
dose of iohexol for lumbar myelography in an adult is 10 to
15 ml with a concentration of 170 to 190 mg/ml. Higher
concentrations of water-soluble contrast are required if
higher areas of the spine are to be demonstrated. Consult the
package insert of the contrast used. The needle can be
removed if a water-soluble contrast (iohexol) is used. The
needle must remain in place and be covered with a sterile
towel if isophendylate is used.
Allow the contrast material to flow caudally for the best
views of the lumbar roots and distal sac. Make spot films in
the anteroposterior, lateral, and oblique projections. A full
lumbar examination should include thoracic evaluation to
about the level of T7 because lesions at the thoracic level
may mimic lumbar disc disease. Take additional spot films
as the contrast proceeds cranially.
If a total or cervical myelogram is desired, allow the
1965
contrast to proceed cranially. Extend the neck and head

maximally to prevent or minimize intracranial migration of
the contrast medium.
If isophendylate (oil contrast) was used, remove the
contrast medium by extracting through the original needle
or a multiholed stylet inserted through the original needle or
by inserting another needle if extraction through the first
needle is difficult. A small amount of medium occasionally
is retained, but remove as much as possible.
If blood is present in the initial tap, abandon the
procedure if oil contrast is to be used. It can be attempted
again in several days if the patient has no symptoms related
to the first tap and is well hydrated. If the proper needle
position is confirmed in the anteroposterior and lateral views
and CSF flow is minimal or absent, suspect a neoplastic
process. Then place the needle at a higher or lower level as
indicated by the circumstances. If attempts to obtain CSF
continue to fail, abandon the procedure and reevaluate the
clinical situation.
The most common technical complications of myelography

are significant retention of contrast medium (oil contrast only),
persistent headache from a dural leak, and epidural injection.
These problems usually are minor. Persistent dural leaks
usually are responsive to a blood patch. With the use of a
water-soluble contrast medium, the persistent abnormalities
caused by retained medium and epidural injection are
eliminated.
COMPUTED TOMOGRAPHY
COMPUTED TOMOGRAPHY
Computed tomography revolutionized the diagnosis of spinal
disease (Fig. 39-9). Most clinicians now agree that CT is an
extremely useful diagnostic tool in the evaluation of spinal
disease.
The current technology and computer software have made
possible the ability to reformat the standard axial cuts in almost
any direction and magnify the images so that exact measurements of various structures can be made. Software is available
to evaluate the density of a selected vertebra and compare
it with vertebrae of the normal population to give a numerically reproducible estimate of vertebral density to quantitate
osteopenia.
Numerous types of CT studies for the spine are available.
These studies vary from institution to institution and even
within institutions. One must be careful in ordering the study to
be certain that the areas of clinical concern are included.
Several basic routines are used in most institutions. The
most common routine for lumbar disc consists of making serial
cuts through the last three lumbar intervertebral discs. If the
equipment has a tilting gantry, an attempt is made to keep the
axis of the cuts parallel with the disc. However, frequently
the gantry cannot tilt enough to allow a parallel beam through
the lowest disc space. This technique does not allow demon-
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Fig. 39-9 A, CT scan scout view of lumbar disc herniation at lumbar disc level showing angled
gantry technique. B, CT scan scout view of straight gantry technique. C, CT scan of lumbar disc
herniation at L4-5 disc level showing cross-sectional anatomy with gantry straight. D, CT scan of
L4-5 disc herniation at lumbar disc level showing cross-sectional, sagittal, and coronal anatomy
using computerized reformatted technique. E, CT scan of L4-5 disc herniation at lumbar disc level
showing cross-sectional anatomy 2 hours after metrizamide myelography. F, CT scan of lumbar disc
herniation at L4-5 disc level showing cross-sectional anatomy after intravenous injection for greater
soft tissue contrast.
stration of the canal at the pedicles. Another method involves

making cuts through the discs without tilting the gantry. Once
again, the entire canal is not demonstrated, and the lower cuts
frequently have the lower and upper endplates of adjacent
vertebrae superimposed in the same view.
The final and most complex method consists of making
multiple parallel cuts at equal intervals. This allows computer
reconstruction of the images in different planesusually
sagittal and coronal. These reformatted views allow an almost
three-dimensional view of the spine and most of its structures.
The greatest benefit of this technique is the ability to see
beyond the limits of the dural sac and root sleeves. Thus the
diagnosis of foraminal encroachment by bone or disc material
can now be made in the face of a normal myelogram. The
proper procedure can be chosen that fits all the pathological
conditions involved.
Optimal reformatted CT should include enlarged axial and
sagittal views with clear notation as to laterality and sequence
of cuts. Several sections of the axial cuts should include the

local soft tissue and contiguous abdominal contents. Finally, a
set of images adjusted for improved bony detail should be
included for evaluation of the facet joints as well as the lateral
recesses. Naturally this study should be centered on the level of
greatest clinical concern. The study can be enhanced further if
done after water contrast myelography or with intravenous
contrast medium. Enhancement techniques are especially
useful if the spine being evaluated has been operated on
previously.
This noninvasive, painless, outpatient procedure can supply
more information about spinal disease than was previously
available with a battery of invasive and noninvasive tests
usually requiring hospitalization. Unfortunately, CT does not
demonstrate intraspinal tumors or arachnoiditis and is unable to
differentiate scar from recurrent disc herniation. Bell et al.
compared myelography with CT scanning and noted that
myelography was more accurate. They did not compare the
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Fig. 39-10 Magnetic resonance imaging of lumbar spine.

A, Normal T2-weighted image. B, T2-weighted image showing
degenerative bulging and/or herniated discs at L3-4, L4-5, and
L5-S1.
results of postmyelogram CT scanning. Weiss et al. and Teplick

and Haskin in separate reports suggested that the use of
intravenous contrast medium (Fig. 39-9, E) followed by CT can
improve the definition between scar and disc herniation.
Myelography is still required to demonstrate intraspinal tumors
and to run the spine to detect occult or unsuspected lesions.
The development of low-dose metrizamide or iohexol myelography with reformatted CT done as an outpatient procedure
allows a maximum of information to be obtained with a
minimum of time, risk, discomfort, and cost.
MAGNETIC RESONANCE IMAGING

MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI) is the newest technological
advance in spinal imaging. This technique uses the interaction
of an unpaired electron with an external oscillating electromagnetic field that is changing as a function of time at a particular
frequency. Energy is absorbed and subsequently released by
selected nuclei at particular frequencies after excitation with
radiofrequency electromagnetic energy. The released energy is
recorded and formatted by computer in a pattern similar to CT.
Current MRI techniques concentrate on imaging the proton
(hydrogen) distribution present as H2O primarily. The advantages of this technique include the ability to demonstrate
intraspinal tumors, examine the entire spine, and identify
degenerative discs based on decreased H2O content. Unfortunately, the equipment required for this procedure is costly and
requires specially constructed facilities (Fig. 39-10).
Szypryt et al. found MRI slightly better than myelography in
the identification of spinal lesions. The accuracy of MRI
in their study was 88% and that of myelography was 75%;
1967
combined accuracy was 94%. MRI is clearly superior in the

detection of disc degeneration, tumors, and infections. Most
MRI scans allow evaluation of a complete spinal region (such
as cervical, thoracic, or lumbar) rather than three segments.
They also can clearly view areas in the foramen and the
paraspinal soft tissues.
MRI is so accurate that a significant number of lesions can
be identified in asymptomatic patients. Gibson et al. found disc
degeneration in all symptomatic adolescent patients and in 4
of 20 asymptomatic adolescents. Boden et al. found cervical
spinal abnormalities in 14% of asymptomatic patients younger
than 40 years of age and in 28% of asymptomatic patients over
the age of 40 years. Cervical disc degeneration was found in
25% of those younger than 40 years of age and in 60% of those
60 years and older. They studied lumbar MRI scans of 67
asymptomatic patients and found that 20% of those younger
than 60 years of age had herniated nuclei pulposi, which were
also present in 36% of those over the age of 60 years.
Asymptomatic abnormalities were found in 57% of those 60
years of age or older. Lumbar disc degeneration was found in
35% of those from 20 to 39 years of age and in 100% of those
over 50 years of age. Therefore the demonstrated findings must
be carefully correlated with the clinical impression.
POSITRON EMISSION TOMOGRAPHY

POSITRON EMISSION TOMOGRAPHY
Positron emission tomography (PET) and single photon
emission CT (SPECT) are other similar techniques that may
offer additional diagnostic information. Collier et al. and others
reported that SPECT is more sensitive than planar bone
scintigraphy in the identification of symptomatic sites in
spondylolysis. PET scanners are considered experimental by
most third-party payers at this time. Their use currently is
limited to relatively few centers.
Currently, imaging capabilities exceed clinical abilities to
identify the source of pain. However, some patients may have
nonanatomical causes for their pain and there is no imaginable
explanation for their symptoms. In these patients, imaging
studies are useful to rule out significant pathology that may
explain their symptoms, such as with spinal cord tumors,
infections, polyradiculopathies, or myeloradiculopathies.
OTHER DIAGNOSTIC TESTS

OTHER DIAGNOSTIC TESTS
Numerous diagnostic tests have been used in the diagnosis of
intervertebral disc disease in addition to roentgenography,
myelography, and CT. The primary advantage of these tests is
to rule out diseases other than primary disc herniation, spinal
stenosis, and spinal arthritis.
Electromyography is the most notable of these tests. One
advantage of electromyography is in the identification of
peripheral neuropathy and diffuse neurological involvement
indicative of higher or lower lesions. Electromyography and
nerve conduction velocity can be helpful if a patient has a
history and physical examination suggestive of radiculopathy at
either the cervical or lumbar level with inconclusive imaging
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studies. Macnab et al. reported that denervation of the

paraspinal muscles is found in 97% of previously operated
lumbar spines as a result of the surgery. Therefore paraspinal
muscles in a patient with a previous posterior operation usually
are abnormal and are not a reliable diagnostic finding.
The somatosensory evoked potentials (SSEP) test is another
diagnostic tool that can identify the level of root involvement.
Unlike electromyography this test can only indicate a problem
between the cerebral cortex and the end organs; the test cannot
pinpoint the level of the lesion. This procedure is of benefit
during surgery to avoid neurological damage. Both electromyography and SSEP depend on the skill of the technician and
interpreter. Delamarter et al. used cortical evoked potentials to
monitor experimentally induced spinal stenosis. They noted
changes in the cortical response at 25% constriction. This was
the only change noted in this group. Higher degrees of
constriction were accompanied by much more significant
changes. The SSEP is an extremely sensitive monitoring
technique.
Bone scans are another procedure in which positive findings
usually are not indicative of intervertebral disc disease, but they
can confirm neoplastic, traumatic, and arthritic problems in the
spine. Various laboratory tests such as a complete blood count,
differential white cell count, biochemical profile, urinalysis,
and sedimentation rate are extremely good screening procedures for other causes of pain in the spine. Rheumatoid
screening studies such as rheumatoid arthritis latex, antinuclear
antibody, lupus erythematosus cell preparation, and HLA-B27
also are useful when indicated by the clinical picture.
Some tests that were developed to enhance the diagnosis of
intervertebral disc disease have been surpassed by the more
advanced technology. Lumbar venography and sonographic
measurement of the intervertebral canal are two examples.
Injection Studies
Injection Studies
Whenever a diagnosis is in doubt and the complaints appear
real or the pathological condition is diffuse, identification of the
source of pain is problematic. The use of local anesthetics or
contrast media in various specific anatomical areas can be
useful. These agents are relatively simple, safe, and minimally
painful. Contrast media such as diatrizoate meglamine
(Hypaque), iothalamate meglumine (Conray), iohexol (Omnipaque), iopamidol, and metrizamide (Amipaque) have been
used for discography and blocks with no reported ill effects.
Reports of neurological complications with contrast media used
for discography and subsequent chymopapain injection are well
documented. The best choice of a contrast medium for
documenting structures outside the subarachnoid space is an
absorbable medium with low reactivity because it might be
injected inadvertently into the subarachnoid space. Iohexol and
metrizamide are the least reactive, most widely accepted, and
best tolerated of the currently available contrast media. Local
anesthetics such as lidocaine (Xylocaine), tetracaine (Pontocaine), and bupivacaine (Marcaine) are used frequently both
epidurally and intradurally. The use of bupivacaine should be

limited to low concentrations and low volumes because of
reports of death after epidural anesthesia using concentrations
of 0.75% or higher.
Steroids prepared for intramuscular injection also have been
used frequently in the epidural space with few and usually
transient complications. Spinal arachnoiditis in years past was
associated with the use of epidural methylprednisolone acetate
(Depo-Medrol). This complication was thought to be caused by
the use of the suspending agent, polyethylene glycol, which has
since been eliminated from the Depo-Medrol preparation. For
epidural injections, we prefer the use of Celestone Soluspan,
which is a mixture of betamethasone sodium phosphate and
betamethasone acetate. Celestone Soluspan provides both
immediate and long-term duration of action, is highly soluble,
and contains no harmful preservatives. Isotonic saline is the
only other injectable medium used frequently about the spine
with no reported adverse reactions.
When discrete, well-controlled injection techniques directed
at specific targets in and around the spine are used, grading the
degree of pain before and after selective spinal injection is
helpful in determining the location of the pain generator. The
patient is asked to grade the degree of pain on a 0 to 10 scale
before and at various intervals after the selective spinal
injection (Box 39-1). If a selective spinal injection done under
fluoroscopic control results in a 50% or more decrease in the
level of pain, which corresponds to the duration of action of the
anesthetic agent used, then the target area injected is presumed
to be the pain generator.
EPIDURAL CORTISONE INJECTIONS

EPIDURAL CORTISONE INJECTIONS
Epidural injections in the cervical, thoracic, and lumbosacral
spine were developed to diagnose and treat spinal pain.
Information obtained from epidural injections can be helpful in
confirming pain generators that are responsible for a patients
discomfort. Structural abnormalities do not always cause pain
and diagnostic injections can help to correlate abnormalities
seen on imaging studies with associated pain complaints. In
addition, epidural injections can provide pain relief during the
recovery of disc or nerve root injuries and allow patients to
increase their level of physical activity. Because severe pain
from an acute disc injury with or without radiculopathy often is
time-limited, therapeutic injections help to manage pain and
may alleviate or decrease the need for oral analgesics.
Epidural injections were first done in the lumbar region. In
1901 the first reports were published of epidural injections of
cocaine for low back pain and sciatica. In 1930 Evans reported
good results in 22 of 40 patients treated with procaine and
saline injection into the sacral epidural space for unilateral
sciatica, and in the early 1950s Robecchi and Capral were the
first to report epidural injection of cortisone into the first sacral
neuroforamen for the treatment of low back pain. The earliest
references for cervical epidural injections were published by
Catchlove and Braha and Shulman et al. No historical
information on thoracic epidural injections has been published.
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BOX 39-1 Pain Scale and Diary

0
1
2
3
4-5
6
7-9
10
No pain
Mild pain that you are aware of but not bothered by
Moderate pain that you can tolerate without medication
Moderate pain that is discomforting and requires medication
More severe and you begin to feel antisocial
Severe pain
Intensely severe pain
Most severe pain; you might contemplate suicide over it
Activity
Comments
Location of Pain
Time
Severity of Pain (0 to 10)
From White AH: Back school and other conservative approaches to low back pain, St Louis, 1983, Mosby.
The efficacy of epidural injections is not reliably known

because of the lack of well-controlled studies. Inconsistencies
in indications and protocols are striking among reports, and
many epidural steroid injection studies were done without
fluoroscopic-guided needle placement to confirm correct
positioning, adding another variable to the interpretation of the
results. Nevertheless, more than 40, mostly uncontrolled,
studies on more than 4000 patients have been published on the
efficacy of lumbar and caudal epidural corticosteroid injections, and according to Bogduk, only 4 recommended against
the use of lumbosacral epidural corticosteroids in the management of radicular pain in the lumbosacral spine. Kepes and
Duncalf calculated the average favorable response rate obtained with lumbar epidural steroid injections to be 60%,
whereas White calculated the favorable response rate to be
75%. Several studies reported the usefulness of transforaminal
epidural corticosteroid injections (selective epidural or selective nerve root block) to identify or confirm a specific nerve
root as a pain generator when the diagnosis is not clear based
on clinical evidence.
Few serious complications occur in patients receiving
epidural corticosteroid injections; however, epidural abscess,
epidural hematoma, durocutaneous fistula, and Cushing syndrome have been reported as individual case reports. The most
adverse immediate reaction during an epidural injection is a
vasovagal reaction. Dural puncture has been estimated to occur
in 0.5% to 5% of patients having cervical or lumbar epidural
steroid injections. The anesthesiology literature reported a
7.5% to 75% incidence of postdural puncture (positional)
headaches, with the highest estimates associated with the use of
16- and 18-gauge needles. Headache without dural puncture
has been estimated to occur in 2% and is attributed to air
injected into the epidural space, increased intrathecal pressure
from fluid around the dural sac, and possibly an undetected
dural puncture. Some of the minor, more common complaints
caused by corticosteroid injected into the epidural space
include nonpositional headaches, fascial flushing, insomnia,

low-grade fever, and transient increased back or lower
extremity pain. Epidural corticosteroid injections are contraindicated in the presence of infection at the injection site,
systemic infection, bleeding diathesis, uncontrolled diabetes
mellitus, and congestive heart failure.
We do epidural corticosteroid injections in a fluoroscopy
suite equipped with resuscitative and monitoring equipment.
Intravenous access is established in all patients with a 20-gauge
angiocatheter placed in the upper extremity. Mild sedation is
achieved through intravenous access. We recommend the use of
fluoroscopy for diagnostic and therapeutic epidural injections
for several reasons. Epidural injections performed without
fluoroscopic guidance are not always made into the epidural
space or the intended interspace. Even in experienced hands,
needle misplacement occurs in up to 40% of caudal and 30% of
lumbar epidural injections when done without fluoroscopic
guidance. Accidental intravascular injections also can occur,
and the absence of blood return with needle aspiration before
injection is not a reliable indicator of this complication. In the
presence of anatomical anomalies, such as a midline epidural
septum or multiple separate epidural compartments, the desired
flow of epidural injectants to the presumed pain generator will
be restricted and remain undetected without fluoroscopy. In
addition, if an injection fails to relieve pain, it would be
impossible without fluoroscopy to determine whether the
failure was caused by a genuine poor response or by improper
needle placement.
Cervical Epidural Injection

Cervical epidural steroid injections have been used with
some success to treat cervical spondylosis associated with acute
disc disruption and radiculopathies, cervical strain syndromes
with associated myofascial pain, postlaminectomy cervical
pain, reflex sympathetic dystrophy, postherpetic neuralgia,
acute viral brachial plexitis, and muscle contraction headaches.
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The best results with cervical epidural steroid injections have

been in patients with acute disc herniations or well-defined
radicular symptoms and in patients with limited myofascial pain.
Interlaminar Approach
TECHNIQUE 39-2
Place the patient prone on a pain management table. We use
a low-attenuated carbon fiber table top that allows better
imaging and permits unobstructed C-arm viewing. For
optimal placement and comfort, place the patients face in a
cervical prone cutout cushion. Cervical epidural injections
using a paramedian approach should be done routinely at the
C7-T1 interspace unless previous surgery of the posterior
cervical spine has been done at that level, in which case the
C6-C7 or T1-T2 level is injected. Aseptically prepare the
skin area with isopropyl alcohol and povidone-iodine
several segments above and below the laminar interspace to
be injected. If the patient is allergic to povidone-iodine, then
substitute with chlorhexidine gluconate (Hibiclens). Drape
the patient in sterile fashion. Using anteroposterior fluoroscopic imaging, identify the target laminar interspace. With
the use of a 27]-gauge needle, anesthetize the skin so that
a skin wheal is raised over the target interspace on the side
of the patients pain with 1 to 2 ml of 1% preservative-free
Xylocaine without epinephrine. To diminish the burning
discomfort of the anesthetic, mix 3 ml of 8.4% sodium
bicarbonate in a 30-ml bottle of 1% preservative-free
Xylocaine without epinephrine. Nick the skin with an
18-gauge hypodermic needle. Under fluoroscopic control
insert and advance a 312-inch, 22-gauge spinal needle in a
vertical fashion until contact is made with the upper edge of

the T1 lamina 1 to 2 mm lateral to the midline.
Anesthetize the lamina with 1 to 2 ml of 1%
preservative-free Xylocaine without epinephrine. Then
anesthetize the soft tissues with 2 ml of 1% preservative-free
Xylocaine without epinephrine as the spinal needle is
withdrawn. Insert a 312-inch, 18-gauge Tuohy epidural
needle and advance it vertically within the anesthetized soft
tissue track until contact is made with the T1 lamina under
fluoroscopy. Walk off the lamina with the Tuohy needle
onto the ligamentum flavum. Remove the stylet from the
Tuohy needle and attach a 10-ml syringe filled halfway with
air and sterile saline. Advance the Tuohy needle into the
epidural space using the loss of resistance technique. Once
loss of resistance has been achieved, aspirate to check for
blood or spinal fluid. If neither is evident, remove the
syringe from the Tuohy needle and attach a 5-ml syringe
containing 1.5 ml of nonionic contrast dye. Confirm
epidural placement by producing an epidurogram with
the nonionic contrast agent (Fig. 39-11). To further confirm proper placement adjust the C-arm to view the area
from a lateral perspective. A spot roentgenogram can
be obtained to document placement. Inject a test dose of
1 to 2 ml of 1% preservative-free Xylocaine without
epinephrine and wait 3 minutes. If the patient is without
complaints of warmth, burning, significant paresthesias, or
signs of apnea, place a 10-ml syringe on the Tuohy needle
and slowly inject 2 ml of 1% preservative-free Xylocaine
without epinephrine and 2 ml of 6 mg/ml Celestone
Soluspan slowly into the epidural space. If Celestone
Soluspan cannot be obtained, 40 mg/ml of triamcinolone is
a good substitute.
Fig. 39-11 Posteroanterior view cervical interlaminar epidurogram demonstrating characteristic

C7 to T1 epidural contrast flow pattern.
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Transforaminal Approach
TECHNIQUE 39-3
Place the patient in a modified lateral decubitus position
with the painful side up on a pain management table.
Aseptically prepare the skin area with isopropyl alcohol and
povidone-iodine several segments above and below the
neuroforamen to be injected. Drape the patient in sterile
fashion. Identify the foramen level to be injected under
fluoroscopy, orienting the beam so that it is slightly tilted
caudal to cephalad and anterior to posterior to maximize
the view of the neuroforamen. Insert and slowly advance a
312-inch 25-gauge spinal needle until contact is made with
the lower aspect of the superior articular process under
fluoroscopy. Stay posterior to the foramen to avoid the
vertebral artery. To maximize posterior positioning of the
spinal needle bevel, orient the needle notch anteriorly.
Orient the C-arm so that the fluoroscopy beam is in an
anteroposterior projection. Redirect the spinal needle and
walk off bone into the foramen 3 to 4 mm but no farther
medially than the midpoint of the articular pillar on
anteroposterior imaging. Remove the stylet. After a negative
aspiration, inject 0.5 ml of nonionic contrast dye under
fluoroscopy. Once an acceptable dye pattern is seen (filling
of the oval neuroforamen and flow of contrast along the
exiting nerve root), inject slowly a 1-ml volume, containing
0.5 ml of 2% to 4% preservative-free Xylocaine without
epinephrine and 0.5 ml of 6 mg/ml Celestone Soluspan.
Thoracic Epidural Injection

Epidural steroid injections in the thoracic spine have been
shown to provide relief from thoracic radicular pain secondary
to disc herniations, trauma, diabetic neuropathy, herpes zoster,
and idiopathic thoracic neuralgia, although reports in the
literature are few.
TECHNIQUE 39-4
A paramedian rather than a midline approach is used
because of the angulation of the spinous processes. Place the
patient prone on a pain management table. The preparation
of the patient and equipment is identical to that used for
interlaminar cervical epidural injections. Aseptically prepare the skin area several segments above and below the
interspace to be injected. Drape the patient in sterile fashion.
Identify the target laminar interspace using anteroposterior
visualization under fluoroscopic guidance. Anesthetize the
skin over the target interspace on the side of the patients
pain. Under fluoroscopic control, insert and advance a
312-inch, 22-gauge spinal needle to the superior edge of the
target lamina. Anesthetize the lamina and the soft tissues as
the spinal needle is withdrawn. Mark the skin with an 18gauge hypodermic needle and then insert a 312-inch,
18-gauge Tuohy epidural needle and advance it at a 50- to
60-degree angle to the axis of the spine and a 15- to 30-degree
angle toward the midline until contact with the lamina is
made. To better view the thoracic interspace, position the
C-arm so that the fluoroscopy beam is in the same plane as
the Tuohy epidural needle. Walk off the lamina with the
Tuohy needle into the ligamentum flavum. Remove the stylet
from the Tuohy needle and, using the loss of resistance
technique, advance it into the epidural space. Once loss of
resistance has been achieved, aspirate to check for blood or
spinal fluid. If neither is evident, inject 1.5 ml of nonionic
contrast dye to confirm epidural placement. To further
confirm proper placement, adjust the C-arm to view the area
from a lateral projection (Fig. 39-12). A spot roentgenogram
or epidurogram can be obtained. Inject 2 ml of 1%
preservative-free Xylocaine without epinephrine and 2 ml of
6 mg/ml Celestone Soluspan slowly into the epidural space.
Fig. 39-12 A, Anteroposterior view of thoracic interlaminar epidurogram demonstrating characteristic contrast flow pattern. B, Lateral roentgenogram of thoracic interlaminar epidurogram.
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Fig. 39-13 Anteroposterior and lateral view of lumbar interlaminar epidurogram demonstrating
characteristic contrast flow pattern.
Lumbar Epidural Injection

Certain clinical trends are apparent with lumbar epidural
steroid injections. When nerve root injury is associated with a
disc herniation or lateral bony stenosis, most patients who
received substantial leg pain relief from a well-placed transforaminal injection, even if temporary, will benefit from
surgery for the radicular pain. Patients who do not respond and
who have had radicular pain for at least 12 months are unlikely
to benefit from surgery. Patients with back and leg pain of an
acute nature (less than 3 months) respond better to epidural
corticosteroids. Unless a significant reinjury results in an acute
disc or nerve root injury, postsurgical patients tend to respond
poorly to epidural corticosteroids.
TECHNIQUE 39-5
Place the patient prone on a pain management table.
laminar interspace to be injected. Drape the patient in a
sterile fashion. Under anteroposterior fluoroscopy guidance,
identify the target laminar interspace. Using a 27]-gauge
needle, anesthetize the skin over the target interspace on
the side of the patients pain with 1 to 2 ml of 1%
preservative-free Xylocaine without epinephrine. Insert a
312-inch, 22-gauge spinal needle vertically until contact is
made with the upper edge of the inferior lamina at the target
interspace, 1 to 2 cm lateral to the caudal tip of the inferior
spinous process under fluoroscopy. Anesthetize the lamina
with 2 ml of 1% preservative-free Xylocaine without
epinephrine. Then anesthetize the soft tissue with 2 ml of
1% Xylocaine as the spinal needle is withdrawn. Nick the

skin with an 18-gauge hypodermic needle and then insert a
312-inch, 17-gauge Tuohy epidural needle and advance it
vertically within the anesthetized soft tissue track until
contact with the lamina has been made under fluoroscopy.
Walk off the lamina with the Tuohy needle onto the
ligamentum flavum. Remove the stylet from the Tuohy
needle and attach a 10-ml syringe filled halfway with air and
sterile saline to the Tuohy needle. Advance the Tuohy needle
into the epidural space using the loss of resistance
technique. Avoid lateral needle placement to decrease the
likelihood of encountering an epidural vein or adjacent
nerve root. Remove the stylet once loss of resistance has
been achieved. Aspirate to check for blood or spinal fluid. If
neither is present, remove the syringe from the Tuohy needle
and attach a 5-ml syringe containing 2 ml of nonionic
contrast dye. Confirm epidural placement by producing an
epidurogram with the nonionic contrast agent (Fig. 39-13).
A spot roentgenogram can be taken to document placement.
Remove the 5-ml syringe and place on the Tuohy needle a
10-ml syringe containing 2 ml of 1% preservative-free
Xylocaine and 2 ml of 6 mg/ml Celestone Soluspan. Inject
the corticosteroid preparation slowly into the epidural space.
Transforaminal Approach
TECHNIQUE 39-6
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medial edge of the pedicle. Adjust the C-arm to a lateral

projection to confirm the position and then return it to the
anteroposterior view. Remove the stylet. Inject 1 ml of
nonionic contrast slowly to produce a perineurosheathogram. After an adequate dye pattern of the S1 nerve root is
obtained, insert a 2-ml volume containing 1 ml of 0.75%
preservative-free Marcaine and 1 ml of 6 mg/ml Celestone
Soluspan.
Caudal Approach
Fig. 39-14
pattern.
Right L5 selective nerve root injection contrast
interspace to the injected. Drape the patient in sterile

fashion. Under anteroposterior fluoroscopic guidance, identify the target interspace. Anesthetize the soft tissues over
the lateral border and midway between the two adjacent
transverse processes at the target interspace. Insert a
434-inch, 22-gauge spinal needle and advance it within the
anesthetized soft tissue track under fluoroscopy until contact
is made with the lower edge of the superior transverse
process near its junction with the superior articular process.
Retract the spinal needle 2 to 3 mm and redirect it toward
the base of the appropriate pedicle and advance it slowly to
the 6-oclock position of the pedicle under fluoroscopy.
Adjust the C-arm to a lateral projection to confirm the
position then return the C-arm to the anteroposterior view.
Remove the stylet. Inject 1 ml of nonionic contrast slowly to
produce a perioneurosheathogram (Fig. 39-14). After an
adequate dye pattern is observed, inject slowly a 2-ml
volume containing 1 ml of 0.75% preservative-free bupivacaine and 1 ml of 6 mg/ml Celestone Soluspan.
The S1 nerve root also can be injected using the
transforaminal approach. Place the patient prone on the pain
management table. After appropriate aseptic preparation,
direct the C-arm so that the fluoroscopy beam is in a
cephalocaudad and lateral-to-medial direction so that the
anterior and posterior S1 foramina are aligned. Anesthetize
the soft tissues and the dorsal aspect of the sacrum with 2 to
3 ml of 1% preservative-free Xylocaine without epinephrine. Insert a 312-inch, 22-gauge spinal needle and advance
it within the anesthetized soft tissue track under fluoroscopy
until contact is made with posterior sacral bone slightly
lateral and inferior to the S1 pedicle. Walk the spinal
needle off the sacrum into the posterior S1 foramen to the
TECHNIQUE 39-7
Aseptically prepare the skin area from the lumbosacral
junction to the coccyx with isopropyl alcohol and povidoneiodine. Drape the patient in sterile fashion. Try to identify by
palpation the sacral hiatus, which is located between the two
horns of the sacral cornu. The sacral hiatus can best be
observed by directing the fluoroscopic beam laterally.
Anesthetize the soft tissues and the dorsal aspect of the
sacrum with 2 to 3 ml of 1% preservative-free Xylocaine
without epinephrine. Keep the C-arm positioned so that
the fluoroscopic beam remains lateral. Insert a 312-inch,
22-gauge spinal needle between the sacral cornu at about 45
degrees, with the bevel of the spinal needle facing ventrally
until contact with the sacrum is made. Using fluoroscopic
guidance, redirect the spinal needle more cephalad, horizontal and parallel to the table, advancing it into the sacral
canal through the sacrococcygeal ligament and into the
epidural space. Remove the stylet. Aspirate to check for
blood or spinal fluid. If neither is evident, inject 2 ml of
nonionic contrast dye to confirm placement. Move the C-arm
into the anteroposterior position and look for the characteristic Christmas tree pattern of epidural flow (Fig. 39-15).
If a vascular pattern is seen, reposition the spinal needle and
again confirm epidural placement with nonionic contrast
dye. Once the correct contrast pattern is obtained, inject
slowly a 10-ml volume containing 3 ml of 1% preservativefree Xylocaine without epinephrine, 3 ml of 6 mg/ml
Celestone Soluspan, and 4 ml of sterile normal saline.
ZYGAPOPHYSEAL (FACET) JOINT INJECTIONS

ZYGAPOPHYSEAL (FACET) JOINT INJECTIONS
The facet joint can be a source of back pain; the exact cause
of the pain remains unknown. Theories include meniscoid
entrapment and extrapment, synovial impingement, chondromalacia facetae, capsular and synovial inflammation, and
mechanical injury to the joint capsule. Osteoarthritis is another
cause of facet joint pain; however, the incidence of facet joint
arthropathy is equal in both symptomatic and asymptomatic
patients. As with other osteoarthritic joints, roentgenographic
changes correlate poorly with pain.
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C1
laaj
g
C2vr
ton
mb
a
C7
T1
Fig. 39-15 Anteroposterior view of caudal epidurogram demonstrating characteristic contrast flow pattern.
Although the history and physical examination may suggest

that the facet joint is the cause of spine pain, no noninvasive
pathognomonic findings distinguish facet jointmediated pain
from other sources of spine pain. Fluoroscopically guided facet
joint injections therefore are commonly considered the gold
standard for isolating or excluding the facet joint as a source of
spine or extremity pain.
Clinical suspicion of facet joint pain by a spine specialist
remains the major indicator for diagnostic injection, which
should be done only in patients who have had pain for more
than 4 weeks and only after appropriate conservative measures
have failed to provide relief. Facet joint injection procedures
may help to focus treatment on a specific spinal segment and
provide adequate pain relief to allow progression in therapy.
Either intraarticular or medial branch blocks can be used for
diagnostic purposes. Although injection of cortisone into the
facet joint was a popular procedure through most of the 1970s
and 1980s, many investigators have found no evidence that this
effectively treats low back pain caused by a facet joint. The
only controlled study on the use of intraarticular corticosteroids
in the cervical spine found no added benefit from intraarticular
betamethasone over bupivacaine.
Cervical Facet Joint
Fig. 39-16 Proper needle placement for posterior approach to

C4 and C6 medial branch blocks. Second cervical ganglion (g),
third occipital nerve (ton), C2 ventral ramus (C2vr) and lateral
atlantoaxial joint (laaj) are noted. (Redrawn from Boduk N: Back
pain: Zygapophyseal blocks and epidural steroids. In Cousins MJ,
Bridenbaugh PO, eds: Neural blockade in clinical anesthesia and
management of pain, ed 2, Philadelphia, 1988, JB Lippincott.)
directed fluoroscopy. Each cervical facet joint from C3-4 to

C7-T1 is supplied from the medial nerve branch above and
below that joint which curves consistently around the
waist of the articular pillar of the same numbered
vertebrae (Fig. 39-16). For example, to block the C6 facet
joint nerve supply, anesthetize the C6 and C7 medial
branches. Insert a 22- or 25-gauge, 312-inch spinal needle
perpendicular to the pain management table and advance it
under fluoroscopic control ventrally and medially until
contact is made with periosteum. Direct the spinal needle
laterally until the needle tip reaches the lateral margin of the
waist of the articular pillar and then direct the needle until
it rests at the deepest point of the articular pillars concavity
under fluoroscopy. Remove the stylet. If there is a negative
aspirate, inject 0.5 ml of 0.75% preservative Marcaine.
Lumbar Facet Joint
Medial Branch Block Injection

TECHNIQUE 39-8
Place the patient prone on the pain management table.
Rotate the patients neck so that the symptomatic side is
down. This allows the vertebral artery to be positioned
farther beneath the articular pillar, creates greater accentuation of the cervical waists, and prevents the jaw from being
superimposed. Aseptically prepare and drape the side to be
injected. Identify the target location using anteroposterior-
Intraarticular Injection
TECHNIQUE 39-9
Aseptically prepare and drape the patient. Under fluoroscopic guidance, identify the target segment to be injected.
Upper lumbar facet joints are oriented in the sagittal
(vertical) plane and often can be seen on direct anteroposterior views, whereas the lower lumbar facet joints,
especially at L5-S1, are obliquely oriented and require an
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ipsilateral oblique rotation of the C-arm to be seen. Position

the C-arm under fluoroscopy until the joint silhouette first
appears. Insert and advance a 22- or 25-gauge, 312-inch
spinal needle toward the target joint along the axis of the
fluoroscopy beam until contact is made with the articular
processes of the joint. Enter the joint cavity through the
softer capsule and advance the needle only a few millimeters. Capsular penetration is perceived as a subtle change
of resistance. If midpoint needle entry is difficult, redirect
the spinal needle to the superior or inferior joint recesses.
Confirm placement with less than 0.1 ml of nonionic
contrast dye with a 3-ml syringe to minimize injection
pressure under fluoroscopic guidance. Once intraarticular
placement has been verified, inject a total volume of 1 ml of
injectant (local anesthetic with or without corticosteroids)
into the joint.
Medial Branch Block Injection

TECHNIQUE 39-10
Aseptically prepare and drape the patient. Because there is
dual innervation of each lumbar facet joint, two medial
branch blocks are required. It is important to remember that
the medial branches cross the transverse processes below
their origin (Fig. 39-17). For example, the L4-5 facet joint
is anesthetized by blocking the L3 medial branch at the
transverse process of L4, and the L4 medial branch at the
transverse process of L5. In the case of the L5-S1 facet joint,
anesthetize the L4 medial branch as it passes over the L5
transverse process and the L5 medial branch as it passes
across the sacral ala. Using anteroposterior fluoroscopic
imaging, identify the target transverse process. For L1
through L4 medial branch blocks, penetrate the skin using a
22- or 25-gauge, 312-inch spinal needle lateral and superior
to the target location. Under fluoroscopic guidance, advance
the spinal needle until contact is made with the dorsal
superior and medial aspects of the base of the transverse
process so that the needle top rests against the periosteum.
To ensure optimal spinal needle placement, reposition the
C-arm so that the fluoroscopy beam is ipsilateral oblique and
the Scotty dog is seen. Position the spinal needle in the
middle of the eye of the Scotty dog. Slowly inject
(over 30 seconds) 0.5 ml of 0.75% Marcaine.
To inject the L5 medial branch (more correctly, the L5
dorsal ramus), position the patient prone on the pain
management table with the fluoroscopic beam in the
anteroposterior projection. Identify the sacral ala. Rotate the
C-arm 15 to 20 degrees ipsilateral obliquely to maximize
exposure between the junction of the sacral ala and the
superior process of S1. Insert a 22- or 25-gauge, 312-inch
spinal needle directly into the osseous landmarks approxi-
1975
mb
mb
Fig. 39-17 Posterior view of lumbar spine demonstrating

location of medial branches of dorsal rami, which innervate lumbar
facet joints (a). Needle position for L3 and L4 medial branch
blocks shown on left half of diagram would be used to anesthetize
the L4-5 facet joint. Right half of diagram demonstrates L3-4,
L4-5, and L5-S1 intraarticular facet joint injection positions.
(Redrawn from Boduk N: Back pain: zygapophyseal blocks and
epidural steroids. In Cousins MJ, Bridenbaugh PO, eds: Neural
blockade in clinical anesthesia and management of pain, ed 2,
Philadelphia, 1988, JB Lippincott.)
mately 5 mm below the superior junction of the sacral ala

with the superior articular process of the sacrum under
fluoroscopy. Rest the spinal needle on the periosteum and
position the bevel of the spinal needle medial and away from
the foramen to minimize flow through the L5 or S1 foramen.
Slowly inject 0.5 ml of 0.75% Marcaine.
Sacroiliac Joint
The sacroiliac joint remains a controversial source of primary
low back pain despite validated scientific studies. It often is
overlooked as a source of low back pain because its anatomical
location makes it difficult to examine in isolation and many
provocative tests place mechanical stresses on contiguous
structures. In addition, several other structures may refer pain
to the sacroiliac joint.
The sacroiliac joint, like other synovial joints, moves;
however, sacroiliac joint movement is involuntary and is
caused by shear, compression, and other indirect forces.
Muscles involved with secondary sacroiliac joint motion
include the erectae spinae, quadratus lumborum, psoas major
and minor, piriformis, latissimus dorsi, obliquus abdominis,
and gluteal. Imbalances in any of these muscles as a result of
central facilitation may cause them to function in a shortened
state that tends to inhibit their antagonists reflexively.
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Fig. 39-18 Pain diagram. A, Patient reported pain diagram

consistent with sacroiliac joint dysfunction. B, Patient reported
diagram inconsistent with sacroiliac joint dysfunction. (From
Fortin JD, Dwyer AP, West S, Pier J: Spine 19:1475, 1994).
Fig. 39-19 Sacroiliac joint injection showing medial (A) and

lateral (B) joint planes (silhouettes). Entry into joint is achieved
above most posterior-inferior aspect of joint.
Theoretically, dysfunctional movement patterns may result.

Postural changes and body weight also can create motion
through the sacroiliac joint.
Because of the wide range of segmental innervation (L2-S2)
of the sacroiliac joint, there is a myriad of referral zone
patterns. In studies of asymptomatic subjects, the most constant
referral zone was localized to a 3 10 cm area just inferior to
the ipsilateral posterior superior iliac spine (Fig. 39-18);
however, pain may be referred to the buttocks, groin, posterior
thigh, calf, and foot.
Sacroiliac dysfunction, also called sacroiliac joint mechanical pain or sacroiliac joint syndrome, is the most common
painful condition of this joint. The true prevalence of mediated
pain from sacroiliac joint dysfunction is unknown; however,
several studies indicated that it is more common than expected.
Because no specific or pathognomonic historical facts or
physical examination tests accurately identify the sacroiliac
joint as a source of pain, diagnosis is one of exclusion.
However, sacroiliac joint dysfunction should be considered if
an injury was caused by a direct fall on the buttocks, a rear-end
motor vehicle accident with the ipsilateral foot on the brake at
the moment of impact, a broadside motor vehicle accident with
a blow to the lateral aspect of the pelvic ring, or a fall in a hole
with one leg in the hole and the other extended outside. Lumbar
rotation and axial loading that can occur during ballet or ice
skating is another common mechanism of injury. Although
somewhat controversial, the risk of sacroiliac joint dysfunction
may be increased in individuals with lumbar fusion or hip
pathology. Other causes include insufficiency stress fractures,
fatigue stress fractures, metabolic processes, such as deposition
diseases, degenerative joint disease, infection, and inflamma-
tory conditions, such as ankylosing spondylitis, psoriatic

arthritis, and Reiters disease. The diagnosis of sacroiliac joint
pain can be confirmed if symptoms are reproduced upon
distention of the joint capsule by provocative injection and
subsequently abated with an analgesic block.
TECHNIQUE 39-11
Aseptically prepare and drape the side to be injected. Rotate
the C-arm until the medial (posterior) joint line is seen. Use
a 27]-gauge needle to anesthetize the skin of the buttock 1
to 3 cm inferior to the lowest aspect of the joint. Using
fluoroscopy insert a 312-inch, 22-gauge spinal needle until
the needle rests 1 cm above the most posteroinferior aspect
of the joint (Fig. 39-19). Rarely, a larger spinal needle is
required in obese patients. Advance the spinal needle into
the sacroiliac joint until capsular penetration occurs. Confirm intraarticular placement under fluoroscopy with 0.5 ml
of nonionic contrast dye. A spot roentgenogram can be taken
to document placement. Inject a 2-ml volume containing
1 ml of 0.75% preservative-free Marcaine and 1 ml of
6 mg/ml Celestone into the joint.
DISCOGRAPHY
DISCOGRAPHY
Discography has been used since the late 1940s for the
experimental and clinical evaluation of disc disease in both the
cervical and lumbar regions of the spine. Since that time
discography has had a limited but important role in the
evaluation of suspected disc pathology.
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The clinical usefulness of the data obtained from discography remains controversial. In 1968 Holt published a landmark
study that showed a 37% false-positive rate. He concluded that
lumbar discography was an unreliable diagnostic tool. However, Holts studies had numerous design flaws, including
suboptimal imaging equipment, neurotoxic contrast agents,
inadequate needle placement, and failure to determine if pain
responses were concordant or discordant with patients typical
pain patterns. Using modern techniques, Walsh et al. in 1990
published a well-controlled prospective study that, unlike
Holts study, required an abnormal nucleogram and a concordant pain response to indicate a positive provocative
discogram. The investigators of this study found a 0%
false-positive rate for discography compared with 37%
reported by Holt. These authors concluded that, with current
technique and standardized protocol, discography was a highly
reliable test.
In independent studies, Cloward and Smith emphasized that
reproduction of a patients pain was the key feature of cervical
discography. In 1964 Holt reported that cervical discography
had no diagnostic value because pain reproduction and
fissuring were features of cervical discs in normal volunteers.
Later investigative work by Simmons and Segil demonstrated
the importance of discriminating between painful and nonpainful discs, while avoiding pain reproduction and disc morphology as absolute entities. Carrying this idea further, Roth in 1976
introduced analgesic cervical discography with the rationale
that once a painful disc is identified, pain relief should occur by
injecting a local anesthetic into the disc. He reported a high
success rate for anterior disc excision and fusion using this
form of precision diagnostic testing.
The most important aspect of discography is provocative
testing for concordant pain (that which corresponds to a
patients usual pain) to provide information regarding the
clinical significance of the disc abnormality. Although difficult
to standardize, this distinguishes discography from other
anatomical imaging techniques. If the patient is unable to
distinguish customary pain from any other pain, the procedure
is of no value. In patients who have a concordant response
without evidence of a radial annular fissure on discography, CT
should be considered because some discs that appear normal on
discography show disruption on CT scan.
Indications for lumbar discography include surgical planning of spinal fusion, testing of the structural integrity of an
adjacent disc to a known abnormality such as spondylolisthesis
or fusion, identifying a painful disc among multiple degenerative discs, ruling out secondary internal disc disruption or
suspected lateral or recurrent disc herniation, and determining
the primary symptom-producing level when chemonucleolysis
is being considered. Thoracic discography is a useful tool in the
investigation of thoracic, chest, and upper abdominal pain.
Degenerative thoracic disc disease, with or without herniation,
has a highly variable clinical presentation, frequently mimicking visceral conditions, as well as causing back or musculoskeletal pain. In the cervical spine, discography is an important
adjunct for diagnosing primary discogenic pain and determin-
1977
ing which disc is affected and will require surgery. Discography

also may be justified in medicolegal situations to establish a
definitive diagnosis even though treatment may not be planned
on that disc.
Compression of the spinal cord, stenosis of the roots,
bleeding disorders, allergy to the injectable material, and active
infection are contraindications to diagnostic discography
procedures. Although the risk of complications from discography is low, potential problems include discitis, nerve root
injury, subarachnoid puncture, chemical meningitis, bleeding,
and allergic reactions. In addition, in the cervical region,
retropharyngeal and epidural abscess can occur. Pneumothorax
is a risk in both the cervical and thoracic regions.
Lumbar Discography
Lumbar discography originally was done using a transdural
technique in a manner similar to myelography with a lumbar
puncture. The difference between lumbar myelography and
discography was that the needle used for the latter was
advanced through the thecal sac. The technique later was
modified, consisting of an extradural, extralaminar approach
that avoided the thecal sac, and it was refined further to enable
entry into the L5-S1 disc using a two-needle technique to
maneuver around the iliac crest.
A patients response during the procedure is the most
important aspect of the study. Pain alone does not determine if
a disc is the cause of the back pain. The concordance of the pain
in regard to the quality and location are paramount in
determining whether the disc is a true pain generator. A control
disc is necessary to validate a positive finding on discography.
TECHNIQUE 39-12 (Falco)
Place the patient on a procedure or fluoroscopic table. Insert
an angiocatheter into the upper extremity and infuse
intravenous antibiotics to prevent discitis. Some physicians
prefer to give antibiotics intradiscally during the procedure
in lieu of the intravenous route. Place the patient in a
modified lateral decubitus position with the symptomatic
side down to avoid having the patient confuse the pain
caused by the needle with the actual pain on that same side.
This position also allows for easier fluoroscopic imaging of
the intervertebral discs and mobilizes the bowel away from
the needle path. Lightly sedate the patient with an intravenous opioid and short-acting benzodiazepine. Prepare and
drape the skin sterilely, including the lumbosacral region.
Under fluoroscopic control, identify the intervertebral
discs. Adjust the patients position or the C-arm so that the
lumbar spine is in an oblique position with the superior
articular process, dividing the intervertebral space in half
(Fig. 39-20). Anesthetize the skin overlying the superior
articular process with 1 to 2 ml of 1% lidocaine if necessary.
Advance a single 6-inch spinal needle (or longer, depending
on the patients size) through the skin and deeper soft tissues
to the outer annulus of the disc. The disc entry point is just
continued
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Fig. 39-20 Lumbar spine in an oblique position with superior

articular process (arrow) dividing disc space (d) in half. (Courtesy
Frank JE Falco, MD)
anterior to the base of the superior articular process and just

above the superior endplate of the vertebral body, which
allows the needle to safely pass by the exiting nerve root
(Fig. 39-21). Advance the needle into the central third of the
disc, using anteroposterior and lateral fluoroscopic imaging.
Confirm the position of the needle tip within the central third
of the disc with anteroposterior and lateral fluoroscopic
imaging. Inject either saline or nonionic contrast dye into
each disc. Record any pain that the patient experiences
during the injection as none, dissimilar, similar, or exact in
relationship to the patients typical low back pain. Record
intradiscal pressures to assist in determining if the disc is the
cause of the pain. Obtain roentgenograms of the lumbar
spine upon completion of the study, paying particular
attention to the contrast-enhanced disc. Obtain a CT scan if
necessary to assess disc anatomy further.
An alternative method is a two-needle technique in
which a 6- or 8-inch spinal needle is passed through a
shorter introducer needle (typically 312 inches in length)
into the disc in the same manner as a single needle. This
approach may reduce the incidence of infection by allowing
the procedure needle to pass into the disc space without ever
penetrating the skin. The introducer needle also may assist
in more accurate needle placement, reducing the risk of
injuring the exiting nerve root. The two-needle approach
may require more time than the single-needle technique, and
the larger introducer needle could cause more pain to the
patient.
The two-needle technique often is used to enter the
L5-S1 disc space with one modification. The procedure
needle typically is curved (Fig. 39-22). To bypass the iliac
crest, the introducer needle is advanced at an angle that
Fig. 39-21 Disc entry point is just anterior (arrow) to base of

superior articular process (s) and just above superior endplate of
vertebral body. (Courtesy Frank JE Falco, MD)
Fig. 39-22 Curved procedure needle (c) passing through straight

introducer needle (n). (Courtesy Frank JE Falco, MD)
places the needle tip in a position that does not line up with
the L5-S1 disc space, which makes it difficult if not
impossible for a straight procedure needle to advance into
the L5-S1 disc. A curved procedure needle, on the other
hand, allows the needle tip to align with the L5-S1 disc as
it is advanced towards and into the disc adjusting for
malalignment.
Thoracic Discography
Thoracic discography has been refined to provide a technique
that is reproducible and safe. A posterolateral extralaminar
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Fig. 39-23 Oblique position with superior articular process

(arrow) dividing thoracic intervertebral space in half. p, Pedicle.
r, rib head. (Courtesy Frank JE Falco, MD)
approach similar to lumbar discography is used with a

single-needle technique. The significant difference between
thoracic and lumbar discography is the potential for complications because of the surrounding anatomy of the thoracic spine.
In contrast to lumbar discography, which typically is performed
in the mid to lower lumbar spine below the spinal cord and
lungs, thoracic discography has the inherent risk of pneumothorax and direct spinal cord trauma; other complications
include discitis and bleeding.
Essentially the same protocol is used for thoracic discography as for lumbar discography.
Place the patient in a modified lateral decubitus position on
the procedure table with the symptomatic side down. Begin
antibiotics through the intravenous catheter. Alternatively,
intradiscal antibiotics may be given during the procedure.
Lightly sedate the patient and prepare and drape the skin in
a sterile manner.
Using fluoroscopic imaging, identify the intervertebral
thoracic discs. Move the patient or adjust the C-arm
obliquely to position the superior articular process so that it
divides the intervertebral space in half (Fig. 39-23). At this
point, the intervertebral discs and endplates, subjacent
superior articular process, and adjacent rib head should be in
clear view. The endplates, the superior articular process, and
the rib head form a box (Fig. 39-24) that delineates a safe
pathway into the disc, avoiding the spinal cord and lung.
Keep the needle tip within the confines of this box while
advancing it into the annulus.
After proper positioning and exposure, anesthetize the
skin overlying the superior articular process with 1 to 2 ml
1979
Fig. 39-24 Thoracic endplates (e), superior articular process (s),

and rib head (r) form box. (Courtesy Frank JE Falco, MD)
of 1% lidocaine if necessary. Advance a single 6-inch spinal

needle (a shorter or longer needle can be used, depending on
the patients size) through the skin and the deeper soft tissues
into the outer annulus within the box just anterior to the
base of the superior articular process and just above the
superior endplate. Continue into the central third of the disc,
using anteroposterior and lateral fluoroscopic guidance.
Inject either saline or a nonionic contrast dye into each
disc in the same manner as for lumbar discography. Record
any pain response and analyze for reproduction of concordant pain using the same protocol as for lumbar
discography. Obtain roentgenograms and CT imaging of the
thoracic spine upon completion of the study.
Cervical Discography
The approach to the cervical spine is distinctly different from
the approaches used for discography of the lumbar and thoracic
spine. The cervical spine is approached anteriorly rather than
posteriorly. Complications associated with cervical discography because of the surrounding anatomy include injury to the
trachea, esophagus, carotid artery, and jugular veins, as well as
spinal cord injury and pneumothorax. As with lumbar and
thoracic discography, discitis also is a concern in the cervical
spine, although the disc infection often originates from the
gram-negative and anaerobic flora of the esophagus as opposed
to the gram-positive skin flora seen in lumbar discography.
Traditionally, the approach to the cervical intervertebral
discs has been via a paralaryngeal route that requires displacement of the trachea and esophagus away from the site of entry.
A more lateral approach that is gaining popularity bypasses
these structures and does not require such displacement.
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After needle placement with either technique, the rest of

the procedure is essentially the same as that described for
thoracic or lumbar discography. Inject either saline or a
nonionic contrast dye into each disc. Record any pain
response and analyze for concordance using the same
protocol employed for lumbar and thoracic discography.
Obtain roentgenograms and CT imaging of the cervical
spine upon completion of the study.
Psychological Testing
Psychological Testing
Fig. 39-25 Foraminal position for performing cervical discography with anterolateral approach. f, Foramen; v, vertebral body;
d, intervertebral disc. (Courtesy Frank JE Falco, MD)
The same protocol for lumbar and thoracic discography is

used in cervical discography.
Place the patient supine on the procedure table. Insert an
angiocatheter into the upper extremity and begin intravenous antibiotic infusion. Alternatively, intradiscal antibiotics
can be given during surgery. Sedate the patient and prepare
and drape the skin sterilely, including the anterolateral
aspect of the neck.
Under fluoroscopic imaging, identify the intervertebral
discs with aligned endplates and sharp margins of the
intervertebral discs. Approach the paralaryngeal area from
the right, using a finger to displace the esophagus and
trachea to the left and the carotid artery to the right side.
With the other hand, insert a 2- or 312-inch spinal needle
over the finger through the skin and into the outer annulus
of the disc. Advance the needle into the center of the disc,
using anteroposterior and lateral fluoroscopic guidance.
An alternative method is a more lateral approach to the
cervical spine using a single needle. This approach may
reduce the incidence of infection by passing the needle
posterior to the trachea and esophagus en route to the disc
space. Position the patient or the C-arm to place the cervical
spine in an oblique position for optimal foraminal exposure
and continue adjusting until the endplates, disc space, and
uncovertebral process are in sharp focus (Fig. 39-25). Insert
a 2- or 312-inch needle into the skin and advance it until the
tip makes contact with the subjacent uncovertebral process.
Walk off the needle just anterior to the uncovertebral
process. Advance the needle into the center of the disc, using
anteroposterior and lateral fluoroscopic guidance.
As discussed previously in this section, pain in some patients is

the result of nonanatomical causes. Many, but not all, patients
report the onset of their symptoms after a work-related incident,
which may have been relatively minor. Some patients present
acutely, and for these patients treatment as outlined for
nonspecific back pain should be followed. It is known that
patients who do not return to work in 6 months are at increased
risk for long-term disability. Patients with acute injuries or with
history of chronic pain require closer evaluation. Increasing
evidence suggests that the preeminence of psychosocial factors
over physical variables is responsible for prolonged disability.
Over the past several decades extensive studies have been
done on various evaluation tools for patients with abnormal
illness behavior. Waddell et al. defined this as maladaptive
overt illness-related behavior which is out of proportion to the
underlying physical disease and more readily attributable to
associated cognitive and affective disturbances. Waddell et al.
also developed clinical tools designed to detect the presence of
abnormal illness behavior by identifying physical signs or
symptoms and descriptions that are nonorganic in nature. Five
nonorganic signs and seven nonorganic symptom descriptions
(Table 39-4) have been identified. Waddell initially described
these for use in patients with chronic pain and suggested that
the presence of three signs was required to determine
abnormal illness behavior. Several studies evaluated the
ability of these signs and symptom descriptions to predict
return to work but have proved inconclusive; nevertheless, they
appear to be useful in detecting patients at increased risk for
poor outcome with surgical intervention.
The Minnesota Multiphasic Personality Inventory (MMPI)
has been used for psychological assessment in many previous
studies and has been demonstrated to be a reasonable predictor
of surgical and conservative treatment results regardless of the
spinal pathological condition. Unfortunately, the MMPI is
lengthy and difficult to administer in an orthopaedic clinical
setting and probably is best given by a psychiatrist or
psychologist. By comparison, the Distress and Risk Assessment
Method (DRAM) is relatively easily administered and scored
and has been validated in clinical settings with regard to
patients with back pain. The DRAM consists of the Modified
Somatic Perception Questionnaire (MSPQ) and the Zung
Depression Index (ZDI). With this simplified method, patients
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Table 39-4
Signs and Symptoms for

Diagnosis of Abnormal Illness
Behavior
Nonorganic Signs
Organic Signs
Regional disturbances
A widespread region of sensory

changes or weakness that is
divergent from accepted
neuroanatomy
Tenderness of the skin to light
touch (superficial) or deep tenderness felt over a widespread
area not localized to one structure (nonanatomical)
Superficial/nonanatomical
tenderness
Simulation
Axial loading
Rotation
Distraction
Straight leg raising
Overreaction
Low back pain reported with

pressure on the patients head
while standing
Low back pain reported when the
shoulders and pelvis are rotated
in the same plane as the patient
stands
Inconsistent limitation of straight
leg raising in supine and seated
positions
Disproportionate verbalization,
facial expression, muscle tension, collapsing, sweating, and
so forth during examination
Nonorganic Symptom Descriptors
1. Do you get pain in your tailbone?

2. Do you have numbness in your entire leg (front, side, and
back of leg at the same time?)
3. Do you have pain in your entire leg (front, side, and back
of the leg at the same time?)
4. Does your whole leg ever give way?
5. Have you had any time during this episode when you have
had very little back pain?
6. Have you had to go to the emergency room because of
back pain?
7. Has all treatment for your back made your pain worse?
From Fritz JM, Wainner RS, Hicks GE: Spine 25:1925, 2000.
identified as psychologically distressed are three to four times

more likely to have a poor outcome after any form of treatment.
It is our recommendation that some type of formal psychological evaluation be used preoperatively in patients who have
chronic pain but no clear cause of their symptoms; whether the
MMPI or the DRAM is used is less important.
The experience at this clinic has been primarily with the
MMPI, which we routinely use for assessment of patients who
have symptoms seemingly out of proportion to their anatomical
abnormalities and are being evaluated for surgical treatment,
especially spinal fusion. The MMPI is one of the most reliable
Table 39-5
Result Expectancy Related

to Hs and Hy T Scores on the
MMPI Test
Hs and Hy T
Scores
Number
of Patients
Chances of Good
or Excellent
Functional
Recovery (%)
10
32
31
36
21
63
10
16
39
72
90
48
85 and above
75 to 84
65 to 74
55 to 64
54 and below
Prediction from
base rate
From Wiltse LL, Rocchio PD: J Bone Joint Surg 57A:478, 1975.
and well-documented tests used for this purpose. This test is

predictive of preinjury susceptibility to back injury and the
potential for failure of conservative and surgical treatment.
Wiltse and Rocchio demonstrated that elevations of the hysteria
(Hs) and hypochondriasis (Hy) T scores above 75 are indicative
of a poor postoperative response (16% good results). Their
study evaluated patients treated with chymopapain, and their
clinical results are illustrated in Tables 39-5 and 39-6.
Table 39-5 indicates the rate of good or excellent results
using the MMPI test Hs and Hy scores alone in the study by
Wiltse and Rocchio. Table 39-6 illustrates the lack of statistical
significance between the MMPI scores and the presence of the
following objective findings: reflex changes, motor weakness,
sensory deficits, positive myelogram, positive electromyogram,
and elevated CSF protein.
Similar studies of surgically and conservatively treated
patients have had similar findings. Written reports are helpful,
but the raw T score read on the far right or left side of the
standard test result sheet is the simplest guide to postoperative
outcome. If surgery is necessary in a patient with an elevated
Hs or Hy score, then psychiatric or psychological assistance
before and after the procedure can be helpful, but a poor result
should be anticipated. Gentry observed a group of patients with
objective evidence of psychological disturbance as indicated by
the MMPI. Those patients who had surgery were less likely to
return to work, less likely to have a reduction in their pain, and
more likely to have greater disability than similar patients
who did not have surgery. Wiltse and Rocchio recommended
restraint and conservative treatment in these patients. Elevation
of the Hs and Hy scores on the MMPI should be a relative
contraindication to elective spinal surgery.
Additional material on this test can be found in the excellent
articles by Dennis et al., Wiltse and Rocchio, and Southwick
and White. Numerous other tests are available, but none has
been shown to be as predictive of surgical outcome as the Hs
and Hy scores on the MMPI. Riley et al. investigated a MMPI-2
and found that the results replicated those of the older MMPI.
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Table 39-6
Hs and Hy T Scores of Patients with Good or Excellent Results Versus Number

of Preexisting Objective Deficits
Hs and Hy T scores
75 and over
64 and below
Percentage with the No. of Preinjection Objective

Deficits Indicated*
Number of Patients
Percentage Good
or Excellent Results
42
57
25
87
95.0
95.2
57.5
64.4
30.0
32.6
7.5
8.7
2.5
2.2
From Wiltse LL, Rocchio PD: J Bone Joint Surg 57A:478, 1975.
*X2 <0.001.
Patients with MMPI and MMPI-2 findings of depressedpathological profile and a conversion V profile reported greater
dissatisfaction with surgical outcome.
Similar outcomes have been noted for nonoperative
treatment of these patients. Gatchel et al. noted similar
problems in patients with acute back pain who were questioned
6 months later.
The main problem with the MMPI is that it requires the
ability to read and comprehend the material. Pincus et al. also
noted that the MMPI questions may be in line with natural
disease processes such as rheumatoid arthritis. Patients with
chronic diseases may, by the nature of their disease symptoms,
have MMPI elevations. Chronic back pain without a specific
disease association should not be considered as similar to
chronic disease such as rheumatoid arthritis. Chapman and
Pemberton noted that the MMPI failed to predict the subjective
outcome as reported by patients with chronic back pain who
were in an interdisciplinary pain-management program.
A simple test that is a good screening aid is the pain
drawing. The pain drawing correlates well with the Hs and Hy
scores. This test also requires some ability to follow simple
directions (Fig. 39-26). Additional information can be found in
the articles by Rainsford, Cairns, and Mooney and by Dennis
et al. Ude n and Landin found that the pain drawing correlated
well with clinical results. Ohnmeiss reported that the pain
drawing remained consistent over 8 months in patients who
reported no change in their symptoms. Also, the intraevaluator
repeatability was found to be high in this as in other studies.
Patients with low Rainsford scores were most likely to have
definite pathological conditions and those with high Rainsford
scores were least likely to have a demonstrable pathological
condition. Cummings and Routan warned that the pain drawing
should not be used to identify areas of somatic disturbance in
chronic pain patients.
Cervical Disc Disease

Cervical Disc Disease
Herniation of the cervical intervertebral disc with spinal cord
compression has been identified since Key detailed the
pathological findings of two cases of cord compression by
intervertebral substance in 1838. During the late 1800s and
early 1900s there were many reports of chondromas of the
cervical spine. Stookey described the clinical findings and
anatomical location of cervical disc herniation in 1928 but

attributed the lesion to a cervical chondroma. Mixter and Barr
reported lumbar disc herniation in 1934 and included four
cervical disc protrusions.
The classic approach to discs in this region has been
posteriorly with laminectomy. This approach had been used as
a standard exposure for extradural tumors. In 1943 Semmes and
Murphey reported four patients in whom cervical disc rupture
simulated coronary disease and introduced the concept that
cervical disc disease usually manifested itself in root symptoms
and not cord compression symptoms. Bailey and Badgley,
Cloward, and Smith and Robinson in the 1950s popularized the
anterior approach coupled with interbody fusion. Robertson in
1973, after the initial report by Hirsch in 1960, reported anterior
cervical discectomy without fusion. He showed that simple
anterior disc excision without fusion can give results similar to
anterior cervical disc excision with anterior interbody fusion.
More recently, Yamamoto et al. reported the long-term (2 to 13
year) results of anterior cervical disc excision without fusion.
They noted 81% improvement in patients with soft disc hernias
but only 47% improvement in patients with spondylosis; 49%
had neck and scapular pain as new postoperative symptoms for
the first 4 weeks after surgery (Table 39-7). Spontaneous fusion
was noted in 79% at 29 months. Currently, anterior cervical
discectomy with fusion is the procedure of choice when the disc
is removed anteriorly to avoid disc space collapse, prevent
painful and abnormal cervical motion, and to speed intervertebral fusion. Foraminotomy is the procedure of choice when
the disc fragment is removed posteriorly.
In an epidemiological study of acute cervical disc prolapse,
Kelsey et al. indicated that cervical disc rupture was more
common in men by a ratio of 1.4 to 1. Factors associated with
the injury were frequent heavy lifting on the job, cigarette
smoking, and frequent diving from a board. The use of
vibrating equipment and time spent in motor vehicles were not
positively associated with this problem. Participation in sports
other than diving, frequent wearing of shoes with high heels,
frequent twisting of the neck on the job, time spent sitting on
the job, and smoking of cigars and pipes were not associated
with cervical intervertebral disc collapse. Horal reported that
40% of the population in Sweden were sometimes affected by
neck pain during their lives. Patients with cervical disc disease
are also likely to have lumbar disc disease. MRI studies have
shown increasing cervical disc degeneration with age.
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Fig. 39-26 A, Pain drawing and corresponding MMPI raw score sheet of patient
with conversion V who was unrelieved
of pain after disc surgery. B, Pain drawing
and corresponding MMPI raw score sheet
of patient with normal findings who was
relieved of pain after disc surgery.
Table 39-7
Postoperative Neck
or Scapular Pain
Follow-up
Period
Soft
Disc
Percentage
Spondylosis
Percentage
1
1
2
4
4/11
1/11
0/10
0/5
36
9
0
0
8/34
10/29
6/24
4/21
53
34
25
19
month
year
years
years
From Yamamoto I, Ikeda A, Shibuya N, et al: Spine 16:272, 1991.
The pathophysiology of cervical disc disease is the same as

degenerative disc disease in other areas of the spine. Disc
swelling is followed by progressive annular degeneration.
Frank extrusion of nuclear material can occur as a complication
of this normal degenerative process. Kramer postulated that
hydraulic pressure on the disc rather than excessive motion
produces traumatic disc herniation. As the disc degeneration
proceeds, hypermobility of the segment can result in instability

or degenerative arthritic changes or both. Unlike in the lumbar
spine, these hypertrophic changes are predominantly at the
uncovertebral joint (uncinate process) (Fig. 39-27). Hypertrophic changes eventually develop about the facet joints and
vertebral bodies. As in lumbar disease, progressive stiffening of
the cervical spine and loss of motion are the usual result in
the end stages. Hypertrophic spurring anteriorly occasionally
results in dysphagia. Kang et al. identified the production of
increased amounts of matrix metalloproteinases, nitric oxide,
prostaglandin E2, and interleukin-6 in disc material removed
from cervical disc hernias. They suggested that these products
are involved in the biochemistry of disc degeneration. These
substances also are implicated in pain production. These
findings are similar to those in the lumbar spine. Kauppila and
Penttila reported the presence of degenerative changes in the
common arteries that supply the cervicobrachial area, and they
suggested that impaired blood flow may play a part in
cervicobrachial disorders.
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C2-3
C3-4
C4-5
C5-6
C6-7
Fig. 39-28 Composite map of the results in all volunteers

depicting characteristic distribution of pain from facet joints at
segments C2-3 to C6-7. (Redrawn from Dwyer A, Aprill C,
Bogduk N: Spine 15:456, 1990.)
Fig. 39-27 A, Comparison of points at which nerve roots emerge

from cervical and lumbar spine. B, Cross-sectional view of cervical
spine at level of disc (D). Uncinate process (U) forms ventral wall
of foramen. Root (N) exits dorsal to vertebral artery (A). (A from
Kikuchi S, Macnab I, Moreau P: J Bone Joint Surg 63B:272,
1981.)
SIGNS
SIGNS AND
AND SYMPTOMS
SYMPTOMS
The signs and symptoms of intervertebral disc disease are best
separated into symptoms related to the spine itself, symptoms
related to nerve root compression, and symptoms of myelopathy. Several authors reported that, when the disc is punctured
anteriorly for the purpose of discography, pain is noted in the
neck and shoulder. Complaints of neck pain, medial scapular
pain, and shoulder pain are therefore probably related to
primary pain about the disc and spine. Anatomical studies have
indicated cervical disc and ligamentous innervations. This has
been inferred to be similar in the cervical spine to that of the
lumbar spine with its sinu-vertebral nerve. Tamura noted
cranial symptoms such as headache, vertigo, tinnitus, and
ocular problems associated with C3-4 root sleeve defects on
myelography. Dwyer, Aprill, and Bogduk completed a twostage investigation of the facet joints of the cervical spine as
possible sources of pain. By injecting contrast medium into
the facet joints of normal volunteers under roentgenographic
control to the point of pain production, a topographical map

was produced. Although the number of volunteers was small,
the findings were consistent (Fig. 39-28). The second stage of
the study included a small number of patients who had
therapeutic injections based on the location of their pain, as it
related to the previously constructed pain map. Pain relief
occurred immediately and completely in 9 of 10 patients who
had had prior evaluation and failed other treatments. These pain
patterns are not predicted by accepted dermatomal maps.
Symptoms of root compression usually are associated with
pain radiating into the arm or chest with numbness in the
fingers and motor weakness. Cervical disc disease also can
mimic cardiac disease with chest and arm pain. Usually the
radicular symptoms are intermittent and combined with the
more frequent neck and shoulder pain.
The signs of midline cervical spinal cord compression
(myelopathy) are unique and varied. The pain is poorly
localized and aching in nature; pain may be only a minor
complaint. Occasional sharp pain or generalized tingling may
be described with neck extension. This is not unlike the
Lhermitte sign in multiple sclerosis. The pain can be in both the
shoulder and pelvic girdles; it is occasionally associated with a
generalized feeling of weakness in the lower extremities and a
feeling of instability.
In patients with predominant cervical spondylosis, symptoms of vertebral artery compression also may be found. These
symptoms consist of dizziness, tinnitus, intermittent blurring of
vision, and occasional episodes of retroocular pain.
The signs of lateral root pressure from a disc or osteophytes
are predominantly neurological (Boxes 39-2 to 39-6). By
evaluating multiple motor groups, multiple levels of deep
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BOX 39-2 C5 Nerve Root Compression*
Sensory Deficit
Upper lateral arm and elbow
Sensory Deficit
Ring finger, little finger, and ulnar border of palm
Motor Weakness
Deltoid
Biceps (variable)
Motor Weakness
Interossei
Finger flexors (variable)
Flexor carpi ulnaris (variable)
Reflex Change
Biceps (variable)
1985
Reflex Change
None
*Indicative of C4-5 disc rupture or other pathological condition at that

level.
*Indicative of C7-T1 disc rupture or other pathological condition at that

level.
BOX 39-6 T1 Nerve Root Compression*
Sensory Deficit
Lateral forearm, thumb, and index finger
Sensory Deficit
Medial aspect of elbow
Motor Weakness
Biceps
Extensor carpi radialis longus and brevis
Motor Weakness
Interossei
Reflex Change
None
Reflex Change
Biceps
Brachioradialis
*Indicative of T1-2 disc rupture or other pathological condition at that

level.
*Indicative of C5-6 disc herniation or other local pathological condition

at that level.

Sensory Deficit
Middle finger (variable because of overlap)
Motor Weakness
Triceps
Wrist flexors (flexor carpi radialis)
Finger flexors (variable)
Reflex Change
Triceps
*Indicative of C6-7 disc rupture or other pathological condition at that
level.
tendon reflexes, and sensory abnormalities, the level of the

lesion can be localized as accurately as any other lesion in the
nervous system. The multiple innervation of muscles can
sometimes lead to confusion in determining the exact root
involved. For this reason, myelography or other studies done
for roentgenographic confirmation of the clinical impression
usually are helpful.
Rupture of the C4-5 disc with compression of the C5 nerve
root should result in weakness in the deltoid and biceps
muscles. The deltoid is almost entirely innervated by C5, but
the biceps has dual innervation. The biceps reflex may be
diminished with injury to this nerve root, although it also has a

C6 component, and this must be considered. Sensory testing
should show a patch on the lateral aspect of the proximal arm
to be diminished (Fig. 39-29).
Rupture of the C5-6 disc with compression of the C6 root
can be confused with other root levels because of dual
innervation of structures. Weakness may be noted in the biceps
and extensor carpi radialis longus and brevis. As mentioned
above, the biceps is dually innervated by C5 and C6, whereas
the long extensors are dually innervated by C6 and C7. The
brachioradialis and biceps reflexes also may be diminished at
this level. Sensory testing usually indicates a decreased
sensibility over the lateral proximal forearm, thumb, and index
finger.
Rupture of the C6-7 disc with compression of the C7 root
frequently results in weakness of the triceps. Weakness of the
wrist flexors, especially the flexor carpi radialis, also is more
indicative of C7 root problems. Extensor digitorum communis
weakness also can indicate C7 root involvement and may be
more readily apparent because of the normal relative weakness
of this muscle compared to the triceps. Weakness of the flexor
carpi ulnaris usually is caused more by C8 lesions. As
mentioned above, finger extensors also may be weakened in
that they have both C7 and C8 innervation. The triceps reflex
may be diminished. Sensation is lost in the middle finger. C7
sensibility is variable because it is so narrow and overlap is
prominent. Strong sensibility change can be difficult to
document.
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1986
Fig. 39-29 C5 neurological

level. (After Hoppenfeld S:
Physical examination of the
spine and extremities, Norwalk,
Conn, 1976, AppletonCentury-Crofts.)
Rupture between C7 and T1 with compression of the C8

nerve root results in no reflex changes. Weakness may be noted
in the finger flexors and in the interossei of the hand. Sensibility
is lost on the ulnar border of the palm, including the ring and
little fingers. Compression of T1 produces weakness of the
interosseus muscles, decreased sensibility about the medial
aspect of the elbow, and no reflex changes.
The clinical series of Odom, Finney, and Woodhall noted
considerable variability in the level of compression and the
neurological findings. Change in the triceps reflex was the
predominant reflex change with compression of the sixth
cervical root (56%). It also was the predominant reflex change
in seventh root compression (64%). Similarly the index finger
was the predominant digit with sensory change, with evidence
of hypalgesia in both sixth (68%) and seventh (70%) cervical
root compression.
Care should be taken in the examination of the extremity
when radicular problems are encountered to rule out more
distal compression syndromes in the upper extremities such as
thoracic outlet syndrome, carpal tunnel syndrome, and cubital
tunnel syndrome. The lower extremities should be examined
with special attention to long tract signs indicative of
myelopathy.
No tests for the upper extremity correspond with straight
leg raising tests in the lower extremity. Davidson, Dunn, and
Metzmaker described the shoulder abduction relief sign. This

can be helpful in the diagnosis of cervical root compression
syndromes. The test consists of shoulder abduction and elbow
flexion with placement of the hand on the top of the head. This
should relieve the arm pain caused by radicular compression. It
is interesting to note that if this position is allowed to persist for
a minute or two and pain is increased, then more distal
compressive neuropathies such as a tardy ulnar nerve syndrome
(cubital tunnel syndrome) or primary shoulder pathological
conditions often are the cause. Viikari-Juntura, Porras, and
Laasonen noted that the shoulder abduction, axial compression,
and manual axial traction tests are related to disc disease, but
the sensitivity of these tests is low.
Cervical paraspinal spasm and limitation of neck motion are
frequent findings of cervical spine disease but are not indicative
of a specific pathological process. Special maneuvers involving
neck motion can be helpful in the selection of conservative
treatment and identification of pathological processes. The
distraction test, which involves the examiner placing his hands
on the occiput and jaw and distracting the cervical spine in the
neutral position, can relieve root compression pain but also can
increase pain caused by ligamentous injury. Neck extension and
flexion with or without traction can be helpful in selecting
conservative therapies.
Patients relieved of pain with the neck extended, with or
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without traction, usually have hyperextension syndromes with

ligamentous injury posteriorly, whereas patients relieved of
pain with distraction and neck flexion are more likely to have
nerve root compression caused by either a soft ruptured disc or
most likely hypertrophic spurs in the neural foramina. Pain
usually is increased in any condition with compression. One
must be careful before applying compression or distraction to
be sure no cervical instability or fracture is present. One must
also be careful in interpreting the distraction test to be certain
the temporomandibular joint is not diseased or injured because
distraction also will increase the pain in this area.
The signs of midline disc herniation are those of spinal cord
compression. If the lesion is high in the cervical region,
paresthesias, weakness, atrophy, and occasionally fasciculations may occur in the hands. Also present may be a Hoffmans
sign (upper cervical spinal cord) or the inverted radial reflex
(typically indicating C5-6 pathology). Most commonly, however, the first and most prominent symptoms are those of
involvement of the corticospinal tract; less commonly the
posterior columns are affected. The primary signs are sustained
clonus, hyperactive reflexes, and the Babinski reflex. Lesser
findings are varying degrees of spasticity, weakness in the legs,
and impairment of proprioception. Equilibrium may be grossly
disturbed, but sense of pain and temperature sense rarely are
lost and usually are of little localizing value.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of cervical disc disease is best
separated into extrinsic and intrinsic factors. Extrinsic factors
generally include disease processes extrinsic to the neck
resulting in symptoms similar to primary neck problems.
Included in this group are tumors of the chest, nerve
compression syndromes distal to the neck, degenerative
processes such as shoulder and upper extremity arthritis,
temporomandibular joint syndrome, and lesions about the
shoulder such as acute and chronic rotator cuff tears and
impingement syndromes. Intrinsic problems primarily consist
of lesions directly associated with the cervical spine, the most
common being cervical disc degeneration with a concomitant
complication of disc herniation and later development of
hypertrophic arthritis. Congenital factors such as spinal
stenosis in the cervical region also may produce symptoms.
Primary and secondary tumors of the cervical spine and
fractures of the cervical vertebrae also should be considered as
intrinsic lesions.
Cervical disc disease has been categorized by Odom et al.
into four groups: (1) unilateral soft disc protrusion with nerve
root compression, (2) foraminal spur, or hard disc, with nerve
root compression, (3) medial soft disc protrusion with spinal
cord compression, and (4) transverse ridge or cervical
spondylosis with spinal cord compression. Soft disc herniations
usually affect one level, whereas hard disc herniations can
affect multiple levels. Central lesions usually result in cord
compression symptoms, and lateral lesions usually result in
radicular symptoms.
1987
Odom et al. reported that most of the soft disc herniations in

their series occurred at the sixth cervical interspace (70%) and
fifth cervical interspace (24%). Only six occurred at the seventh
interspace. Foraminal spurs also were found predominantly at
the sixth interspace (48%). The fifth interspace (39%) and
seventh interspace (13%) accounted for the remaining levels
where foraminal spurs were found. They also noted the
incidence of medial soft disc protrusion with myelopathy to be
rare (14 of 246 patients).
Disc material sometimes is extruded into the midline of the
spinal canal anteriorly, with compression of the spinal cord and
without nerve root involvement. Occasionally this is caused
by a violent injury to the cervical spine, with or without
fracture-dislocation, and at times it is associated with immediate quadriplegia. However, in some instances the symptoms
are progressive and may be suggestive of spinal cord tumor or
degenerative diseases of the spinal cord, such as amyotrophic
lateral sclerosis, posterolateral sclerosis, and multiple sclerosis.
In most of these ailments no block of the spinal canal has been
reported, and for many years the mechanism causing the
cervical cord compression was not understood. However, in the
rare patients whom we have observed, spinal fluid block could
be produced by hyperextending the neck, although with the
neck in the neutral or flexed position the canal was completely
open. This finding has been previously reported. It has since
been observed that during operation on such patients when the
neck is hyperextended, the superior edge of the lamina
compresses the cord against the herniated disc, and it is
therefore probable that repeated hyperextension of the neck
over a period of weeks, months, or years gradually damages the
spinal cord.
In view of the disturbances of the spinal fluid dynamics just
mentioned, jugular compression should be carried out during
lumbar puncture with the neck in the flexed, neutral, and
hyperextended positions. Roentgenographically there is more
often than not little or no alteration in the cervical curve. MRI
usually demonstrates the abnormality without the need for
myelography.
CONFIRMATORY TESTING
Roentgenographic evaluation of the cervical spine frequently
shows loss of normal cervical lordosis. Disc space narrowing
and hypertrophic changes frequent increase with age but are not
indicative of cervical disc rupture. Usually roentgenograms
are most helpful to rule out other problems. Oblique roentgenograms of the cervical spine may reveal foraminal
encroachment.
MRI of the cervical spine has rapidly become the major
diagnostic procedure for neck, arm, and shoulder symptoms.
Maruyama evaluated the cervical discs in 36 cadavers using
MRI and anatomical dissection and concluded that degeneration appeared to parallel T2 low intensity, but the incidence of
false-positive posterior protrusion on MRI was remarkably
high. MRI should confirm the objective clinical findings.
Asymptomatic findings should be expected to increase with the
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age of the patient. Cervical myelography usually is indicated

only after noninvasive evaluation by MRI fails to reveal the
cause or level of the lesion. If MRI is inconclusive,
electromyography or nerve conduction velocity may be
indicated to demonstrate active radiculopathy before proceeding with myelography, especially if the history and physical
examination are not strongly supportive of the presence of
radiculopathy. Cervical myelography usually is more precise
than lumbar myelography, regardless of the contrast medium
used. Postmyelogram CT scanning with block imaging and thin
cuts is very helpful.
Cervical discography is a highly controversial technique
with limited benefits. It is not indicated in frank disc rupture,
spondylosis, or spinal stenosis. The primary use is in patients
with persistent neck pain without localized neurological
findings in whom standard MRI, myelographic, and CT scan
studies are negative. Some investigators maintain that isolated
painful discs can be identified in some patients by discography.
Certainly a degenerative disc without pain on injection is not
the source of the patients complaint. Cervical discography
requires considerable care and caution. It should be considered
a preoperative test in those patients in whom an anterior disc
excision and interbody fusion are considered for primary neck
and shoulder pain. Assessing the psychosocial well-being of a
patient is recommended before proceeding with surgical
treatment. Great care is required both in the technique and
interpretation if reproducible results are desired. Cervical root
blocks also have been suggested for the localization and
confirmation of symptomatic root compression when used in
conjunction with cervical discography. Facet joint injections
also should be considered before fusion as a therapeutic as well
as diagnostic procedure.
Myelography
When a component of dynamic cord compression is present,
myelography remains a valuable tool, although dynamic MRI
has reduced the role of myelography. Myelography is
performed in the same way as for ruptured lumbar discs except
that considerable attention must be paid to the flow of the
column of contrast medium with the neck in hyperextended,
neutral, and flexed positions. One cannot conclude that spinal
cord compression is not present until one is certain that the
cephalad flow of the medium is not obstructed with the neck
acutely hyperextended. The neck should be hyperextended
carefully because of the danger of further damage to the
spinal cord.
NONOPERATIVE TREATMENT
As discussed earlier, most patients with symptomatic cervical
disc herniations respond well to nonoperative treatment,
including some patients with nonprogressive radicular weakness. Reasonably good evidence shows that acute disc
herniations actually decrease in size over time in the cervical
region. Many conservative treatment methods for neck pain are
used for multiple diagnoses. The primary purpose of the
cervical spine and associated musculature is to support and

mobilize the head while providing a conduit for the nervous
system. The forces on the cervical spine are therefore much
smaller than on the lower spinal levels. The cervical spine is
vulnerable to muscular tension forces, postural fatigue, and
excessive motion. Most nonoperative treatments focus on one
or more of these factors. The best primary treatment is short
periods of rest, massage, ice, and antiinflammatory agents with
active mobilization as soon as possible. The position of the
neck for comfort is essential for relief of pain. The position of
greatest relief may suggest the offending pathological process
or mechanism of injury. Patients with hyperflexion injuries
usually are more comfortable with the neck in extension over
a small roll under the neck. No specific position is indicative of
lateral disc herniation, although most tolerate the neutral
position best. Patients with spondylosis (hard disc) are most
comfortable with the neck in flexion.
Cervical traction can be helpful in selected patients. Care
must be exercised in instructing the patient in the proper use of
the traction. It should be applied to the head in the position of
maximal pain relief. Traction never should be continued if it
increases pain. The weights should rarely exceed 10 pounds
(weight of the head). The proper head halter and duration of
traction sessions should be chosen to prevent irritation of the
temporomandibular joint. Traction applied by a patientcontrolled pneumatic force, which is more mobile than
halter-type units, avoids irritation of temporomandibular joint.
Traction also should allow general relaxation of the patient.
Poor mans traction is a simple method of evaluating the
efficacy of cervical traction. It uses the weight of the
unsupported head for the traction weight (about 10 pounds).
For extension traction, the patient is supine and the head is
allowed to gently extend off the examining table or bed. For
flexion the same procedure is repeated in the prone position.
The patient continues the exercise in the position that is most
comfortable for 5 to 10 minutes several times daily.
The postural aspects of neck pain can be treated with more
frequent changes in position and ergonomic changes in the
work area to prevent fatigue and encourage good posture.
Techniques to minimize or relieve tension also are helpful.
Cervical braces usually limit excessive motion. Like traction, they should be tailored to the most comfortable neck
position. They may be most helpful for patients who are very
active.
Neck and shoulder exercises are most beneficial as the acute
pain subsides. Isometric exercises are helpful in the acute
phase. Occasionally, shoulder problems such as adhesive
capsulitis may be found concomitantly with cervical spondylosis; therefore complete immobilization of the painful
extremity should be avoided.
OPERATIVE TREATMENT
OPERATIVE TREATMENT
The primary indications for operative treatment of cervical disc
disease are (1) failure of nonoperative pain management,
(2) increasing neurological deficit, and (3) cervical myelopathy
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that will predictably progress, based on natural history studies.

In most patients the persistence of pain is the primary
indication. Intuitively, the level of persistent pain should be
severe enough to consistently interfere with the patients
desired activity and greater than would reasonably be expected
after operative treatment. The choice of approach should be
determined by the position and type of lesion. Soft lateral discs
are easily removed from the posterior approach, whereas soft
central or hard discs (central or lateral) probably are best treated
with an anterior approach. Any controversy that existed relative
to the need for fusion with anterior discectomy essentially has
been resolved with long-term follow-up studies of patients
without fusion, such as that by Yamamoto et al. mentioned
previously. Osteophytes that were not removed at surgery have
been shown frequently to be reabsorbed at the level of fusion.
The use of a graft also prevents the collapse of the disc space
and maintains adequate foraminal size.
Removal of Posterolateral Herniations
by Posterior Approach (Posterior Cervical

Foraminotomy)
TECHNIQUE 39-15
With the patient under general endotracheal anesthesia in
the prone position and the face in a Mayfield positioner, flex
the neck to obliterate the cervical lordosis as much as
possible. The upright position for surgery decreases venous
bleeding, but concern regarding the possibility of air
embolism and cerebral hypoxia in the event of a significant
drop in blood pressure makes us reluctant to recommend its
use. Usually a slight reverse Trendelenburg position works
well in posterior cervical surgery coupled with careful
dissection to minimize bleeding. The shoulders are retracted
inferiorly with tape if roentgenograms of the lower cervical
levels are contemplated.
Appropriately prepare and drape the operative field.
Make a midline incision 2.5 cm lower than the interspace to
be explored (Fig. 39-30). Retract the edges of this incision
and the skin will withdraw in a cephalad direction so that the
wound becomes properly placed. Divide the ligamentum
nuchae longitudinally to expose the tips of the spinous
processes above and below the designated area. The correct
position is reasonably well ensured by palpation of the last
bifid spine, which usually is the sixth cervical vertebra.
However, it should be verified intraoperatively by a marker
attached to the spinous process and documented on the
lateral cervical spine roentgenogram. Dissect subperiosteally the paravertebral muscles from the laminae on the
side of the lesion and retract them with a self-retaining
retractor or with the help of an assistant using a Hibbs
retractor.
With a small high-speed drill, grind away the caudal edge
of the lateral portion of the lamina cephalad to the
interspace. Usually minimal bone removal from the
1989
cephalad edge of the lateral portion of the caudal lamina is

needed. Only a small amount of the medial portion of the
facet needs to be removed in most patients. A small Kerrison
rongeur (1 to 2 mm) can be used to enlarge this keyhole as
needed. Sharply excise the ligamentum flavum with a small
Kerrison rongeur and identify the nerve root, which is
commonly displaced posteriorly and flattened by pressure
from the underlying disc fragments. Removal of additional
bone along the dorsal aspect of the foramen and immediately above and below the nerve root often is beneficial at
this point. Once the bony removal has been completed, we
prefer to use the operative microscope for the remainder of
the procedure. This allows more delicate work around the
neural elements while minimizing additional bone removal
and allows better hemostasis.
The herniated nucleus pulposus most often lies slightly
caudal to the center of the nerve root but occasionally
cephalad. Gently retract the nerve root superiorly to expose
the extruded nuclear fragments or a distended posterior
longitudinal ligament. The nerve root should not be
retracted in a caudal direction. If additional exposure is
needed, remove more bone rather than risk nerve root or
spinal cord injury from traction on the root. To control
troublesome venous oozing at this point use bipolar cautery
if possible. Otherwise, place tiny pledgets of cotton and
thrombin-soaked Gelfoam above and below the nerve root.
Take care not to pack the pledgets tightly around the nerve.
The nerve root then can be retracted slightly in a cephalad
direction to allow incision of the posterior longitudinal
ligament over the herniated nucleus pulposus in a cruciate
manner to permit the removal of the disc fragments.
After removal of all visible loose fragments, it is
imperative to make a thorough search for additional
fragments, both laterally and medially. It is equally
important to be sure that the nerve root is thoroughly
decompressed by inserting a probe in the intervertebral
foramen. If the nerve root still seems to be tight, remove
more bone from the articular facets until the nerve root is
completely free. Since recurrence is so rare, do not curet
the intervertebral space. Remove any cotton pledgets and
Gelfoam after meticulous hemostasis has been achieved.
Hemostasis must be complete because postoperative hemorrhage can produce cord compression and quadriplegia.
Close the wound by suturing the fascia to the supraspinous
ligament with interrupted sutures and then suturing the
subcutaneous layers and skin.
AFTERTREATMENT. Neurological function is closely monitored after surgery. Discharge is permitted when the patient can
walk and void. Pain should be controlled with oral medication.
Currently most patients are discharged within 24 hours after
surgery. Radicular pain relief usually is dramatic and prompt,
although hypesthesia can persist for weeks or months. The
patient is allowed to return to clerical work when comfortable
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A
B
Fig. 39-30 Technique of removal of disc between fifth and sixth cervical vertebrae. A, Midline
incision extending from spinous process of fourth cervical vertebra to that of first thoracic vertebra.
B, Paraspinal muscles have been dissected from laminae and retracted laterally. Hole is to be drilled
with Hudson burr (see text). C, Ligamentum flavum is being dissected. D, Defect measuring about
1.3 cm has been made (see text) to expose nerve root and lateral aspect of dura. E, Nerve root has
been separated from nucleus and retracted superiorly to expose herniated disc. F, Longitudinal
ligament has been incised, and loose fragment of nucleus is being removed.
and to manual labor after 6 weeks. As a rule, neither support nor

physical therapy is necessary, and the patients future activity is
not restricted. Isometric neck exercises, upper extremity rangeof-motion exercises, and posterior shoulder girdle exercises can
be useful for patients in whom atrophy or inactivity has been
considerable. A soft cervical collar can help relieve immediate
postoperative pain.
Results. In few if any operations in orthopaedic surgery are

the results better than after the removal of a lateral herniated
cervical disc. In the series of 250 operations reported by
Simmons there were no deaths or major complications
involving the brain or spinal cord. Three patients had reflex
sympathetic dystrophy postoperatively. Two of these completely recovered and one almost so. Two patients continued to
have arm pain after operation and were reexplored during the
initial hospital stay; in each, several more fragments of disc
were found and removed. It is assumed that these fragments
were overlooked at the initial operation. One patient had a
recurrent extrusion at the same level. Two other patients had
soft extrusions on the opposite side at another level, also

requiring a second operation.
Murphey, Simmons, and Brunson analyzed the results in a
series of 150 patients who returned questionnaires concerning
the success or failure of the operation. They were asked to state
the percentage of benefit they derived from the procedure
(Table 39-8), whether they were performing the same work as
they had done preoperatively, and if not, whether the change of
work had resulted from neck trouble. Approximately 90% had
extremely good results, and there were none who were not
significantly improved, as the data concerning work done
confirm. Only 7 (6%) of the 125 patients who answered this
part of the questionnaire found a change of work necessary
because of neck trouble.
Anterior Approach to Cervical Disc

Smith and Robinson in 1955 were the first to recommend
an anterior approach to the cervical spine in the treatment
of cervical disc disease. They described an anterolateral
discectomy with interbody fusion (Fig. 39-31). This pro-
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Table 39-8
Relief (%)
95-100
90-94
75-89
50-74
Total
Results of Removal of Lateral

Herniated Discs in Cervical
Region (Patients Estimate
of Percent Improvement)
Patients
Improved (%)
Number
of Patients
65.3
23.3
8.0
3.3
100.0
98
35
12
5
150
1991
Type I (50.9) KP/cm2
A
Anteroposterior
Lateral
Type II (41.6) KP/cm2
Murphey F, Simmons JCH, Brunson B: J Neurosurg 38:679, 1973.
Anteroposterior
cedure attained widespread acceptance and application after

Cloward in 1958 modified the procedure and introduced new
instrumentation.
Three basic techniques are used for anterior cervical disc
excision and fusion. The Cloward technique involves making a
round hole centered at the disc space. A slightly larger, round
iliac crest plug is then inserted into the disc space hole. The
Smith-Robinson technique involves inserting a tricortical plug
of iliac crest into the disc space after removing the disc and
cartilaginous endplate. The graft is inserted with the cancellous
side facing the cord (posterior). Bloom and Raney modified this
technique by fashioning the tricortical graft to be thicker in its
midportion and then inserting the graft with the cancellous
portion facing anteriorly. The Bailey-Badgley technique involves the creation of a slot in the superior and inferior
vertebral bodies. This technique is most applicable to reconstruction when one or more vertebral bodies are excised for
tumor, stenosis, or other extensive pathological conditions.
Simmons and Bhalla modified this technique by using a
keystone graft that increases the surface area of the graft by
30% and allows more complete locking of the graft. Biomechanically, the Smith-Robinson technique provides the
greatest stability and least risk of extrusion, compared to the
Cloward or Bailey-Badgley type fusions.
White et al. reported relief of pain in 90% of 65 patients
undergoing anterior cervical spine fusion for spondylosis with
the technique of Smith and Robinson. Analysis of 90 patients
with anterior cervical discectomies and fusion for cervical
spondylosis with radiculopathy using the Cloward technique
showed good or excellent results in 82% in the study by Jacobs,
Krueger, and Levy. These investigators did not use discography. Others also have found that discography does not
statistically improve the results. The Smith-Robinson technique
is used almost exclusively at this clinic for anterior cervical
discectomy procedures.
The choice of right- or left-sided approach to the cervical
spine is somewhat controversial. The right side of the neck is
preferred by some right-handed surgeons because of the ease of
dissection. The reported increased risk of recurrent laryngeal
nerve trauma when operating on the right is not judged by those
Lateral
Type III (35.2) KP/cm2
C
Anteroposterior
Lateral
Fig. 39-31 Types of anterior cervical fusion. A, Smith-Robinson

fusion. B, Cloward fusion. C, Bailey-Badgley fusion. D, BloomRaney modification of Smith-Robinson fusion. (A to C redrawn
from White AA, Jupiter J, Southwick WO, Panjabi MM: Clin
Orthop 91:21, 1973; D redrawn from Bloom MH, Raney FL:
J Bone Joint Surg 63A:602, 1981.)
who use it to be a significant deterrent to choosing this

exposure. Exposure from the left is more inconvenient for a
right-handed surgeon but decreases the risk of recurrent
laryngeal nerve injury. This nerve on the left consistently
descends with the carotid sheath and exits from the carotid
sheath and vagus nerve intrathoracically. The nerve then
courses under the arch of the aorta and ascends in the neck
beside the trachea and esophagus. The course of the nerve on
the right is not as consistent. The nerve usually descends with
the carotid sheath and then loops around the subclavian artery
and ascends between the trachea and esophagus. Occasionally
the right recurrent laryngeal nerve exits the carotid sheath early
and crosses anteriorly behind the thyroid. A large series of
anterior cervical procedures implicated the endotracheal tube
in combination with self-retaining retractors as the cause of
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recurrent laryngeal nerve injuries. The recommendation made

was to deflate the cuff of the endotracheal tube after retractor
placement to allow the tip of the tube to reposition itself. This
significantly decreased the incidence of recurrent laryngeal
nerve palsy in a series of 600 patients. See Chapter 36 for a
complete description of anterior cervical discectomy and
fusion.
Anterior Foraminotomy. Recently there have been several
reports of microsurgical anterior foraminotomy to treat
unilateral foraminal nerve compression from soft disc herniations or uncovertebral joint degenerative change. Verbiest first
described this technique; Jho reported a modification, and
Johnson reported a small clinical series. This technique appears
to allow adequate decompression of the ventral aspect of the
foramen unilaterally while removing the lateral portion of the
disc, thus preserving the remaining disc. The long-term results
are not yet available to compare this technique with anterior
discectomy with fusion. We do not have any clinical experience
with this technique.
Microsurgical Anterior Cervical Foraminotomy

TECHNIQUE 39-16 (Jho)
After anesthesia has been administered by means of
endotracheal intubation, place the patient supine, with a
bolster placed behind both shoulders to maintain gentle
extension of the cervical spine. Position the head with the
midline upright. Gently pull both shoulders caudally and fix
with tape for a good lateral view of the cervical spine on
intraoperative roentgenogram. Do not use a cervical traction
device. Prepare the anterior neck with antiseptic solution
and drape.
Make a 3- to 5-cm long transverse incision in a skin
crease ipsilateral to the radiculopathy. The first two thirds
of the incision should be medial to the sternocleidomastoid muscle and the remainder should be lateral to the
medial border of that muscle. Incise the subcutaneous
tissue and platysma muscle along the line of the skin
incision. Cleanly undermine the loose connective tissue
layer under the platysma muscle to provide space in which
to work. Use a combination of sharp and blunt dissection
to access the anterior column of the cervical spine. Keep
the carotid artery and the sternocleidomastoid muscle
lateral and the strap muscle, trachea, and esophagus
medial. Open the prevertebral fascia and expose the anterior
column of the cervical spine. Confirm the correct level
roentgenographically.
Use an anterior cervical discectomy retractor system to
expose the ipsilateral longus colli muscle (Fig. 39-32, A).
Use only smooth-tipped retractor blades to avoid injury to
the trachea and esophagus medially and the carotid artery
and vagus nerve laterally. Use the operating microscope at
this stage and excise the medial portion of the longus colli
muscle to expose the medial parts of the transverse
processes of the upper and lower vertebrae (Fig. 39-32, B).

Expose the vertebral artery anterior to the C7 transverse
process. When operating at C6-7 take care not to injure the
vertebral artery while removing the medial portion of
the longus colli muscle. For operations above C6-7, the
vertebral artery is not exposed purposely at this point.
Once the medial parts of the transverse processes of
the upper and lower vertebrae have been identified, the
ipsilateral uncovertebral joint between them can be seen.
The interface of the uncovertebral joint is angled approximately 30 degrees cephalad from the horizontal line of the
intervertebral disc. Make a sharp vertical incision of the disc
at the medial margin of the ipsilateral uncovertebral joint to
prevent inadvertent internal disruption of the remaining
disc. While drilling the bone, repeated sharp cutting of the
deeper disc may be required. Remove the thin layer of disc
material located at the uncovertebral joint.
Drill between the transverse processes of the uncovertebral joint using a high-speed microdrill attached to an angled
handpiece (Fig. 39-32, B). To prevent injury to the vertebral
artery, leave the thin cortical bone attached to the ligamentous tissue covering the medial portion of this artery.
Continue drilling down to the posterior longitudinal ligament (Fig. 39-32, C). While drilling posteriorly, gently
incline medially. When the posterior longitudinal ligament
is exposed, a piece of thin cortical bone remains attached
lateral to the ligamentous tissue covering the vertebral
artery. Dissect the lateral remnant of the uncinate process
from the ligamentous tissue and fracture it at the base of the
uncinate process (Fig. 39-32, D). Further dissect it from the
surrounding soft tissue and remove it. The vertebral artery
can be identified by its pulsation between the transverse
processes of the vertebrae. Drilling at the base of the
uncinate process must proceed cautiously because the nerve
root lies just behind it. After the uncinate process becomes
loosened at its base, remove the remaining thin bone of the
uncinate process by fracturing it from its base rather than by
continued drilling. Once the remaining piece of uncinate
process is removed, the compressed nerve root will be
distended forward by bone decompression (Fig. 39-32, E).
The size of the hole that is made by drilling at the
uncovertebral joint usually is approximately 5 to 8 mm wide
transversely and 7 to 10 mm wide vertically. If there is no
ruptured herniated disc fragment behind the posterior
longitudinal ligament, this will end the nerve root
decompression.
At this point the posterior longitudinal ligament still
covers the nerve root and the lateral margin of the spinal
cord. If the disc fragment has ruptured through the posterior
longitudinal ligament, the tail of the disc material will be
visible. Remove this disc fragment at this time. To avoid
overlooking a hidden disc fragment, use a no. 15 blade knife
or micro scissors to incise the ligament and remove any
fragment with a 1- or 2-mm foot-plated bone punch. The
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ipsilateral one third to one half of the spinal cord is thus

exposed and the nerve root can be seen laterally as it exits
behind the vertebral artery (Fig. 39-32, F).
Jho reported excision of the posterior longitudinal
ligament in selected cases because it is unlikely that a
hidden ruptured disc fragment could be present without
disruption of this ligament. Removal of the ligament sometimes is complicated by epidural bleeding. If the ligament
is not removed, the procedure is much simpler and the
operating time is shorter. If epidural bleeding occurs during
removal of the posterior longitudinal ligament, use bipolar
coagulation. To avoid any potential compressive material
coming into contact with the nerve root or spinal cord, do
not use hemostatic agents. Although epidural bleeding
usually is not a problem, removing the posterior longitudinal
ligament is the most difficult part of this procedure. The disc
within the intervertebral space remains untouched and
preserved.
Close the platysma with interrupted 3-0 absorbable
stitches and approximate the skin with subcuticular sutures.
The operation can be performed at multiple levels. To
1993
Fig. 39-32 Anterior foraminotomy.

(Redrawn from Johnson JP, Filler AG,
McBride DQ, Batzdorf U: Spine 25:906,
2000.)
minimize postoperative incisional pain, inject a few

milliliters of local anesthetic subcutaneously.
Thoracic Disc Disease

Thoracic Disc Disease
The thoracic spine is the least common location for disc
pathology. C.A. Key has been credited with the first report of a
spinal cord injury caused by thoracic disc herniation, which
appeared in 1838 in the Guys Hospital Report. In the early
twentieth century several reports of enchondromata, chondromata, or echondromata appeared. In their study in 1934 Mixter
and Barr included four patients with a thoracic location of the
herniated nucleus pulposus. Of the four patients in this series,
three were treated operatively and one nonoperatively. The
patient with nonoperative treatment died soon after diagnosis.
Of the surgical group, two had complete paraplegia postoperatively. The third surgical patient died several months later for
unknown reasons. These three were treated with posterior
laminectomy. This initial report not only described the condition, but also revealed some of the difficulties of treatment.
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Since the 1960s many other approaches have been described

and validated through clinical experience. It is apparent that
posterior laminectomy has no role in the surgical treatment of
this problem. Other posterior approaches, such as costotransversectomy, have good indications. Fessler and Sturgill, as well
as Vanichkachorn and Vaccaro, chronicled the history and
treatment evolution for thoracic disc disease.
Symptomatic thoracic disc herniations remain relatively
rare, with an estimated incidence of 1 in 1,000,000 persons per
year. They represent 0.25% to 0.75% of the total incidence of
symptomatic disc herniations. The most common age of onset
is between the fourth and sixth decades. As with the other areas
of the spine, the incidence of asymptomatic disc herniations is
high. Wood et al. reviewed MRI studies in 90 asymptomatic
patients and found thoracic disc abnormalities in 73%. Of
these, 37% had frank herniations and 29% showed cord
compression. At a mean follow-up of 26 months with repeat
MRI of some of these patients none had become symptomatic.
Also, Wood et al. noted that small herniations often increased,
whereas the larger herniations often regressed. Operative
treatment of thoracic disc herniations is indicated in the rare
patient with acute disc herniation with myelopathic findings
attributable to the lesion, especially progressive neurological
symptoms.
SIGNS AND SYMPTOMS

SIGNS AND SYMPTOMS
Fortunately, the natural history of symptomatic thoracic disc
disease is similar to that in other areas, in that symptoms and
function typically improve with conservative treatment and
time. However, the clinical course can be quite variable, and a
high index of suspicion must be maintained to make the correct
diagnosis. The differential diagnosis for the symptoms of
thoracic disc herniations is fairly extensive and includes
nonspinal causes occurring with the cardiopulmonary, gastrointestinal, and musculoskeletal systems. Spinal causes of
similar symptoms can occur with infectious, neoplastic,
degenerative, and metabolic problems within the spinal column
as well as the spinal cord.
Two general patient populations have been documented in
the literature. The smaller group of patients is younger and has
a relatively short history of symptoms, often with a history of
trauma. Typically, an acute soft disc herniation with either acute
spinal cord compression or radiculopathy is present. Outcome
generally is favorable with operative or nonoperative treatment.
The larger group of patients has a longer history, often more
than 6 to 12 months of symptoms, which result from chronic
spinal cord or root compression. Disc degeneration, often with
calcification of the disc, is the underlying process.
Pain is clearly the most common presenting feature of
thoracic disc herniations. There appear to be two patterns of
pain: one is axial and the other is bandlike radicular pain along
the course of the intercostal nerve. The T10 dermatomal level
is the most commonly reported distribution, regardless of the
level of involvement. This is a band extending around the lower
lateral thorax and caudally to the level of the umbilicus. This
T4
T8
T10
T12
Fig. 39-33 Sensory dermatomes of trunk region. (Redrawn from

Klein JD: Clinical evaluation of patients with spinal disorders. In
Garfin SR, Vaccaro AR, eds: Orthopaedic knowledge update:
spine, Rosemont, Ill, 1997, American Academy of Orthopaedic
Surgeons.)
radicular pattern is more common with upper thoracic and

lateral disc herniations. Some axial pain often occurs with this
pattern as well. Associated sensory changes of paresthesias
and dysesthesia in a dermatomal distribution also occur.
(Fig. 39-33). High thoracic discs (T2 to T5) can present
similarly to cervical disc disease with upper arm pain,
paresthesias, radiculopathy, and even Horners syndrome.
Myelopathy also may occur. Complaints of weakness, which
may be generalized by the patient, typically involving both
lower extremities present in the form of mild paraparesis. The
presence of sustained clonus, a positive Babinski sign, and
wide-based and spastic gait are all signs of myelopathy. Bowel
and bladder dysfunction occur in only about 15% to 20% of
these patients. The neurological evaluation of patients with
thoracic disc herniations must be meticulous because there are
few localizing findings. Abdominal reflexes, cremasteric reflex,
dermatomal sensory evaluation, rectus abdominis contraction
symmetry, lower extremity reflex, strength, and sensory examinations, as well as determination of long tract findings, are all
important.
Plain roentgenograms are of some help to evaluate traumatic
injuries and to determine potential osseous morphological
variations that may help to localize findings, especially on
intraoperative films, if these become necessary. MRI is the most
important and useful imaging method to demonstrate thoracic
disc herniations. In addition to the disc herniation, neoplastic or
infectious pathology can be seen. The presence of intradural
pathology, including disc fragments, also usually is demonstrated on MRI. The spinal cord signal may indicate the
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presence of inflammation or myelomalacia as well. Despite all

these advantages, MRI may underestimate the thoracic disc
herniation, which often is calcified and thus has low signal
intensity on T1 and T2 sequences.
Myelography followed by CT scanning also can be useful
in evaluating the bony anatomy, as well as more accurately
assessing the calcified portion of the herniated thoracic disc.
Regardless of the imaging methods used, the appearance and
presence of a thoracic disc herniation must be carefully
considered and correlated with the patients complaints and
detailed examination findings.
TREATMENT RESULTS
TREATMENT RESULTS
As mentioned previously, nonoperative treatment usually is
effective. Brown reported that 63% of patients improved using
a combination of nonoperative treatments. A specific regimen
cannot be recommended for all patients; however, the principles of short-term rest, pain relief, antiinflammatory agents,
and progressive directed activity restoration appear most
appropriate. These measures generally should be continued at
least 6 to 12 weeks if feasible. If neurological deficits progress
or present as myelopathy, or if pain remains at an intolerable
level, surgery should be recommended. The initial procedure
recommended for this lesion was posterior thoracic laminectomy and disc excision. At least half of the lesions have been
identified as being central, making the excision from this
approach extremely difficult, and the results were somewhat
disheartening. Most series reported fewer than half of the
patients improving, with some becoming worse after posterior
laminectomy and discectomy. Most recent studies suggest that
lateral rachiotomy (modified costotransversectomy) or an
anterior transthoracic approach for discectomy produces considerably better results with no evidence of worsening after the
procedure. Video-assisted thoracic surgery (VATS) has been
used in several series to successfully remove central thoracic
disc herniations without the need for a thoracotomy or fusion.
Bohlman and Zdeblick reported the results of anterior thoracic
disc excision in 19 patients: 16 patients had excellent or good
results, and 3 had fair or poor results. Pain was relieved in 10,
decreased in 8, and unchanged in 1. None had worsening of
neurological symptoms. Regan, BinYashay, and Mack reported
a series of 29 thoracoscopic disc excisions with 76% satisfactory results.
OPERATIVE TREATMENT
OPERATIVE TREATMENT
The best surgical approach for these lesions depends on the
specific characteristics of the disc herniation, as well as on the
particular experience of the surgeon. Simple laminectomy
really has no role in the treatment of thoracic disc herniations.
Posterior approaches, including costotransversectomy, transpedicular approach, and the lateral extracavitary approach,
have all been used successfully. Anterior approaches via
thoracotomy, a transsternal approach, or VATS also have been
used successfully (Fig. 39-34).
1995
Costotransversectomy
Costotransversectomy is probably best suited for thoracic disc
herniations that are predominantly lateral or herniations that are
suspected to be extruded or sequestered. Central disc
herniations are probably best approached transthoracically.
Some surgeons have recommended subsequent fusion after disc
removal anteriorly or laterally.
TECHNIQUE 39-17
The operation usually is done with the patient under general
anesthesia with a cuffed endotracheal tube or a Carlen tube
to allow lung deflation on the side of approach. Place the
patient prone and make a long midline incision or a curved
incision convex to the midline centered over the side of
involvement. Expose the spine in the usual manner out to
the ribs. Remove a section of rib 5 to 7.5 cm long at the level
of involvement, taking care to avoid damage to the
intercostal nerve and artery. Carry the resection into the
lateral side of the disc, exposing it for removal. Additional
exposure can be made by laminectomy and excision of the
pedicle and facet joint. Fusion is unnecessary unless more
than one facet joint is removed. Close the wound in layers.
AFTERTREATMENT. The aftertreatment is similar to that for

lumbar disc excision without fusion (Technique 39-21).
Anterior Approach for Thoracic Disc Excision

Because of the relative age of patients with thoracic disc
ruptures, special care must be taken to identify those with
pulmonary problems. In these patients the anterior approach
can be detrimental medically, making a posterolateral approach
safer. Patients with midline protrusions probably are best
treated with the transthoracic approach to ensure complete disc
removal.
TECHNIQUE 39-18
The operation is done with the patient under general
anesthesia, using a cuffed endotracheal tube or Carlen tube
for lung deflation on the side of the approach. Place the
patient in a lateral recumbent position. A left-sided anterior
approach usually is preferred, making the operative procedure easier. Make a skin incision along the line of the rib
that corresponds to the second thoracic vertebra above the
involved intervertebral disc except for approaches to the
upper five thoracic segments, where the approach is through
the third rib. Choose the skin incision by inspection of the
anteroposterior roentgenogram. Cut the rib subperiosteally
at its posterior and anterior ends and then insert a rib
retractor. Save the rib for grafting later in the procedure. One
can then decide on an extrapleural or transpleural approach
depending on familiarity and ease. Exposure of the thoracic
vertebrae should give adequate access to the front and
opposite side. Dissect the great vessels free of the spine.
continued
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Fig. 39-34 Exposure of thoracic disc provided by standard laminectomy (A), transpedicular approach (B), costotransversectomy
approach (C), lateral extracavitary approach (D), and anterolateral
thoracotomy (E). (Redrawn from Fessler RG, Sturgill M: Surg Neurol
49:609, 1998.)
Laminectomy
Transpedicular
Costotransversectomy
Lateral extracavitary
Transthoracic
Ligate the intersegmental vessels near the great vessels and

not near the foramen. One should be able to insert the tip of
a finger against the opposite side of the disc when the
vascular mobilization is complete. Exposure of the intervertebral disc without disturbing more than three segmental
vessels is preferable to avoid ischemic problems in the
spinal cord. In the thoracolumbar region strip the diaphragm
from the eleventh and twelfth ribs. The anterior longitudinal
ligament usually is sectioned to allow spreading of the
intervertebral disc space. Remove the disc as completely
as possible if fusion is planned. The use of the operating
microscope or loupe magnification eases the removal of the

disc near the posterior longitudinal ligament. Use curets and
nibbling instruments to remove the disc up to the posterior
longitudinal ligament. Then place a finger on the opposite
side of the disc to avoid penetration when removing disc
material on the more distant side. Carefully inspect the
posterior longitudinal ligament for tears and extruded
fragments. Remove the posterior longitudinal ligament only
if necessary. Significant bleeding can occur if the venous
plexus near the dura is torn. After removal of the disc, strip
the endplates of their cartilage. Make a slot in one vertebral
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I
S
S
A
4
1 2 3
Fig. 39-35 Position on operating table

and operating room setup. Surgeons (S)
and nurse with instruments (I) stand in
front of patient. Monitor (M) placed at
back. Working channels (1,2,3) converge toward spine. Channel for optical system (4) situated ventrally. (From
Rosenthal D, Rosenthal R, de Simone A:
Spine 19:1087, 1994.)
body and a hole in the body on the opposite side of the disc
space to accept the graft material. Make the hole large
enough to accept several sections of rib, but make the slot
large enough to accept only one rib graft at a time. Then
insert iliac, tibial, or rib grafts into the disc space. Tie
the grafts together with heavy suture material when the
maximal number of grafts have been inserted. Close the
wound in the usual manner and employ standard chest
drainage. As an alternative, if fusion is not desired a more
limited resection using the operating microscope can be
done. After the vascular mobilization, resect the rib head to
allow observation of the pedicle and foramen caudal to the
disc space. The pedicle can be removed with a high-speed
burr and Kerrison rongeurs, thus exposing the posterolateral
aspect of the disc. This allows careful, blunt development of
the plane ventral to the dura with removal of the disc
herniation and preservation of the anterior majority of the
disc, as well as limiting the need for fusion. A similar
technique using VATS is described in Technique 39-19.
The transthoracic approach removing a rib two levels
above the level of the lesion can be used up to T5. The
transthoracic approach from T2 to T5 is best made by
excision of the third or fourth rib and elevation of the
scapula by sectioning of attachments of the serratus anterior
and trapezius from the scapula. The approach to the T1-2
disc is best made from the neck with a sternal splitting
incision.
AFTERTREATMENT. Postoperative care is the same as for a

thoracotomy. The patient is allowed to walk after the chest
tubes are removed. Extension in any position is prohibited. A
brace or body cast that limits extension should be used if the
stability of the graft is questionable. The graft usually is stable

without support if only one disc space is removed. Postoperative care is the same as for anterior corpectomy and fusion if
more than one disc level is removed. If no fusion is done, the
patient is mobilized as pain permits without a brace.
Thoracic Endoscopic Disc Excision

Microsurgical and endoscopic surgical techniques are being
applied to the anterior excision of thoracic disc herniation.
Rosenthal et al. and Horowitz et al. first performed these
procedures on cadavers to perfect the technique. Because these
methods are highly technical, they should be performed by a
surgeon who is proficient in this technique and in the use of
endoscopic equipment and with the assistance of an experienced thoracic surgeon. Ideally the procedure should be done
on cadavers or live animals first. Regan et al. also described this
technique, with different portal positions.
TECHNIQUE 39-19 (Rosenthal et al.)
(Figs. 39-35 and 39-36)
Place the patient in the left lateral decubitus position to

allow a right-sided approach and displacement of the aorta
and heart to the left. Insert four trocars in a triangular
fashion along the middle axillary line converging on the disc
space. Introduce a rigid endoscope with a 30-degree optic
angle attached to a video camera into one of the trocars,
leaving the other three as working channels. Deflate the lung
using a Carlin tube or similar method. Split the parietal
pleura starting at the medial part of the intervertebral space
and extending up to the costovertebral process. Preserve and
mobilize the segmental arteries and sympathetic nerve out
of the operating field. Drill away the rib head and lateral
continued
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Fig. 39-36 Endoscopic removal of thoracic disc. Horizontal

view at T6 level. Patient is in left lateral decubitus position.
A, Right lung (collapsed). B, Heart and pericardium. C, Esophagus. D, Aorta. E, Forceps and endoscope. F, Left lung. (From
Rosenthal D, Rosenthal R, de Simone A: Spine 19:1087, 1994.)
portion of the pedicle. Remove the remaining pedicle with

Kerrison rongeurs to improve exposure to the spinal canal.
Removing the superior posterior portion of the vertebra
caudal to the disc space allows safer removal of the disc
material, which then can be pulled anteriorly and inferiorly
away from the spinal canal to be removed. Use endoscopic
instruments for surgery in the portals. Remove the disc
posteriorly and the posterior longitudinal ligament, restricting bone and disc removal to the posterior third of the
intervertebral space and costovertebral area to maintain
stability. Insert chest tubes in the standard fashion and set
them to water suction; close the portals.
AFTERTREATMENT. The patient is rapidly mobilized as

tolerated by the chest tubes. Discharge is possible once the
chest tubes have been removed and the patient is ambulating well.
Lumbar Disc Disease

SIGNS AND SYMPTOMS
Lumbar Disc Disease

SIGNS AND SYMPTOMS
Although back pain is common from the second decade of life
on, intervertebral disc disease and disc herniation are most
prominent in otherwise healthy people in the third and fourth
decades of life. Most people relate their back and leg pain to a
traumatic incident, but close questioning frequently reveals that
the patient has had intermittent episodes of back pain for many
months or even years before the onset of severe leg pain. In
many instances the back pain is relatively fleeting and is
relieved by rest. This pain often is brought on by heavy
exertion, repetitive bending, twisting, or heavy lifting. In other
instances an exacerbating incident cannot be elicited. The pain
usually begins in the lower back, radiating to the sacroiliac
region and buttocks. The pain can radiate down the posterior
thigh. Back and posterior thigh pain of this type can be elicited
from many areas of the spine, including the facet joints,
longitudinal ligaments, and the periosteum of the vertebra.
Radicular pain, on the other hand, usually extends below the
knee and follows the dermatome of the involved nerve root.
The usual history of lumbar disc herniation is of repetitive
lower back and buttock pain, relieved by a short period of rest.
This pain is then suddenly exacerbated by a flexion episode,
with the sudden appearance of leg pain much greater than back
pain. Most radicular pain from nerve root compression caused
by a herniated nucleus pulposus is evidenced by leg pain equal
to, or in many cases much greater than, the degree of back pain.
Whenever leg pain is minimal and back pain is predominant,
great care should be taken before making the diagnosis of a
symptomatic herniated intervertebral disc. The pain from disc
herniation usually is intermittent, increasing with activity,
especially sitting. The pain can be relieved by rest, especially in
the semi-Fowler position, and can be exacerbated by straining,
sneezing, or coughing. Whenever the pattern of pain is bizarre
or the pain itself is constant, a diagnosis of symptomatic
herniated disc should be viewed with some skepticism.
Other symptoms of disc herniation include weakness and
paresthesias. In most patients the weakness is intermittent,
variable with activity, and localized to the neurological level of
involvement. Paresthesias also are variable and limited to the
dermatome of the involved nerve root. Whenever these
complaints are generalized, the diagnosis of a simple unilateral
disc herniation should be questioned.
Numbness and weakness in the involved leg and occasionally pain in the groin or testicle can be associated with a high
or midline lumbar disc herniation. If a fragment is large or the
herniation is high, symptoms of pressure on the entire cauda
equina can be elicited. These include numbness and weakness
in both legs, rectal pain, numbness in the perineum, and
paralysis of the sphincters. This diagnosis should be the
primary consideration in patients who complain of sudden loss
of bowel or bladder control. Whenever the diagnosis of a cauda
equina syndrome or acute midline herniation is suspected,
evaluation and treatment should be aggressive.
PHYSICAL FINDINGS
PHYSICAL FINDINGS
The physical findings in back pain with disc disease are
variable because of the time intervals involved. Usually
patients with acute pain show evidence of marked paraspinal
spasm that is sustained during walking or motion. A scoliosis or
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BOX 39-7 L4 Root Compression*
BOX 39-8 L5 Root Compression*
Sensory Deficit
Posterolateral thigh, anterior knee, and medial leg
Sensory Deficit
Anterolateral leg, dorsum of the foot, and great toe
Motor Weakness
Quadriceps (variable)
Hip adductors (variable)
Motor Weakness
Extensor hallucis longus
Gluteus medius
Extensor digitorum longus and brevis
Reflex Changes
Patellar tendon
Tibialis anterior tendon (variable)
*Indicative of L3-4 disc herniation or pathological condition localized to
the L4 foramen.
a list in the lumbar spine may be present, and in many patients

the normal lumbar lordosis is lost. As the acute episode
subsides, the degree of spasm diminishes remarkably, and the
loss of normal lumbar lordosis may be the only telltale sign.
Point tenderness may be present over the spinous process at the
level of the disc involved, and in some patients pain may extend
laterally.
If there is nerve root irritation, it centers over the length of
the sciatic nerve, both in the sciatic notch and more distally
in the popliteal space. In addition, stretch of the sciatic nerve at
the knee should reproduce buttock, thigh, and leg pain (i.e.,
pain distal to the knee). A Lase`gue sign usually is positive on
the involved side. A positive Lase`gue sign or straight leg raising
should elicit buttock or leg pain distal to the knee or both on the
side tested. Occasionally if leg pain is significant the patient
will lean back from an upright sitting position and assume the
tripod stance to relieve the pain. Contralateral leg pain
produced by straight leg raising should be regarded as
pathognomonic of a herniated intervertebral disc. The absence
of a positive Lase`gue sign should make one skeptical of the
diagnosis, although older individuals may not have a positive
Lase`gue sign. Likewise, inappropriate findings and inconsistencies in the examination usually are nonorganic in origin (see
discussion of nonspecific back pain). If the leg pain has
persisted for any length of time, atrophy of the involved limb
may be present, as demonstrated by asymmetrical girth of the
thigh or calf. The neurological examination will vary as
determined by the level of root involvement (Boxes 39-7 to
39-9). Smith et al. examined the motion of the spinal roots in
cadavers. They observed 0.5 to 5 mm of linear motion and 2%
to 4% strain on the nerves at L4, L5, and S1. With increased
strain, the roots moved lateral to the pedicle.
Unilateral disc herniation between L3 and L4 usually
compresses the fourth lumbar root as it crosses the disc before
exiting at the L4 intervertebral foramen. Pain may be localized
around the medial side of the leg. Numbness may be present
over the anteromedial aspect of the leg. The tibialis anterior
may be weak as evidenced by inability to heel walk. The
quadriceps and hip adductor group, both innervated from L2,
L3, and L4, also may be weak and, in extended ruptures,
1999
Reflex Change
Usually none
Tibialis posterior (difficult to elicit)
*Indicative of L4-5 disc herniation or pathological condition localized to
the L5 foramen.
BOX 39-9 S1 Root Compression*

Sensory Deficit
Lateral malleolus, lateral foot, heel, and web of fourth and
fifth toes
Motor Weakness
Peroneus longus and brevis
Gastrocnemius-soleus complex
Gluteus maximus
Reflex Change
Tendo calcaneus (gastrocnemius-soleus complex)
*Indicative of L5-S1 disc herniation or pathological condition localized
to the S1 foramen.
atrophic. Reflex testing may reveal a diminished or absent

patellar tendon reflex (L2, L3, and L4) or tibialis anterior
tendon reflex (L4). Sensory testing may show diminished
sensibility over the L4 dermatome, the isolated portion of
which is the medial leg (Fig. 39-37), and the autonomous zone
of which is at the level of the medial malleolus.
Unilateral disc herniation between L4 and L5 results in
compression of the fifth lumbar root. Fifth lumbar root
radiculopathy should produce pain in the dermatomal pattern.
Numbness, when present, follows the L5 dermatome along the
anterolateral aspect of the leg and the dorsum of the foot,
including the great toe. The autonomous zone for this nerve is
the dorsal first web of the foot and the dorsum of the third toe.
Weakness may involve the extensor hallucis longus (L5),
gluteus medius (L5), or extensor digitorum longus and brevis
(L5). Reflex change usually is not found. A diminished tibialis
posterior reflex is possible but difficult to elicit.
With unilateral rupture of the disc between L5 and S1 the
findings of an S1 radiculopathy are noted. Pain and numbness
involve the dermatome of S1. The S1 dermatome includes the
lateral malleolus and the lateral and plantar surface of the foot,
occasionally including the heel. There is numbness over the
lateral aspect of the leg and, more important, over the lateral
aspect of the foot, including the lateral three toes. The
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Fig. 39-37 L4 neurological level. (After

Hoppenfeld S: Physical examination of
the spine and extremities, Norwalk, Conn,
1976, Appleton-Century-Crofts.)
autonomous zone for this root is the dorsum of the fifth toe.
Weakness may be demonstrated in the peroneus longus and
brevis (S1), gastrocnemius-soleus (S1), or gluteus maximus
(S1). In general, weakness is not a usual finding in S1
radiculopathy. Occasionally, mild weakness may be demonstrated by asymmetrical fatigue with exercise of these motor
groups. The ankle jerk usually is reduced or absent.
Massive extrusion of a disc involving the entire diameter of
the lumbar canal or a large midline extrusion can produce pain
in the back, legs, and occasionally perineum. Both legs may be
paralyzed, the sphincters may be incontinent, and the ankle
jerks may be absent. Tay and Chacha in 1979 reported that the
combination of saddle anesthesia, bilateral ankle areflexia, and
bladder symptoms constituted the most consistent symptoms of
cauda equina syndrome caused by massive intervertebral disc
extrusion at any lumbar level. In these instances a cystometrogram may show bladder denervation.
More than 95% of the ruptures of the lumbar intervertebral
discs occur at L4 or L5. Ruptures at higher levels in many
patients are not associated with a positive straight leg raising
test. In these instances, a positive femoral stretch test can be
helpful. This test is carried out by placing the patient prone and
acutely flexing the knee while placing the hand in the popliteal
fossa. When this procedure results in anterior thigh pain, the
result is positive and a high lesion should be suspected. In

addition, these lesions may occur with a more diffuse
neurological complaint without significant localizing neurological signs.
Often the neurological signs associated with disc disease
vary over time. If the patient has been up and walking for a
period of time, the neurological findings may be much more
pronounced than if he has been at bed rest for several days, thus
decreasing the pressure on the nerve root and allowing the
nerve to resume its normal function. In addition, various
conservative treatments can change the physical signs of disc
disease.
Comparative bilateral examination of a patient with back
and leg pain is essential in finding a clear-cut pattern of signs
and symptoms. It is not uncommon for the evaluation to
change. Adverse changes in the examination may warrant more
aggressive therapy, whereas improvement of the symptoms
or signs should signal a resolution of the problem. Early
symptoms or signs suggestive of cauda equina syndrome or
severe or progressive neurological deficit should be treated
aggressively from the onset. McLaren and Bailey warn that the
cauda equina syndrome is more frequent when disc excision is
performed in the presence of an untreated spinal stenosis at the
same level.
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DIFFERENTIAL
DIAGNOSIS
The differential diagnosis of back and leg pain is extremely
lengthy and complex. It includes diseases intrinsic to the spine
and those involving adjacent organs but causing pain referred to
the back or leg. For simplicity, lesions can be categorized as
being extrinsic or intrinsic to the spine. Extrinsic lesions
include diseases of the urogenital system, gastrointestinal
system, vascular system, endocrine system, nervous system not
localized to the spine, and the extrinsic musculoskeletal system.
These lesions include infections, tumors, metabolic disturbances, congenital abnormalities, and the associated diseases of
aging. Intrinsic lesions involve those diseases that arise
primarily in the spine. They include diseases of the spinal
musculoskeletal system, the local hematopoietic system, and
the local neurological system. These conditions include trauma,
tumors, infections, diseases of aging, and immune diseases
affecting the spine or spinal nerves.
Although the predominant cause of back and leg pain in
healthy people usually is lumbar disc disease, one must be
extremely cautious to avoid a misdiagnosis, particularly given
the high incidence of disc herniations present in asymptomatic
patients as discussed previously. Therefore a full physical
examination must be completed before making a presumptive
diagnosis of herniated disc disease. Common diseases that can
mimic disc disease include ankylosing spondylitis, multiple
myeloma, vascular insufficiency, arthritis of the hip, osteoporosis with stress fractures, extradural tumors, peripheral
neuropathy, and herpes zoster. Infrequent but reported causes of
sciatica not related to disc hernia include synovial cysts, rupture
of the medial head of the gastrocnemius, sacroiliac joint
dysfunction, lesions in the sacrum and pelvis, and fracture of
the ischial tuberosity.
CONFIRMATORY IMAGING
CONFIRMATORY IMAGING
Although the diagnosis of a herniated lumbar disc can be
suspected from the history and physical examination, imaging
studies are necessary to rule out other causes, such as a tumor
or infection. Plain roentgenograms are of limited use in the
diagnosis because they do not show disc herniations or other
intraspinal lesions, but they can demonstrate infection, tumors,
or other anomalies and should be obtained, especially if surgery
is planned. Currently, the most useful test for diagnosing a
herniated lumbar disc is MRI. Since the advent of MRI,
myelography is used much less frequently, although in some
situations it may help to demonstrate subtle lesions. When
myelography is used, it should be followed with a CT scan.
The number and variety of nonoperative therapies for back and
leg pain are overwhelming. Treatments range from simple rest
to expensive traction apparatus. All these therapies are reported
with glowing accounts of miraculous cures; unfortunately,
2001
few have been evaluated scientifically. In addition, the natural

history of disc disease is characterized by exacerbations and
remissions with eventual improvement regardless of treatment.
Finally, several distinct symptom complexes appear to be
associated with disc disease. Few if any studies have isolated
the response to specific and anatomically distinct diagnoses.
The simplest treatment for acute back pain is rest. Deyo,
Diehl, and Rosenthal reported that 2 days of bed rest were
better than a longer period. Biomechanical studies indicate that
lying in a semi- Fowler position (i.e., on the side with the hips
and knees flexed) with a pillow between the legs should relieve
most pressure on the disc and nerve roots. Muscle spasm can be
controlled by the application of ice, preferably with a massage
over the muscles in spasm. Pain relief and antiinflammatory
effect can be achieved with nonsteroidal antiinflammatory
drugs (NSAIDs). Most acute exacerbations of back pain
respond quickly to this therapy. As the pain diminishes, the
patient should be encouraged to begin isometric abdominal and
lower extremity exercises. Walking within the limits of comfort
also is encouraged. Sitting, especially riding in a car, is
discouraged. Malmivaara et al. compared the efficacy of bed
rest alone, back extension exercises, and continuation of
ordinary activities as tolerated in the treatment of acute back
pain. They concluded that continuation of ordinary activities
within the limits permitted by pain led to a more rapid recovery.
Education in proper posture and body mechanics is helpful
in returning the patient to the usual level of activity after the
acute exacerbation is eased or relieved. This education can take
many forms, from individual instruction to group instruction.
Back education of this type is now usually referred to as back
school. Although the concept is excellent, the quality and
quantity of information provided may vary widely. The work of
Bergquist-Ullman and Larsson and others indicates that patient
education of this type is extremely beneficial in decreasing the
amount of time lost from work initially but does little to
decrease the incidence of recurrence of symptoms or length of
time lost from work during recurrences. Certainly the
combination of back education and combined physical therapy
is superior to placebo treatment. Cohen et al. reviewed 13
studies on group back education and concluded that the
evidence was insufficient to recommend group education.
A study by Galm et al. regarding sacroiliac joint dysfunction in
patients with image-proven herniated nucleus pulposus and
sciatica but without motor or sensory deficits found that 75%
improved with respect to sciatic and back pain with intensive
physiotherapy.
Numerous medications have been used with varied results in
subacute and chronic back and leg pain syndromes. The current
trend appears to be moving away from the use of strong
narcotics and muscle relaxants in the outpatient treatment of
these syndromes. This is especially true in the instances of
chronic back and leg pain where drug habituation and increased
depression are frequent. Oral steroids used briefly can be
beneficial as potent antiinflammatory agents. The many types
of NSAIDs also are helpful when aspirin is not tolerated or is
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of little help. Numerous NSAIDs are available for the treatment

of low back pain. When depression is prominent, mood
elevators such as amitriptyline can be beneficial in reducing
sleep disturbance and anxiety without increasing depression. In
addition, amitriptyline also decreases the need for narcotic
medication.
Physical therapy should be used judiciously. The exercises
should be fitted to the symptoms and not forced as an absolute
group of activities. Patients with acute back and thigh pain
eased by passive extension of the spine in the prone position
can benefit from extension exercises rather than flexion
exercises. Improvement in symptoms with extension is
indicative of a good prognosis with conservative care. On the
other hand, patients whose pain is increased by passive
extension may be improved by flexion exercises. These
exercises should not be forced in the face of increased pain.
This may avoid further disc extrusion. Any exercise that
increases pain should be discontinued. Lower extremity
exercises can increase strength and relieve stress on the back,
but they also can exacerbate lower extremity arthritis. The true
benefit of such treatments may be in the promotion of good
posture and body mechanics rather than of strength. Hansen
et al. compared intensive, dynamic back muscle exercises,
conventional physiotherapy (manual traction, flexibility, isometric and coordination exercises, and ergonomics counseling),
and placebo-control treatment in a randomized, observer blind
trial. Regardless of the method used, patients who completed
therapy reported a decrease in pain. However, physiotherapy
appeared to have better results in men, and intensive back
exercises gave better results in women. Patients with hard
physical occupations responded better to physiotherapy,
whereas patients with sedentary occupations responded better
to intensive back exercises.
Numerous treatment methods have been advanced for the
treatment of back pain. Some patients respond to the use of
transcutaneous electrical nerve stimulation (TENS). Others do
well with traction varying from skin traction in bed with 5 to 8
pounds to body inversion with forces of over 100 pounds. Back
braces or corsets may be helpful to other patients. Ultrasound and
diathermy are other treatments used in back pain. The scientific
efficacy of many of these treatments has not been proved. In
addition, all therapy for disc disease is only symptomatic.
EPIDURAL STEROIDS
EPIDURAL STEROIDS
The epidural injection of a combination of a long-acting steroid
with an epidural anesthetic is an excellent method of
symptomatic treatment of back and leg pain from discogenic
disease and other sources. Most studies show a 60% to 85%
short-term success rate that falls to a 30% to 40% long-term
(6-month) good result rate. The local effect of the steroids has
been shown to last at least 3 weeks at a therapeutic level. In a
well-controlled study Berman et al. found that the best results
were obtained in patients with subacute or chronic leg pain with
no prior surgery. They also found that the worst results were in
patients with motor or reflex abnormalities (12% to 14% good

results). A negative myelogram also was associated with a
better result. Cuckler et al. in a double-blind, randomized study
of epidural steroid treatment of disc herniation and spinal
stenosis found no difference in the results at 6 months between
placebo and a single epidural injection. Our experience
parallels that of Berman et al. We agree that epidural steroids
are not a cure for disc disease, but they do offer relatively
prolonged pain relief without excessive narcotic intake if
conservative care is elected. Hopwood and Abram observed
that factors associated with poor surgical outcome also were
associated with a poor outcome from epidural steroid injection.
These factors included lower educational levels, smoking, lack
of employment, constant pain, sleep disruption, nonradicular
diagnosis, prolonged duration of pain, change in recreational
activities, and extreme values on psychological scales.
In experienced hands the complication rate from this
procedure should be small. White, Derby, and Wynne reported
that the most common problem is a 25% rate of failure to place
the material in the epidural space. Renfrew et al. and el-Khoury
et al. observed that the use of fluoroscopic control dramatically
decreased the failure rate. Another technique-related problem is
intrathecal injection with inadvertent spinal anesthesia. Other
reported complications include transient hypotension, difficulty
in voiding, severe paresthesias, cardiac angina, headache, and
transient hypercorticoidism. Kushner and Olson reported
retinal hemorrhage in several patients who had epidural steroid
injection for chronic back pain. They recommended careful
consideration of this procedure in patients who have bleeding
problems and in patients who have only one eye. DeSio et al.
reported facial flushing and generalized erythema in patients
after epidural steroid injection. The most serious complication
reported was bacterial meningitis. The total complication rate
in most series is about 5%, and the complications are almost
always transient.
This procedure is contraindicated in the presence of
infection, neurological disease (such as multiple sclerosis),
hemorrhagic or bleeding diathesis, cauda equina syndrome, and
a rapidly progressive neural deficit. Rapid injections of large
volumes or the use of large doses of steroid also can increase
the complication rate. The exact effects of intrathecal injection
of steroids are not known. This technique must be used only in
the low lumbar region. We prefer to abort the procedure if a
bloody tap is obtained or if CSF is encountered.
We prefer to do the procedure in a room equipped for
resuscitation and with the capability to monitor the patient. This
procedure lends itself well to outpatient use, but the patient
must be prepared to spend several hours to recover from the
block. Methylprednisolone (Depo-Medrol) is the usual steroid
injected. The dosage may vary from 80 to 120 mg. The
anesthetics used may include lidocaine, bupivacaine, or
procaine. Our current protocol is to inject the patient three
times. These injections are made at 7- to 10-day intervals. This
ensures at least one good epidural injection and decreases the
volume of material injected at each procedure.
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TECHNIQUE 39-20 (Brown)

The equipment needed includes material for an appropriate
skin preparation, sterile rubber gloves, a 312-inch, 20-gauge
or 22-gauge disposable spinal needle (45-degree blunt- or
curve-tipped epidural needles are preferred), several disposable syringes, bacteriostatic lidocaine, and methylprednisolone acetate, 40 mg/ml. The injection may be done with the
patient in the sitting or lateral decubitus position. Anesthetize the skin near the midline. Advance the needle until the
resistance of the ligamentum flavum is encountered. Then
attach a syringe and slowly advance the needle while
applying light pressure on the syringe. When the epidural
space is encountered, the resistance is suddenly lost and the
epidural space will accommodate the air. Remove the
syringe and inspect the needle opening for blood or spinal
fluid. If there is no flow out of the needle, then inject 3 ml
of 1% lidocaine or other appropriate anesthetic. This may
be preceded or followed by the chosen dosage of
methylprednisolone.
Several variations also can be used. Some physicians use
a sterile balloon to indicate the proper space. Others use the
disappearing drop technique, which involves placing a
drop of sterile saline over the hub of the needle. When the
epidural space is entered, the drop disappears. Caudal
injection also is used, but this may require larger volumes to
wash the steroid up to the involved level. This method is
safer but less reliable than an injection at L4-5.
OPERATIVE TREATMENT
OPERATIVE TREATMENT
If nonoperative treatment for lumbar disc disease fails, the next
consideration is operative treatment. Before this step is taken,
the surgeon must be sure of the diagnosis. The patient must be
certain that the degree of pain and impairment warrants such a
step. Both the surgeon and the patient must realize that disc
surgery is not a cure but may provide symptomatic relief. It
neither stops the pathological processes that allowed the
herniation to occur nor restores the back to a normal state. The
patient must still practice good posture and body mechanics
after surgery. Activities involving repetitive bending, twisting,
and lifting with the spine in flexion may have to be curtailed or
eliminated. If prolonged relief is to be expected, then some
permanent modification in the patients lifestyle may be
necessary.
The key to good results in disc surgery is appropriate patient
selection. The optimal patient is one with predominant, if not
only, unilateral leg pain extending below the knee that has been
present for at least 6 weeks. The pain should have been
decreased by rest, antiinflammatory medication, or even
epidural steroids but should have returned to the initial levels
after a minimum of 6 to 8 weeks of conservative care. Some
managed care plans now insist on a trial of physiotherapy. The
work of Hansen et al. is indicative of the problems with such
2003
requirements, not only because of gender and occupation

variations in response to physiotherapy and intensive back
exercises, but also because no therapy appeared to have the
same or better results. Physical examination should reveal
signs of sciatic irritation and possibly objective evidence of
localizing neurological impairment. CT, lumbar MRI, or
myelography should confirm the level of involvement consistent with the patients examination.
Surgical disc removal is mandatory and urgent only in cauda
equina syndrome with significant neurological deficit, especially bowel or bladder disturbance. All other disc excisions
should be considered elective. This should allow a thorough
evaluation to confirm the diagnosis, level of involvement, and
the physical and psychological status of patient. Frequently, if
there is a rush to the operating room to relieve pain without
proper investigation, both the patient and physician later regret
the decision.
Regardless of the method chosen to treat a disc rupture
surgically, the patient should be aware that the procedure is
predominantly for the symptomatic relief of leg pain. Patients
with predominant back pain may not be relieved of their major
complaintback pain. Spangfort, in reviewing 2504 lumbar
disc excisions, found that about 30% of the patients complained
of back pain after disc surgery. Failure to relieve sciatica was
proportional to the degree of herniation. The best results of
99.5% complete or partial pain relief were obtained when the
disc was free in the canal or sequestered. Incomplete herniation
or extrusion of disc material into the canal resulted in complete
relief for 82% of patients. Excision of the bulging or protruding
disc that had not ruptured through the annulus resulted in
complete relief in 63%, and removal of the normal or
minimally bulging disc resulted in complete relief in 38%,
which is near the stated level for the placebo response.
Likewise, the incidence of persistent back pain after surgery
was inversely proportional to the degree of herniation. In
patients with complete extrusions the incidence was about 25%,
but with minimal bulges or negative explorations the incidence
rose to over 55% (Figs. 39-38 and 39-39).
General Principles for Open Disc Surgery

Most disc surgery is performed with the patient under
general endotracheal anesthesia, although local anesthesia has
been used with minimal complications. Patient positioning
varies with the operative technique and surgeon. To position the
patient in a modified kneeling position, a specialized frame or
custom frame modified from the design of Hastings is popular.
Positioning the patient in this manner allows the abdomen to
hang free, minimizing epidural venous dilation and bleeding
(Fig. 39-40). A head lamp allows the surgeon to direct light into
the lateral recesses where a large proportion of the surgery may
be required. The addition of loupe magnification also greatly
improves the identification and exposure of various structures.
Some surgeons also use the operative microscope to further
improve visibility. The primary benefit of the operating
microscope compared with loupes is the view afforded the
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Fig. 39-38 Percentage relief of sciatica with type of disc herniation. (From Spangfort E: Acta
Orthop Scand Suppl 142:1, 1972.)
Fig. 39-39 Types of disc herniation. A, Normal bulge. B, Protrusion. C, Extrusion. D, Sequestration.
Fig. 39-40 Kneeling position for lumbar disc excision allows

abdomen to be completely free of external pressure.
assistant. Roentgenographic confirmation of the proper level is

necessary. Care should be taken to protect neural structures.
Epidural bleeding should be controlled with bipolar electrocautery. Any sponge, pack, or cottonoid patty placed in the wound
should extend to the outside. Pituitary rongeurs should be
marked at a point equal to the maximal allowable disc depth to
prevent accidental biopsy of viscera or aorta. Considerable
research has gone into techniques to prevent epidural fibrosis.

Hoyland et al. noted dense fibrous connective tissue about
previously operated nerve roots. They also found fibrillar
foreign material within the scar in 55% of patients. This finding
should remind the surgeon to minimize the use of cotton
patties. The placement of autogenous fat appears to be a
reasonable although not foolproof or complication-free tech-
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C
A
F
E
D
Fig. 39-41 Technique of lumbar disc excision. A, With lamina and ligamentum flavum exposed,
use curet to remove the ligamentum flavum from inferior surface of lamina. Kerrison rongeur is used
to remove bone. B, Elevate ligamentum flavum at upper corner and carefully dissect it back to
expose dura and epidural fat below. Patties should be used to protect dura during this procedure.
C, Expose dura and root. Remove additional bone if there is any question about adequacy of
exposure. D, Retract nerve root and dural sac to expose disc. Inspect capsule for rent and extruded
nuclear material. If obvious ligamentous defect is not visible, then carefully incise capsule of disc.
If disc material does not bulge out, press on disc to try to dislodge herniated fragment. E, Carefully
remove disc fragments. It is safest to avoid opening pituitary rongeur until it is inserted into disc
space. F, After removing disc, carefully explore foramen, subligamentous region, and beneath dura
for additional fragments of disc. Obtain meticulous hemostasis using bipolar cauterization.
nique of minimizing postoperative epidural fibrosis. Commercially available products may reduce scar volume, but clinical
benefit remains uncertain.
Ruptured Lumbar Disc Excision (Open Technique)

TECHNIQUE 39-21
After thoroughly preparing the back, identify the spinous
processes of L3, L4, L5, and S1 by palpation. Make a
midline incision 5 to 8 cm long, centered over the interspace
where the disc herniation is located. Incise the supraspinous
ligament; then, by subperiosteal dissection, strip the muscles
from the spinous processes and laminae of these vertebrae

on the side of the lesion. Retract the muscles either with a
self-retaining retractor or with the help of an assistant and
expose one interspace at a time. Verify the location with a
roentgenogram so that no mistake is made regarding the
interspaces explored. Secure hemostasis with electrocautery,
bone wax, and packs. Leave a portion of each pack
completely outside the wound for ready identification.
Denude the laminae and ligamentum flavum with a curet
(Fig. 39-41). Commonly the lumbosacral interspace is large
enough to permit exposure and removal of a herniated
nucleus pulposus without removal of any bone. If not,
continued
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remove a small part of the inferior margin of the fifth lumbar

lamina. Exposure of the disc at higher levels usually
requires removal of a portion of the inferior lamina. Thin the
ligamentum flavum using a pituitary rongeur to remove the
superficial layer. Detach the ligamentum from its cephalad
or caudad laminar attachment using a small curet. Use care
to keep the cutting edges of the curet directed posteriorly to
minimize the chance of dural laceration. Using an angled
Kerrison rongeur, preferably one with a thin foot plate and
appropriate width, remove the detached ligamentum laterally and preserve the more medial ligamentum. Keep the
Kerrison rongeur oriented parallel to the direction of the
nerve root to minimize the risk of root injury, and the root
will be more posterior than is normal due to the displacement caused by the herniated disc fragment. An
alternative technique that can be used with good lighting and
magnified visual aid is to divide the ligamentum parallel
with its fibers using a no. 11 blade knife. Once the full
thickness of the ligamentum has been divided, bluntly
extend the division across the interspace with a Penfield 4
dissector and remove the lateral portion of the ligamentum.
The lateral shelving portion of the ligamentum should be
excised, often with a portion of the medial inferior facet to
gain access to the lateral aspect of the nerve root. Next,
retract the dura medially and identify the nerve root. If the
root is compressed by a large extruded fragment, it
commonly will be displaced posteriorly. Retract the nerve
root, once identified, medially so that the underlying
extruded fragment or bulging posterior longitudinal ligament can be seen. Occasionally the nerve root adheres to the
fragment or to the underlying ligamentous structures and
requires blunt dissection from these structures. If the
position of the root is not known for certain, remove the
lamina posterior to the root and medial to the pedicle until
the root is clearly identified. Bipolar cautery on a low setting
can be used to coagulate the epidural veins and maintain
hemostasis. Gelfoam and small cottonoids also are useful.
Take care to minimize packing about the nerve root. Retract
the root or dura, identify any bleeding vein, and cauterize it
with a bipolar cautery. Earlier insertion of cotton patties may
well displace fragments from view. The underlying disc
should be clearly visible at this time.
Gently retract the nerve with a Love root retractor or a
blunt dissector, thus exposing the herniated fragment or
posterior longitudinal ligament and annulus. If an extruded
fragment is not seen, carefully palpate the posterior
longitudinal ligament and seek a defect or hole in the
ligamentous structures. A microblunt hook can be used for
this. If no obvious abnormality is detected, follow the root
around the pedicle or even outside the canal in search of
fragments that may have migrated far laterally. Additional
searching in the root axilla helps ensure that fragments that
have migrated inferiorly are not missed. If the expected
pathology is not found, obtain another roentgenogram with
a blunt dissector at the level of the disc to be certain of the
proper level and review preoperative imaging studies to

confirm proper sidedness.
If the herniated fragment is especially large, it is much
better to sacrifice a portion of the facet to obtain a more
lateral exposure than to risk injury to the root or cauda
equina by excessive medial retraction. With such a lateral
exposure the nerve root usually can be elevated, and the
herniated fragment can be teased from beneath the nerve
root and cauda equina, even when the fragment is large
enough to block the entire canal. If the fragment is very
large as with cauda equina lesions typically, a bilateral
laminectomy is preferred to allow safer removal. If the disc
cannot be teased from under the root, make a cruciate
incision in the disc laterally. Gently remove disc fragments
until the bulge has been decompressed to allow gentle
retraction of the root over the defect.
If the herniation is upward or downward, further removal
of bone from the lamina and facet edges may be required.
The herniated nucleus pulposus may be covered by a layer
of posterior longitudinal ligament or may have ruptured
through this structure. In the latter event, carefully lift the
loose fragments out by suction, blunt hook, or pituitary
forceps. If the ligament is intact, incise it in a cruciate
fashion and remove the loose fragments. The tear or hole in
the annulus should then be identifiable in most instances.
The cavity of the disc can be entered through this hole, or
occasionally the hole may need to be enlarged to allow
insertion of the pituitary forceps. Remember that the
anterior part of the annulus is adjacent to the aorta, vena
cava, or iliac arteries and veins and that one of these
structures can be injured if one proceeds too deeply.
Remove other loose fragments of nucleus pulposus with the
pituitary forceps and remove additional nuclear material
along with the central portion of the cartilaginous plates,
both above and below as necessary.
When placing instruments into the disc space do not
penetrate beyond a depth of 15 mm to avoid injury to the
anterior viscera. Then carry out a complete search for
additional fragments of nucleus pulposus, both inside and
outside the disc space. Additional fragments commonly
migrate medially beneath the posterior longitudinal ligament but outside the annulus and can easily be missed. Then
remove all cotton pledgets and control residual bleeding
with Gelfoam and bipolar cautery. Forcefully irrigate any
loose fragments from the disc space using a syringe with a
spinal needle placed into the disc space under direct vision
until no fragments are returned with the irrigating solution.
Close the wound routinely with absorbable sutures in the
supraspinous ligament and subcutaneous tissue. Various
absorbable sutures are most commonly used in routine skin
closure. Staples are avoided for patient comfort.
AFTERTREATMENT. Neurological function is closely monitored after surgery. The patient is allowed to turn in bed at will
and to select a position of comfort such as a semi-Fowler
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position. Pain should be controlled with oral medication.

Muscle relaxants are used postoperatively as well. Bladder
stimulants can be used to assist voiding. The patient is allowed
to stand with assistance on the evening after surgery to go to the
bathroom. Discharge is permitted when the patient is able to
walk and void. Currently most patients are discharged within
24 hours after surgery. Isometric abdominal and lower
extremity exercises are started. The patient is instructed to
minimize sitting and riding in a vehicle. Increased walking on
a daily basis is recommended. Lifting, bending, and stooping
are prohibited for the first several weeks. As the patients
strength increases, gentle isotonic leg exercises are started.
Between the fourth and sixth postoperative week, back
school instruction is resumed or started, provided that pain is
minimal. Lifting, bending, and stooping are gradually restarted
after the sixth week. Increased sitting is allowed as pain
permits, but long trips are to be avoided for at least 4 to 6
weeks. Lower extremity strength is increased from the eighth to
twelfth postoperative weeks. Patients with jobs requiring much
walking without lifting are allowed to return to work within 2
to 3 weeks. Patients with jobs requiring prolonged sitting
usually are allowed to return to work within 4 to 6 weeks
provided minimal lifting is required. Patients with jobs
requiring heavy labor or long periods of driving are not allowed
to return to work until 6 to 8 weeks and then to a modified duty.
Some patients with jobs requiring exceptionally heavy manual
labor may have to permanently modify their occupation or seek
a lighter occupation. Keeping the patient out of work beyond
3 months rarely improves recovery or pain relief.
Microlumbar Disc Excision

Microlumbar disc excision has replaced the standard open
laminectomy as the procedure of choice for herniated lumbar
disc. This procedure can be done on an outpatient basis and
allows better lighting, magnification, and angle of view with a
much smaller exposure. Because of the limited dissection
required there is less postoperative pain and a shorter hospital
stay. Zahrawi reported 103 outpatient microdiscectomies,
noting 88% excellent and good results in the 83 who responded.
Newman reported 75 conventional laminectomies done on an
outpatient basis and noted 2 complications unrelated to the
procedure or the outpatient setting. Kelly et al. noted less
pulmonary morbidity and temperature elevation in patients
after microlumbar discectomy. Numerous other investigators
such as Silvers, Zahrawi, Lowell et al., and Moore et al.
reported excellent results with low morbidity and early return
to activity using microlumbar disc excision. Williams, the
originator of the term, questioned its current usage, since the
concept of the technique has changed over the years.
Microlumbar discectomy requires an operating microscope
with a 400-mm lens, special retractors, a variety of smallangled Kerrison rongeurs of appropriate length, micro instruments, and preferably a combination suctionnerve root
retractor. The procedure is performed with the patient prone. A
vacuum pack is molded around the patient, and an inflatable
pillow is positioned under the abdomen and is removed after
evacuation of the vacuum pack. Alternatively, the Andrews

type frame previously described can be used. The microscope
can be used from skin incision to closure. However, the initial
dissection can be done under direct vision. A lateral
roentgenogram is taken to confirm the level.
TECHNIQUE 39-22 (Williams, Modified)
Make the incision from the spinous process of the upper
vertebra to the spinous process of the lower vertebra at the
involved level. This usually results in a 1-inch (2.5-cm) skin
incision (Fig. 39-42). Maintain meticulous hemostasis with
electrocautery as the dissection is carried to the fascia.
Incise the fascia at the midline using electrocautery. Then
insert a periosteal elevator in the midline incision. Using
gentle lateral movements separate the deep fascia and
muscle subperiosteally from the spinous processes and
lamina. Obtain a lateral roentgenogram with a metal clamp
attached to the spinous process to verify the level. Now,
using a Cobb elevator gently sweep the remaining muscular
attachments off in a lateral direction exposing the interlaminar space and the edge of each lamina. Meticulously
cauterize all bleeding points. Insert the microlumbar
retractor into the wound and adjust the microscope. Identify
the ligamentum flavum and lamina. Use a pituitary rongeur
to remove the superficial leaf of the ligamentum. Using a no.
15 blade with the microscope, carefully incise the thinned
ligamentum flavum superficially. Then use a Penfield no. 4
dissector to perforate the ligamentum. Minimal force should
be used in this maneuver to prevent penetration of the dura.
Once the ligamentum is open, use a 45-degree Kerrison
rongeur to remove the ligamentum flavum laterally. The
lamina, facet, and facet capsule should remain intact.
However, one must remove the ligamentum flavum and
bone from the lamina as needed to clearly identify the nerve
root. Once identified, carefully mobilize the root medially;
this may require some bony removal. Gently dissect the
nerve free from the disc fragment to avoid excessive traction
on the root. Bipolar cautery for hemostasis is very helpful.
Once mobilized, retract the root medially. Maintain the
orientation of the Kerrison parallel to that of the nerve root
at all times. Once identified, the nerve root can be gently
mobilized and retracted medially. Then make an extradural
exploration using a 90-degree hook. In large herniations the
nerve root appears as a large, white, glistening structure and
can easily be mistaken for a ruptured disc. Follow the root
to the pedicle if necessary to be certain of its location. The
small opening and magnification can make the edge of the
dural sac appear as the nerve root. When using bipolar
cautery make sure only one side is in contact with the nerve
root to avoid thermal injury to the nerve. Also, when using
a Kerrison rongeur for bone or ligamentum removal, orient
it parallel to the course of the nerve root as much as possible
to minimize the risk of nerve root or dural injury. Epidural
fat is not removed in this procedure. Insert the suctionnerve
root retractor, with its tip turned medially under the nerve
root, and hold the manifold between the thumb and index
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L3
L4
L5
Ligamentum
flavum
Spinous
process
Penfield no. 4
dissector
Spinous
process
Lamina
Ilium
Lamina
Facet joint
capsule
Sacrum
Micro 45-degree angle

Kerrison rongeur
Ligamentum
flavum
Spinous
process
Nerve
root
Suction
retractor
Penfield no. 4 dissector

(into opening in HNP)
Lamina
Lamina
Lamina
Lamina
Facet
Spinous process
Disc forceps
Suction
retractor
Fig. 39-42 Microlumbar disc excision. A, Position of

skin incision for microlumbar disc excision. B, Entrance
of epidural space by penetration of ligamentum flavum.
C, Removal of ligamentum flavum with Kerrison rongeur.
D, Dilation of annular defect before removal of disc fragment. E, Decompression of disc hernia by repeated small
evacuations with discectomy forceps. (Redrawn from
Cauthen JC: Lumbar spine surgery, Baltimore, 1983,
Williams & Wilkins.)
finger. With the nerve root retracted, the disc will now be
visible as a white, fibrous, avascular structure. Small tears
may be visible in the annulus under the magnification. Now
enlarge the annular tear with a Penfield no. 4 dissector and
remove the disc material with the microdisc forceps. Do not
Nerve
root
Nerves E
Disc
Vertebra
insert the instrument into the disc space beyond the angle of
the jaws, which usually is about 15 mm, to minimize the risk
of anterior perforation and vascular injury. Remove the
exposed disc material. Do not curet the disc space. Inspect
the root and adjacent dura for disc fragments. Irrigate the
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disc space using a lock syringe and 18-gauge spinal needle

inserted into the disc space. Obtain meticulous hemostasis.
If the expected pathology is not found, review preoperative
imaging studies for level and sidedness. Also obtain a repeat
roentgenogram with a metallic marker at the disc level to
verify the level. Be aware of bony anomalies that may alter
the numbering of the vertebrae on imaging studies. Close
the fascia and the skin in the usual fashion, using absorbable
sutures.
AFTERTREATMENT. Postoperative care is similar to that

after standard open disc surgery. Typically this procedure is
done on an outpatient basis. Injecting the paraspinal muscles
on the involved side with Bupivacaine 0.5% with epinephrine
at the beginning of the procedure and additional Bupivacaine
at the conclusion aids patient mobilization immediately
postoperatively.
L4
2009
L4 root
L4-L5 disc
L5
Fig. 39-43 Lateral approach for discectomy. L4 foraminotomy

allows exposure of root. (Redrawn from Donaldson WF et al: Spine
18:1264, 1993; original by P Gretsky.)
Endoscopic Techniques
Endoscopic techniques have been developed over the past
several years with the purported advantage of shortened
hospital stay and faster return to activity. These techniques
generally are variations of the microdiscectomy technique
using an endoscope rather than the microscope and different
types of retractors. Thus far the purported advantages have not
been demonstrated. This remains another alternative technique.
Each system is somewhat unique, and the reader is referred to
the technique guide of the various manufacturers for details.
The basic principles remain the same as with microdiscectomy.
Additional Exposure Techniques

A large disc herniation or other pathological condition such
as lateral recess stenosis or foraminal stenosis may require a
greater exposure of the nerve root. Usually the additional
pathological condition can be identified before surgery. If the
extent of the lesion is known before surgery, the proper
approach can be planned. Additional exposure includes
hemilaminectomy, total laminectomy, and facetectomy. Hemilaminectomy usually is required when identifying the root is
a problem. This may occur with a conjoined root. Total
laminectomy usually is reserved for patients with spinal
stenoses that are central in nature, which occurs typically in
cauda equina syndrome. Facetectomy usually is reserved for
foraminal stenosis or severe lateral recess stenosis. If more than
one facet is removed, then a fusion should be considered in
addition. This is especially true in the removal of both facets
and the disc at the same interspace in a young, active person
with a normal disc height at that level.
On rare occasions disc herniation has been reported to be
intradural. An extremely large disc that cannot be dissected
from the dura or the persistence of an intradural mass after
dissection of the disc should alert one to this potential problem.
Excision of an intradural disc requires a transdural approach,
which increases the risk of complications from CSF leak and
intradural scarring.
A disc that is far lateral may require exposure outside the

spinal canal. This area is approached by removing the
intertransverse ligament between the superior and inferior
transverse processes lateral to the spinal canal. The disc hernia
usually is anterior to the nerve root that is found in a mass of
fat below the ligament. A microsurgical approach or a percutaneous approach are good methods for dealing with this
problem. Maroon et al. also recommended discography to
confirm the lesion before surgery. Epstein noted little difference
between lateral intertransverse exposure, facetectomy, and a
more extensive hemilaminectomy with medial facetectomy.
Donaldson et al. recommended the lateral approach after first
finding the root medially and dissecting laterally down to a
probe on top of the root (Fig. 39-43), and Strum et al.
recommended an anterolateral approach.
Lumbar Root Anomalies

Lumbar nerve root anomalies (Figs. 39-44 to 39-47) are
more common than may be expected, and they rarely are
correctly identified with myelography. Kadish and Simmons
identified lumbar nerve root anomalies in 14% of 100 cadaver
examinations. They noted nerve root anomalies in only 4% of
100 consecutive metrizamide myelograms. They identified four
types of anomalies. Type I is an intradural anastomosis between
rootlets at different levels. Type II is an anomalous origin of the
nerve roots. They separated this type into four subtypes:
(1) cranial origin, (2) caudal origin, (3) combination of cranial
and caudal origin, and (4) conjoined nerve roots. Type III is an
extradural anastomosis between roots. Type IV is the extradural
division of the nerve root. The surgeon must be aware of the
possibility of anomalous roots hindering the disc excision. This
may require a wider exposure. Sectioning of these roots results
in irreversible neurological damage. Traction on anomalous
nerve roots has been suggested as a cause of sciatic symptoms
without disc herniation.
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Fig. 39-44 Type I nerve root anomaly: intradural anastomosis.

(From Kadish LJ, Simmons EH: J Bone Joint Surg 66B:411, 1984.)
Results of Open (Micro or Standard) Surgery

for Disc Herniation
Numerous retrospective and some prospective reviews of
open disc surgery are available. The results of these series vary
greatly with respect to patient selection, treatment method,
evaluation method, length of follow-up, and conclusions. Good
results range from 46% to 97%. Complications range from
none to over 10%. The reoperation rate ranges from 4% to over
20%. The detailed studies of Spangfort, Weir, and Rish are
suggested for more detailed analysis. A comparison between
techniques also reveals similar reports.
Several points do stand out in the analysis of the results of
lumbar disc surgery. Patient selection appears to be extremely
important. Several studies noted that a low educational level is
significantly related to poor results of surgery. The works of
Wiltse and Rocchio, and Gentry indicate that valid results of the
MMPI (hysteria and hypochondriasis T scores) are very good
indicators of surgical outcome regardless of the degree of the
pathological condition. The extremely detailed work of Weir
suggests that the duration of the current episode, the age of the
patient, the presence or absence of predominant back pain,
the number of previous hospitalizations, and the presence or
absence of compensation for a work injury are factors affecting
final outcome. Spangforts work also indicates that the softer
the findings for disc herniation clinically and at the time of
surgery, the lower the chance for a good result.
Fig. 39-45 Type II: anomalous origin of nerve roots. A, Cranial

origin. B, Caudal origin. C, Closely adjacent nerve roots. D, Conjoined nerve roots. (From Kadish LJ, Simmons EH: J Bone Joint
Surg 66B:411, 1984.)
Fig. 39-46 Type III nerve root anomaly: extradural anastomosis.

Complications of Open Disc Excision

The complications associated with standard disc excision
and microlumbar disc excision are similar. Spangforts series
(Table 39-9) of 2503 open disc excisions lists a postoperative
mortality of 0.1%, a thromboembolism rate of 1.0%, a
postoperative infection rate of 3.2%, and a deep disc space
infection rate of 1.1%. Postoperative cauda equina lesions
developed in five patients. Laceration of the aorta or iliac artery

also has been described as a rare complication of this operation.
Rish, in a more recent report with a 5-year follow-up, noted a
total complication rate of 4% in a series of 205 patients. The
major complication in his series involved a worsening
neuropathy postoperatively. There was one disc space infection
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Fig. 39-47 Type IV nerve root anomaly: extradural division.

Table 39-9
Complications of Lumbar Disc

Surgery
Complication
Incidence (%)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
0.2
1.0
0.4
2.2
0.07
2.0 (1122 patients)
1.6
0.5
*
*
*
Cauda equina syndrome

Thrombophlebitis
Pulmonary embolism
Wound infection
Pyogenic spondylitis
Postoperative discitis
Dural tears
Nerve root injury
Cerebrospinal fluid fistula
Laceration of abdominal vessels
Injury to abdominal viscera
Modified from Spangfort EV: Acta Orthop Scand Suppl 142:65, 1972.
*Rare occurrence (numbers 10 and 11 not identified in Spangforts study but
reported elsewhere).
and one wound infection. Dural tears with CSF leaks,

pseudomeningocele formation, CSF fistula formation, and
meningitis also are possible but are more likely after reoperation. The complications of microlumbar disc excision
appear to be lower than with standard laminectomy. Alexander
reviewed patients who had sustained incidental durotomy at the
time of disc surgery and found no perioperative morbidity or
compromise of results if the dura was repaired. They noted a
4% incidence of this complication in 450 discectomies.
The presence of a dural tear or leak results in the potentially
serious problems of pseudomeningocele, CSF leak, and
meningitis. Eismont, Wiesel, and Rothman suggested five basic
principles in the repair of these leaks (Fig. 39-48):
1. The operative field must be unobstructed, dry, and well
exposed.
2. Dural suture of a 4-0 or 6-0 gauge with a tapered or
reverse cutting needle is used in either a simple or
running locking stitch. If the leak is large or inaccessible,
2011
a free fat graft or fascial graft can be sutured to the dura.

Fibrin glue applied to the repair also is helpful but will
not seal a significant leak.
3. All repairs should be tested by using the reverse
Trendelenburg position and Valsalva maneuvers.
4. Paraspinous muscles and overlying fascia should be
closed in two layers with nonabsorbable suture used in a
watertight fashion. Drains should not be used.
5. Bed rest in the supine position should be maintained for
4 to 7 days after the repair of lumbar dural defects. A
lumbar drain should be placed if the integrity of the
closure is questionable.
The development of headaches on standing and a stormy
postoperative period should alert one to the possibility of an
undetected CSF leak. This can be confirmed by MRI studies.
The presence of glucose in drainage fluid is not a reliable
diagnostic test. On rare occasions a pseudomeningocele has
been implicated as a cause of persistent pain from pressure on
a nerve root by the cystic mass.
Dural Repair Augmented with Fibrin Glue

Dural repair can be augmented with fibrin glue. Pressure testing
of a dural repair without fibrin glue reveals that the dura is able
to withstand 10 mm of pressure on day 1 and 28 mm on day 7.
With fibrin glue the dura is able to withstand 28 mm on day 1
and 31 mm on day 7. Fibrin glue also can be used in areas of
troublesome bleeding or difficult access for closure such as the
ventral aspect of the dura.
TECHNIQUE 39-23
Mix 20,000 U of topical thrombin and 10 ml of 10 calcium
chloride. Draw the mixture up into a syringe. In another
syringe, draw 5 U of cryoprecipitate and inject equal
quantities of each onto the dural repair or tear. Allow the
glue to set to the consistency of Jello (Box 39-10).
Commercially available kits also are available.
Free Fat Grafting

Fat grafting for the prevention of postoperative epidural
scarring has been suggested by Kiviluoto; Jacobs, McClain,
and Neff; and Bryant, Bremer, and Nguyen. The study by
Jacobs et al. indicated that free fat grafts were superior to
Gelfoam in the prevention of postoperative scarring. The
current rationale for free fat grafting appears to be the possibility of making any reoperation easier. Unfortunately, the
benefit of reduced scarring and its relationship to the prevention
of postoperative pain have not been established, neither has the
increased ease of reoperation in patients in whom fat grafting
was performed. Caution should be taken in applying a fat graft
to a large laminar defect because this has been reported to result
in an acute cauda equina syndrome in the early postoperative
period. We currently reserve the use of a fat graft (or fascial
grafts) for dural repairs and small laminar defects where the
graft is supported by the bone. A study by Jensen et al. found
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Fig. 39-48 A, Illustration of dural

repair using running-locking dural
suture on taper or reverse-cutting,
one-half-circle needle. A smallersized suture should be used. Use
of suction with sucker and small
cotton pledgets is essential to protect nerve roots while operative field
is kept dry of CSF. B, Single dural
stitches can be used to achieve
closure, each suture end being left
long. Second needle then is attached
to free suture end, and ends of suture are passed through piece of
muscle or fat, which is tied down
over repaired tear to help to achieve
watertight closure. Whenever dural
material is inadequate to allow
closure without placing excessive
pressure on underlying neural
tissues, free graft of fascia or fascia
lata, or freeze-dried dural graft,
should be secured to margins of
dural tear using simple sutures of
appropriate size. C, For small dural
defects in relatively inaccessible
areas, transdural approach can be
used to pull small piece of muscle
or fat into defect from inside out,
thereby sealing CSF leak. Central durotomy should be large
enough to expose defect from dural
sac. Durotomy is then closed in
standard watertight fashion. (From
Eismont FJ, Wiesel SW, Rothman RH: J Bone Joint Surg 63A:
1132, 1981.)
BOX 39-10 Fibrin Glue
the patient is thin, a separate incision over the buttock may be

required to get sufficient fat to fill the defect.
INGREDIENTS
Two vials of topical thrombin, 10,000 U each
10 ml of calcium chloride
5 U of cryoprecipitate
Two 5-ml syringes
Two 22-gauge spinal needles
INSTRUCTIONS
Do not use saline that comes with thrombin
Mix thrombin and calcium chloride
Draw mixture into syringe
Draw cryoprecipitate into second syringe
Apply equal amounts to area of need
Allow to set to a Jello consistency
that fat grafts decreased the dural scarring but not radicular scar
formation. The clinical outcome was not improved.
The technique of free fat grafting is straightforward. At the
end of the procedure, just before closing, take a large piece of
subcutaneous fat and insert it over the laminectomy defect. If
CHEMONUCLEOLYSIS
CHEMONUCLEOLYSIS
Chemonucleolysis has been used in the United States for more
than 30 years. The enzyme was released for general use by the
Food and Drug Administration (FDA) in December of 1982.
Before its release in the United States it was used extensively
in Europe and Canada. A wealth of experimental and clinical
information exists concerning the technique and the enzyme.
Specific guidelines have been suggested by the FDA regarding
the use of the enzyme in the United States. The initial
enthusiasm for the use of chymopapain has all but vanished in
the United States; however, the use of this enzyme is still
popular in Europe and elsewhere, with therapeutic results
similar to surgery.
Because of the disclosure of neurological sequelae and other
complications, the original guidelines issued in January of 1983
were radically changed. Those interested in performing the
technique should contact the pharmaceutical companies that
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Table 39-10
2013
Results and Complications of Chemonucleolysis and Open Disc Excision

Results (percent)
Technique
Year
Open Disc
Semmes
1955
Spangfort
1972
Weir
1979
Rish
1984
Chemonucleolysis
Illinois trial
1982
Javid
1983
Nordby
1983
No.
Performed
Excellent
Partial/
Good
None
Worse
Complications
Reoperation
1440
2503
100
57
53.6
76.9
73.0
74.0
43.3
17.0
22.0
17.0
1.7
5.0
3.0
9.0
1.4
0.5
1.0
NA
8.0
NA
4.0
6.3
273
40
641
90.0
82.0
55.0
10.0
18.0
25.0
produce the drug for information regarding training and

certification in the technique. Treating physicians also are
encouraged to frequently check the package insert accompanying the drug and the information bulletins sent out by the
FDA and the pharmaceutical companies regarding any new
changes in the protocol or use of the enzyme. Careful patient
selection and proficiency in performing this procedure are
mandatory.
The indications for the use of chemonucleolysis are the
same as for open surgery for disc herniation. Fraser reported the
results of 60 patients treated for lumbar disc herniation in a
2-year double-blind study of chemonucleolysis. At 2 years 77%
of the patients treated with chymopapain were improved,
whereas only 47% of the saline injection group were improved.
At 2 years from injection 57% of the chymopapain group were
pain-free compared with 23% of the placebo group. Numerous
other studies of the efficacy of the drug place the good or
excellent results between 40% and 89%, which is comparable
to the clinical reports for open surgery (Table 39-10).
Tregonning et al. reviewed 145 patients who had received
chymopapain injection and 91 patients who had laminectomy at
10-year follow-up and concluded that the surgically treated
group had slightly better results than the chymopapain group.
Javid compared 100 patients who had laminectomy with 100
patients who had chemonucleolysis and reported that patients
who had received chymopapain had better results with respect
to 6-month overall improvement, short-term improvement in
numbness and motor strength, and longer improvement in
sensory status. Also, chymopapain was significantly less
expensive than laminectomy. Nordby and Wright reviewed 45
clinical studies of chymopapain and laminectomy. They
concluded that chemonucleolysis was somewhat less effective
than open disc excision, but it did avoid the trauma of surgery
and postoperative fibrosis.
As with open disc surgery, this technique is not applicable in
all lumbar disc herniations. The use of the drug is limited to the
lumbar spine. The patient optimally has predominantly
unilateral leg pain and localized neurological findings consistent with confirmatory testing with MRI, CT, or myelogra-
Persistent
Back Pain
31.5
NA
18.0
1.1
20.0
NA
NA
phy. Patients with moderate lateral recess or foraminal stenosis

may worsen after the procedure because of collapse of the disc
space and narrowing of the foraminal opening. Large disc
herniations may not shrink sufficiently to result in relief of
symptoms, and sequestered discs may be untouched by the
enzyme. Smith et al. reported cauda equina syndromes in three
patients after chymopapain was injected after a myelogram
revealed a complete block.
Chymopapain injection is specifically contraindicated in
patients with a known sensitivity to papaya, papaya derivatives,
or food containing papaya, such as meat tenderizers. Other
contraindications include severe spondylolisthesis, severe,
progressive neurological deficit or paralysis, and evidence of
spinal cord tumor or a cauda equina lesion. The enzyme cannot
be injected in a patient who has been previously injected,
regardless of the level injected. Use of chymopapain is limited
to the lumbar intervertebral discs. Relative contraindications
include allergy to iodine or iodine contrast material, use of the
enzyme in a previously operated disc, patients with elevated
allergy studies such as radioallergosorbent (RAST), ChymoFast, and skin testing with the drug, and patients with a severe
allergic history, especially with a previous anaphylactic attack.
Spinal Instability from Degenerative

Disc Disease
Spinal Instability from Degenerative
Disc Disease
Farfan defined spinal instability (caused by degenerative disc
disease) as a clinically symptomatic condition without new
injury, in which a physiological load induces abnormally large
deformations at the intervertebral joint. Biomechanical studies
have revealed abnormal motion at vertebral segments with
degenerative discs and the transmission of the load to the facet
joints. Numerous attempts at roentgenographic definition of
spinal instability with disc disease have resulted in more
controversy than agreement as to a standard method of
measurement. The method described by Knutsson is simple and
relatively efficient in determining anteroposterior motion. The
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Fig. 39-49 Loss of motion segment integrity. A, Translation.

B, Angular motion. (From American Medical Association:
Guide to the evaluation of permanent impairment, ed 4, Chicago,
1993, AMA.)
fourth edition of the American Medical Association Guide to

the Evaluation of Permanent Impairment defined instability as
an anterior slip of 5 mm or more in the thoracic or lumbar spine
(Fig. 39-49, A) or a difference in the angular motion of two
adjacent motion segments more than 11 degrees from T1 to L5
and motion greater than 15 degrees at L5-1 compared with L4-5
(Fig. 39-49, B). There is little controversy as to the surgical
treatment of lumbar spinal instability and spinal fusion of the
unstable segments. The type of fusion performed and the
indications for fusion are areas of controversy.
The major problem in spinal instability is the correlation of
the patients symptoms of giving way, catching, and predominant back pain to the roentgenographic identification of
instability. Other factors such as concomitant spinal stenosis,
disc herniation, and psychological problems only complicate
any evaluation of spinal instability. Currently the decision for
surgery for clinically significant lumbar spine instability caused
by degenerative disc disease should be made on an individual
patient basis with all the factors and risks weighed carefully.
DISC EXCISION AND FUSION

DISC EXCISION AND FUSION
The necessity of lumbar fusion at the same time as disc excision
was first suggested by Mixter and Barr. In the first 20 years after
their discovery the combination of disc excision and lumbar
fusion was common. More recent data comparing disc excision
alone with the combination of disc excision and fusion by
Frymoyer et al. and others indicate that there is little if any
advantage to the addition of a spinal fusion to the treatment of
simple disc herniation. These studies do indicate that spinal
fusion increases the complication rate and lengthens recovery.
The indications for lumbar fusion should be independent of the
indications for disc excision for sciatica.
LUMBAR
LUMBAR VERTEBRAL
VERTEBRAL INTERBODY
INTERBODY FUSION
FUSION
Anterior lumbar intervertebral fusion (ALIF) and posterior
lumbar intervertebral fusion (PLIF) have been suggested as
definitive procedures for lumbar disc disease. Biomechanically
the lumbar interbody fusion offers the greatest stability. It
also eliminates the disc segment as a further source of pain.
The primary problems are the more involved and potentially dangerous dissection, the risk of graft extrusion, and
pseudarthrosis.
Most series of these fusions include a significant number of
salvage procedures and complex pathological conditions, thus
making direct comparison with primary disc surgery difficult.
The routine use of such procedures for simple lumbar disc
herniation with sciatica is not justified.
Most often, different types of grafts are taken from the iliac
crest; however, hollow, perforated cylinders filled with
autologous bone are now available for use in posterior and
anterior lumbar intervertebral fusion. These cylinders are not
indicated for spondylolisthesis greater than grade 1, osteopenia,
malignancy, or gross obesity. Kuslich and Dowdle reported
98% fusion at one level anteriorly and 89% fusion at two levels
with a slightly better functional improvement than the fusion
rates using this device. This device also can be introduced by
a percutaneous, laparoscopic anterior approach. The laparoscopic approach requires a team consisting of a laparoscopic
general surgeon, spine surgeon, anesthesiologist, camera
operator, scrub nurse, circulating nurse, and a radiology
technician. It is strongly advised that the team attend a course
on this technique or observe several cases before attempting
such a procedure.
Anterior Lumbar Interbody Fusion

TECHNIQUE 39-24
Place the patient supine on a radiolucent operating table.
Support the lumbar spine with a rolled sheet or inflatable
bag. Prepare and drape the patients abdomen from upper
chest to groin, leaving the iliac crests exposed for obtaining
bone grafts. Expose the lumbar spine through a transabdominal or retroperitoneal approach as desired. Mobilize the
great vessels over the segment to be excised. Ligate the
median artery and vein at the bifurcation of the aorta to
prevent tearing this structure when exposing the disc at L4-5
or L5-S1.
Identify and inspect all major structures before and after
disc excision and fusion. Use anteroposterior fluoroscopy to
confirm the proper disc level. Then incise the anterior
longitudinal ligament superiorly or inferiorly over the edge
of the vertebral body. Elevate the ligament as a flap if
possible. Next remove the annular and nuclear material of
the disc. The use of magnification can be beneficial as the
dissection nears the posterior longitudinal ligament. Remove all nuclear material from the disc space.
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A
Fig. 39-50 Anterior lumbar intervertebral fusion (ALIF) can be performed using tricortical iliac
crest graft (A) or fibular grafts (B). (A from Ruge D, Wiltse LL: Spinal disorders: diagnosis and
treatment, Philadelphia, 1977, Lea & Febiger; B from Wiltse LL: Instr Course Lect 28:207, 1979.)
Techniques for fusion vary. Some prefer to use dowel

grafts to fill the space. Others prefer to use tricortical iliac
grafts (Fig. 39-50). Obtain the grafts from the iliac crest as
described for anterior cervical fusions (Chapter 36). Prepare
the graft area for the desired grafting technique. We prefer
tricortical grafts for this fusion. Good results using fibular
grafts and banked bone also have been reported. Prepare the
vertebrae by curetting the endplates to cancellous bone
posteriorly. Then carefully make a slot in the vertebra to
accommodate the grafts; use an osteotome slightly larger
than the width of the disc space for this purpose and direct
the cut toward the inferior vertebral body. Try to leave the
upper and lower lips of the vertebral bodies intact. Remove
enough tricortical iliac bone to allow insertion of at least
three individual grafts. Fashion the grafts to fit snugly in the
space with a laminar spreader in place. Insert the grafts so
that the cancellous portions face the decorticated endplates.
The grafts should be 3 to 4 mm shorter than the
anteroposterior diameter of the vertebral body. Impact the
grafts and seat them behind the anterior rim of the vertebral
bodies. Usually three such grafts can be inserted. Add
additional cancellous chips around the grafts. Suture the
anterior longitudinal ligament. Close the retroperitoneum
and abdomen in the usual manner.
AFTERTREATMENT. The patient is allowed to sit as soon as

possible. Extension of the lumbar spine is prohibited for at least
6 weeks. Bracing or casting is left to the discretion of the
surgeon after considering the stability of the grafts and
reliability of the patient.
Posterior Lumbar Interbody Fusion

TECHNIQUE 39-25 (Cloward)
Position the patient in the prone or kneeling position as
desired. Expose the spine through a midline incision
centered over the level of the pathological condition. Strip
the muscle subperiosteally from the lamina bilaterally. Insert
the laminar spreader between the spinous processes at the
level of pathological findings. Open and remove the
ligamentum flavum from the midline laterally. Enlarge
the opening laterally by removing the lower one third of the
inferior facet and the medial two thirds of the superior facet
(Fig. 39-51, A). The upper lamina also can be thinned by
undercutting to increase the anteroposterior diameter of the
canal. Retract the lower nerve root and dura to the midline
and protect it with the self-retaining nerve root retractor.
Cauterize the epidural vessels with bipolar cautery. Cut out
the disc and vessels over the annulus laterally. Remove as
continued
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Fig. 39-51 Posterior lumbar interbody fusion technique. A, Bilateral laminotomy with preservation
of facets. Control of epidural
hemorrhage. Dipolar or insulated
coagulation forceps are used on left
side. On right side, epidural hemorrhage is controlled by impacted
surgical tampons. Impacted surgical tampons also push nerve root
medially and expose disc space
without need for nerve root retractor. B, After intervertebral rims
are removed, cleavage of disc attachment to cortical plate is identified. Curved, up-bite curet is used
to remove concave centrum of
lower cartilaginous plate. Then
detached large chunks of disc
material are removed with rongeur.
C, Medial graft advancement with
single chisel. (From Cauthen JC:
Lumbar spine surgery, Baltimore,
1983, Williams & Wilkins.)
much disc material as possible (Fig. 39-51, B). Remove a

thin layer of the endplates posteriorly. Repeat this process
on the opposite side. Remove the remaining anterior edges
of the endplates to the anterior longitudinal ligament. This
must be done under direct vision to avoid injury to the great
vessels. Prepare a surface of bleeding cancellous bone on
both vertebral bodies. Obtain tricortical iliac crest grafts as
previously noted from the posterior iliac crest. (Cloward
used frozen human cadaver bone grafts.) Shape the grafts to
be slightly shorter and the same height or slightly higher
than the disc shape. Tamp the first graft in place and lever it
medially to allow insertion of the remaining grafts. Repeat
the procedure on the opposite side (Fig. 39-51, C). Remove
the laminar spreader and check the graft for stability.
Close the wound in the usual fashion.
AFTERTREATMENT. Aftertreatment is the same as for

lumbar discectomy (p. ). Early walking is encouraged.
Failed Spine Surgery

Failed Spine Surgery
One of the greatest problems in orthopaedic surgery and
neurosurgery is the treatment of failed spine surgery. Numerous
reasons for the failures have been advanced. The best results
from repeat surgery for disc problems appear to be related to
the discovery of a new problem or identification of a previously
undiagnosed or untreated problem. Waddell et al. suggested
that the best results from repeat surgery occur when the patient
had experienced 6 months or more of complete pain relief after
the first procedure, when leg pain exceeded back pain, and
when a definite recurrent disc could be identified. They
identified adverse factors such as scarring, previous infection,
repair of pseudarthrosis, and adverse psychological factors.
Similar factors were identified by Lehmann and LaRocca and
Finnegan et al. Satisfactory results from reoperation have been
reported to be from 31% to 80%. Patients should expect
improvement in the severity of symptoms rather than complete
relief of pain. As the frequency of repeat back surgeries
increases, the chance of a satisfactory result drops precipitously. Spengler et al. and Long et al. observed that the major
cause of failure is improper patient selection.
The recurrence or intensification of pain after disc surgery
should be treated with the usual conservative methods initially.
If these methods fail to relieve the pain, the patient should be
completely reevaluated. Frequently a repeat history and
physical examination will give some indication of the problem.
Additional testing should include psychological testing, myelography, MRI to check for tumors or a higher disc herniation,
and reformatted CT scans to check for areas of foraminal
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stenosis or for lateral herniation. The use of the differential

spinal, root blocks, facet blocks, and discograms also can help
identify the source of pain. The presence of abnormal
psychological test results or an abnormal differential spinal
should serve as a modifier to any suggested treatment indicated
by the other testing. Satisfactory nonoperative treatment of this
problem should be attempted before additional surgery is
performed, provided that this surgery is elective. A distinct,
surgically correctable, anatomical problem should be identified
before surgery is contemplated. The surgery should be tailored
specifically to the anatomical problem(s) identified.
REPEAT LUMBAR DISC SURGERY

REPEAT LUMBAR DISC SURGERY
The technique of repeat lumbar disc surgery at the same level
and side as the previous procedure is nearly the same as for
initial surgery. The procedure is longer and involves more
meticulous dissection.
TECHNIQUE 39-26
Approach the spine using the method described previously.
Identify normal tissue first. Use a curet to carefully remove
scar from the edges of the lamina. Then remove additional
bone as necessary to expose normal dura. Identify the
pedicles superiorly and inferiorly if there is any question of
position and status of the root. Carry the dissection from the
pedicles to identify each root. This will allow the
development of a normal plane between the dura and scar.
Maintain meticulous hemostasis with bipolar cautery. Then
remove disc material as indicated by the preoperative
evaluation. Meticulously check the roots, dura, and posterior
longitudinal ligament after removal of the offending disc
herniation. Spinal fusion is not performed unless an unstable
spine is created by the dissection or was identified
preoperatively as a correctable and symptomatic problem.
2017
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EPIDEMIOLOGY
AFTERTREATMENT. Aftertreatment is the same as for disc
excision (p. ).
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PERCUTANEOUS LUMBAR DISCECTOMY

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COMPLICATIONS OF LUMBAR SPINE SURGERY

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FAILED SPINE SURGERY

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Lower Back Pain and Disorders

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Lower Back Pain and Disorders

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C H A P T E R

Lower Back Pain and Disorders

Several physical maneuvers were devised to isolate the true

Copyright 2003. Elsevier Science (USA). All Rights Reserved.

@sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02

Pg: 1955 Team:

recognize the excised tissue as disc material and interpreted it

Fig. 39-1 Forty-year trends in chronic low back disability.

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Pg: 1956 Team:

C H A P T E R 3 9 Lower Back Pain and Disorders of Intervertebral Discs

pain in 1980. Because this company represents only 9% of the

ever, have found no relationship between obesity and back

General Disc and Spine Anatomy

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Pg: 1957 Team:

Fig. 39-2 Schematic representation of

21% loss in disc height after 6 hours of standing or sitting.

Fig. 39-3 Schematic representation of orientation of fibers in

of the disc is relatively high when its avascularity is considered

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Pg: 1958 Team:

C H A P T E R 3 9 Lower Back Pain and Disorders of Intervertebral Discs

Fig. 39-4 Discs are named for vertebral

pars interarticularis. Three branches from the dorsal ramus

Natural History of Disc Disease

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Pg: 1959 Team:

is dysfunction, which is seen in those 15 to 45 years of age. It

ing neural tissue in the late instability and early stabilization

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Pg: 1960 Team:

C H A P T E R 3 9 Lower Back Pain and Disorders of Intervertebral Discs

Phases of Spinal Degeneration

damage. Neumann et al. suggested that the amount of bone

Also, our understanding of certain pathophysiological entities

NONSPECIFIC LUMBAR PAIN

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Pg: 1961 Team:

Selective Indications for

Age >50 years

adolescents aged 13 to 16 years recorded low back pain in

Fig. 39-6 Diminishing chance of return to work with increasing

some patients. Another finding that is evident from the

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C H A P T E R 3 9 Lower Back Pain and Disorders of Intervertebral Discs

Classification for Spinal Nerve

SPINAL NERVE DEFORMATION IN LATERAL RECESS

1 year in a university hospital. Unfortunately, when these

facet syndrome and hypertrophic arthritis of the lumbar spine.

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Fig. 39-8 A, Anteroposterior roentgenogram of metrizamide

Arachnoiditis is a severe complication that has been

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