Revision Spine Surgery

Pearls and Pitfalls

 Revision Spine Surgery
Pearls and Pitfalls

Edited by
Gregory D. Schroeder, MD
Assistant Professor of Orthopaedic Surgery at Thomas Jefferson University,
Spine Surgeon at The Rothman Institute,
Philadelphia, Pennsylvania

Ali A. Baaj, MD
Associate Professor of Neurological Surgery
Co-Director, Spinal Deformity and Scoliosis Program, Weill Cornell Medical
College, New York-Presbyterian Hospital, New York City, New York

Alexander R. Vaccaro, MD, PhD, MBA

Richard H. Rothman Professor and Chairman,
Department of Orthopaedic Surgery, Professor of Neurosurgery,
Co-Director, Delaware Valley Spinal Cord Injury Center,
Co-Chief of Spine Surgery,
Sidney Kimmel Medical Center at Thomas Jefferson University,
President, Rothman Institute, Philadelphia, Pennsylvania
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Library of Congress Cataloging-in-Publication Data

Names: Vaccaro, Alexander R., editor. | Baaj, Ali A., editor. | Schroeder, Gregory D., editor.
Title: Revision spine surgery : pearls and pitfalls / edited by Alexander R. Vaccaro, Ali Baaj, Gregory D. Schroeder.
Other titles: Revision spine surgery (Vaccaro)
Description: Boca Raton : CRC Press, 2019. | Includes index.
Identifiers: LCCN 2019010037| ISBN 9781498773829 (hardback : alk. paper) | ISBN 9780429188848 (e-book)
Subjects: | MESH: Spine--surgery | Reoperation--methods | Spinal Diseases--surgery
Classification: LCC RD768 | NLM WE 725 | DDC 617.4/82--dc23
LC record available at https://lccn.loc.gov/2019010037

Visit the Taylor & Francis Web site at

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This book is dedicated to my wife Katie, and our three sons, Leo, Henry and Grant. Your support is an
incredible gift that I am blessed to have.
Gregory D. Schroeder

This book is dedicated to my beautiful daughter, Hannah, who has filled our hearts with endless joy.
Ali A. Baaj

This book is dedicated to my nephew Luke Vaccaro. There is a wise saying that the meaning of life is to find
your gift and the purpose of life is to give that gift away. Luke your gift is your courage, tenacity, resiliency
and love for family. Your parents are proud of you and you will always be a role model for your younger
brother Drew.
Alexander R. Vaccaro
Contents

Video list xi
Contributors xiii

GENERAL 1

1 The approach to revision procedures 3

Joseph A. Weiner and Wellington K. Hsu
2 How to dissect the plane between the scar of a laminectomy defect in the posterior
cervical spine 13
Ken Ishii
3 How to dissect the plane between the scar of a laminectomy defect in the posterior
thoracic and lumbar spine 19
Nickul S. Jain and Raymond J. Hah
4 Local muscle flaps in the setting of revision spine surgery: Indications, operative planning,
principles, and postoperative management 27
Briar L. Dent, Jaime L. Bernstein, and Jason A. Spector
5 Revision and reimplantation of a spinal cord stimulator device 35
Fadi Al-Saiegh, John M. DePasse, Francis J. Sirch IV,
Gregory D. Schroeder, and Chengyuan Wu

Part 1  ANTERIOR CERVICAL 39

6 Revision ACDF at the same level 41

Fadi Al-Saiegh, George M. Ghobrial, and James S. Harrop
7 Revision ACDF: Adjacent level 47
Courtney Pendleton, Matthew S. Galetta, and Jack Jallo
8 Converting a total disc replacement to an ACDF 51
Joseph D. Smucker and Rick C. Sasso
9 Treatment of adjacent segment disease after total disc replacement (TDR) 59
Bruce V. Darden II

vii
viii Contents

Part 2  POSTERIOR CERVICAL 65

10 Revision suboccipital decompression for complex Chiari malformation 67

Jacob L. Goldberg, Ibrahim Hussain, Ali A. Baaj, and
Jeffrey P. Greenfield
11 How to revise a failed occipital cervical fusion 77
Joshua T. Wewel, Mazda K. Turel, Joseph E. Molenda, and 
Vincent C. Traynelis
12 How to revise a failed C1–C2 fusion 83
Nizar Moayeri and Michael G. Fehlings
13 Treatment of postlaminectomy kyphosis 89
Christopher T. Martin and John M. Rhee
14 Revision of failed posterior cervical fusions 101
Trevor Mordhorst, Vadim Goz, and William Ryan Spiker
15 Complications necessitating surgical intervention following cervical laminoplasty 109
Michael J. Moses, Amos Z. Dai, and Themistocles S. Protopsaltis

Part 3 THORACIC/THORACOLUMBAR SPINE 115

16 Revision surgery for proximal junctional kyphosis following thoracolumbar fusion 117
Sundeep S. Saini, Daniel Cataldo, Christopher R. Cook, Hamadi Murphy,
Paul W. Millhouse, and Kris Radcliff
17 Pedicle subtraction osteotomy (PSO) nonunion revision 127
Jason W. Savage
18 Treatment of a nonunion of a thoracolumbar deformity, not at the site of a three-column
osteotomy 133
Randall B. Graham, Tyler R. Koski, and Patrick A. Sugrue
19 How to safely remove a pedicle screw abutting the aorta 145
Kevin Savage, Paul W. Millhouse, Hamadi Murphy, Gregory D. Schroeder,
and Alexander R. Vaccaro

Part 4  LUMBAR SPINE 149

20 Revision of an anterior lumbar interbody fusion (ALIF) nonunion 151

Edward Delsole, Rishi Sharma, and Gregory D. Schroeder
21 How to revise nonunion of a lateral lambar interbody fusion (LLIF) through a lateral approach 155
Heeren S. Makanji, Jacqueline Koomson, Dhruv K.C. Goyal, and
Gregory D. Schroeder
22 How to surgically manage a recurrent lumbar herniated nucleus pulposus (HNP) 161
Taylor Paziuk, Matthew S. Galetta, and Jeffrey A. Rihn
23 How to perform revision lumbar decompression 167
Jacob Hoffman, Ryan Murphy, Mark L. Prasarn, and 
Shah-Nawaz M. Dodwad
24 How to perform revision lumbar decompression at the index level through a minimally
invasive (MIS) approach 173
Aaron Hillis, Christoph Wipplinger, Sertac Kirnaz, Franziska A. Schmidt, and
Roger Härtl
 Contents ix

25 How to revise a transforaminal lumbar interbody fusion (TLIF) nonunion with recurrent
stenosis at the index level (open) 183
Jesse E. Bible and Gregory Pace
26 How to revise a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF)
nonunion with recurrent stenosis at the index level through an MIS approach 191
Fady Y. Hijji, Ankur S. Narain, Gregory D. Lopez, Krishna T. Kudaravalli,
Kelly H. Yom, and Kern Singh
27 How to revise a posterior lateral decompression and fusion at the index level 199
Fadi Sweiss, Cristian Gragnaniello, Anthony J. Caputy, and Michael Rosner
28 How to revise a posterior lumbar fusion that has developed adjacent-level stenosis with
or without instability 205
Patrick Curry and Mark F. Kurd
29 Flat back deformity revision surgery 211
Jefferson Wilson, Matthew S. Galetta, and Srinivas Prasad
30 Revision high-grade spondylolisthesis surgery 217
Peter D. Angevine
31 Management of a ventrally displaced graft following ALIF, TLIF or DLIF 223
Dhruv K.C. Goyal, Heeren S. Makanji, Gregory D. Schroeder, and 
Brian W. Su

Part 5  SPECIAL CASES 229

32 Treatment of symptomatic cervical and lumbar pseudomeningocoeles 231

Joshua E. Heller and George Rymarczuk
33 Treatment of a persistent cervical dural tear 241
Jessica L. Block and D. Greg Anderson
34 Treatment of a ventral thoracic dural defect 245
Ibrahim Hussain, Peter F. Morgenstern, and Ali A. Baaj
35 Treatment of a persistent lumbar dural tear 251
Joseph S. Butler, Matthew S. Galetta, and Barrett I. Woods
36 Treatment of a chronic postoperative cervical and lumbar spine infection 255
Kamil Okroj and Christopher Kepler

Index 261
Video list

Video 6.1 ACDF Revision Same Level https://youtu.be/vYsMl-9KIUs

Video 7.1 ACDF Revision ASD https://youtu.be/ie59oxSEiuM
Video 11.1 Failed OC Fusion https://youtu.be/giUNd1w1mDI
Video 15.1 Protopsaltis French Door Laminoplasty https://youtu.be/Yhy2SiA6hJ4
Video 16.1 PJK Correction Video https://youtu.be/9yVJRzCM1GI

xi
Contributors

D. Greg Anderson md Jessica L. Block bs

Departments of Orthopaedics and Neurological Drexel University College of Medicine
Surgery Philadelphia, Pennsylvania
Rothman Institute
Joseph S. Butler phd, frcs
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania
Thomas Jefferson University
Peter D. Angevine md, mph Philadelphia, Pennsylvania
Associate Professor
Anthony J. Caputy md
Quality Chair
Department of Neurosurgery
Department of Neurological Surgery
George Washington University School of
Columbia University
Medicine & Health Sciences
Daniel and Jane Och Spine Hospital
George Washington University
New York City, New York
Washington, DC
Ali A. Baaj md
Daniel Cataldo do
Associate Professor of Neurological
Orthopedic Spine Surgery Fellow
Surgery Co-Director
Icahn School of Medicine at Mount Sinai
Spinal Deformity and Scoliosis Program Weill
New York City, New York
Cornell Medical College
New York-Presbyterian Hospital Christopher R. Cook do
New York City, New York Orthopedic Spine Surgeon
Graves Gilbert Clinic
Jaime L. Bernstein md
Western Kentucky Orthopaedic and
Division of Plastic Surgery
Neurosurgical Associates
New York–Presbyterian Hospital/Weill Cornell
Bowling Green, Kentucky
Medicine
New York City, New York Patrick Curry md
Western Orthopaedics
Jesse E. Bible md
Denver, Colorado
Assistant Professor
Department of Orthopaedics and Amos Z. Dai md
Rehabilitation Department of Orthopaedic Surgery
Pennsylvania State University New York University
Milton S. Hershey Medical Center Langone Medical Center
Hershey, Pennsylvania New York City, New York

xiii
xiv Contributors
Bruce V. Darden, II md
OrthoCarolina Spine Center
Charlotte, North Carolina
Edward Delsole md
Department of Orthopaedic Surgery
Rothman Orthopaedic Institute
Thomas Jefferson University
Philadelphia, Pennsylvania
Briar L. Dent md
Division of Plastic Surgery
New York-Presbyterian Hospital/Weill Cornell
Medicine
New York City, New York
John M. DePasse md
Department of Orthopaedic Surgery
Rothman Institute
Thomas Jefferson University
Philadelphia, Pennsylvania
Shah-Nawaz M. Dodwad md
Department of Orthopaedic Surgery
University of Texas Health Sciences Center at
Houston
Houston, Texas
Michael G. Fehlings md, phd, frcsc
Division of Neurosurgery
Toronto Western Hospital
University Health Network
and
Department of Surgery
University of Toronto
Toronto, Canada
Matthew S. Galetta ba
Department of Orthopaedic Surgery
Rothman Institute
Merion Station, Pennsylvania
George M. Ghobrial md
Department of Neurological Surgery
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Jacob L. Goldberg md
Department of Neurological Surgery
Weill Cornell Brain and Spine Center
New York, New York
Dhruv K.C. Goyal ba
Department of Orthopaedic Surgery
Rothman Orthopaedic Institute
Thomas Jefferson University
Philadelphia, Pennsylvania
Vadim Goz md
Department of Orthopaedics
University of Utah School of Medicine
Salt Lake City, Utah
Cristian Gragnaniello md, phd
Department of Neurosurgery
George Washington University
Washington, DC
Randall B. Graham md
Department of Neurological Surgery
Northwestern University
Feinberg School of Medicine
Chicago, Illinois
Jeffrey P. Greenfield md, phd
Pediatric Neurological Surgery
Weill Cornell Brain and Spine Center
New York, New York
Raymond J. Hah md
Assistant Professor of Orthopaedic Surgery and
Neurosurgery
Keck School of Medicine
University of Southern California
Los Angeles, California
James S. Harrop md
Professor of Neurological Surgery and Orthopedics
Department of Neurological Surgery
Division of Spine and Peripheral Nerve Surgery
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Roger Härtl md
Department of Neurological Surgery
Weill Cornell Brain and Spine Center
New York-Presbyterian Hospital/Weill Cornell
Medicine
New York City, New York
Joshua E. Heller md, mba
Department of Orthopaedic Surgery
Rothman Institute
Thomas Jefferson University
Philadelphia, Pennsylvania
 Contributors xv

Aaron Hillis, md Sertac Kirnaz md

Department of Neurological Surgery
Weill Cornell Brain and Spine Center
New York-Presbyterian Hospital/Weill Cornell
Medicine
New York City, New York
Department of Neurological Surgery
Weill Cornell Brain and Spine Center
New York-Presbyterian Hospital/Weill Cornell
Medicine
New York City, New York

Fady Y. Hijji bs Jacqueline Koomson ms

Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Rush University Medical Center Rothman Orthopaedic Institute
Chicago, Illinois Thomas Jefferson University
Philadelphia, Pennsylvania
Jacob Hoffman md
Department of Orthopaedic Surgery Tyler R. Koski md
University of Texas Health Sciences Center at Department of Neurological Surgery
Houston Northwestern University
Houston, Texas Feinberg School of Medicine
Chicago, Illinois
Wellington K. Hsu md
Clifford C. Raisbeck Distinguished Professor of Krishna T. Kudaravalli bs
Orthopaedic Surgery Department of Orthopaedic Surgery
Northwestern University Feinberg School of Rush University Medical Center
Medicine Chicago, Illinois
Chicago, Illinois
Mark F. Kurd md
Ibrahim Hussain md Associate Professor of Orthopaedic Surgery
Department of Neurological Surgery Thomas Jefferson University
Weill Cornell Brain and Spine Center Philadelphia, Pennsylvania
New York-Presbyterian Hospital
New York City, New York Gregory D. Lopez md
Department of Orthopaedic Surgery
Ken Ishii md, phd Rush University Medical Center
Keio University School of Medicine Chicago, Illinois
Tokyo, Japan
Heeren S. Makanji md
Jack Jallo md Department of Orthopaedic Surgery
Department of Neurological Surgery Rothman Orthopaedic Institute
Jefferson Medical College Thomas Jefferson University
Thomas Jefferson University Philadelphia, Pennsylvania
Philadelphia, Pennsylvania
Christopher T. Martin md
Nickul S. Jain md Orthopaedic Surgery
Southern California Orthopedic Institute Emory Spine Center
Bakersfield, California Emory University School of Medicine
Atlanta, Georgia
Christopher Kepler md
Orthopaedic Surgery Paul W. Millhouse md, mba
Thomas Jefferson University Hospital Thomas Jefferson University
Philadelphia, Pennsylvania Philadelphia, Pennsylvania
xvi Contributors

Nizar Moayeri md, phd Taylor Paziuk md

University Medical Center Utrecht Department of Orthopaedic Surgery
Utrecht University Sidney Kimmel Medical College
Utrecht, Netherlands Jefferson University
Philadelphia, Pennsylvania
Joseph E. Molenda md
Department of Neurosurgery Courtney Pendleton md
Rush University Medical Center Department of Neurological Surgery
Chicago, Illinois Sidney Kimmel Medical College
Jefferson University
Michael J. Moses md Philadelphia, Pennsylvania
Department of Orthopaedic Surgery
New York University Langone Medical Center Mark L. Prasarn md
New York City, New York Department of Orthopaedic Surgery
University of Texas Health Sciences Center at
Trevor Mordhorst bs Houston
University of Wyoming Houston, Texas
Laramie, Wyoming
Srinivas Prasad md, ms
Peter F. Morgenstern md Department of Neurological Surgery
Department of Neurological Surgery Sidney Kimmel Medical College
Weill Cornell Brain and Spine Center Jefferson University
New York-Presbyterian Hospital Philadelphia, Pennsylvania
New York City, New York
Themistocles S. Protopsaltis md
Hamadi Murphy md Chief, Division of Spine Surgery
SIU School of Medicine Associate Professor of Orthopaedic Surgery and
Southern Illinois University Neurosurgery
Springfield, Illinois Department of Orthopedic Surgery
NYU Langone Health
Ryan Murphy md
New York City, New York
Department of Orthopaedic Surgery
University of Texas Health Sciences Center at Kris Radcliff md
Houston Departments of Orthopedic Surgery and
Houston, Texas Neurological Surgery
Rothman Institute
Ankur S. Narain ba
Thomas Jefferson University
Department of Orthopaedic Surgery
Philadelphia, Pennsylvania
Rush University Medical Center
Chicago, Illinois John M. Rhee md
Orthopaedic Surgery
Kamil Okroj md Emory Spine Center
Department of Orthopaedic Surgery Emory University School of Medicine
Sidney Kimmel Medical College Atlanta, Georgia
Jefferson University
Philadelphia, Pennsylvania Jeffrey A. Rihn md
Rothman Orthopaedics
Gregory Pace md Philadelphia, Pennsylvania
Orthopaedic Resident
Department of Orthopaedics and Rehabilitation Michael Rosner md
Milton S. Hershey Medical Center Professor of Surgery
Pennsylvania State University F. Edward Hebert School of Medicine
Hershey, Pennsylvania Bethesda, Maryland
 Contributors xvii

George Rymarczuk md Francis J. Sirch IV ba

Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Rothman Institute Rothman Institute
Thomas Jefferson University Thomas Jefferson University
Philadelphia, Pennsylvania Philadelphia, Pennsylvania

Fadi Al-Saiegh md Joseph D. Smucker md

Department of Neurosurgery Surgery Indiana Spine Group
Thomas Jefferson University Hospital Carmel, Indiana
Philadelphia, Pennsylvania
Jason A. Spector md, facs
Sundeep S. Saini do Division of Plastic Surgery
PGY-IV New York–Presbyterian Hospital/Weill Cornell
Department of Orthopaedic Surgery Medicine
Rowan University School of Osteopathic Medicine New York City, New York
Stratford, New Jersey
William Ryan Spiker md
Rick C. Sasso md Department of Orthopaedic Surgery
Indiana Spine Group University of Utah
Carmel, Indiana Salt Lake City, Utah

Jason W. Savage md Brian W. Su md

Associate Professor of Orthopaedic Surgery California Orthopedics and Spine
Cleveland Clinic Larkspur, California
Cleveland, Ohio
Patrick A. Sugrue md
Kevin Savage md Department of Neurological Surgery
Feinberg School of Medicine
Franziska A. Schmidt md
Northwestern University
Department of Neurological Surgery
Chicago, Illinois
Weill Cornell Brain and Spine Center
New York-Presbyterian Hospital/Weill Cornell Fadi Sweiss md
Medicine Department of Neurological Surgery
New York City, New York George Washington School of Medicine and
Gregory D. Schroeder md Health Sciences
Assistant Professor of Orthopaedic Surgery George Washington University
Thomas Jefferson University Washington, DC
and
Vincent C. Traynelis md
Spine Surgeon
Department of Neurosurgery
The Rothman Institute
Rush University Medical Center
Philadelphia, Pennsylvania
Chicago, Illinois
Rishi Sharma bs
Department of Orthopaedic Surgery Mazda K. Turel md
Rothman Orthopaedic Institute Department of Neurosurgery
Thomas Jefferson University Rush University Medical Center
Philadelphia, Pennsylvania Chicago, Illinois

Kern Singh md Alexander R. Vaccaro md, phd, mba

Department of Orthopaedic Surgery Department of Orthopedic Surgery
Rush University Medical Center Thomas Jefferson University
Chicago, Illinois Philadelphia, Pennsylvania
xviii Contributors

Joseph A. Weiner md Barrett I. Woods md

Department of Orthopaedic Surgery
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Joshua T. Wewel md
Department of Neurosurgery
Rush University Medical Center
Chicago, Illinois
Jefferson Wilson md, phd
Department of Neurosurgery
University of Toronto
Toronto, Ontario
Christoph Wipplinger md
Department of Neurological Surgery
Weill Cornell Brain and Spine Center
New York-Presbyterian Hospital/Weill Cornell
Medicine
New York City, New York
Rothman Institute
Thomas Jefferson University
Philadelphia, Pennsylvania
and
Department of Orthopaedic Surgery
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Chengyuan Wu md, msbme
Department of Orthopaedic Surgery
Rothman Institute
Thomas Jefferson University
Philadelphia, Pennsylvania
Kelly H. Yom ba
Department of Orthopaedic Surgery
Rush University Medical Center
Chicago, Illinois
     

General

1 The approach to revision procedures 3

Joseph A. Weiner and Wellington K. Hsu
2 How to dissect the plane between the scar of a laminectomy defect in the posterior
cervical spine 13
Ken Ishi
3 How to dissect the plane between the scar of a laminectomy defect in the posterior
thoracic and lumbar spine 19
Nickul S. Jain and Raymond J. Hah
4 Local muscle flaps in the setting of revision spine surgery: Indications, operative planning,
principles, and postoperative management 27
Briar L. Dent, Jaime L. Bernstein, and Jason A. Spector
5 Revision and reimplantation of a spinal cord stimulator device 35
Fadi Al-Saiegh, John M. DePasse, Francis J. Sirch IV,
Gregory D. Schroeder, and Chengyuan Wu

The approach to revision procedures
JOSEPH A. WEINER AND WELLINGTON K. HSU
Introduction 3
Patient evaluation 3
Clinical considerations 5
INTRODUCTION
Spine surgery is frequently performed in the
treatment of spine trauma, tumors, and complex
degenerative disorders. With an estimated 413,000
fusion procedures performed in the United States
annually, the number of procedures performed has
increased 2.4-fold since 1998.1 As more patients
undergo spine surgery and patients live longer, a
greater proportion of these patients will require
revision surgery. Apart from common etiologies
such as stenosis and disk herniation, recurrent back
pain after surgery can result from infection, iatro-
genic fracture, failure of fusion, or adjacent seg-
ment pathology. Pseudarthrosis has been reported
at rates as high as 48% in multilevel posterolateral
lumbar fusions.2 Given that failed spine surgery is
a major burden on our healthcare system, substan-
tial research has been dedicated to identifying fac-
tors that contribute to this problem and developing
methods for successful revision surgery.
Revision surgical procedures are challeng-
ing undertakings for both surgeons and patients
alike. Multiple host and surgical issues often
complicate revision spine procedures, including
impaired biology secondary to the primary sur-
gical procedure. Often, the factors that originally
lead to pseudarthrosis are still present and must be
1
Conclusion 8
References 8
addressed prior to repeat procedures. Compared
with primary surgeries, these interventions have
higher rates of return to the operating room, infec-
tion rates, and inferior patient-reported outcomes
(according to the Owesty Disability Index/Visual
Analog Scale [ODI/VAS]).3–5 Due to the risks of
revision spine surgery, proper patient assessment
and selection are critical for patients with failed
spine surgery.
PATIENT EVALUATION
Patient-reported satisfaction following both cervi-
cal and lumbar fusion surgeries is highly variable.6
Identification of factors leading to poor patient-
reported outcomes is a major focus of recent spine
research. Studies have identified that preopera-
tive factors such as smoking, poor mental health,
obesity, low bone mineral density and workers
compensation status are negative, independent
predictors of patient reported outcomes.6,7 In addi-
tion, patient expectations are also a strong predic-
tor of postoperative satisfaction.
History
Recurrent neck/back pain and/or neurological
symptoms following spine surgery require careful
3
4  The approach to revision procedures
assessment to determine the exact symptom gen-
erator. The first step in this process is obtaining a
detailed history to establish the duration and char-
acter of their symptoms. The time course of symp-
toms helps to define whether there was a pain-free
interval following the initial surgery. Absence of
a pain-free interval may indicate an inadequate
surgical decompression or failure of surgical tech-
nique. Conversely, in cases when the patient ini-
tially has immediate relief but symptoms recur
during follow-up after a fusion procedure, one
must consider pseudarthrosis, infection, or adja-
cent segment disease. Asking the patient about the
character of symptoms can help to determine if the
current symptoms are similar or different to their
complaint before surgery. Mechanical back pain
that is worse with movement can be indicative of
pseudarthrosis, while nonmechanical pain associ-
ated with fever, chills and weight loss may suggest
infection.
A crucial element of history-taking in the post-
surgical patient population is the mental health
evaluation. Numerous studies have identified men-
tal health as a strong predictor of patient-reported
outcomes.8,9 Both preemptive and postoperative
depression symptoms correlate with clinical out-
comes after lumbar spine surgery.10 Hart et  al.
recently reported that lumbar spine fusion has also
been associated with symptoms of posttraumatic
stress disorder (PTSD) during the first postop-
erative year in 11% of patients undergoing elective
lumbar fusion. Postoperative PTSD was a stronger
predictor of reduced clinical benefit than either
preoperative psychiatric diagnosis or preopera-
tive mental composite scores.11 Diagnostic criteria
for depression includes sleep disturbances, loss of
interest in daily activities, feelings of guilt, lack of
energy, impaired cognition and concentration, loss
of appetite, psychomotor retardation, and suicidal
ideation. Addressing these mental health concerns
prior to revision surgery is critical to ensure a good
outcome.12
Physical exam
A thorough physical exam should be performed
to evaluate for the common causes of back pain.
Special attention should be given to the neurologi-
cal exam, including sensory, motor, deep tendon
Table 1.1  Waddell criteria of non-organic back
pain
Tenderness
• Tender to superficial palpation
• Non-anatomic distribution of tenderness
(i.e. pain over pelvis, thoracic spine, etc.)
Simulation
• Low back pain with axial compression on
cranium
• Increase in low back pain with passive
rotation of the shoulders and pelvis in the
same plane
Distraction
• Difference in results of straight leg raise in
sitting vs. supine positions
• Inconsistent exam findings when patient is
distracted
Regional Disturbances
• Motor: Generalized weakness of the lower
extremities with cogwheel resistance on
exam.
• Sensory: Non-dermatomal distribution of
sensory loss. Stocking and glove
distribution.
Overreaction
• Disproportionate response to stimulus
• Bracing: Both arms supporting body weight
while seated
• Clutching back for >3 seconds
• Dramatic grimacing
• Collapsing
reflexes, and gait pattern. During the evaluation of
any patient with neck and/or back pain, the sur-
geon must always consider nonorganic etiologies
for their symptoms. Waddell’s signs are a group
of well-described physical exam findings that sug-
gest a nonorganic and/or psychosocial etiology to
low back pain. These include superficial or diffuse
nonanatomic tenderness, overreaction to nonpain-
ful stimuli, and change in exam findings when the
patient is distracted13 (see Table 1.1).
Imaging
After completion of a thorough history and physi-
cal examination, imaging studies are generally
warranted to evaluate for pseudarthrosis or new

pathology. Plain radiography is generally used for
the initial assessment of pseudarthrosis because of
its widespread availability and low cost. However,
these studies may significantly overestimate the
likelihood of fusion. Brodsky et  al. demonstrated
a 64% correlation rate between postoperative
anteroposterior and lateral radiographs and surgi-
cal exploration.14 Furthermore, the time to radio-
graphic presentation of a pseduarthrosis can vary
between patients. Although many clinical studies
use 1 year as the end point for a fusion study,15,16
Kim et  al. reported an average time of 3.5 years
(range 12–131 months) before the detection of
pseudarthrosis using plain radiographs.17 It is well
known that the appearance of a fusion radiograph-
ically can change even after the 1-year milestone.
Another option for evaluation of arthrodesis is uti-
lizing flexion-extension films to assess for motion
of the fused segment. Pseudarthrosis is likely when
motion is present; however, there is not a consen-
sus regarding the amount of motion that is con-
sidered a solid fusion. Criteria for approval by the
U.S. Food and Drug Administration (FDA) of
spine fusion systems includes evidence of bridging
trabecular bone between the involved motion seg-
ment, translational motion <3 mm, and angular
motion <5 degrees.15
Computed tomography (CT) imaging has the
strongest correlation with intraoperative assess-
ment of fusion.14,18 These scans allow careful evalu-
ation of bony anatomy, previous hardware, and the
surface area that is fused. Lucencies around screws
or hardware failure can be suggestive of pseudar-
throsis, but these findings do not always correlate
with intraoperative findings.19 CT also allows reso-
lution of trabecular bone within interbody cages,
giving surgeons a more accurate means to assess
interbody fusion. Kanemura et al. used thin-slice
CT to demonstrate longitudinally that a 1-mm
radiolucent ring around an interbody cage at 12
months is a strong predictor of pseudarthrosis.20
Given the improved sensitivity and specificity
of CT imaging, thin-section CT is the imaging
modality of choice for evaluation of fusion failure.
Laboratory tests
Prior to revision spine surgery, laboratory evalu-
ation needs to focus on reversible causes of
Clinical considerations  5
pseudarthrosis and other conditions that can lead
to surgical failure. Workup generally includes
infectious markers, nutritional markers, and
HbA1c. To rule out infection as a cause of recur-
rent back pain, surgeons should check a complete
blood count (CBC) with differential in addition
to an erythrocyte sedimentation rate (ESR) and
C-reactive protein (CRP). In the setting of infec-
tion, one should expect to see an increased white
count, with a shift toward polymorphonuclear cells
and elevated ESR and CRP. If those tests return
results concerning for infection, blood cultures
should be drawn.
Nutritional markers, such as albumin levels,
should be used to evaluate the nutritional status of
a patient prior to the revision procedure. Decreased
albumin levels are associated with poor wound heal-
ing, postoperative infectiou, complications, mor-
tality, and immune suppression.21 Serum albumin
levels <3.5 g/dL are widely accepted to represent a
state of malnutrition.22 Furthermore, the severity of
the deficiency is correlated with incidence of com-
plications. In 2016, Singh et al. reported that spine
patients with preoperative albumin <3.5 g/dL were
at higher risk for wound dehiscence, surgical site
infection, and 30-day readmission.23 Further evalu-
ation, including HbA1c and vitamin D levels, will
be discussed in detail in the following section.
CLINICAL CONSIDERATIONS
Given the challenges of revision spine surgery,
it is important that surgeons have a thorough
understanding of why patients fail. Knowledge
of the mechanism of causes of failure can lead to
­preemptive or preventative treatment.
Infection
Patients with an ongoing infection can present
with the insidious onset of nonmechanical back
pain, fevers, chills, and weight loss. However, in
some situations, these constitutional symptoms
are absent. Similar to other surgical procedures,
the risk is directly correlated with the length and
complexity of the primary surgery. Risk factors
for infection include obesity, greater intraopera-
tive blood loss, 10 or more people in the operat-
ing room, a dural tear, history of diabetes, chronic
6  The approach to revision procedures
obstructive pulmonary disease, coronary heart
disease, and osteoporosis.24 The causative organ-
ism most often seen is Staphylococcus aureus, with
methicillin-resistant S. aureus reported in 34%
of cultures. Other causative organisms may be
Staphylococcus epidermidis, Enterococcus faecalis,
Pseudomonas, and Propionibacterium acnes.25,26
Laboratory evaluation can demonstrate an
elevated white blood count (WBC), with a shift
toward polymorphonuclear cells, ESR, or CRP lev-
els. Blood cultures should be drawn at the time of
peak fever. Plain radiographs and CT imaging may
reveal radiolucency around instrumentation, indi-
cating potential screw loosening. If magnetic reso-
nance imaging (MRI) with contrast is performed,
increased gadolinium uptake in the area of infec-
tion may be noted.
Treatment of surgical site infections gener-
ally involves early recognition, copious irrigation,
debridement of infected and necrotic tissues, and
culture-directed intravenous (IV) antibiotic ther-
apy.26 Depending on the extent of infected and
necrotic tissue, the wound can either be closed
primarily or packed and left open for subsequent
debridements. Vacuum-assisted closure (VAC)
dressings and closed suction irrigation systems can
be utilized to aid in the healing process. Mehbod
et  al. reported that wound VAC devices decrease
the number of visits to the operating room (OR) for
debridement by nearly 50%.27 In patients with spi-
nal instrumentation, hardware should be removed
only when multiple debridements and antibiotic
therapy have failed to eradicate the infection.28
Cigarette smoking
Numerous studies have linked cigarette smoking to
delayed union and pseudarthrosis in spinal fusion
procedures29,30 with a 10%‒12% decrease in fusion
rates.30,31 Failure to quit smoking in the postopera-
tive period also further diminishes bone-healing
potential.30 All patients have both modifiable and
nonmodifiable risk factors that can affect out-
comes after spine procedures. Given the dramatic
impact of smoking on bone healing, patients pre-
senting with pseudarthrosis must be educated on
the risks of smoking both before and after surgery.
Those with an extensive smoking history should
be referred to tobacco cessation programs before
a revision procedure is considered.31,32 These pro-
grams have established that an active smoking
intervention started 6–8 weeks before surgery can
decrease the frequency of postoperative complica-
tions by 50%.32
Defining a single mechanism by which cigarette
smoking impedes bone healing is challenging, as
cigarette smoke contains upward of 4,000 distinct
chemical components. Carbon monoxide present
in the gas phase of cigarette smoke displaces oxy-
gen from hemoglobin, significantly diminishing
the capacity for blood to carry vital oxygen to pro-
liferating osteoblasts at the site of bone healing. 33
Nicotine, a potent anti-inflammatory and immu-
nosuppressive substance, has been shown to have
deleterious effects on fibroblasts, red blood cells,
and macrophages,34–36 in addition to diminishing
blood flow to tissues by promoting vasoconstric-
tion.36,37 However, the effects of nicotine on bone
health are likely dose-dependent and not solely
responsible for decreased fusion rates. Using the
rabbit model of lumbar posterolateral fusions,
Daffner et al. demonstrated that low-dose nicotine
patches improve spinal fusion rates, while high-
dose nicotine patches produce fusion rates equiva-
lent to controls.38
More recent research has identified dioxins, a
class of potent carcinogenic polycyclic aromatic
hydrocarbons, as playing a major part in the inhi-
bition of osteogenesis.39 In vitro and in vivo work
has demonstrated that dioxin has toxic effects on
bone, adversely affecting bone growth and remod-
eling, matrix composition, mechanical strength,
and osteoblast differentiation.40 Although the exact
mechanism of osteoblastic inhibition from smok-
ing remains somewhat unclear, many surgeons cur-
rently associate nicotine with the negative impact of
smoking on bone healing. The association of dioxin
and the Ahr pathway with bone-healing inhibition
from smoking cigarettes offers a promising new
approach to the mitigation of these effects.
Vitamin D deficiency
When evaluating a patient for causes of pseudar-
throsis, it is important to consider the contribution
of vitamin D deficiency. Given the multifactorial
nature of most pseudarthoses, it is critical to opti-
mize controllable variables prior to considering a
 Clinical considerations  7

revision procedure. Vitamin D plays a key role in Table 1.2  Serum 25-hydroxyvitamin D (25(OH)D)
maintaining metabolic bone homeostasis. Vitamin concentrations and health
D deficiency, present in 33% of healthy young adults
nmol/L ng/mL Health status
and more than 50% of general medicine inpa-
tients,41 can negatively affect bone health. As vita- <30 <12 Vitamin D deficiency,
min D is depleted, absorption of calcium decreases leading to rickets in
and parathyroid hormone is upregulated. This infants and children
hormonal dysregulation can cause an increase in and osteomalacia in
osteoclast bone resorption and predisposes patients adults
to pseudarthrosis.42,43 Metzger et al. established that 30 to <50 12 to <20 Vitamin D insufficiency
vitamin D helps to modulate the consolidation of ≥50 ≥20 Generally considered
the fusion mass in a posterolateral spinal fusion rat adequate for bone
model. Their results indicated that increased levels and overall health in
of dietary vitamin D correlate directly with the den- healthy individuals
sity of the fusion mass.44 In 2010, Bogunovic et al. >125 >50 Emerging evidence links
reported that 43% of a 723-patient cohort sched- potential adverse
uled to undergo an orthopedic procedure were defi- effects to such high
cient in vitamin D.45 Considering the financial and levels, particularly
clinical burden of pseudarthrosis, knowledge of the >150 nmol/L
prevalence, evaluation, and t­ reatment for hypovita- (>60 ng/mL)
minosis D is critical for all spine surgeons.
Although the importance of vitamin D in
musculoskeletal health has been well established, of complications during primary spine procedures,
the majority of spine surgeons fail to recognize many of these medically complex patients fail their
the utility of preoperative testing. Dipaola et  al. initial surgery and seek revision procedures.
revealed that only 20% of spine surgeons order Berven et  al. recently reported that increased
serum vitamin D levels as part of a pseudarthrosis body mass index (BMI) was independently associ-
workup.46 Given the impact of vitamin D on spine ated with increased complication rate after adjust-
fusion and the prevalence of deficiency, it is the ing for age, functional status, American Society of
authors’ recommendation that preoperative test- Anesthesiologists (ASA) score, bleeding disorder,
ing of serum vitamin D levels should be routine and diabetes.52 This extends the widely accepted
prior to both primary and revision procedures. idea that obesity increases the complication rate
Thresholds for vitamin D levels, which are well after primary spine surgery to support the concept
established in the literature (Table 1.2),42,47 should that obesity is a significant risk factor for compli-
be used to institute treatment. Patients deficient cations after revision spine surgery. Despite the
in vitamin D are typically prescribed 50,000 IU increase in complications during both primary
of oral vitamin D2 (ergocalciferol) per week for and revision procedures, obese patients have simi-
8 weeks, followed by maintenance therapy of lar pain and functional outcomes when compared
1,500–2,000 IU/day.42 to nonobese patients.53 Therefore, similar to smok-
ing, obesity does not contraindicate revision spine
Obesity surgery-it is a modifiable risk factor that neces-
sitates counseling and nutritional intervention to
Recent literature has identified obesity as an inde- minimize complications.
pendent risk factor for complications and poor
outcomes following primary spine surgery.48–51 Diabetes mellitus
Obese patients have been described to have higher
rates of surgical site infection, venous thromboem- Diabetes mellitus (DM) is a common disorder of
bolism, blood loss, respiratory compromise, and blood glucose regulation affecting between 12%
need for reoperation. 51 Given the increased rates and 14% of the U.S. population.54 Long-term,
8  The approach to revision procedures
poorly controlled diabetes has well-described
complications affecting the microvasculature,
including cardiovascular, ophthalmic, renal, and
peripheral vascular disease.55 Given the impact of
poor glycemic control on the microvasculature,
these patients generally experience poor wound
healing and higher rates of postoperative com-
plications following surgical procedures.56 For all
patients presenting with pseudarthrosis or other
complications from a primary spine surgery, it is
critical that their glycemic control be evaluated.
Glycated hemoglobin (HbA1c) can be used
to diagnose and monitor diabetes and poor gly-
cemic control. Both the American Diabetes
Association and American Association of Clinical
Endocrinologists advocate the use of HbA1c > 6.5%
to diagnose DM.57 Koutsoumbelis et  al. reported
that a clinical diagnosis of diabetes prior to sur-
gery significantly increased the risk for postopera-
tive infection after instrumented lumbar fusion.24
Recent work has further demonstrated that both
controlled and uncontrolled diabetic patients
undergoing degenerative lumbar spine surgery
have an increased risk of postoperative infection.58
Given the challenging biologic environment in
revision surgery, microvascular disease and poor
healing secondary to DM can significantly compli-
cate the decision to proceed with revision. Zheng
et  al. reported that having three or more comor-
bid conditions was associated with longer hospi-
tal stays and more blood transfusions in patients
undergoing lumbar revision surgery.59 As with
other controllable factors, preoperative HbA1c
needs to be optimized prior to surgery. However, it
is important to counsel patients that despite main-
taining perfect glycemic control, diabetic patients
remain at elevated risk for complications.
Psychiatric illness
The role of treating neck and back pain with a bio-
psychosocial approach has been well established
for several decades.60 Within the population of
patients with back pain, there is a distinct cohort
that has poor surgical outcomes, regardless of
pathology. Klinger et  al. conducted a systematic
literature review on risk factors that predicted pain
after spine surgery. They reported the three stron-
gest predictors of poor outcomes were negative
psychological factors, preexisting chronic pain,
and psychological disorders.61 Given these findings,
spine surgeons must strongly consider psychologi-
cal factors when evaluating patients with recurrent
back pain following a surgical intervention.
As previously discussed, a simple screen for
depression or other mood disorders during the ini-
tial history can help to identify patients with con-
current mental illness. When psychological factors
are suspected, multimodal treatment programs that
include psychological pain management therapy
should be considered prior to surgical intervention.
If surgery is unavoidable, postoperative management
should integrate psychological pain therapy as soon
as possible to avoid unnecessary complications.
CONCLUSION
Revision spine surgeries are challenging undertak-
ings for surgeons and patients alike. With the overall
rate of spine surgery increasing, revision procedures
are likely to become more common. Careful preop-
erative patient evaluation, including history, physi-
cal examination, mental health evaluation, and the
appropriate use of imaging and laboratory studies,
is vital for successful spine revision surgery. Given
the impaired biology present in revision procedures,
surgeons must optimize controllable risk factors
such as smoking, DM, obesity, and vitamin D defi-
ciency prior to proceeding with revision cases.
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How to dissect the plane between the
scar of a laminectomy defect in the
posterior cervical spine
KEN ISHII
Indications 13
Relative contraindications 13
Expectations 14
Principles of revision surgery 14
INDICATIONS
Revision posterior cervical laminectomy, with or
without a fusion procedure, may be indicated in
patients with persistent, progressive, or recurrent
symptomatic cervical radiculopathy or myelopa-
thy, symptomatic pseudarthrosis, and progressive
spinal deformity. The most common indications
for early-revision cervical laminectomy include
persistent stenosis following a previous decom-
pressive procedure and previous wrong-level sur-
gery. Patients presenting in a more delayed fashion
commonly show adjacent segment degeneration,
junctional kyphosis, postlaminectomy kypho-
sis, and pseudarthrosis. A  clear diagnosis should
be established that correlates physical exam and
imaging studies, and in most cases, an attempt at
nonsurgical management should be made prior to
proceeding with revision surgery.
2
Preoperative planning and OR setup 14
Operative technique 15
Postoperative management 17
Complications 17
RELATIVE CONTRAINDICATIONS
Revision cervical laminectomy should be con-
sidered only after a complete patient evaluation
as outlined later in this chapter. Patients with
low-grade cervical kyphosis or asymptomatic
pseudarthrosis without associated radiculopa-
thy or myelopathy may be closely observed, so
long as there are no signs of progression of the
deformity or development of neurologic symp-
toms. Certain cervical pathology, including
rigid kyphotic deformity that cannot be cor-
rected with neck extension or preoperative trac-
tion, should be managed with either an anterior
approach or a combined anterior and posterior
approach. An anterior approach in this situation
may afford the opportunity to avoid a revision
laminectomy.
13
14  How to dissect the plane between the scar
EXPECTATIONS
Patients who are being considered for revision
surgery should be counseled preoperatively to
establish appropriate expectations. These patients
are likely to have longstanding symptoms that
may reduce the likelihood of complete resolution,
despite adequate decompression. In situations of
myelopathy, patients should be educated that the
goals of surgery are to halt progression of symp-
toms rather than to return them to their predisease
functional status. Patients with pseudarthrosis
should be informed of their modifiable risk factors
for pseudarthrosis, and all attempts to correct them
should be made prior to proceeding with revision
surgery. Finally, revision surgery increases the
complication risk, and patients should be informed
of the risks inherent to revision posterior cervical
laminectomy, discussed in detail next.
PRINCIPLES OF REVISION SURGERY
Prior to proceeding with any revision surgery, the
surgeon needs to perform a detailed history and
physical exam. Preoperative imaging should be
scrutinized so that the surgeon is familiar with
the levels and extent of previous decompression,
as well as any abnormal anatomy due to scarring
or deformity. Previous operative reports should
be obtained whenever possible to determine the
indications for surgery, the implants used, and the
operative findings from the initial surgery.
In most cases, it is appropriate to attempt a
trial of nonoperative management prior to pro-
ceeding with revision surgery. This is particularly
important, as revision surgery is rarely as reliably
successful as the initial surgery. However, con-
tinued nonoperative management may be inap-
propriate in cases of progressive myelopathy and
rapidly progressive deformity. Once the decision
to proceed with revision surgery has been estab-
lished, the patient and surgeon need to choose the
optimal operative approach, keeping in mind the
goals of the surgery. While deformity correction
may require a combined anterior and posterior
approach, using an anterior-only or posterior-
only approach may afford the opportunity to
approach the spine through a previously unoper-
ated field.
Once an operative approach has been deter-
mined, there are several principles that dictate the
revision operative technique. In general, the previ-
ous incision should be extended in either direction
to allow the identification of normal anatomy prior
to proceeding with the dissection into the previous
surgical wound. Within the previous wound, care
should be taken to identify the bony margins of the
previous laminectomy bed so that mobilization of
the scar tissue can be performed. Details of this
technique are discussed next.  
PREOPERATIVE PLANNING AND
OR SETUP
A detailed preoperative evaluation, including history
and physical exam, is necessary before considering
revision cervical surgery. In particular, information
should be obtained regarding all previous surger-
ies, the patient’s symptoms prior to surgery, and
the response to surgery and duration of symptom-
free intervals. Failure to obtain relief may indicate
incomplete decompression or incorrect initial diag-
nosis, whereas initial relief followed by recurrent or
differing symptoms may indicate disease at adjacent
levels or progressive deformity. Previous operative
reports should be carefully reviewed, as well as iden-
tification of any previous instrumentation.
Preoperative imaging should begin with stan-
dard anterioposterior (AP) and lateral radiographs,
as well as flexion and extension radiographs. The
AP and lateral radiographs will help to determine
the presence and degree of existing deformity,
as well as previous instrumentation, while the
dynamic x-rays help to determine the status of any
previous attempts at fusion, as well as the stability
of any unfused levels of the spine. Evaluation of the
degree of deformity and the amount of correction
obtained on extension radiographs is important in
planning the surgical approach.
If previous fusion has been attempted, a com-
puted tomography (CT) scan should be used to
confirm the presence of complete fusion at all
levels. The CT scan is also used for evaluation of
previous instrumentation for signs of breakage or
loosening, as well as aiding in planning start points
and trajectories for revision instrumentation.
Finally, magnetic resonance imaging (MRI) helps
to determine the degree of nerve root and spinal

cord compression, as well as the degree of epidural
scar tissue. On T2-weighted MRI, increased signal
intensity is seen laterally and posteriorly within
the paraspinal muscles at the operative site, indi-
cating edema within this tissue (Figure 2.1), while
scarring in this location may display low signal
intensity (Figure 2.2). The addition of gadolinium
contrast will help differentiate scarring from new
or recurrent disc herniation. Scar tissue is vascular,
so it enhances after intravenous (IV) administra-
tion of gadolinium.
All imaging should be compared to previously
performed studies to evaluate for the completeness
of previous decompression, progression of degen-
erative disease, and deformity. In patients who
(a)
Figure 2.1  T2-weighed sagittal (a) and axial (b) MRIs. White arrows indicate high signal intensity within the
previous surgical plane.
(a)
Figure 2.2  T2-weighed sagittal (a) and axial (b) MRIs. White arrows indicate epidural scar tissue with low
signal intensity.
Operative technique  15
obtained only partial or no significant relief from
their initial surgery, it is important to confirm the
initial diagnosis. In this situation epidural injec-
tions, nerve root injections, or an electromyogra-
phy (EMG) may be beneficial.
OPERATIVE TECHNIQUE
Patients who are indicated for revision posterior
surgery as detailed previously should have neu-
tral to lordotic alignment, a kyphotic deformity
that is reducible with neck extension in the oper-
ating room for patients who have undergone pre-
vious anterior surgery to correct their deformity.
For patients with myelopathy or significant cord
(b)
(b)
16  How to dissect the plane between the scar

compression, awake fiberoptic intubation should
be considered, with minimal manipulation of the
neck to prevent further compression of the spinal
cord. Following induction, anesthesia patients are
placed in Mayfield tongs, which allow control of
overall alignment of the spine, as well as access
for intraoperative fluoroscopy. Overall neutral
alignment of the cervical spine may be confirmed
prior to draping with a lateral x-ray or fluoroscopy.
Fluoroscopic imaging and operative exposure may
be aided by taping of the shoulders, but excessive
traction should be avoided. Intraoperative neuro-
monitoring is used and should include somatosen-
sory evoked potential (SSEP), as well as transcranial
motor-evoked potential (TcMEP).
The previous surgical incision should be marked
out and extended cephalad and caudad so that it
goes into normal tissue at least 2 cm on either end,
allowing exposure of normal anatomy to help guide
further dissection in the area of the previous lami-
nectomy site. Once the lamina and lateral masses of
the level above and below the previous laminectomy
have been exposed, the dissection should continue
into the previous wound. Initial dissection should
remain lateral, avoiding direct sharp dissection
into the laminectomy bed. Working from lateral
to medial, the bony margins of the previous lami-
nectomy bed should be defined and cleaned of soft
tissue, and a curette can be used to establish this
plane (Figure 2.3). Removal of part of the lamina
above and below the previous decompression will
allow exposure of normal dura and help to identify
the correct dissection plane (Figure 2.4). This can
be done using a combination of a burr and Kerrison
rongeur. Once the previous laminectomy bed and
cephalad and caudad dura have been exposed, over-
laid scar tissue can be removed using a rongeur to
tension the tissue away from the dura, with a Cobb

(a) (b)

(c)

Figure 2.3  The laminectomy is extended cephalad and caudad, allowing exposure of the area above and
below the scar tissue. (a) Demonstrates a posterior cervical laminectomy bed with scar. (b) Demonstrates
clearly identifying the bony edges, and (c) identifies the cephalad and caudal lamina that should be
removed.

Scar tissue
Figure 2.4  The laminectomy is extended cephalad and caudad, allowing exposure of the area above and
below the scar tissue.
or Woodson elevator helping to define the plane.
Careful attention should be paid to any dural adhe-
sions or thinning of the dura during this step. It may
be necessary to leave some scars in place to avoid
durotomy, but it should be confirmed that the scars
are not causing neural compression. Following
removal of the epidural scar tissue, decompression
may proceed as in primary cases using a Kerrison
rongeur to perform foraminotomies or a burr to
extend the laminectomy to additional levels.
In most cases of revision cervical laminectomy,
an instrumented fusion will be performed or pre-
vious instrumentation revised. In cases in which
a deformity correction is required, strong anchor
points above and below the deformity will aid in
construct stability; thus, often C2 and C7 or T1
pedicle screws are used in addition to typical lat-
eral mass screws throughout. Following instru-
mentation, the facet joints are decorticated, and
bone graft is placed in the lateral gutters.
POSTOPERATIVE MANAGEMENT
Patients who have undergone prolonged prone
surgery may benefit from delayed extubation once
Complications 17
Spinal cord
facial swelling has decreased. This decision should
be made in conjunction with the anesthesia team.
Postoperative immobilization is at the discretion
of the individual surgeon and depends on the
relative stability of the bone and hardware and
the degree of deformity correction preformed. For
patients undergoing large corrections or with poor
bone quality, a hard cervical collar should be used
for 6–8 weeks postoperatively. X-rays should be
obtained at regular intervals to evaluate for main-
tenance of correction, as well as for signs of fusion.
Patients generally may return to all activities at
3 months postoperatively.
COMPLICATIONS
Revision cervical laminectomy is associated with
increased risk for intraoperative and postopera-
tive complications compared to primary surgery.
Distorted anatomy, as well as the presence of scar-
ring, increase the risk for dural tear and neurologic
injury, and revision surgery places the patient at
higher risk for postoperative surgical site infection.
Durotomy is most likely to occur during removal of
scarring from the dura. As previously mentioned,
18  How to dissect the plane between the scar
it is important to identify areas of adhesion, as well
as areas of dural thinning, as these areas predis-
posed to durotomy. If a dural tear does occur, it
should be fixed primarily with 5-0 or 6-0 suture,
and the repair may be supplemented with fibrin
glue or a patch if needed. Patients should remain
with the head of their bed elevated for at least 24
hours following a dural repair to facilitate closure
and prevent formation of a pseudomeningocele.
In revision wounds, previous surgical dissec-
tion may have led to devascularization and atrophy
of the muscular layers, predisposing to infection.
Careful attention to wound closure should occur
with the muscle, fascia, subcutaneous skin, and
dermis closed in layers. Previous scarring in the
dermis and subdermal layers may require excision
to allow appropriate approximation of the skin. In
certain cases, the assistance of a plastic surgeon
may aid in appropriate coverage of the wound.
Pearls and Pitfalls
●● Patients undergoing revision cervical lami-
nectomy should have a clear diagnosis
that correlates a physical exam and imag-
ing studies, as well as appropriate expec-
tations for the results of revision surgery,
which is often less predictable than pri-
mary surgery.
●● Preoperative imaging should be scrutinized
for evaluation of previous fusion, distorted
anatomy, and the presence and location of
peridural scarring.
●● Extension of the previous incision will allow
identification of normal anatomy cephalad
and caudad to the surgical wound to enable
dissection within the plane between scar
tissue and the intact dura.
●● Dissection within the previous surgical field
should proceed from lateral to medial to
prevent sharp dissection within the previ-
ous laminectomy bed.
●● In cases with revision, instrumentation care
should be taken to ensure strong anchor
points at the ends of the construct to facili-
tate deformity correction and fusion.
●● The wound should be closed meticulously
in multiple layers, and the aid of a plastic
surgeon may be required in certain high-
risk individuals.

How to dissect the plane between the
scar of a laminectomy defect in the
posterior thoracic and lumbar spine
NICKUL S. JAIN AND RAYMOND J. HAH
Indications 19
Relative contraindications 20
Expectations 20
Principles of revision surgery 20
Preoperative planning and operating
room (OR) setup (including the utility of
neuromonitoring) 21
INDICATIONS
Thoracic and lumbar laminectomies are well-tol-
erated, effective surgeries for symptomatic spinal
stenosis. Following laminectomy, epidural fibro-
sis forms over the thecal sac to create a scar tissue
known as the laminectomy membrane. This has
been postulated as a potential cause of symptom-
atic recurrent compression of neurologic elements.
Indications for revision thoracic and lumbar
surgery include inadequate decompression, symp-
tom recurrence, instability, and postlaminectomy
kyphosis following a previous decompressive lami-
nectomy. Peridural scarring has been shown to be
a risk factor for recurrent radicular symptoms that
may require a revision surgical procedure.
In revision cases, there is often a need to dis-
sect between the laminectomy scar and the
dura, or between laminectomy scar and osseous
3
Operative technique 22
Postoperative management 24
Complications 24
structures, to achieve adequate decompression
such that the thecal sac and nerve roots are unte-
thered and have normal mobility during routine
thoracolumbar spine motion, as well as to allow
appropriate access for interbody fusion or oste-
otomy procedures.
Indications for dissecting the laminectomy scar
include symptomatic subarticular lateral recess or
foraminal stenosis following previous laminec-
tomy; need for posterior or transforaminal lumbar
interbody fusion; new injuries requiring operative
intervention; adjacent segment disease requiring
exposure of previously operated levels; infection
(including discitis, osteomyelitis, and epidural
abscesses); tumor; and the need for adequate expo-
sure to perform osteotomy procedures. Additionally,
deformity correction procedures can potentially
result in laminectomy membrane buckling during
correction, causing symptomatic stenosis.
19
20  How to dissect the plane between the scar of a laminectomy defect
RELATIVE CONTRAINDICATIONS
Dissection of the laminectomy membrane poses
a higher risk for dural injury and should be per-
formed only if absolutely necessary to achieve
treatment goals. Relative contraindications for
performing this dissection include surgical situ-
ations where alternative approaches (i.e., indirect
decompression via anterior or lateral interbody
technique) can be used to address the symptomatic
pathology and if residual compression is not being
caused by laminectomy scarring.
Patients with postlaminectomy iatrogenic insta-
bility would not typically require dissection of the
laminectomy membrane unless they presented
with symptomatic foraminal or lateral recess ste-
nosis, causing radicular symptoms as well as axial
back pain.
Additional patient-related factors to consider
include known risk factors for poor outcomes, such
as intravenous (IV) drug use, chronic malnutri-
tion, litigation situations, incorrect diagnosis, and
comorbid conditions that preclude surgical inter-
vention. Anatomic factors such as poor soft tis-
sue envelope, ongoing severe infection, and severe
osteopenia are relative contraindications to surgery.
Patients with chronic nerve injury, which
may be less likely to respond to surgical treat-
ment, should be counseled regarding appropriate
expectations.
EXPECTATIONS
The primary goal of revision surgery is to achieve
adequate decompression of the neural elements,
obtain successful bony fusion if indicated, and cor-
rect symptomatic deformity. Appropriate patient
counseling and management of expectations are
extremely important to the success revision spine sur-
gery. Diagnostic determinations of which pain gener-
ators are responsible for which symptoms will greatly
improve both indications for surgery and chances
of success. Increased risk of complications, includ-
ing infection, wound complications, durotomy, and
nerve root injury, should be discussed with patients
preoperatively. Additionally, the chronicity of pathol-
ogy may limit the extent of neurological recovery.
PRINCIPLES OF REVISION SURGERY
The success of revision surgery is contingent on
an accurate diagnosis of the cause of present-
ing symptoms. A thorough history and physical
should focus on previous operations, the rea-
sons for those operations, and the changes in
symptoms before and after the index procedures.
Additionally, patients should be carefully que-
ried for any potential postoperative complica-
tions after each procedure and the way that they
were managed. Previous operative reports and
hospital records should be obtained to identify
previous instrumentation and intraoperative and
perioperative complications. Patient-related fac-
tors known to affect outcomes should be identi-
fied, including pending legal action, workers’
compensation, unmanaged psychiatric comor-
bidity, nutritional status, opioid abuse or toler-
ance, tobacco use, and poorly optimized medical
comorbidity. Alternative pathologies should be
ruled out (i.e., vascular claudication, hip pathol-
ogy, neuropathy, and peripheral entrapment).
Appropriate imaging should be obtained and
reviewed for residual neural compression, solid
arthrodesis, and evidence of pseudomeningocele
or arachnoiditis. Prior laminectomy and lami-
notomy defects should be noted and carefully
approached during exposure. Electrodiagnostics
and targeted injections may be useful to establish
specific pain generators.
Surgical principles include ensuring adequate
decompression of neural elements, obtaining
solid fixation and spinal stabilization, and cor-
recting spinal deformities. In the setting of revi-
sion decompression, instrumentation should be
available even if fusion is not planned in case the
extent of decompression substantially destabilizes
the spine. Surgeons must practice a safe dissec-
tion technique, working from native landmarks
to scars, maintaining meticulous hemostasis, and
obtaining adequate visualization. Dissection of
the laminectomy membrane off the dura should
be performed only if necessary to accomplish the
goals of surgery; if otherwise adequately decom-
pressed, some laminectomy membranes can be
left “floating.”
 Preoperative planning and operating room (OR) setup (including the utility of neuromonitoring)  21
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
(INCLUDING THE UTILITY OF
NEUROMONITORING)
Preoperative planning is essential for success in
revision spine surgery. Surgeons should obtain
previous surgical records to confirm previous
decompressed levels, determine if any periop-
erative complications occurred, and evaluate for
previous durotomy. Preoperative optimization of
patient comorbid conditions is critical to ensure
good outcomes. Revision spine surgery typically
has inferior outcomes and higher complication
rates than primary surgeries, and optimal patient
conditions can help reduce the risk of periop-
erative complications and increase success rates.
Prehabilitation-type interventions prior to elective
procedures may be beneficial to the long-term out-
come. These include mandated cessation of tobacco
products, diagnosis and treatment of osteoporosis,
weight loss for morbid obesity, methicillin-resis-
tant Staphylococcus aureus (MRSA) screening and
decolonization, and opioid weaning protocols.
A thorough history must be obtained to deter-
mine the nature of a patient’s symptoms. The dis-
tinction between pain since an index operation and
recurrent pain after a pain-free interval of days,
weeks, months, or years afterward can provide
information regarding the potential pathology and
cause of symptoms. An accurate physical examina-
tion is also necessary to confirm any preoperative
neurological deficits and evaluate previous surgical
incisions to determine the adequacy of skin bridges
and previous surgical approach type. Poor soft-tis-
sue quality secondary to multiple prior procedures,
decreased paraspinal muscle mass typical in elderly
patients, and previously irradiated tissue may
require muscle flaps and/or complex wound closure.
Plain lumbar radiographs, including upright
and/or flexion and extension views, can demon-
strate previous laminar defects, reveal segmen-
tal instability, and evaluate for pseudoarthrosis.
Scoliosis radiographs and inclusion of the femo-
ral heads in the lumbar films can help evalu-
ate regional and global balance and spinopelvic
parameters.
Magnetic resonance imaging (MRI), with and
without IV contrast, is critical to determine areas
of compression of neural elements. The addition of
gadolinium can help distinguish peridural fibrosis
from recurrent disc herniation or residual steno-
sis. Additionally, MRI will show an asymptomatic
contained pseudomeningocele, which may need
to be avoided or addressed. MRI imaging must
also be carefully examined to determine the site
of stenosis: central, lateral recess, or foraminal.
Examination of the residual bony anatomy (both
normal and previously altered) to establish how
much additional bony resection may be required.
This distinction will allow an appropriate surgi-
cal plan to maximize chances of success. MRI will
show the transition zone between native and previ-
ously operated anatomy in order to find a safe entry
point for dissection (Figure 3.1). In patients with
previous instrumentation, visualization of neural
elements is obscured due to artifacts. In these situ-
ations, computed tomography (CT) myelogram
can be useful.
We find that a combination of both MRI (with
and without contrast enhancement) and a CT
myelogram can be useful in cases with previous
instrumentation. Metal subtraction sequences
can add clarity in cases of previous instrumenta-
tion. Bone scans and discography are not typically
required.
Increased blood loss can be encountered in
revision surgery. Type and crossmatching and
coordination with the blood bank should be rou-
tine. For larger procedures with expected blood
loss in excess of 20% of the patient’s blood volume,
adjuncts such as intraoperative blood salvage, acute
normovolemic hemodilution, and/or use of tran-
sexamic acid can be utilized. The surgeon should
account for additional time for revision dissection.
We routinely use a radiolucent Jackson table
to allow adequate imaging. Hips are extended
and knees flexed to ensure lordotic positioning
of the spine. The eyes and bony prominences are
carefully padded and the abdomen hangs free.
Headlight illumination, loupe magnification, and
operating microscope are used if needed for ade-
quate visualization. Operative instruments should
be well maintained and sharpened to facilitate
22  How to dissect the plane between the scar of a laminectomy defect

(a) (b) (c)

Figure 3.1  Lateral upright radiograph (a) and sagittal (b) and axial (c) T2 MRIs of a patient with previous
L3‒L5 laminectomies and flexible rod placement requiring revision. Note the absence of visible spinous
processes on both radiographs and MRIs, as well as fibrosis overlying decompressed dura and paraspinal
musculature atrophy.

dissection. Cobb elevators, fine curettes, Penfield
and dural elevators, Kerrison ronguers, and high-
speed drills are all routinely used. Open or tubular
retractors should be employed depending on the
planned approach, technique, and patient body
habitus. Given the increased risk of durotomy
during dissection of the laminectomy membrane,
dural repair materials including appropriate
suture, microinstruments, dural patches or colla-
gen matrices, and hydrogel or fibrin glue should be
available. Appropriate instrumentation should be
available, even if fusion is not planned.
Neuromonitoring with both motor-evoked
potentials (MEPs) and somatosensory evoked
potentials (SSEPs) is largely reserved for concomi-
tant deformity correction; however, triggered elec-
tromyography (EMG) can be a useful adjunct in
placement of instrumentation.
OPERATIVE TECHNIQUE
Our operative technique begins with patient posi-
tioning as described here after general anesthe-
sia. Given the wide variability of complexity and
magnitude of revision cases, the need for a Foley
catheter, arterial lines, large-bore IV lines, neu-
romonitoring, mean arterial pressure goals, and a
central line should be discussed with the anesthesia
team. The back is prepped and draped in the usual
sterile fashion. Previous skin incisions should be
evaluated to avoid narrow skin bridges. Previous
incisions may also be excised to allow vascularized
primarily healing.
After facial incision, dissection proceeds crani-
ally and caudally to the previously operated lev-
els to find a residual spinous process or lamina
and determine the depth of the spinal canal. This
guides the amount of laminectomy scarring that
can be mobilized from the midline, before dis-
section proceeds laterally. Sharp Cobb elevators
are useful to elevate laminectomy scars and work
toward the lateral borders of the previous lami-
nectomy. Another method would be to work lat-
erally immediately; however, this leaves a larger
bulk of laminectomy membrane, which may leave
substantial dead space if removed later. Previously
placed hardware can serve as a useful depth land-
mark during the approach.
The pars should be identified and can be fully
exposed with electrocautery. Once this and the
medial border of the residual facet joint are identi-
fied through careful dissection, the border between
bone and the laminectomy membrane is carefully
separated using a fine-angled curette, keeping the
cutting surface toward the bone. This allows mobi-
lization of the neural elements and laminectomy
membrane together. We typically avoid dissect-
ing through the membrane itself. Woodson eleva-
tor, Frazier dural elevator, and Penfield number
1 all can be useful instruments to dissect against

Figure 3.2 Identify bone-scar interface using a
Woodson elevator beginning at native levels.
Figure 3.3 A Penfield 1 instrument can be used
to dissect the bone-scar interface safely along the
lateral bony border of the canal.
the lateral bony surface of the canal (Figures 3.2
and 3.3). After establishing a plane between bony
structures, including residual lamina or overgrown
facet, Kerrison rongeurs are used to decompress the
lateral recess and foramen.
If substantial difficulty is encountered obtain-
ing a plane between residual bony elements and
the laminectomy scar, an alternative technique is
to thin the medial border of the previous lami-
nectomy to help establish a safe plane and facili-
tate easier dissection of the scar-bone interface
Operative technique  23
Figure 3.4 If there is difficulty establishing the
bone-scar interface, using a high-speed drill to
remove excess bone can thin bony structures and
make identification of the bone-scar plane easier
to dissect.
(Figure  3.4). Next, angled curettes are used to
­gently free thinned bone laterally to medially from
the scar. This provides a new plane to dissect down
the lateral canal, but excessive resection can result
in iatrogenic instability, which may require fusion
(Figure 3.5).
In cases of previous transforaminal interbody
fusion with facet resection, we start our dissec-
tion from the contralateral preserved facet joint
and work our way across the midline. If revision
foraminal decompression is needed on the ipsilat-
eral side and the exiting nerve root cannot easily
be identified or mobilized, it is safest to hug the
medial and superior borders of the inferior pedicle,
working carefully with a fine-angled curette and
an appropriately sized Kerrison rongeur.
Removing postlaminectomy scar from the dura
itself is performed as needed. A plane is established
between the laminectomy scar and dura beginning
from native anatomy using tension and counter-
tension. Laminectomy scars can be grasped with
a rongeur or pituitary rongeur and gentle tension
applied. A forward-angled curette then can be
used to release adhesions between the laminec-
tomy membrane and native dura, while keeping
the blunt portion of the curette toward the dura
24  How to dissect the plane between the scar of a laminectomy defect
Figure 3.5 An angled curette can be used with
the cup facing away from the dura and toward the
laminectomy scar and the cutting surfaces used
sharply against the remaining bone to create a
safe dissection plane.
Figure 3.6 A pituitary rongeur can be used to
apply gentle tension on the laminectomy scar and
a curette used to release adhesions between the
dura and laminectomy scar to allow safe removal
of the laminectomy scar.
(Figure 3.6). If substantial adhesions are encoun-
tered, it is advisable to leave a small remnant of
laminectomy scar attached to native dura; this can
be facilitated with a number 15 blade.
An angled ball-tip probe or dural elevator is
used to assess adequate lateral recess and forami-
nal decompression and nerve root mobility. The
Valsalva maneuver is performed to assess for
undetected durotomy and cerebrospinal fluid
(CSF) leak. Prior to closing, some surgeons advo-
cate for application of a layer of collagen or gelatin
matrix to help prevent recurrent postlaminectomy
scarring. Meticulous layered closure is important,
particularly when a durotomy has occurred and
monofilament suture is typically used, given the
revision setting.
POSTOPERATIVE MANAGEMENT
In the absence of complications, our postoperative
protocol is similar to primary posterior lumbar
spine cases. Patients are mobilized on postop-
erative day 0. Routine bracing is not used. Venous
thromboembolic prophylaxis is started on postop-
erative day 1.
COMPLICATIONS
Dural defects or tears are common during revi-
sion laminectomy scar dissection. They should
be repaired in a watertight fashion. We typically
use GORE-TEX, NUROLON, or prolene. Sutures
should extend beyond the edges of the tear. For
simple linear tears, a simple running or locked
running stitch will usually suffice. Small Gelfoam
pieces or cottonoids can be used to reduce herni-
ated rootlets and prevent suturing of the nerve
rootlet to the dura during repair. Collagen matrix
can also be tucked under the dural edges to func-
tion as a ball valve. Multiple hydrogels and tis-
sue sealants are available, which can supplement
repairs. They should be placed over the repair
or at the interface of the dura and dural substi-
tute. Several of these products swell after applica-
tion, and care should be taken to avoid iatrogenic
compression. A Valsalva maneuver to 40 mm Hg
is used to confirm lack of egress of spinal fluid.
Fascial closure is paramount, and often a double-
layered fascial closure is employed. This allows
adequate healing of the fascia and skin even if
the dural does not heal, creating a contained
pseudomeningocele.
 Complications 25

Depending on the integrity of the repair,

patients are kept on bed rest with the head of the Pearls and Pitfalls
bed flat, limited coughing, and incentive spirom- Pearls
etry. Care should be taken at mealtimes to prevent ●● Perform extensive preoperative planning,
aspiration. If there is any concern of the patient’s with careful history and physical examina-
ability to protect the airway while lying flat, then tion to and review of imaging to determine
she or he should be made nil per os (NPO). offending pathology and primary source of
Persistent leaking may be addressed with reex- symptoms.
●● Ensure availability to adequate equipment,
ploration and repair, oversewing the wound, sub- surgical tools, dural repair materials, and
arachnoid drain diversion, and subfascial drain ample operative time.
diversion. ●● Work from known bony anatomy to free
Other possible complications include iatro- adherent scar and dura.
genic nerve root injury, postoperative wound ●● Surgical principles of traction and counter-
traction can be helpful to release the lami-
complications, iatrogenic instability, postopera- nectomy membrane from native dura.
tive hematoma, deep vein thrombosis (DVT), pul-
monary embolism (PE), postoperative infection, Pitfalls
and positioning related complications including ●● Inadequate imaging
compression or traction neuropathies and optic ●● Dissecting through laminectomy scars, as
opposed to working around it
neuropathy. ●● Inadequate exposure
●● Lack of a preoperative plan

Local muscle flaps in the setting of
revision spine surgery: Indications,
operative planning, principles, and
postoperative management
BRIAR L. DENT, JAIME L. BERNSTEIN, AND JASON A. SPECTOR
Indications 27
Relative contraindications 27
Expectations 28
Principles of revision surgery 28
Preoperative planning and operating room
(OR) setup 29
INDICATIONS
An increasing body of literature demonstrates that
wound morbidity after complex spine reconstruc-
tion is significantly reduced by the immediate cov-
erage of the operated spine with local muscle flaps.1,2
Those same studies indicate that in addition to well-
known indications for muscle flaps such as active
infection, hardware exposure, and cerebrospinal
fluid (CSF) leak, almost every patient undergoing
revision spine surgery may be considered an appro-
priate candidate for local muscle flap coverage,
given the increased amount of less well vascular-
ized scar tissue present within the operative field.
Additional indications may include malignancy of
the spine, with prior or anticipated radiation ther-
apy; paralysis or immobility that would increase the
risk of pressure necrosis of the overlying skin; and
4
Operative technique 30
Postoperative management 32
Complications 32
References 33
comorbidities such as diabetes mellitus (DM), active
tobacco use, immunosuppression, or steroid use.
Finally, any patient with a thin soft tissue envelope
over the operative field, as judged by the spine sur-
geon, should be considered for muscle flap coverage.
RELATIVE CONTRAINDICATIONS
The only contraindication to wound closure with
local muscle flaps is if the patient is unable to tol-
erate the marginal anesthesia time needed for flap
closure, whether because of existing comorbidities
and perioperative cardiac risk or because of intra-
operative complications or hemodynamic instabil-
ity. In general, the additional time required ranges
from 30 minutes to 1.5 hours, depending upon the
number of levels involved and therefore the num-
ber of flaps requiring mobilization.
27
28  Local muscle flaps in the setting of revision spine surgery

(a) Posterior view (b) Cervical level Trapezius

muscle

Trapezius muscle
Paraspinous
muscle

(c) Thoracic level Latissimus dorsi

muscle

Paraspinous
muscle

Paraspinous
muscle
(d) Lumbar level Thoracolumbar
Latissimus dorsi fascia
muscle
Thoracolumbar
fascia

Paraspinous
muscle

Figure 4.1  (a) Posterior view of superficial and deep muscles of the back, commonly used for flap recon-
struction of the spine. Axial cuts of two layer flap closures through the (b) cervical level, (c) thoracic level,
and (d) lumbar level. (Reprinted from Clin Neurol Neurosurg, 171, Franck P, Bernstein JL, Cohen LE, Härtl
R, Baaj AA, Spector JA. Local muscle flaps minimize post-operative wound morbidity in patients with neo-
plastic disease of the spine, 100-105, Copyright (2018), with permission from Elsevier.)

EXPECTATIONS ●● Create a soft tissue barrier between the skin and

Closure of the wound with muscle flaps usually
includes the paraspinous as the deep layer, and
depending on the spinal levels involved, it also
may include the trapezius, latissimus dorsi, tho-
racolumbar fascia, and/or gluteus maximus as a
more superficial layer. This allows one to two lay-
ers of robust, well-vascularized muscle to cover
the spinal column, in addition to any associated
hardware and avascular graft material. It has been
our experience that these patients endure fewer
postoperative wound healing complications and
that, when such complications do occur, they are
more likely managed nonoperatively. Thus, the
muscle flaps impart many advantages, including
the following:
●● Provide additional soft tissue padding and
mechanical support over the spinal column
(Figure 4.1).
the spine that will continue to protect the spine
in the event of superficial dehiscence or full
thickness skin necrosis and allow the healing
of superficial wounds with conservative wound
care alone (Figure 4.5).
●● Obliterate dead space created by removal of
bone, therefore reducing the potential for fluid
accumulation at the surgical site; the flaps also
provide more direct apposition of muscle tissue
over exposed cord, which will improve dural
healing.
●● Increase perfusion to the surgical site, thereby
facilitating wound healing, graft revasculariza-
tion, and antibiotic delivery to any infected tissue.
PRINCIPLES OF REVISION SURGERY
The most important principles in wound recon-
struction with muscle flaps are (1) preservation of
the blood supply to both the skin and underlying
 Preoperative planning and operating room (OR) setup  29

muscle flaps and (2) minimization of tension on

the closure at all levels.
Preservation of the blood supply to the skin and
underlying musculature sometimes can be chal-
lenging in the setting of revision surgery due to the
presence of scars from prior surgeries, each of which
interrupts blood flow. Consequently, the spine sur-
geon and plastic surgeon should always discuss the
location of any planned incisions and the soft-tissue
approach to the spinal column. When the previous
surgery was performed through a midline inci-
sion with a direct approach to the spine, the same
approach can usually be made safely. However,
when paramedian incisions have been used previ-
ously (or are required), or if additional scars are
present in the vicinity, consultation with a plastic
surgeon is recommended to avoid inadvertently
interrupting the blood supply to the intervening
skin and to prevent damage to the underlying mus-
cles during the soft-tissue approach to the spine.
During elevation of the muscle flaps by the plas-
tic surgery team, careful attention is made to pre-
serve the blood supply to the muscles, as well as any
perforating vessels encountered between the vari-
ous layers of the closure. The dissection is extended
laterally until each muscle layer and the skin can
be advanced to the midline without undue tension
Figure 4.2 Relaxing incision through the lateral
on the closure. Any further dissection is unneces- muscle fascia to increase medial release of the
sary and will only reduce perfusion to the muscles muscle flaps.
and/or skin. When necessary, releasing incisions
in the muscle fascia can be performed laterally ●● Temporary suspension of anticoagulants and
(Figure 4.2), beyond where sutures will be placed reversal of coagulopathies, when appropriate
because the fascia represents the strength layer ●● Discontinuation of vasopressors, when appropri-
of the tissue that will hold the suture tension, to ate, as these decrease perfusion to the muscle flaps
increase the mobility of the muscle layers, thereby ●● Smoking cessation and discontinuation of any
reducing the tension on the closure. vasoconstrictive nicotine products
●● Optimization of glycemic control
PREOPERATIVE PLANNING AND ●● Discontinuation of steroids, when appropri-
OPERATING ROOM (OR) SETUP ate, or reversal of their negative wound-healing
effects with supplemental vitamin A
Whenever possible, the patient should be medi-
cally and nutritionally optimized prior to any sur- As previously mentioned, the spine surgeon
gery. To maximize the chance of successful wound and plastic surgeon should discuss the location
reconstruction with muscle flaps, the patient of planned surgical incisions and the anticipated
should undergo routine preoperative medical and soft-tissue approach to the spine to avoid com-
cardiac clearance, as well as the following: promising the blood supply to either the skin or
underlying muscle.
●● Nutritional optimization and protein supple- Patient positioning and draping are typically
mentation, as necessary dictated by the needs of the spine surgery team.
30  Local muscle flaps in the setting of revision spine surgery

Whenever possible, a wide surgical site shave and
skin preparation are preferred, as this allows the
plastic surgery team access to the surrounding
periincisional skin during wound closure and
drain placement.
Elevation and closure of the muscle flaps can typ-
ically be performed with the same instruments used
by the spine surgery team. Ideally, a dedicated plas-
tic surgery instrument tray should also be available.
OPERATIVE TECHNIQUE
Upon arrival of the plastic surgery team to the room,
a thorough signout is delivered by the spine surgery
team. This signout should include such elements as
the nature of the spinal procedure performed, the
presence and location of any exposed cord, the risk
of postoperative CSF leak, the location of any hard-
ware that needs to be covered, the location of any
graft material or antibiotic powder that needs to be
left undisturbed, and the estimated blood loss.
Closure of the wound begins with a thorough
wound inspection and hemostasis. Any devitalized
muscle is excised until healthy, bleeding muscle
edges are noted. The wound bed is then thoroughly
irrigated. If necessary, vancomycin powder can be
reapplied.
The muscle flaps are now elevated. In the
cervical and superior thoracic spine, closure is
performed using the bilateral trapezius and para-
spinous muscles. In the inferior thoracic and lum-
bar spines, closure is performed using the bilateral
latissimus dorsi and paraspinous muscles. In sacral
spinal wounds, a second layer of vascularized cov-
erage can be obtained with the thoracolumbar
fascia or bilateral gluteus maximus muscle flaps
(Figure 4.1). To begin elevating the muscle flaps,
an assistant retracts the skin and subcutaneous tis-
sue with a sharp rake, while the surgeon provides
countertraction on the muscle using toothed for-
ceps. The skin and subcutaneous tissue are elevated
off the muscle fascia using monopolar cautery. This
dissection is carried along the entire length of the
spinal wound until there is sufficient mobility to
advance the muscle and muscle fascia to the mid-
line without tension (Figure 4.3a). It is important
to preserve the fascia investing the muscle flap, as
this is the portion that will bear the suture ten-
sion; with the slightest tension sutures will tend
to pull through muscle tissue without overlying
fascia. Attention is made to preserving perforators
between the muscle and skin whenever possible.
If necessary, relaxing incisions can be made lon-
gitudinally in the lateral muscle fascia to increase

(a) (b) (c)

Figure 4.3  (a) Superficial muscle flap; X indicates superficial layer of muscle and fascia after dissection of
the subcutaneous tissue. (b) Deep muscle flap; triangle marks the paraspinous muscles. (c) Visualization of
both the superficial (X) and deep (triangle) dissected muscle layers.

mobility of the muscle flaps (Figure 4.2). After the
superficial muscle flap is satisfactorily dissected
from the overlying skin and subcutaneous tissue,
attention is then paid to the deep muscle flap.
Using a similar technique, the assistant retracts
the superficial muscle and muscle fascia using a
sharp rake, while the surgeon provides counter-
traction on the deep muscle and muscle fascia with
toothed forceps (Figure 4.3b). The surgeon now
elevates the superficial muscle flap off the deep
muscle fascia using monopolar cautery. This dis-
section is continued along the entire length of the
wound until both the deep and superficial muscle
flaps have sufficient mobility to be advanced to the
midline, again without tension (Figure 4.3c). The
appropriate plane between the deep and superficial
muscle layers is mostly avascular, but large, perfo-
rating vessels may need to be cauterized. In certain
cases, coverage with two separate layers of myofas-
cial flaps is not possible, but in nearly every case, at
least one layer is available for watertight coverage.
Separating the layers of the posterior trunk in this
fashion allows significant release medially.
A drain is placed in the deep submuscular plane
over the exposed spinal column and secured to
the skin. If there is concern for possible CSF leak-
age postoperatively, this drain is placed to straight
drainage (attached to a bile bag), which will allow
(a) (b)
Figure 4.4  (a) Image showing an open spinal wound with hardware in place. (b) The deep paraspinous
muscle layer is well approximated and imbricated to obliterate the underlying dead space and create a
watertight closure. (c) The superficial muscle layer, well approximated at midline to provide a second layer
of coverage.
Operative technique  31
excess fluid evacuation without exerting a suction-
ing force within the wound bed. If there is no risk
for CSF leakage, then this drain can be placed on
bulb self-suction. The deep (paraspinous) muscle
flaps are now advanced to the midline and secured
to one another with large (number 0 or 1), absorb-
able sutures (Figure 4.4a, b); these can be monofila-
ment or braided, looped continuous or interrupted,
according to the preference of the surgeon. If the lat-
ter is chosen, then figure-of-eight knots are recom-
mended. Barbed continuous suture may also be used
for flap approximation. It is our preference to use
continuous suture if tension is minimal; however, if
there is appreciable tension, then we will place mul-
tiple interrupted figure-of-eight sutures, which will
be tied after all sutures have been placed to mini-
mize the risk of premature tearing of the myofascial
flap due to excessive tension. A drain is not usually
placed between the deep and superficial muscle lay-
ers. Using the same technique, the superficial (i.e.,
trapezius, latissimus dorsi, thoracolumbar fascia,
and/or gluteus maximus) flaps are now advanced to
the midline and secured to one another (Figure 4.4c).
A drain is placed in the subcutaneous space and
secured to the skin. This drain can be attached to a
bulb and placed on self-suction. All drains should be
well labeled (superficial and deep) in the operating
room to facilitate postoperative monitoring.
(c)
32  Local muscle flaps in the setting of revision spine surgery

The skin edges are now inspected, and any surgeon. A common goal prior to drain removal
devitalized or traumatized skin and subcutaneous is for the 24-hour drain output to remain below
tissue are sharply excised until healthy, bleeding 20–30 mL for two consecutive days. Our published
edges are reached. The superficial fascia and der- experience demonstrates that drains may be left
mis are closed in separate layers using absorbable safely in place for 2–4 weeks as necessary and do
suture. If the skin edges are healthy, a subcuticular not increase the risk of infection.
suture is run using an absorbable, barbed suture.
If the skin edges are still of uncertain viability and COMPLICATIONS
cannot be further debrided, then the subcuticular
suture is omitted, and instead the skin is closed The literature is clear that patients who undergo
with nylon sutures using a running or horizontal reoperative spine reconstruction with muscle flaps
mattress technique. experience fewer postoperative wound healing
The incision is reinforced with a skin adhesive complications and, when such complications do
and wound closure strips if only absorbable sutures occur, they are more likely to recover with nonop-
were used in the skin closure. The incision and erative intervention.1,2 This latter element is key;
drains are then covered with occlusive dressings. even in the setting of fasciocutaneous necrosis or
Alternatively, an incisional subatmospheric inci- dehiscence, the underlying muscle flaps remain
sional dressing may be placed for several days. intact, and therefore, what would likely be a deep
space infection involving the spine and associate
POSTOPERATIVE MANAGEMENT hardware remains a superficial one that may be
treated only with dressing changes or subatmo-
Postoperatively, the patient is encouraged to spheric dressings (Figure 4.5).
minimize direct pressure on the reconstruction.
If hardware remains prominent through the soft
tissue, then it is preferable for the patient to be
positioned slightly to one side or another with
pillows.
The occlusive, sterile dressings from the oper-
ating room are maintained for 48–72 h postop-
eratively unless they are saturated or soiled. After
48–72 h, the dressings are removed and the wound
inspected. It is our preference to then place a new
occlusive dressing over the incision, changed every
1–2 days, for the duration of the patient’s hospital-
ization. The dressing can be removed on the day of
discharge, and any wound closure strips allowed to
fall off on their own. As an alternative to an occlu-
sive dressing, an incisional subatmospheric dress-
ing may be left in place for several days or until the
patient is ready to be discharged, whichever comes
first. Occlusive dressings containing chlorhexidine
gluconate gel covers are left in place over the drain
sites until drain removal.
Drain outputs should be recorded as needed, but
at least every shift, by the nursing staff. Upon dis-
charge from the hospital, the patient is instructed
to strip and empty his or her drains at least daily Figure 4.5  Superficial dehiscence demonstrating
and to keep a daily log of the drain output. Drain deeper muscle flaps that were still intact (arrows)
removal is performed at the discretion of the and covering deeper space/hardware.

There is no evidence that performing muscle
flaps increases risk for hematoma, surgical site
infection, skin necrosis, dehiscence, and other
complications related to their spinal procedure.1,2
The decision to perform muscle flaps, however, does
increase the time that the patient spends under
anesthesia and the amount of soft tissue dissection
performed, which may increase the risk of seroma
formation and the duration of indwelling drains.
Pearls and Pitfalls
●● Consider consulting a plastic surgeon for
wound closure with local muscle flaps for
any patient who is at high risk for wound
complications; in general, any patient
undergoing reoperative instrumentation
and fusion falls into this category.
●● Risk factors for wound complications
include prior spinal surgery; malignancy;
prior or anticipated radiation therapy;
infection; CSF leakage; paralysis or immo-
bility; comorbidities such as DM, tobacco
use, immunosuppression, and steroid use;
and finally, a thin, soft-tissue envelope over
the operative site.
References 33
●● Muscle flaps provide soft tissue bulk over
the spinal processes and hardware; protect
the spine and hardware in the event of skin
necrosis, dehiscence, or superficial surgical
site infection; obliterate dead space; and
increase perfusion and antibiotic delivery
to the surgical site.
●● Patients who undergo complex wound clo-
sure with muscle flaps experience fewer
postoperative wound healing complica-
tions. Furthermore, when these compli-
cations do occur, they can more likely be
managed nonoperatively with local wound
care and antibiotics.
REFERENCES
1. Cohen LE, Fullerton N, Mundy LR, et  al.
Optimizing successful outcomes in complex
spine reconstruction using local muscle flaps.
Plast Reconstr Surg. 2016;137(1):​295–301.
2. Franck P, Bernstein JL, Cohen LE, Härtl R,
Baaj AA, Spector JA. Local muscle flaps mini-
mize post-operative wound morbidity in
patients with neoplastic disease of the spine.
Clin Neurol Neurosurg. 2018;171:​100–105.

Revision and reimplantation of a spinal
cord stimulator device
FADI AL-SAIEGH, JOHN M. DEPASSE, FRANCIS J. SIRCH IV,
GREGORY D. SCHROEDER, AND CHENGYUAN WU
Introduction 35
Indications for revision 36
Contraindications 36
Expectation 36
Principles of revision surgery 36
INTRODUCTION
Spinal cord stimulation (SCS) is an effective
neuromodulation technique used to manage
patients with both sympathetic and neuropathic
chronic pain. The device consists of stimulation
leads, a pulse generator, and connecting leads.
Percutaneous, or “cylindrical,” leads are inserted
using loss of resistance or the “hanging drop” tech-
nique with a 14-gauge epidural needle, and they
emit stimulation circumferentially. Percutaneous
surgery does not require general anesthesia and
thus allows patient confirmation of electrode
placement, decreased acute perioperative risk,
and reduced likelihood of lead fracture. However,
cylindrical leads are susceptible to lead migration
and have less contact with spinal cord surfaces,
potentially decreasing clinical effectiveness. Paddle
lead implantation is done surgically as a laminot-
omy or laminectomy, and it requires anesthesia,
tissue dissection, and muscle retraction. Paddle
5
Preoperative planning 36
Operating room (OR) setup 36
Operative technique 36
Postoperative management 37
Complications 37
leads are wider and flat, with a varying number of
electrodes, providing unidirectional stimulation
toward the spinal cord. Paddle lead placement is
often confirmed with electromyography (EMG)
or somatosensory evoked potential neurophysi-
ological monitoring. Paddle leads may increase
the likelihood of acute perioperative risk; however,
they tend to result in lower rates of displacement
and reoperation and are associated with improved
clinical outcomes.
SCS often results in positive outcomes, with sig-
nificant reduction in chronic pain. Nevertheless,
with multiple derivations of hardware and surgi-
cal techniques, there are potentials for complica-
tions that require surgical revision. Loss of pain
coverage is often caused by lead migration or
fracture and is the most common cause of revi-
sion surgery. Additional complications include
hardware-derived and spinal infections, dural
punctures, seromas, and development of tolerance
to stimulation. SCS implantation may appear to be
35
36  Revision and reimplantation of a spinal cord stimulator device

a relatively straightforward procedure, but post- nutritional, and overall condition in order to
surgical changes can make revision surgery a chal- optimize the patient perioperatively
lenge. In this chapter, our goal is to provide a basic
framework for the r­ evision and reimplantation of PREOPERATIVE PLANNING
an SCS device.
●● Use computed tomography (CT) myelogram
to assess lead location and vertebral canal
INDICATIONS FOR REVISION accessibility.
●● Lead migration ●● Assess postsurgical changes that influence the
●● Lead breakage choice of surgical technique and intraoperative
●● Pain at generator site hardware.
●● Postimplantation infection or abscess ●● Remain aware of potential for scar formation
●● Ineffective pain suppression around chronically placed leads.
●● Spinal cord trauma ●● Prepare implantations tools to dissect epidural
●● Development of tolerance scar tissues.
●● Review the preoperative CT scan carefully to
recognize the sites of the previous laminoto-
CONTRAINDICATIONS mies to avoid iatrogenic dural injury.
●● Morbid obesity or severe cardiopulmonary
compromise OPERATING ROOM (OR) SETUP
●● Patients with coagulopathy/bleeding disorders ●● Ensure a clear surgical field and pay special care
(i.e., thrombocytopenia)
to superficial tissue to avoid risk of ­postoperative
●● Systemic or local infection
infection.
●● Incompatibility of pacemakers and defibrillators ●● Stimulator electrode placement may be carried
out with the patient sitting in a lateral or prone
EXPECTATION position in order to provide stability during
surgery.
●● Replacement or reimplantation/reprogram- ●● Ensure that patient positioning allows fluoro-
ming of broken leads scopic guidance up to the intended spinal seg-
●● Replacement or reimplantation of leads, with ment—anterioposterior (AP) views should be
increase in anchoring capability used to assess needle movement in the appro-
●● Revision of lead to achieve complete chronic priate direction, and a lateral view should be
pain suppression utilized when planning an approach toward the
●● Control of infection and removal of infected epidural space.
hardware (if present) ●● Inspect the integrity of the SCS system.
●● Utilization of paddle lead should necessitate
PRINCIPLES OF REVISION somatosensory evoked potential (SSEP) to
SURGERY appropriately measure and achieve the targeted
level of paresthesia.
●● Maintain proper orientation to remove scar tis-
sue from relevant landmarks OPERATIVE TECHNIQUE
●● Utilize appropriate visualization tools such as
intraoperative guidance or visual augmenta- 1. The implantable pulse generator (IPG) should
tion, as necessary, to facilitate surgical dissec- be interrogated to ensure functionality and
tion and optimize surgical outcomes check impedances.
●● Identify risk factors associated with the specific 2. If the interrogation reveals no malfunction
case, and improve the patient’s immunologic, and reuse of the IPG is intended, start the

procedure by reopening the pocket harboring
the IPG for its removal. This should be done
without the use of monopolar electrocautery
because that can lead to battery depletion.
3. Once the IPG is disconnected and removed,
reopen the thoracic spine incision with the use
of electrocautery.
4. As dissection is carried out, it is helpful to
expose parts of the lamina cephalad and cau-
dal to the previous surgery to ensure a good
understanding of the anatomy.
5. Once the leads are identified, follow them
proximally towards the paddle electrode.
6. Carefully dissect the fibrous sheath that forms
around the paddle electrode before attempting
to remove the electrode to avoid breakage of
the lead.
7. Once enough dissection is carried out, gently
remove the lead. Note that in cases of remote
placement, bone can regrow around the pre-
vious laminotomy site and may need to be
removed.
8. Carefully inspect the epidural space that pre-
viously contained the electrode and disrupt
the fibrous sheath encasing the implant using
both a nerve hook and Woodson elevator; this
will reduce the risk of another lead migration.
9. Pass the new electrode into the space and ver-
ify its proper positioning via fluoroscopy. Note
the following:
●● If the paddle tends to veer off into the lat-
eral gutter, insert the electrode cephalad at
the previous insertion site.
●● Inserting a small laminotomy cephalad to
the insertion level may allow better manip-
ulation of the electrode into the center of
the epidural space.
10. Confirm proper positioning via x-ray and test
the system.
11. Secure the leads to the fascia using sutures and
tunnel them toward the IPG site.
12. The revision spinal cord stimulator implanta-
tion is complete at this point, and the patient
can be closed up in a standard fashion.
POSTOPERATIVE MANAGEMENT
●● Program the pulse generator prior to dis-
charge—most patients will be able to leave the
Complications 37
same day following surgery, but some may need
to stay overnight.
●● Discharge the patient with appropriate short-
term narcotic medications and counsel to
avoid nonsteroidal anti-inflammatory drug
(NSAID) use.
●● Counsel the patient about appropriate activity
restrictions, encourage early ambulation, and
give proper instructions regarding wound care
and recognition of serious complications.
●● Schedule the patient to come back 10–14 days
following surgery to remove sutures and staples
and to adjust the pulse generator as needed.
COMPLICATIONS
●● Cylindrical leads often have less anchorage, and
thus may result in lead migration and loss of
paresthesia at the site of pain—a complication
that cannot be resolved through reprogram-
ming of the SCS system.
●● Electrode fractures and disconnections are
common mechanical complication that can be
resolved with reprogramming; one can measure
impedance if this is suspected, as a higher value
is associated with a fracture/disconnection.
●● Although rare, a spinal hematoma may occur,
especially in patients receiving anticoagulation.
●● There is a risk of dural puncture and cerebrospi-
nal leak due to using a 14-gauge epidural needle
to access the working space for lead placement;
this can be especially relevant with revision sur-
gery, as the epidural space may have additional
scar tissue.
●● With a posterior thoracic approach to SCS revi-
sion, one must be cognizant of potential intra-
operative neurologic injury.
Pearls and Pitfalls
Lead placement
●● During threading of the lead, avoid perpen-
dicular needle placement into the epidural
space to avoid bending of the introduced
stimulator.
●● Generator placement should be located
within reach of the patient’s dominant
hand for easy adjustment of programming.
38  Revision and reimplantation of a spinal cord stimulator device

●● During lead placement, the anchoring
device should be located as close as pos-
sible to the initial fascial plane; utilize the
tip of the anchor to protrude into the fascia
to avoid bending the angle of the lead.
●● Consider using strain relief loops at the
anchor point of the stimulator and the
generator site to mitigate the risk of lead
migration and fracture.
●● Avoid tunneling the lead stimulator around
mobile structures to reduce the risk of
migration and fracture.
 1
Part    

Anterior Cervical

6 Revision ACDF at the same level 41

Fadi Al-Saiegh, George M. Ghobrial, and James S. Harrop
7 Revision ACDF: Adjacent level 47
Courtney Pendleton, Matthew S. Galetta, and Jack Jallo
8 Converting a total disc replacement to an ACDF 51
Joseph D. Smucker and Rick C. Sasso
9 Treatment of adjacent segment disease after total disc replacement (TDR) 59
Bruce V. Darden II

Revision ACDF at the same level
FADI AL-SAIEGH, GEORGE M. GHOBRIAL, AND JAMES S. HARROP
Indications for same-level ACDF revision 41
Revision surgery of same-level ACDF:
basic principles 42
Expectations from revision surgery 43
Preoperative planning 43
INDICATIONS FOR SAME-LEVEL
ACDF REVISION
Anterior cervical discectomy and fusion (ACDF)
is a commonly performed procedure for cervi-
cal spondylosis and numerous other pathologies
resulting in compression of the spinal canal and
neural foramen. It has gained significant popu-
larity since its first description in 1955 by Smith
and Robinson, with up to 150,000 procedures
performed annually in the United States. It serves
to decompress the neural elements via restora-
tion or preservation of the intradiscal height and
restore cervical lordosis, with excellent success
rates (>90%). The success rate depends on thor-
ough decompression and the formation of a robust
osseous fusion. Complications from ACDF surgery
generally arise in an early or delayed fashion. Early
complications are relatively uncommon among
spinal approaches and are related to neurovascular
or tracheoesophageal injury or the development
of a postoperative hematoma. The most common
complications in this group are hoarseness and
dysphagia, which occur in about 10% of cases
and are usually transient. Rarely, early complica-
tions cause neurologic deterioration or airway
6
Operating room (OR) setup and
operative technique 43
Postoperative management 45
Complications 45
compromise and necessitate emergent surgical
exploration. Late complications are often a sign of
pseudarthrosis, including instrumentation failure,
screw dislodgement and migration, graft subsid-
ence, extrusion, retropulsion, adjacent-segment
disease (ASD), and potentially even mechanical
instability from pseudarthrosis.
Risk factors for late complications are related to a
variety of factors, including patients’ comorbidities,
such as osteoporosis, obesity, malnutrition, diabe-
tes mellitus (DM), immunocompromised states,
and use of tobacco products, but also the operative
technique of preparing the end plates, the type of
graft used, and use of internal fixation with a plate.
Not all patients who have radiographic evidence of
hardware failure or pseudarthrosis have poor clini-
cal outcomes. However, neurologic symptoms are
more likely to recur after initial remission because
persistent mobility and excessive bone growth at
the fusion site are likely to cause recurrent neural
compression, resulting in radiculopathy or myelop-
athy. In single-level ACDF, the overall complication
rates range between 10% and 20%, and the revision
rate is reported in the literature at approximately
10%. Multilevel ACDF has a higher rate of compli-
cations, and revision rates can reach 20% or more.
41
42  Revision ACDF at the same level
In its original description, ACDF consisted
of removal of the osteophytes and the disk and
insertion of an autologous tricortical bone graft
harvested from the iliac crest. Although several
refinements were made in the past 50 years, the
goal of the procedure remains the decompres-
sion of the nerve roots and the spinal cord and
the formation of a solid osseous fusion. Adequate
immobilization in a cervical collar for about 6
weeks after the initial procedure is strongly recom-
mended because it is thought to increase the fusion
rate. Follow-up radiographic criteria that are used
to assess for the success of the fusion are bony tra-
beculation in the disk space and remodeling of the
bone graft in the case of an autograft or the absence
of radiolucency at the graft‒end plate interface in
the case of a synthetic graft. Typically, the fusion
rate is 94%–96%, 88%–94%, and 76%–90% in
single-level, two-level, and three-level ACDF,
respectively. Flexion-extension films allow further
radiographic evaluation because they can uncover
motion between the spinous processes in the oper-
ated segments. If, however, osseous fusion cannot
be determined from plain films, computed tomog-
raphy (CT) can be engaged. Failure of fusion, or
pseudarthrosis, is reported to occur in 5%–20%
of single-level ACDF cases, and the incidence
increases with the number of levels involved.
Symptomatic pseudarthrosis in the subaxial
spine most commonly presents with persistent
neck pain with or without radiculomyelopathy.
Occipital or holocranial headache may be expe-
rienced in pseudarthrosis at C4/5 or C5/6 and
scapular pain may be encountered when the C5/6
or C6/7 levels are involved. Nonoperative options
may be considered prior to revision ACDF, which
include orthosis, physical therapy, analgesics, and
interventional pain management. In cases of unre-
mitting symptoms that are intractable to nonsur-
gical management and partially attributable to
pseudarthrosis, revision surgery at the same level
is justifiable. Graft, plate, or screw dislodgement,
which may occur in up to 5% of cases, warrants
earlier treatment. Asymptomatic pseudarthro-
sis or delayed union on radiographic follow-up
may indicate a fibrous union, which can explain
a lack of postoperative painful symptomatology
and elimination of preexisting motion on flexion-
extension radiographs. These patients can be fol-
lowed and typically do not require repeat surgery.
REVISION SURGERY OF SAME-
LEVEL ACDF: BASIC PRINCIPLES
In principle, revision of same-level ACDF can
be achieved through an anterior or posterior
approach. Both routes can be effective, and the
choice should be made after careful assessment of
the initial clinical and radiographic surgical out-
come and the patient’s comorbidities. In the case of
a single-level ACDF, which has a very high fusion
rate, the lack of a successful fusion should prompt
a workup in the clinic to establish causative fac-
tors. Very often, pseudarthrosis from a single-level
ACDF should raise the concern that the patient is
noncompliant with abstaining from tobacco prod-
ucts. Repeat nicotine and cotinine levels should
be evaluated after an open discussion with the
patient. Furthermore, other predisposing medical
conditions for pseudarthrosis should be evaluated
such as osteoporosis, DM, chronic kidney disease,
rheumatoid arthritis, and the use of anti-inflam-
matory or immunomodulatory/immunosuppres-
sant medications. In the case of symptomatic
radiculopathy due to subsidence, revision surgery
at the same level may best be addressed by resto-
ration of interbody height. Alternatively, which
will be discussed next, foraminal stenosis can be
addressed posteriorly via foraminotomies. In the
case of graft or hardware dislodgement, removal
should be addressed via an anterior approach to
avoid the development of symptomatic soft tis-
sue erosion, which can also include esophageal
perforation.
One drawback of anterior revision at the same
level is the need for dissection through obscured
tissue planes, which increases the risk of injuring
tracheoesophageal or neurovascular structures.
The authors recommend a preoperative evaluation
of vocal cord function by use of indirect laryngos-
copy to identify a preexisting unilateral asymp-
tomatic recurrent laryngeal nerve palsy, which
is encountered in 8%–10% of patients who had
undergone ACDF. The risk is higher in patients who
underwent ACDF at the C5 level or lower. If unilat-
eral vocal cord paralysis is diagnosed, the approach
should be same-sided to avoid bilateral recur-
rent laryngeal nerve palsy, as the consequences of
bilateral vocal cord paralysis are devastating and
may require permanent tracheostomy placement.
In the case of normal vocal cord function, either
 Operating room (OR) setup and operative technique  43
sided approach can be taken. Another consider-
ation with the ipsilateral approach is to make a
second incision and use a new tissue plane. This
is uncommon due to the difficulty with exposure
from an oblique angle, as well as the final cosmetic
appearance of two parallel neck incisions, which is
suboptimal.
Another strategy for symptomatic pseudar-
throsis after ACDF is to approach the cervical
spine posteriorly. This allows posterior decom-
pression of the symptomatic nerve roots via
foraminotomies and stabilization with instru-
mented lateral mass fusion at the level of interest.
Another consideration in the patient is that where
failure is attributable to medications and medical
conditions impairing bony fusion or preventing
adequate fixation, both an anterior and poste-
rior approach can be considered, with or without
use of the iliac crest autograft bone. On the other
hand, in the setting of delayed pseudarthrosis and
the loss of lordosis, with or without significant
kyphotic angulation, anterior revision with the
goal of structural anterior column support with
the restoration of lordosis should be strongly con-
sidered, with or without posterior instrumented
stabilization.
EXPECTATIONS FROM REVISION
SURGERY
Subjecting the spine segment to revision surgery
naturally increases the risk for perioperative com-
plications compared to the initial surgery, which
should be communicated to the patient clearly.
However, these risks should be evaluated carefully
in light of the potential for improvement of the
patient’s neurologic symptoms. Therefore, meticu-
lous clinical and radiographic assessment and pre-
operative planning are essential. Special attention
must be paid to correlating the patient’s symptoms
with the radiographic findings in order to differ-
entiate whether the symptoms are accounted for
by failure of the initial surgery or by symptom-
atic ASD. In addition, the patient’s comorbidities
should be taken into account, especially when
choosing a graft. Patients with poor bone quality
and previous pseudarthrosis are at high risk of per-
sistent nonunion after revision surgery. They are
more likely to benefit from an allograft. Otherwise,
tricortical autograft harvested from the iliac crest
provides better structural support and is the graft
of choice. A fibular strut allograft can be consid-
ered, but it lacks osteoinductive properties.
The overall complication rate for revision of
index-level ACDF is approximately 10%–25%, but
the rate varies depending on whether an anterior, a
posterior, or a circumferential approach is selected.
Most of these complications are dysphagia, tran-
sient hoarseness, or radiculopathy. The majority
of patients that undergoes revision surgery expe-
riences saw improvement of their symptoms. This
is especially the case if the presentation is radicu-
lopathy from foraminal stenosis caused by graft
subsidence or myelopathy from focal kyphotic
angulation.
PREOPERATIVE PLANNING
To maximize the success of revision surgery,
plain static and dynamic radiographs should
be obtained and carefully evaluated. Computed
tomography (CT) should also be obtained in all
candidates being considered for revision surgery
because it provides indispensable information on
the assessment of bone quality and bony fusion.
Radiographic assessment must also include evalu-
ation of the cervical sagittal alignment and pres-
ence of any stenosis because both have implications
on whether an anterior or a posterior approach
is more helpful, relatively. Additionally, flexion-
extension radiographs can detect motion at the
fused segments and are useful for planning the
extent of fusion when posterior revision surgery is
selected. Finally, nerve root and spinal cord com-
pression should be confirmed with magnetic reso-
nance imaging (MRI) whenever it is suspected to
be present. It cannot be overstated that the radio-
graphic and clinical findings must be localized to
the level of surgical pathology to maximize clinical
outcomes.
OPERATING ROOM (OR) SETUP
AND OPERATIVE TECHNIQUE
Anterior revision of same-level ACDF
For anterior revision surgery, the patient is posi-
tioned supine on a radiolucent operating table and
the airway is secured via endotracheal intuba-
tion. Fiberoptic intubation is used in patients with
44  Revision ACDF at the same level
cervical myelopathy, severe spinal canal stenosis,
and traumatic cervical injury, with or without
gross instability or displacement. Awake fiberop-
tic intubation allows preintubation and postintu-
bation neurological assessment in these cases.
However, other visualization techniques can be
utilized that limit neck manipulation and are typi-
cally preceded by neurophysiologic assessment of
motor-evoked and somatosensory evoked poten-
tials (MEP/SSEPs), as well as electromyography
(EMG). The decisions to use neuromonitoring, and
which modalities in particular, vary considerably
and are decisions made on a case-by-case basis, as
well as depending on the surgeon’s personal expe-
rience. An arterial line is placed prior to induction
to avoid hypotension at any time, which would
put the susceptible spinal cord at risk for further
injury.
After establishment of baseline neurologic func-
tioning and intubation, positioning commences
with placing a bolster under the shoulder blades to
achieve cervical lordosis. Halo tongs or any other
lordotic distraction device can also be used to facili-
tate interbody work and the maximization of lor-
dotic alignment. The arms are padded at the elbows,
where the ulnar nerve is most susceptible to neura-
praxia. If iliac crest is intended for harvest, then
the side of anterior superior iliac spine is elevated
with a small bump to facilitate surgical exposure.
Localization of incision and sagittal alignment may
be assessed prior to sterile prep and drape with fluo-
roscopy. The shoulders can be taped and retracted
caudally to improve radiographic exposure of the
caudal part of the cervical spine. Gentle retraction
of the shoulders is advised to avoid brachial plexus
injury, which can be monitored by neurophysiology.
Either the ipsilateral scar is incised, or the con-
tralateral level is incised. The anterior cervical spine
is approached in the usual fashion via the Smith-
Robinson approach, which is a soft tissue corri-
dor medial to the carotid sheath and lateral to the
tracheoesophageal structures, as well as through
the pretracheal fascia to the anterior column of the
cervical spine. Once the retropharyngeal space is
reached and the anterior cervical spine is palpated,
the location of the previous fusion is confirmed
with fluoroscopy. The longus colli muscle is mobi-
lized and then elevated. Subsequently, self-retaining
retractors with the blades placed beneath the longus
colli muscle are used to fully expose the instrumen-
tation. The fusion mass is dissected thoroughly by
removal of the graft and excision of scar and fibrous
tissues using curettes, electrocautery, and a high-
speed drill. If lordosis needs to be reestablished,
Caspar distraction pins are drilled into the vertebral
bodies caphalad and caudad to the fusion level. Any
recurring osteophytes or remaining cartilaginous
end plates must be completely removed. If revision is
being performed for recurrent radicular symptoms,
a Kerrison rongeur can be used to achieve foraminal
decompression. The end plates are subsequently pre-
pared for graft placement using a curette or a high-
speed drill. Care should be taken to avoid end-plate
injury that promotes graft subsidence. Afterward,
a spacer is used in the same fashion that it is used
for first-time ACDF procedures (Video 6.1). Once
the correct graft size is identified, an iliac crest tri-
cortical bone graft is harvested and firmly tamped
into the distracted disk space. Next, the Caspar pins
are removed and a cervical plate is sized. The plate
should match the fused levels in its length and the
lordotic contour in its silhouette. Finally, intraop-
erative fluoroscopy is used to ensure optimal place-
ment of the graft and the plate. We strongly advocate
for using a plate, even when revising single-level
ACDF to minimize the risk of graft migration and to
increase the rate of fusion. Once meticulous hemo-
stasis is achieved, the wound is irrigated with antibi-
otic solution and closed in layers in the usual fashion.
The use of a postoperative drain may be done at the
discretion of the spinal surgeon.
Posterior revision of same-level
ACDF
Preparation for revision surgery through the pos-
terior route is initiated by endotracheal intubation,
with the same precautions as mentioned previously,
including neurophysiologic monitoring and subse-
quent skull fixation using a Mayfield three-point
head fixation. Extreme care must be taken to pay
proper attention to skull fixation points and preop-
erative head fixation to avoid the devastating com-
plication of pin loosening and migration, which
can cause scalp laceration or worse. The patient is
then turned to lie prone on a Jackson table and the

head is positioned such that the cervical spine is
parallel to the floor and the chin is in a military
tuck position to decrease overlap of the cervical
lamina. The shoulders are retracted caudally, and
the correct level is determined using fluoroscopy.
Next, baseline somatosensory and somatomotor
evoked potentials are obtained.
A midline longitudinal skin incision is made and
tissue dissection is begun using monopolar electro-
cautery through the nuchal ligament. Subperiosteal
dissection along the spinous processes is carried out
at the levels of the failed anterior arthrodesis and is
extended laterally along the laminae to expose the
lateral masses and facet joints. Care must be taken
not to violate the facet joint capsules of levels not
intended for fusion. Fluoroscopy is then used to
confirm exposure of the correct levels.
If the patient’s symptoms are caused by pseud-
arthrosis of the anterior cervical arthrodesis,
fusion via lateral mass or pedicle screws is suf-
ficient to provide immediate rigid fixation and
promote anterior fusion. However, if the patient
is myelopathic from spinal canal stenosis, decom-
pression via laminectomy and subsequent fusion is
a reasonable consideration.
After exposure of the lateral masses and defin-
ing the correct levels, the screw entry point is iden-
tified. Using the modified Magerl technique, a pilot
hole is drilled medial to the midpoint of the lateral
mass angling approximately 30–40 degrees in the
sagittal and 25 degrees in the axial planes. The hole
is then palpated with a ball-tip probe to ensure the
integrity of the osseous tunnel before placement of
the screw. Preoperatively acquired CT scans aid in
determining the optimum screw length and ros-
tral angulation. Prior to rod contouring, the head
is returned to a lordotic configuration by a fellow
surgeon (Figure 6.1).
In the case of a lateral mass screw-rod con-
struct, titanium rods are then measured and
contoured in the ideal position, which fits into
the tulips without forceful compression maneu-
vers that increase the stress on the construct and
increase the chance of screw backout. Meticulous
hemostasis and irrigation with antibiotic solution
are followed by decortication of the lateral masses
and facet joints, bone graft placement, and closure
in a typical fashion.
Complications 45
POSTOPERATIVE MANAGEMENT
Postoperative management must be directed by the
etiology that made a revision necessary, the pre-
operative pathology, the extent of fusion, and the
patient’s risk factors. Usually, fusion is expected to
become apparent after about 6–12 weeks. Although
the benefits of orthoses after revision ACDF have
yet to be proved, the authors recommend keeping
the patients in a rigid cervical collar for at least 6
weeks postoperatively. Radiographic evaluation
of the fusion construct should be obtained at that
time and the period of immobilization extended
if evidence of beginning bony trabeculation and
graft incorporation is absent. Those who have met-
abolic impediment to healing, such as with DM,
tobacco use, or osteoporosis, may be kept in a col-
lar for longer. Rarely, external immobilization may
be a last resort to facilitate circumferential revision
cervical fusion surgery. Concomitant tight gly-
cemic control, daily ambulation, and abstinence
from tobacco products are strongly advised. Neck-
strengthening exercises along with tapered use of
the cervical collar can be begun once radiographic
fusion becomes evident. Evaluation of the con-
struct using flexion-extension films should not
be obtained before 8 weeks postoperatively. These
time frames should be extended to 2 or 3 months
in patients with delayed fusion or more extensive
constructs or risk factors.
COMPLICATIONS
Revision of ACDF generally carries a higher risk
for complications than the initial procedure. This
includes intraoperative injuries of the neurovascu-
lar or tracheoesophageal structures, as well as early
and delayed complications discussed previously.
Delayed complications can be minimized by suf-
ficient preoperative planning. For example, high-
risk patients who have failed a multilevel ACDF
should be strongly considered for a circumferential
approach because it has proved to be more effective
in achieving a robust bony fusion, even though it
may seem extensive initially. Such patients with
extensive spondylosis and poor bone quality are
unlikely to remain symptom free over the long term
after a stand-alone anterior or posterior revision.
46  Revision ACDF at the same level

(a) (b)

(c) (d)

Figure 6.1  Posterior revision of an ACDF at the same level. A middle-aged man who is an avid smoker
originally underwent ACDF at C5–C7, with C6 corpectomy and use of allograft. He presented again after
about 3 months with severe progressive cervical myelopathy. The plain lateral x-ray film (a) and sagittal CT
scan (b) of the cervical spine revealed lucency along the screw-bone interface and nonunion. The patient
subsequently underwent posterior cervical fusion at C5–C7 using lateral mass screws and rods, as shown
in the AP (c) and swimmer’s view (d) radiographs of the cervical spine.

high-speed drills without sufficient irrigation.

Pearls and Pitfalls This can lead to thermal injury and ablation
A few techniques can be incorporated or of the bone capillaries, with consequent loss
avoided by the surgeon to optimize the nat- of the osteogenic components required for
ural capacity of bone healing. For example, fusion. The same principle applies to exces-
bone grafts are most likely to be incorporated sive use of monopolar cauterization.
successfully when placed under a compressive
axial load, which will stimulate bone remod-
eling and decrease the risk of osteopenia
(Wolff’s law). This will also avoid a delayed
loss of lordosis, which is observed when
Video 6.1
undersized grafts are used. Therefore, the
height of the graft should be a few millimeters ACDF Revision Same Level
greater than the disk space that it is intended (https://youtu.be/vYsMl-9KIUs)
to fill. Another pitfall is the excessive use of

Revision ACDF: Adjacent level
COURTNEY PENDLETON, MATTHEW S. GALETTA, AND JACK JALLO
Indications 47
Relative contraindications 47
Expectations 47
Principles of revision surgery 47
INDICATIONS
Indications for revision surgery include degen-
erative disc disease at an adjacent level, with
symptoms of radiculopathy, myelopathy, or
axial pain  that  is  unrelieved by conservative
management.
RELATIVE CONTRAINDICATIONS
Patients in whom an extension of a preexisting
ACDF would require a construct spanning four
or more levels are generally treated with pos-
terior cervical discectomy and fusion (PCDF)
to avoid extensive exposure, with increased
risk of injury to the surrounding structures.
Contraindications include patients who are med-
ically unstable to undergo operative treatment,
ongoing tobacco use, and symptoms attributable
to dorsal pathology. Additionally, patients with
livelihoods making them adverse to risks associ-
ated with revision ACDF (i.e., singers) should be
withheld from surgery.
7
Preoperative planning and operating room
(OR) setup 48
Operative technique 49
Postoperative management 49
Complications 50
EXPECTATIONS
Patients presenting primarily with neck pain are
counseled that these symptoms may be have eti-
ologies other than cervical spine pathology. Those
with radicular symptoms are advised that pain
and numbness may recover slowly, while those
with myelopathy are told that symptoms may
resolve slowly or partially, and the primary goal
of these surgeries is to prevent progression, with
symptom improvement a secon­dary goal.
The importance of preoperative and postop-
erative nutrition, smoking/tobacco cessation, and
compliance with a rigid cervical collar for 4–6
weeks postoperatively is emphasized.
Risks of postoperative dysphagia are discussed
at length with patients requiring revision or
­extension of multilevel ACDFs.
PRINCIPLES OF REVISION SURGERY
The goal of revision surgery is to remove the
offending pathology and obtain adequate fusion,
47
48  Revision ACDF
while minimizing disruption of the index-level
fusion (Video 7.1). If pseudoarthrosis is the reason
for revision, specific attention is paid to smoking
cessation counseling (if relevant), and planning for
iliac crest bone graft harvesting.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
During preoperative assessment, anterioposterior
(AP) and lateral cervical spine x-rays are obtained
to assess instrumentation, graft position, and
fusion mass (Figure 7.1). Cervical spine computed
tomography (CT) scans are obtained to assess the
involvement of osteophytes and calcified discs, as
well as to ensure that the patient does not have a
pseudarthrosis that needs to be addressed con-
comitantly. Patients receive cervical spine mag-
netic resonance imaging (MRI) to assess cord
compression and signal abnormalities that may
guide operative planning, as well as recommenda-
tions for anterior revision versus posterior decom-
pression and fusion (Figure 7.2).
Figure 7.1  Preoperative AP and lateral cervical spine x-rays demonstrate prior ACDF plating at C3–C6.
The patient presented with progressive myelopathy, gait dysfunction, and hand clumsiness.
Patients are assessed by otolaryngology to deter-
mine vocal cord function. If normal function is
seen bilaterally, an incision is planned contralateral
to the initial incision, so as to minimize the scar
tissue encountered, and reduce challenges in expo-
sure and tissue mobilization that may lead to intra-
operative complications. If abnormal function is
noted, the incision is planned on the ipsilateral side
to avoid bilateral recurrent laryngeal nerve injury.
Patients with myelopathy receive an arterial
line for intraoperative monitoring. The use of arte-
rial lines in nonmyelopathic patients is done at
the discretion of the anesthesia team and is usu-
ally reserved for those with significant medical
comorbidities.
We position patients on a foam pillow with an
inflatable bump horizontally behind the shoulders.
Motor-evoked potentials (MEPs) and somato-
sensory evoked potentials (SSEPs) are obtained
at baseline, and after extension of the neck. In
patients with significant myelopathy, poor align-
ment, or concerns for cervical spine instability,
awake fiberoptic intubation may be considered,

Figure 7.2  An MRI demonstrating significant cord
compression with mild cord changes at the level
below the fusion (C6–C7).
with preintubation and postintubation monitoring
obtained. The shoulders are taped down to provide
additional exposure and optimize the quality of
intraoperative x-rays. Additional neuromonitoring
signals are obtained after taping.
If iliac crest is to be harvested, the side contra-
lateral to the surgeon is prepared, unless contrain-
dicated, to optimize the operating room (OR) flow.
OPERATIVE TECHNIQUE
After positioning and sterile draping, the incision
is made, either through the preexisting scar or on
the contralateral side, as determined by preopera-
tive testing.
Attention is paid to locating and respecting
surgical planes within the scar tissue if a previous
incision is used. Undisturbed landmarks are used
to assist in dissection down to the prevertebral fas-
cia. The trachea and esophagus are mobilized and
held with a handheld Cloward retractor. The lon-
gus colli are elevated and self-retaining retractors
are introduced.
Postoperative management  49
The preexisting plate serves as an intraoperative
landmark, and additional localizing x-rays are not
routinely obtained.
Patients may require single- or multiple-level,
adjacent-level ACDFs. In cases of single-level revi-
sion/extension, the exposure includes the adjacent
half of the vertebral body and plate, as well as the
adjacent level, if a stand-alone spacer with anchors
is used. This minimizes the risk of injury to the soft
tissue during dissection through scar tissue and
exposure of the entire previous plate system.
If the initial ACDF construct demonstrates
adequate fusion on postoperative imaging and
­
revision at more than one level is planned, the
entire plate may be exposed and removed with
subsequent performance of discectomy and spacer
placement at the adjacent levels and placement of
a multilevel plate spanning the index and revision
levels.
In cases of radicular symptoms, foraminoto-
mies are performed to ensure adequate nerve root
decompression.
Final MEPs and SSEPs are obtained after
placement of the graft and plate. The incision is
copiously irrigated with antibiotic saline, and
hemostasis is obtained. A single drain is left. The
platysma is reapproximated, and the deep dermal
tissues are closed with three or four vicryl sutures.
The skin is closed with a subcutaneous monocryl.
The drain is secured with a monocryl suture,
which is removed with the drain on the first post-
operative day.
POSTOPERATIVE MANAGEMENT
Patients are admitted overnight to a telemetry-
monitored bed. An anterior drain is removed on
the first postoperative day. Myelopathic patients
are seen by physical and occupational therapy
on the first postoperative day for clearance and
inpatient rehabiliation is arranged if necessary.
All patients are fitted with hard cervical col-
lars to be worn for 4–6 weeks. They are seen in
the clinic at 2 weeks, and 4‒6 weeks for inci-
sion checks and review of AP and lateral x-rays.
Baseline, standing upright x-rays in the cervical
collar are obtained prior to discharge from the
hospital (Figure 7.3).
50  Revision ACDF

Tracheal and esophageal injuries remain

rare complications, even in revision procedures.
Similarly, the rates of postoperative wound infec-
tions are still low.
Vertebral artery injury may occur and may be
more likely in revision cases, where scar tissue
obscures planes and the midline.

Pearls and Pitfalls

Figure 7.3  Final postoperative x-ray imaging after
revision surgery: ACDF C6–C7 with placement
of a single plate. Prior instrumentation exposed
and removed. Graft incorporation and fusion at
C3–C6 levels were evaluated. C6–C7 was decom-
pressed, with an allograft and a single-level plate
put in place.
COMPLICATIONS
Use of a stand-alone spacer with anchors
allows revision at adjacent levels, while mini-
mizing the need for exposure of the preexist-
ing plate and the risk of injuring surrounding
structures through dissection and retraction
of scar and soft tissue. However, these spac-
ers are generally approved only for single-
level disease.
  Patients with pseudoarthrosis should be
evaluated carefully prior to revision surgery,
and nutrition, tobacco cessation, and bone
density should be optimized to maximize
operative success.
Video 7.1
ACDF Revision ASD
(https://youtu.be/ie59oxSEiuM)

Injury to the recurrent laryngeal nerve can be min-

imized through preoperative assessment and care-
ful intraoperative dissection and retraction.

Converting a total disc replacement to
an ACDF
JOSEPH D. SMUCKER AND RICK C. SASSO
Indications 51
Relative contraindications 52
Expectations 53
Principles of revision surgery 53
INDICATIONS
Anterior cervical spine surgery is a common
method for treatment of degenerative cervical
spine pathology and plays a substantial role in
a spine surgeon’s choice of approach. Anterior
decompressions in the cervical spine have tradi-
tionally been complemented by a reconstruction
following the removal of pathological material
such as cervical disc, osteophytes, and degenera-
tive ligament pathology. Anterior cervical fusion
plays a role in many of these reconstructions, but
there are known concerns related to the index pro-
cedure and the adjacent levels following healing of
the index procedure. Anterior cervical discectomy
and disc replacement is a more recent method
for the treatment of degenerative conditions
focused at the disc level, and seven such devices
have been approved by the U.S. Food and Drug
Administration (FDA) for use. In addition to the
utilization in the FDA trials, which began about a
decade ago, clinical use has slowly increased.
One goal of cervical disc replacement is reten-
tion of index-level motion, a phenomenon that is
8
Preoperative planning and OR setup
(including the utility of neuromonitoring) 53
Operative technique 55
Postoperative management 56
Complications 57
commonly measured with radiographs in the clin-
ical setting. In addition to the index-level motion
retention, cervical disc replacement is proving to
be a more biomechanically favorable treatment
option with respect to the need for revision ante-
rior surgery, especially as adjacent-level concerns
are considered. However, index-level device wear,
device failure, and adjacent-level concerns are
being appreciated as occasional reasons to consider
revision surgery. In addition, adjacent-level wear
can still occur despite clinical and biomechanical
success being achieved at the index level.
There are a number of reasons to consider revi-
sion surgery at the index level, and the traditional
surgical solution often involves conversion of the
motion segment to arthrodesis (fusion). Device
removal and fusion via an anterior approach is
one of two methods of consideration. The other
is device retention and posterior fusion, with or
without consideration of posterior decompres-
sion. Herein, we address the option of conversion
of the index-level device to arthrodesis, commonly
referred to as anterior cervical discectomy and
fusion (ACDF).
51
52  Converting a total disc replacement to an ACDF
Indications for revision via an anterior approach
and conversion to fusion include the following:
recurrence of an index-level neurological concern
such as radiculopathy or myelopathy (device unre-
lated or related); device wear causing loosening;
device wear causing local pathology from debris;
device failure as the result of bearing surface fail-
ure or fracture; device loss of purchase as the result
of failure of primary or secondary fixation (loosing
not secondary to debris); catastrophic device ejec-
tion (Figure 8.1) or local soft tissue injury related
to the device; and patient reaction to device com-
ponents or wear debris. Infections in the anterior
cervical spine are rare, but they represent an indi-
cation for revision. In the current state of anterior
cervical arthroplasty, some of these indications
for revision have been theorized but are not well
described secondary to the relative absence of a
large data set in the clinical setting. As experience
with current and novel bearing surfaces increases,
Figure 8.1 A lateral radiograph demonstrating
catastrophic failure of a cervical disc replacement.
a larger understanding of the indications for ante-
rior revision may occur.
RELATIVE CONTRAINDICATIONS
In consideration of revision anterior surgery with
conversion to arthrodesis, the surgeon must also
consider alternatives and contraindications. In our
experience, there is consideration for device reten-
tion when the device is well fixed, when the device
itself is not the source of current patient pathology,
and when there is no frank indication for ante-
rior revision neurological decompression at the
index level. In such circumstances, the source of
a patient’s concern should be carefully considered.
Patients with facet pathology may be well suited
for posteriorly based revision procedures such as
decompression and fusion (Figure 8.2). Patients
with multilevel compressive concerns may also be
well suited for a posteriorly based treatment plan,
which includes device retention at the index level.
In addition, anterior-only revision may not be suit-
able in isolations for soft-tissue concerns involving
the prevertebral space or other requirements for
multilevel, low-profile anterior reconstructions.
Patients with a history of surgical approach‒
related dysphagia or those with a former injury to
neurological structures involved in phonation or
vocalization should also be considered carefully
for alternatives to anterior revision surgery, and the
chance of further morbidity to anterior soft tissues
Figure 8.2 A lateral radiograph demonstrating
a posterior fusion following a failed cervical disc
replacement.
 Preoperative planning and OR setup (including the utility of neuromonitoring)  53
may be increased. Patients with well-fixed devices
in whom substantial bone removal is anticipated
to facilitate device removal may also need consid-
eration for alternative approaches. Finally, patients
who have initially failed to achieve the intended sur-
gical result of arthroplasty should also be carefully
considered. These patients may have a fundamen-
tally different concern than those who achieve reso-
lution of their index concern and later present with a
new or recurrent concern. The same considerations
for workup of patients with axial and neurologi-
cal concerns should be undertaken in patients who
may be considered for anterior revision of the index
arthroplasty device. Indeed, some of the same con-
traindications for anterior revision surgery that have
been previously described for the revision of fusions
remain present with the revision of arthrodesis.
EXPECTATIONS
Revision of anterior arthroplasty, as described for
the indications noted herein, should be approached
with the expectation of achieving solid arthrodesis
at the operative level. Arthrodesis is anticipated
to follow a successful intraoperative neurological
treatment if required. Surgeons and patients are
well advised to consider the soft-tissue, neurologi-
cal, and biological environments in the anterior
cervical spine to achieve this goal. Patients who
may have biologically challenging healing envi-
ronments may benefit from optimization of their
health or tabolic status prior to consideration of
revision surgery, as determined to be reasonable by
the treating team. This may involve assessment of
bone health and modification of diet or cessation
of intake of substances such as nonsteroidal anti-
inflammatory drugs (NSAIDS) or nicotine.
Surgeons should plan for challenges related to
surgical exposure and soft-tissue concerns, imag-
ing challenges preoperatively and intraoperatively,
issues related to device removal and device debris,
and challenges related to revision neurological
decompression, and they should have good options
for anterior fusion and reconstruction. Anterior
fusion and reconstruction options are numerous
and potentially beyond the scope of this topic;
however, creating a favorable biological environ-
ment is important and may include the use of auto-
graft or alternative reconstruction options that are
not traditionally utilized in primary arthrodesis
procedures.
PRINCIPLES OF REVISION SURGERY
There are a number of important principles of revi-
sion surgery. These include preoperative planning,
operating room (OR) setup and intraoperative care,
operative care, and postoperative management. As
further discussed, preoperative planning involves
patient examination and safety considerations. The
principles of preoperative planning include patient
examination, preoperative imaging, neurological
assessment beyond physical examination, ante-
rior cervical soft tissue assessment, involvement
of select consultants, anesthesia communication,
facility choice and planning, device and implant
planning, and surgical consent. Operative tech-
nique includes consideration of patient position-
ing, anesthetic considerations and techniques,
surgical approach, intraoperative imaging, device
removal, neurological decompression, arthrodesis,
intraoperative morbidity management, and wound
closure. Postoperative care involves postanesthe-
sia care unit (PACU) consideration, ambulatory
versus overnight stay choices, intensive care unit
(ICU) indications, consultant involvement, dis-
charge planning and follow-up, medical manage-
ment and follow-up, and patient imaging.
Complications should be considered as part of
the planning and expectation management phase
of surgical counseling of patients. On the whole,
revision anterior surgery carries a higher risk
of perioperative morbidity and complications.
Arthrodesis carries a different set of surgeon and
patient expectations. Challenges that do occur may
often be better managed by a surgeon and patient
who have planned for and anticipated them.
PREOPERATIVE PLANNING AND OR
SETUP (INCLUDING THE UTILITY OF
NEUROMONITORING)
A preoperative patient history and examination
play a significant role in patient care. While patient
examination is well described, the surgeon’s role
includes a full soft-tissue and neurological exami-
nation, as well as directed questions regarding
the patient’s former surgical care and approach
54  Converting a total disc replacement to an ACDF
and baseline concerns such a chronic versus acute
neurological concerns and data collection. If the
treating surgeon was not involved in the index
arthroplasty event, consideration of requests for
medical records may assist in an understanding of
the patient’s status prior to arthroplasty, in contrast
to their condition at the time of presentation with a
new arthroplasty-related concern. New neurologi-
cal concerns should be discussed and examined,
and issues related to swallowing and phonation
may be documented. Axial concerns should be
quantified and patient expectations should also be
assessed as part of this evaluation.
Preoperative imaging includes functional
radiographs and advanced imaging. Baseline
upright radiographs often include anterioposterior
(AP), neutral lateral, lateral flexion and extension,
and AP bending radiographs to assess device posi-
tion/location, bone integrity, index-level motion,
periarthroplasty soft-tissue and calcification, and
adjacent-level concerns, as well as overall cervi-
cal alignment. Initial assessments of bone quality
may be made and, though rarely, consideration
for advanced bone quality can be considered, such
as dual-energy x-ray absorptiometry (DEXA).
Advanced imaging often plays a substantial role in
preoperative evaluation and often included mag-
netic resonance imaging (MRI) and computed
tomography (CT).
MRI is the workhorse of soft-tissue and neuro-
logical imaging. Soft-tissue concerns around the
index device may be assessed, as well as concerns
for neurological compression and the status of the
adjacent levels and bone. MRI with contrast may
be considered in the circumstance where inherent
bone pathology or infection is of concern. CT is an
excellent tool for evaluation of device location and
fixation, as well as bone destruction related to wear
debris. In some circumstances, CT with myelo-
gram is the advanced imaging tool of choice when
substantial device-related image artifacts are pres-
ent, as may be the case with devices constructed
with stainless steel or cobalt-chromium devices.
Additional neurological examination may
include electromyography with nerve conduction
to assess for the extent of cervical root concerns
versus peripheral nerve concerns. Formal consul-
tation with a neurologist may also be considered if
neurological pathology is not well explained by a
concern primarily involving the cervical spine. A
comparison of these testing modalities to testing
that may have occurred prior to the index proce-
dure is made.
A thorough consideration of baseline soft-tis-
sue concerns in the anterior cervical spine should
be considered. This involves examination of the
patient’s former skin incision and the prior surgical
approaches. The surgeon may consider utilization
of the same incision when there is a contraindica-
tion to a contralateral approach, such a unilateral
vocal-cord paresis. Questioning regarding pho-
nation, swallowing concerns, and vocalization
involved in the patient’s profession is useful and
may play a role in surgical approach planning and
evaluation.
Preoperative consultation with a swallowing
professional and/or otolaryngologist is considered
when baseline swallowing concerns exist or when
postoperative issues are anticipated. Consultants
may perform a swallowing study and/or consider a
laryngoscopy to evaluate the integrity of the esoph-
agus or the vocal cords. The same consultants may
be involved in the surgical approach and postoper-
ative care at the discretion of the treating surgeon.
Communication with the anesthesia team can
be important prior to the surgical intervention.
This may involve consideration of patients who
are anticipated to have a challenging intubation,
patients who will require minimal neck manipu-
lation during intubation or anesthesia, or patients
who may require retention of the airway following
the surgical procedure. Choice of anesthetic tech-
nique may also be related in part to the surgeon’s
plan for intraoperative neuromonitoring.
In our experience, intraoperative neuromoni-
toring utilization and technique choice is at the
discretion of the treating surgeon. Indications for
neuromonitoring may include preoperative cervi-
cal myelopathy, multilevel spinal stenosis, and con-
cern for vocal cord injury. Neuromonitoring often
takes the form of somatosensory evoked potential
(SSEP) and/or motor-evoked potential (MEP), but
is not required for successful performance of revi-
sion anterior cervical spine surgery.
The choice of facility may play a role in preoper-
ative planning. Considerations include anticipated
need for inpatient care, postoperative neurological
concerns, postoperative soft-tissue concerns such

as swallowing dysfunction or airway management,
potential for the need of intensive care, manage-
ment of postsurgical drains related to durotomy,
need for transfusion, and potential management of
surgically created airways. For these reasons, there
may be consideration of performance of the surgi-
cal event in a hospital setting, though outpatient
revision anterior spine surgery can also be safely
performed in the right circumstances.
The surgeon should characterize the index
arthroplasty device and consider the tools required
for successful device removal and conversion to
arthrodesis. Many devices have methods of both
primary and secondary fixation to the adjacent
vertebrae. Common methods of primary fixation
include device rails or screws. Secondary fixa-
tion methods include bone ingrowth or ongrowth
to the device endplates. In select circumstance,
the secondary fixation is also done using screws.
Implant manufacturers should be able to provide
instrumentation related to the device insertion
and/or removal that may play a role in presurgi-
cal planning, though in almost all circumstances,
these instruments will need to be ordered before
the surgical procedure. Documentation related to
the index device placement can help with this plan-
ning, and device companies may be contacted to
review the nature of the index device as consistent
with patient care and protection of the patient pri-
vacy. Standard bone tools such as rongeurs, bone
currettes, bone chisels, bone burrs, and cutting
tools should also be available. Hemostatic agents
and dural repair agents should be available as part
of the planning process.
Finally, patient counseling and surgical con-
sent play a significant role in planning, operative
intervention, and management of postoperative
patient care issues. Consent for removal of the
device with anterior revision decompression and
revision anterior arthrodesis and reconstruc-
tion with instrumentation should be obtained.
Consent may also include consideration of bone
graft needs such as autograft, allograft, interbody
cage devices, and or synthetic bone graft options.
Neuromonitoring is discussed and postoperative
morbidity carefully considered, including all the
issues that are typical for revision anterior cervical
spine approaches. Consideration of the patient’s
concern in relationship to their current status
Operative technique  55
in contrast to postoperative challenges that may
occur is often discussed. These issues may include
new neurological issues, swallowing dysfunction,
phonation issues, arthrodesis healing issues, and
instrumentation-related complications, among
many concerns.
OPERATIVE TECHNIQUE
Patients are positioned supine on an operative
table that will allow appropriate intraoperative
imaging, airway management, and neurological
monitoring. The neck may be placed in a neutral or
slightly extended position to allow for soft-tissue
exposure and imaging. The arms are positioned
at the patient’s side and padded. The entire ante-
rior cervical spine is prepped into the operative
field following successful intubation and baseline
neuromonitoring assessment. Bone graft harvest
sites are also prepped and draped at the surgeon’s
discretion.
The anesthesia specialist will typically place
the endotracheal tube in a fashion that minimizes
neck motion at the time of placement. This may
be especially important when there is a concern
for cervical myelopathy, or when the anterior soft
tissues could be or are currently compromised.
Video-assisted placement can be considered at
this time. Consideration is made for the use of an
esophago-gastric tube to assist with intraoperative
identification of the esophagus in the revision set-
ting, and for postoperative feeding should swallow-
ing function be anticipated to have compromise.
Anesthesia access to the neck from the top of the
table is helpful during surgery if positioning needs
to change.
An anterior surgical approach to the cervical
spine is taken consistent with a Smith-Robinson
technique. Utilization of the former skin inci-
sion or a same-side surgical approach as the index
procedure is considered when issues related to
existing unilateral vocal cord paresis are identi-
fied. A contralateral approach has some advan-
tages, including the presence of native tissue with
fewer concerns for scarring related to the former
index approach. Careful soft-tissue manipulation
is considered as the dissection to the preverte-
bral spaces ensues. The arthroplasty device may
be further identified via palpation and imaging
56  Converting a total disc replacement to an ACDF
during the approach. The entire arthroplasty
device is exposed anteriorly, including the adja-
cent vertebrae. Placement of Caspar pins in the
vertebrae adjacent to the arthroplasty device may
allow device manipulation, exposure, and further
removal. A device with presurgical loosening may
be carefully removed following removal of the
primary fixation device fixation method (screws)
utilizing the implantation tools provided by the
manufacturer or other surgical instrumentation
that allows for a firm grasp of the device. In some
circumstances, the device may not be removed as
a single implant, but in parts.
The well-fixed device may require additional
loosening techniques to address secondary fixa-
tion. Secondary fixation is often achieved via bone
ongrowth or ingrowth on the device end plate.
Careful use of bone curettes or chisels at the bone/
end plate interface while securing the endplate/
device is considered. Imaging may play a role in
the use of these instruments. Retention of as much
bone as possible in the vertebral body is balance,
with the need to remove the implant safely and
successfully.
At the time of the primary procedure, many
implants are placed following discectomy, com-
plete annulus removal, and removal of the posterior
longitudinal ligament. If additional neurological
decompression is required, it is performed at this
time. At the surgeon’s discretion, conversion of the
bone removal to corpectomy is considered to allow
for safe and thorough decompression of the neu-
rological elements. If intraoperative durotomy is
encountered, it is addressed prior to the fusion and
reconstruction.
Intraoperative imaging is helpful in assess-
ing the implant location and bone characteristics
following implant removal and reconstruction.
Fluoroscopy is the workhorse tool and plays a sig-
nificant role during the surgical procedure. Lateral
techniques can assess the implant removal tools
used to lock onto the arthroplasty device and can
help with bone removal in well-fixed implants. The
reconstruction can be assessed prior to wound clo-
sure with similar techniques.
Arthrodesis considerations are multiple. While
simple conversion to interbody fusion may be an
option, the biomechanical environment should be
considered. If reasonable end-plate material exists,
it may be feasible to utilize a traditional precut
allograft for arthrodesis, though a variety of sizing
options should be available. In contrast, if substan-
tial bone removal has occurred, the surgeon must
consider custom-cut allograft or autograft options,
versus cage options. We prefer custom-cut allograft
bone to anterior cages. Following anterior arthrod-
esis, anterior reconstruction is accomplished with
an anterior plate. Primary anterior arthrodesis and
plating without supplemental posterior fixation are
the initial goals, but they are balanced with ante-
rior soft-tissue concerns and with the need for a
more complex anterior reconstruction. Tenuous
anterior reconstruction should prompt the sur-
geon to consider posterior supplementation.
There are a number of intraoperative events that
may need to be addressed at the time of a revision
anterior cervical procedure. These include esopha-
geal injury, bleeding concerns, cerebrospinal fluid
(CSF) leakage/durotomy and challenges with ante-
rior reconstruction. While it may be beyond the
scope of this chapter to proceed with an in-depth
discussion, we consider these challenges as they
occur and attempt to make primary treatments
of the same a priority prior to completion of the
surgical event. Intraoperative challenges are recog-
nized as part of this type of surgery, and efforts to
manage them postoperatively are important.
Wound closure proceeds in a fashion similar
to primary wound closure in a traditional Smith-
Robinson approach. Consideration for placement
of a Penrose drain is made based upon the amount
of intraoperative bleeding that is encountered and
anticipated postoperative soft-tissue concerns.
Drains are typically removed on the first postsur-
gical day after overnight elevation of the head of
the patient’s bed. An endotracheal tube leak test is
performed prior to consideration of extubation.
POSTOPERATIVE MANAGEMENT
In almost all circumstances, patients are taken to the
traditional PACU following these surgical proce-
dures. Exceptions may be made when there is a need
for retention of the endotracheal tube beyond the
first hour of the postsurgical course. Consideration
is made for elevation of the head of the patient’s bed
and judicious use of perioperative steroids to assist
with anterior soft-tissue swelling. An ICU placement

may be considered for patients requiring prolonged
intubation or in whom neurological assessments
are required on a continuous basis. Upright radio-
graphs postoperatively may assist with assessment
of anterior soft-tissue swelling.
Consultation is considered postoperatively
for perioperative medical management, swallow-
ing assessment and management, and phonation
concerns. Diet is carefully advanced as swallow-
ing function improves. Neurological assessments
continue, consistent with revision anterior spinal
surgery. Immobilization is considered at the dis-
cretion of the treating surgeon.
Discharge to the ambulatory setting is made in
the mobile patient who has appropriate swallowing
function, good pain control, and a stable neuro-
logical examination. Patients return for follow-up
to assess the healing of their surgical incisions and
the healing of their arthrodesis at the discretion
of the treating surgeon. Immobilization is discon-
tinued in the same fashion. Postoperative imaging
is performed, consistent with following the status
of the patient’s arthrodesis, and is typically in the
form of upright radiographs.
COMPLICATIONS
Complications are traditionally considered in the
contexts of revision anterior spine surgery and
arthrodesis healing. In this regard, dysphagia, dys-
phonia, and soft-tissue concerns can play an imme-
diate role. Airway concerns are managed with
retention of the temporary airway until extubation
or conversion to a surgical airway. Continuation of
or new neurological concerns are assessed postop-
eratively relative to the patient’s physical examina-
tion and imaging status. CSF leakage/durotomy
has the potential to be a challenging postoperative
concern. Intraoperative recognition of durotomy
precedes intraoperative repair, with consideration
for postoperative sub-arachnoid drain placement.
Complications 57
There may be a need for repeat operation to read-
dress the same concern.
In some circumstances, device removal may
require a complex anterior reconstruction or may
result in a tenuous anterior reconstruction. Should
this occur, consideration of supplemental posterior
interventions is made. This could include supple-
mental posterior instrumentation with fusion and/
or posterior decompression.
Neurological complications are especially
troubling, although rare, following revision pro-
cedures. A workup of new concerns is at the dis-
cretion of the treating surgeon. Failure to relieve
symptoms may be a more common issue requir-
ing additional management over time. Additional
posterior decompression can help to play a role in
residual neurological concerns.
Arthrodesis complications are well described
and can result in pseudoarthrosis and/or instru-
mentation concerns. These are addressed in a fash-
ion similar to that described with any revision of
arthrodesis, and both revision anterior and revi-
sion posterior options exist for treatment. Adjacent
segment concerns with successful arthrodesis
should be considered.
Pearls and Pitfalls
●● Careful preoperative planning is essential
to successful surgical interventions with
respect to surgical approach and device
removal.
●● Revision anterior approaches carry an
increased risk of perioperative morbidity
that is well described and consistent with
revision of anterior cervical spine surgery.
●● Postoperative soft-tissue concerns may be
a challenge with revision procedures.
●● Surgeons should consider primary or
supplemental posterior surgical treat-
ment if anterior treatment is anticipated to
become or becomes inadequate to treat
the patient’s concerns.

Treatment of adjacent segment disease
after total disc replacement (TDR)
BRUCE V. DARDEN II
Introduction 59
Indications 60
Relative contraindications 61
Expectations 61
Principles of revision surgery 61
INTRODUCTION
The treatment of symptomatic adjacent seg-
ment disease of the cervical spine has been one
of the most studied topics in the last 20 years.
Biomechanical studies of anterior cervical discec-
tomy and fusion (ACDF) in vitro show increased
intradiscal pressures and increased range of
motion at adjacent cervical segments. This theo-
retically may result in ACDF accelerating adjacent
segment disease. Cervical total disc replacement
(TDR) was developed as a strategy to minimize
adjacent segment disease in the degenerative spine.
Cervical TDR has been evaluated since the early
2000s, both in Europe and the United States. The
U.S. Food and Drug Administration (FDA) has
required investigational device exemption (IDE)
studies for each device approved, resulting in more
randomized, prospective data on this subject than
any other topic in the recent spine literature. These
studies indicate equivalence or slight clinical supe-
riority of TDR to ACDF. Some evaluations show
more revision surgeries at the index level in ACDF
9
Preoperative planning/operating room
(OR) setup 62
Operative technique 62
Postoperative management 63
Complications 63
Reference 64
patients versus TDR patients; adjacent-level data is
not as clear. Some studies out to 7 years postop-
erative have indicated less adjacent segment dis-
ease requiring surgery. Admittedly, the literature
is recent, and trends may develop with the passage
of time.
The literature surrounding strategies for treat-
ment of symptomatic adjacent segment disease
after cervical TDR is anecdotal at best. Principles
for treatment evolve from the treatment of adjacent
segment disease after ACDF. Use of a TDR adjacent
to a fusion was found to be safe and yielded accept-
able clinical results. Numerous small clinical series
evaluating either multilevel TDR or a combina-
tion of TDR and ACDF (i.e., a hybrid construct)
have demonstrated the safety of these constructs
with clinical equivalence to multilevel ACDF
(Figures  9.1 and 9.2). Biomechanically, m­ ultilevel
TDR and hybrid constructs approach the native
kinematic state of the normal cervical spine.
Therefore, the treatment of symptomatic adjacent
segment disease after TDR can involve any of the
strategies used for the treatment of pathology in
59
60  Treatment of adjacent segment disease after total disc replacement (TDR)

(a) (b)

Figure 9.1  (a) AP and (b) lateral radiographs of a two-level TDR construct using Mobi-C TDR. (Radiographs
courtesy of Alden Milam, MD.)

(a) (b)

Figure 9.2  (a) AP and (b) lateral radiographs of a hybrid construct using ProDisc-C TDR and Zero-P ACDF
space (DePuy Synthes Spine, Raynham, Massachusetts). (Radiographs courtesy of Jack Zigler, MD.)

the intact, native cervical spine. This chapter will
discuss anterior revision surgeries rather than
posterior procedures, which can be performed the
same way as in primary surgery.
For disclosure to the U.S. audience, the porous
coated motion (PCM) TDR (NuVasive, Inc., San
Diego) is the only TDR approved by the FDA for
use adjacent to fusion. The Mobi-C TDR (LDR
Spine, Troyes, France) is the only TDR approved
for use in two-level constructs.
INDICATIONS
The main indication for surgery is symptom-
atic cervical adjacent segment disease causing a
radiculopathy or myelopathy. The patient must

have an imaging study verifying the pathology
and have undergone failed conservative treat-
ment. Axial neck pain is not thought to be an
indication for surgery; the results of surgery
for neck pain are uneven. Myelopathy can be
treated with a TDR if the symptoms are rela-
tively mild and result from a soft disc hernia-
tion. Retrovertebral pathology should be treated
by ACDF and/or corpectomy.
The decision to treat the adjacent segment
pathology with a cervical TDR versus ACDF is a
matter of relative decision-making. Little guid-
ance exists in the literature. However, a study by
Barbagallo et al.1 reflects my philosophy on when
to use each technique.
Their algorithm is as follows:
1. Type of degenerative disc disease
●● Soft disc herniation (TDR)
●● Spondylosis—TDR if flexion/extension
x-rays show >3 degrees of angular motion.
(<3 ACDF)
2 . Degree of spondylotic vertebral body/facet joint
degeneration
●● Advanced spondylosis—vertebral body or
facet joints (ACDF)
●● No advanced spondylosis especially facet
joints (TDR)
3. Amount of bone removal needed to decompress
neural structures
●● The significant burring required can
weaken the vertebral body or increase het-
erotopic ossification risk—ACDF preferred
4. Shape—inferior end plate of cranial vertebra at
disc level involved
●● Significant end plate remodeling required
for TDR placement—can lead to subsidence
or split fractures especially in devices with
rails or keels (ACDF preferred)
5. Presence of adjacent disc degeneration not
needing surgical treatment at the time of proce-
dure (TDR preferred)
RELATIVE CONTRAINDICATIONS
The contraindications for cervical TDR use are
those commonly used in the FDA IDE studies
listed in Table 9.1.
Principles of revision surgery  61
Table 9.1  Contraindications for cervical TDR
• Isolated axial neck pain
• Age > 60 years (upper age in study
parameter)
• Pregnancy
• Autoimmune disease
• Ankylosing spondylitis
• Diffuse idiopathic skeletal hyperostosis
• Ossification posterior longitudinal ligament
• Severe osteoporosis
• Malignancy
• Instability
• Range of motion < 2 degrees
EXPECTATIONS
The results of revision surgery for radiculopathy
and neurological symptoms should be similar to
primary surgery: >90% chance of improvement.
There is only a fair chance of improvement of
axial neck pain, and thus that should not be the
primary indication for surgery. Biomechanically,
the construct should approach the kinematics of
the native vertebral segments. However, the lit-
erature is too sparse and immature to definitively
comment on the effect of TDR on adjacent seg-
ment disease. Also, conflicting thoughts exist on
whether there is an increased or diminished risk of
developing heterotopic ossification with multilevel
constructs. Finally, patients need to be aware that if
a TDR is planned, but intraoperative radiographic
visualization of the target level is inadequate, the
procedure will have to be converted to an ACDF.
PRINCIPLES OF REVISION SURGERY
The key principles of revision anterior cervical sur-
gery are careful preoperative planning and meticu-
lous dissection. Preoperative imaging should assure
the surgeon that there are no anatomical nor index
surgery anomalies. These anomalies can be planned
for and hopefully avoided. Next is the approach dis-
section. Typically, little significant scarring occurs
anterior to the pretracheal fascia. Posterior to the pre-
tracheal fascia, the esophagus and the carotid sheath
are vulnerable to injury. To avoid these structures, the
surgeon should extend the dissection either proximal
or distal to that of the index procedure. This extended
62  Treatment of adjacent segment disease after total disc replacement (TDR)
dissection will allow a more normal plane between
these structures to expose the anterior aspect of the
vertebral bodies between the longus colli muscle
masses. The dissection should be done bluntly to
avoid visceral or vascular injuries. If exposure is ini-
tially required distally, the omohyoid muscle may be
transected. The vascular supply for the omohyoid is
in the cranial third of the muscle. Once the midline
is exposed, sharp dissection can be used to elevate
the vertebral body scar tissue. From there, surgery
­proceeds as with the primary procedures.
PREOPERATIVE PLANNING/
OPERATING ROOM (OR) SETUP
Prior to recommending surgery to the patient, the
radiographic studies must be thoroughly evaluated,
as must the factors listed here in indications. If cervi-
cal TDR is indicated, the patient must be counseled
that if the operative segment cannot be adequately
visualized radiologically in the operating room
(OR), the procedure will have to be converted to
an ACDF. With placement of an adjacent TDR, the
size of the vertebral bodies should be evaluated. In
patients with smaller vertebral bodies, especially if
a keeled TDR has been previously implanted, a non-
keeled TDR should be considered to avoid a split
vertebral body fracture. The side of approach will
have to be determined. If an ipsilateral approach
to the primary surgery is recommended, then the
surgery can proceed. If a contralateral approach is
desired, an ear, nose, and throat (ENT) evaluation
by indirect laryngoscopy is necessary to rule out an
occult recurrent laryngeal nerve injury. If this injury
is present, consideration of an ipsilateral approach
is recommended to avoid the increased risk of a
bilateral recurrent laryngeal nerve injury, and thus
dysphonia. Finally, thorough evaluation of the radio-
graphic studies is important to avoid vertebral artery
anomalies and other anatomic anomalies.
Intraoperatively, meticulous setup is another
key to surgical success, especially with TDR.
With anesthesia, intubation should be performed
with the neck in a neutral position, especially in
the myelopathic patient. Mean arterial pressure
should be maintained at or above 90 mmHg to
ensure adequate spinal cord perfusion. I prefer
using an esophageal stethoscope to allow palpation
of the esophagus during exposure, which helps
avoid the potentially devastating complication of
esophageal perforation. The stethoscope use for
esophageal localization outweighs the potential
risk of recurrent laryngeal nerve injury theoreti-
cally occurring by entrapment between the trachea
and t he ­now-rigid esophagus. Lastly, corticoste­roids
should be considered for ­spinal cord ­protection
and to potentially diminish p ­ ostoperative swelling
and dysphagia. We give appropriate prophylactic
antibiotics based on a preop methicillin-resistant
Staphylococcus ­aureus/­methicillin-susceptible
S. aureus (MRSA/ MSSA) screen.
For TDR, a radiolucent OR table is required to
permit anterioposterior (AP) as well as lateral visu-
alization of the cervical spine. The Mayfield head
holder cannot be used for a TDR because it inter-
feres with AP radiographic evaluation. The neck is
positioned in a neutral position, with the head rest-
ing on a round gel pad and a rolled sheet under the
neck to avoid neck movement during the surgery.
The head is then taped to the bed, with padding
placed over the brow ridge. The shoulders are also
taped to the bed to improve distal cervical radio-
graphic visualization. The C-arm and image inten-
sifier are brought in. The surgeon must ensure that
there are true AP and lateral radiographic images
of the operative segments. The uncovertebral joints
are better landmarks than the spinous processes to
identify the midline on AP images.
Intraoperative neurophysiological monitoring is
important in my regimen. I include somatosensory
evoked potentials (SSEPs), motor-evoked potentials
(MEPs), and free-run electromyographies (EMGs).
While not the standard of care, it allows real-time
neurological assessment and the potential to take
protective steps if spinal cord/nerve root injury is
suspected. MEPs require total intravenous anesthe-
sia and obviate the use of muscle relaxants.
OPERATIVE TECHNIQUE
The surgical procedure involves a standard trans-
verse approach, on the side decided preoperatively
by the surgeon. Blunt dissection is emphasized
deep to the pretracheal fascia. This dissection
minimizes the risks to the carotid sheath and the
esophagus. The exposure can be facilitated by the

use of Kittner dissectors and a Freer elevator. Once
these structures are identified, the esophagus is
mobilized and retracted; sharp dissection in the
midline between the longus colli muscle masses
can be carried out. The longus colli muscle can be
elevated bilaterally to allow a Cloward-type retrac-
tor placement. A marker is then placed adjacent to
the presumed operative disc space. A C-arm lat-
eral radiograph is obtained to verify the level. The
C-arm is moved superiorly between uses to allow
unimpeded access to the surgical site. The next
step is to apply the Caspar-type distraction pins,
either for the TDR or ACDF. Some TDR instru-
ment sets have their own distraction pins. To
facilitate implantation of a TDR, placement of the
distraction pins should be done using the C-arm,
assuring placement in the true midline. Midline
placement will allow quicker and more accurate
TDR preparation later.
Anterior discectomy and decompression is
done as is typical for the surgeon and the specific
pathology. If TDR is to be used, it is important to
err on the aggressive side because it is not possible
to depend on distraction for decompression. Also,
the pathology can recur because there will be con-
tinued motion. Use of a high-speed burr should
be minimized with a TDR, and only with copi-
ous irrigation, due to the potential increased risk
of heterotopic ossification. Typically, the posterior
longitudinal ligament is resected, facilitated by
operative microscope use. At this point, the TDR
is implanted per the protocol of the manufacturer.
Care should be taken to choose the optimal-sized
implant. The implant should cover the end plates as
much as possible. In the lateral plane, the implant
must be placed as posteriorly as possible, especially
with constrained implants, to reestablish normal
kinematics. The end plates prior to implantation
should be parallel on the lateral plane, to avoid the
TDR being placed in extension, potentially limiting
motion and allowing abnormal implant contact.
After implantation, any bleeding bony surfaces
should be treated with bone wax. Copious irriga-
tion is carried out and a standard closure applied,
with a drain placed at the surgeon’s discretion.
If ACDF is being contemplated, several tech-
niques may be used. If the surgeon wants to use a
standard interbody graft/cage and plate, the plate
Complications 63
should be as short as possible to avoid anterior liga-
mentous ossification disease. Diverging screws in
the plate ensure a stable construct. I typically avoid
the zero-profile integrated cage/screw devices in
revision cases if the index procedure is an ACDF.
However, if the index case is a functioning TDR,
less stress is transferred to the cage/screw device,
with potentially less risk of pseudarthrosis. These
devices having a lower profile may diminish post-
operative dysphagia compared to ACDF plates.
POSTOPERATIVE MANAGEMENT
Postoperative care of these patients is essentially
no different from the typical care for the index
procedure. Prophylactic antibiotics are continued
only for 24 hours. No collar is used except for rare
circumstances in which a soft collar is provided for
comfort. A drain is used at the surgeon’s discretion;
in obese patients or patients with difficult dissec-
tions, drainage is probably necessary. Our criteria
for doing these cases as an outpatient include mini-
mal bleeding with the dissection, age ≤ 60 years,
body mass index (BMI)  ≤ 30. ASA ≤ 2, and a
nonsmoker. We observe the patient for 4 hours to
ensure that there are no swallowing issues. If the
patient meets these criteria, then he or she is fine
for discharge. Any other concerns warrant an
overnight observation stay. We prescribe a 3-week
course of nonsteroidal anti-inflammatory drugs
(NSAIDs) to diminish the risk of heterotopic ossi-
fication (HO) after TDR implantation. However, it
has been observed in our patients that heterotopic
ossification may progress for up to 4 years postpro-
cedure. Keeled implants have a higher rate of HO,
so this factor needs to be considered in the preop-
erative planning. Lastly, no restrictions are recom-
mended to postoperative activity. The patient may
resume his or her lifestyle, as tolerated.
COMPLICATIONS
The complications from surgery for adjacent seg-
ment disease are typically no different from the
index procedure except for the approach. Though
still rare, there is a slightly higher risk of injury to
the esophagus in the redo approach. This risk can
be minimized by carrying out the approach from
64  Treatment of adjacent segment disease after total disc replacement (TDR)
the contralateral side to the index procedure or
by slow, blunt dissection with early localization
of the esophagus during an ipsilateral approach.
High suspicion should be taken for these injures;
an intraoperative ENT consult should be requested
if the injury occurs. The risk of recurrent laryngeal
nerve injury (and thus dysphonia) is higher than
in primary surgery, but the risks can be mitigated
by preoperative ENT evaluation and meticulous
dissection. Dysphagia is likewise more common
in redo surgery, but intraoperative corticosteroids
may lower the risk. Vertebral artery injuries are
exceedingly rare and are minimized by preopera-
tive evaluation for vascular anomalies and early
identification of the midline during dissection.
Nerve root and spinal cord injury should be no
more common than in the index procedure.
Pearls and Pitfalls
REFERENCE
The key to success in redo anterior cervical sur-
gery is meticulous preoperative planning. The
other strategies are fairly straightforward. In
TDR implantation, keeled implants should be
avoided in patients with small vertebral bodies
(typically smaller men and most women). The
TDR implant should be sized to adequately
cover the vertebral body, thus avoiding sub-
sidence. The prosthesis should be undersized
in the cranial-caudal dimension. Too large a
prosthesis can limit range of motion of the
segment. A constrained prosthesis placed
too anteriorly can alter the center of rotation,
transferring more stress to the facet joints.
Ensuring that both vertebral end plates are
parallel prevents implantation of the TDR in
extension, which can limit range of motion and
potentially accelerate implant wear. Copious
irrigation, minimal use of the burr, and gener-
ous use of bone wax and NSAIDs help prevent
HO after TDR implantation. With ACDF, simi-
lar principles to the index procedure apply. A
zero-profile device is acceptable adjacent to
a TDR. When using a plate for the ACDF, the
plate should be applied as short as possible
to avoid anterior ligamentous ossification dis-
ease, potentially limiting range of motion of
the adjacent TDR. Finally, with adequate plan-
ning, adjacent anterior cervical surgery can
be performed safely, with satisfactory clinical
results.
1. Barbagallo GMV, Assietti R, Corbino L et al.
Early results and review of the literature of a
novel hybrid technique combining cervical
arthrodesis and disc arthroplasty for treating
multilevel degenerative disc disease: oppo-
site or complimentary techniques? Eur Spine
J 2009;18(suppl. 1):S29–S39, doi: 10.1007/
s00586-009.0978-9.
 Part     2
Posterior Cervical

10 Revision suboccipital decompression for complex Chiari malformation 67

Jacob L. Goldberg, Ibrahim Hussain, Ali A. Baaj, and
Jeffrey P. Greenfield
11 How to revise a failed occipital cervical fusion 77
Joshua T. Wewel, Mazda K. Turel, Joseph E. Molenda, and 
Vincent C. Traynelis
12 How to revise a failed C1–C2 fusion 83
Nizar Moayeri and Michael G. Fehlings
13 Treatment of postlaminectomy kyphosis 89
Christopher T. Martin and John M. Rhee
14 Revision of failed posterior cervical fusions 101
Trevor Mordhorst, Vadim Goz, and William Ryan Spiker
15 Complications necessitating surgical intervention following cervical laminoplasty 109
Michael J. Moses, Amos Z. Dai, and Themistocles S. Protopsaltis

65

Revision suboccipital decompression
for complex Chiari malformation
JACOB L. GOLDBERG, IBRAHIM HUSSAIN, ALI A. BAAJ, AND
JEFFREY P. GREENFIELD
Indications 67
Relative contraindications 68
Expectations 69
Principles of revision surgery 70
INDICATIONS
The Chiari malformations are a diverse group of
anomalies in which a mismatch between the pos-
terior fossa neural and bony elements may result in
a relative descent of the cerebellar tonsils through
the foramen magnum. This may lead to dorsal com-
pression of the brainstem and disturbance of nor-
mal cerebrospinal fluid (CSF) circulation. Patients
can present with a variety of symptoms, including
but not limited to exertionally induced occipi-
tal headaches, neck pain, dysphagia, sleep apnea,
dysmetria, and paraesthesia. Hydrocephalus and
spinal cord syringomyelia can also develop, which
can result in further neurologic deficits and lead
to myelopathy and scoliosis. For patients in whom
clinical and radiographic criteria are met, sub-
occipital decompression is an option to palliate
symptoms or address syringomyelia or a com-
bination of interdependent neurologic findings.
A decompression of the foramen magnum, often
paired with a C1 laminectomy and duraplasty, is
10
Preoperative planning and operating room
(OR) setup 70
Operative technique 71
Postoperative management 74
Complications 74
the standard procedure offered, although many
variations in surgical technique exist (Figure 10.1).
The degree of suboccipital and upper cervical
decompression required should be determined by
the patient’s clinical findings, in conjunction with
the anatomy/radiographic findings, and the degree
to which neural tissue is compressed. In certain
scenarios, posterior fossa compression may be
primarily due to bony involvement, and a dura-
plasty may not be offered initially. C1 laminectomy
should usually be performed to assist with intradu-
ral exploration and duraplasty, particularly when
compression is present well below the foramen
magnum, although anatomic variation dictates
that occasionally a C1 laminectomy may not be
required, or conversely, a C2 laminectomy or lami-
noplasty in fact may be warranted for extremely
caudally oriented compression.
Patients with persistent symptoms despite
initial surgical intervention pose a challenging
clinical scenario. Further clinical assessment
and radiographic evaluations may be useful to
67
68  Revision suboccipital decompression for complex Chiari malformation

(a) (b)

Figure 10.1  Sagittal T2 MRI scans of a patient with Type 1 Chiari malformation. (a) Preoperatively, note
the descent of the cerebellar tonsils through the foramen magnum, resulting in cervicomedullary com-
pression. The dashed line is drawn from the dorsal-inferior tip of the clivus (basion) to opisthion, roughly
approximating the anatomical position of the foramen magnum (also referred to as McRae’s line). The
solid line represents the distance of cerebellar tonsil descent, with values of 5 mm or greater suggesting
a diagnosis of Type 1 Chiari malformation. (b) Postoperatively seen following suboccipital decompression,
C1 laminectomy, and autologous duraplasty. Note the reduction in crowding of the cerebellar tonsils char-
acterized by the presence of T2 hyperintense CSF space dorsal to the cerebellum.

determine if a reoperation might be expected to
further palliate or address recalcitrant symptom-
atology not addressed by a first surgery. Patients
may have persistent posterior fossa crowding,
inadequately decompressed syringomyelia, and/
or abnormal CSF flow within the central nervous
system (CNS), resulting in persistent symptoms,
pain, or clinical manifestations of CNS dysfunc-
tion. There are several reasons why Chiari decom-
pressions fail, including (1) failure to diagnosis
the actual cause of neurologic symptoms in the
presence of an incidental Chiari malformation;
(2)  failure to diagnose a CSF leak or idiopathic
intracranial hypertension (IIH) as the etiology
for cerebellar ectopia (i.e., unnecessary decom-
pression); (3) proper diagnosis but inadequate
decompression; (4) proper diagnosis but overly
aggressive decompression; (5) adequate decom-
pression but operative complications, such as CSF
leak or infection, leading to scarring or pseudome-
ningocoele; or (6) adequate decompression with-
out perioperative complications in the presence
of abnormal skull base geometry or hereditary
connective tissue disorder, leading to postopera-
tive craniocervical instability (CCI) with ventral
brainstem compression. Each of these etiolo-
gies presents a clinical conundrum with its own
challenges. In this chapter, we are going to focus
on some of the technical aspects learned through
attempting many of these revision surgeries and
offer strategies to decide to whom to offer further
surgery and how to minimize the inherent risks.
RELATIVE CONTRAINDICATIONS
There are two critical relative contraindications for
repeat suboccipital decompression in patients with
Chiari 1 or Chiari 1.5, despite persistent symptoms
following an initial surgery. First, patients with con-
tinued neck and occipital pain, particularly when
upright or with activity, may be experiencing symp-
toms of CCI rather than static posterior fossa com-
pression. For these patients, further decompression
may exacerbate instability, and surgeons must be
vigilant for patients with concomitant connective
tissue disorders such as Ehlers–Danlos syndrome
(EDS). Flexion-extension x-rays may demonstrate
listhesis that confirms the diagnosis; however,
even with negative flexion/extension plain films, a
hard-cervical collar trial for 2–6 weeks may be war-
ranted. These trials in patients with craniocervical
instability (CCI) due to EDS may result in obvious
self-reported improvements in pain and symptoms,
providing additional support for a diagnosis of CCI.
 Expectations 69

In these patients, occipitocervical fusion may be dis-
cussed as a more appropriate solution than revision
decompression surgery.
Another situation where repeat suboccipital
decompression may be relatively contraindicated
is when there is persistent or particularly worsened
ventral compression of the brainstem. Patients with
congenital skull base abnormalities such as platybasia
and basilar invagination in association with Chiari
1, or even more commonly Chiari 1.5, malforma-
tions may have persistent symptoms of brainstem
compression that are not relieved by posterior fossa
decompression alone. Even when the cerebellum dis-
plays relative dorsal drift away from the medulla fol-
lowing a suboccipital craniectomy, persistent kinking
of the brainstem, usually at the cervicomedullary
junction, may continue to cause compression and
abnormal CSF pulsations through the foramen mag-
num, contributing to hydrocephalus, syrinx, cranial
neuropathies, and long tract signs (Figure 10.2). The
clivo-axial angle (CXA), also known as the clivus-
canal angle, is a helpful radiographic measurement
determined from the angle at the intersection of the
lines delineating the dorsal slope of the clivus and the
posterior spinal line behind the vertebral body of C2.
Typically, angles less than 125–130 degrees suggest
significant ventral compression. In these situations,
repeat posterior fossa decompression may provide
little to no benefit. Therefore, vental decompression
is required, either through transoral or transnasal
approaches for the anterior arch of C1 resection,
odontoidectomy, and dorsal clivusectomy when indi-
cated to relieve symptoms. Of note, these patients
require occipitocervical fusion prior to ventral
decompression, given the instability that results from
the anterior approach. There is also a rare but recog-
nized subgroup of patients in whom neural imaging
fails to explain symptoms of brainstem compression
that are clinically apparent; in these patients, close
attention to the contribution of connective tissue
disorders and possible inclusion of dynamic imaging
modalities may be necessary to identify the etiology
of often very severe symptomatology.
EXPECTATIONS
Patient expectations of revision suboccipital decom-
pression surgery in patients with Chiari malforma-
tion require significant patient counseling. Many
of the symptoms that these patients develop can be
nonspecific with unpredictable temporal associa-
tions. These patients should have detailed workups
for other neurologic causes of headaches, paresthe-
sias, and dizziness prior to considering reoperation
if initial decompression does not resolve or only
temporarily relieves symptoms. Given that many
of these patients are in the pediatric and adolescent
population, the stress of going through additional
surgeries and hospital stays should be respected and
referrals for psychosocial support made as necessary.

(a) (b)

Figure 10.2  Sagittal T2 MRI scans of a patient with Type 1 Chiari malformation and concomitant basilar
invagination who did not improve clinically following initial posterior decompression surgery. The solid lines
depict the pre- and post-operative clivoaxial angles (CXAs) (a) Postoperative imaging demonstrating per-
sistent syrinx and kinking of the cervicomedullary junction despite adequate suboccipital decompression.
Note the low CXA (95 degrees). (b) Following anterior decompression via endoscopic endonasal odontoid-
ectomy, symptomatology and radiographic findings improved, with a postoperatve CXA of 135 degrees.
Solid lines depict the pre- and post-operative clivoaxial angles (CXAs).
70  Revision suboccipital decompression for complex Chiari malformation

PRINCIPLES OF REVISION SURGERY suboccipital decompression. Magnetic resonance

The principles of revision surgery for failed suboc-
cipital decompression follow similar principles as
other revision surgeries in orthopedics and neuro-
surgery, in that normal anatomy should be identified
first and then used as a guide to slowly identify previ-
ous surgical margins and persistent abnormal anat-
omy. Often, skin incisions needs to be extended to
find normal anatomic margins. Identification of the
C2 spinous process, which in most cases is preserved
on initial surgeries, can serve as a relative indica-
tor of where the C1 laminectomy site resides within
scar tissue and allows the surgeon prevent inadver-
tent durotomy and spinal cord injury. Likewise, the
superior aspect of the incision is usually superior to
the cranial aspect of the previous craniectomy site,
allowing normal occipital skull identification prior
to working caudally toward the craniectomy site.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
Preoperatively, clinical assessments should be
thoroughly documented for baseline status, and
repeat imaging should be reviewed. Typically, a
number of preoperative imaging studies can be
formed. As mentioned previously, flexion/exten-
sion x-rays can help exclude the possibility of
CCI, in which case occipitocervical fusion may
also be required in addition to or in lieu of repeat
imaging (MRI) of the brain and cervical spine
without contrast can assess the extent of persistent
posterior fossa compression. Contrast studies can
reveal scar tissue, and high-resolution T2 imaging,
including Fast Imaging Employing Steady-state
Acquisition (FIESTA) sequences, may help define
adhesions, webs, or other intradural pathology
contributing to deranged CSF flow. In cases of sus-
pected idiopathic intracranial hypertension, ICP
monitor placement is an additional study to con-
sider, and in intracranial hypotension, computed
tomography (CT) or MRI myelogram to look for
possible causative CSF leaks should be discussed.
Noncontrast CT scans can often better appreciate
the degree of bony decompression originally per-
formed. A corollary to this in very young children
is the well-recognized phenomenon of bony reos-
sification of the dura or ligaments in the poste-
rior fossa, leading to the return of symptoms. Our
group has recently adopted the use of high-resolu-
tion thin CT scans that can be translated to three-
dimensional (3D) models. These models can serve
as excellent academic resources to help plan out the
exact measurements of any additional craniectomy
required intraoperatively, aid in patient/parent
explanations, and help demonstrate the relation of
the cranium to cervical spine for patients requiring
occipitocervical fusions (Figure 10.3).
Patients are brought into the OR supine. They
should be intubated and have all intravenous (IV)

(a) (b)

Figure 10.3  3D-printed models of the subocciputal and upper cervical spine in a patient who failed ini-
tial suboccipital decompression and C1 laminectomy surgery for Type 1 Chiari malformation. (a) Dorsal/­
posterior view, which demonstrates an inadequate suboccipital craniectomy and excessive titanium mesh
cranioplasty, which were contributing factors for representation. The C1 laminectomy was adequate.
(b) Cranial to caudal view, again demonstrating the original foramen magnum plus minimal craniectomy.
Note the dens is in the normal vertical position relative to the skull base, and thus ventral compression was
not a precipitating factor.

lines placed in this position, including electro-
physiological monitoring of motor-evoked poten-
tials (MEPs) and somatosensory evoked potentials
(SSEPs) if CCI is suspected and an occipitocervical
fusion is planned. A Mayfield head clamp is applied
to a pressure of 60–70 PSI. Patients are then gently
log-rolled prone onto a flat OR table with chest and
hip bolsters. The arms are tucked at the sides and
kept in place by a sheet rolled and clamped onto
the back. Care should be taken to pad all pres-
sure points of the arms and any bulky anesthetic
equipment. Padding should also be placed under
the knees and the legs kept slightly flexed and sup-
ported. The head is flexed about 30 degrees, mak-
ing sure that at least two fingers can fit between the
chin and the chest and that there is no abnormal
elevation in peak airway pressures. The shoulders
can be taped down to increase skin turgor around
the incision site; however, care should be taken to
prevent brachial plexopathy. Suction tubing and
monopolar and bipolar cautery cables are usually
taken down to the legs to maintain sterility and
ease of use. Depending on the size of the approach
or previous incision, typically the hair is cut in a
5-cm width from the inion to the C2 spinous pro-
cess protuberance. The wound is prepped with
iodine wash or gel rather than chlorhexidine to
minimize the risk of chlorhexidine dripping into
the eyes in the prone position, which can cause ret-
inal scarring and blindness. The operative micro-
scope should be set up in a face-to-face orientation.
OPERATIVE TECHNIQUE
After the patient is positioned and draped, the
original incision is opened. Based on the goals
of revision surgery, this incision can be extended
as needed. As mentioned previously, identifying
normal anatomy is performed first. At the cra-
nial aspect, normal occipital bone is identified.
A small two- or three-prong Weitlaner retractor
is placed. Gentle retraction can help identify the
midline or natural planes of the deeper soft tissues.
Monopolar cautery can be used carefully to open
the remainder of the superficial tissue. Once fas-
cia is identified, extreme caution needs to be taken
with monopolar cauterization to avoid incidental
durotomy. At the caudal aspect, the spinous pro-
cess of C2 is identified and superior aspect of the
Operative technique  71
C2 lamina is exposed, taking care not to unroof
the C1/2 joints bilaterally, which can result in
instability. Single- or double-cerebellar retractors
are then placed for deeper and wider retraction
and visualization.
In the suboccipital region, dissection of the bony
interface with dura/scar is accomplished using a
combination of Penfield dissector, Woodson dis-
sector, and straight or upgoing curettes. Once a
clear plane has been defined around all regions
of the prior craniectomy site, the drill is brought
in. We typically prefer the use of a 4-mm round
cutting burr for this portion of the case. The pre-
determined amount of additional bone requiring
resection is thinned with the drill. The assistant
can place a Penfield 1 or malleable retractor under
the bone and above the dura to provide additional
protection during drilling. Once the bone had been
thinned enough in all directions, Kerrison ron-
geurs can be used to complete the bony resection
(Figure  10.4a–d). The edges should be smoothed
out and waxed to prevent dural injury when
retracting the dura. If the C1 laminectomy needs to
be widened, this is accomplished with careful sub-
periosteal dissection using a Penfield 1 instrument.
Curettes can also be used to clear off the inferior
portion of the lamina. Once freed up, Kerrison
rongeurs can be used to widen the laminectomy.
In portions where the bone is thick, a matchstick
drill can be used to thin down the bone, followed
by resection using the Kerrison rongeur. In some
cases, additional partial C2 laminectomy may
be required. Any bleeding bone edges should be
addressed with bone wax, and any epidural bleed-
ing can be packed with hemostatic matrix (e.g.,
FloSeal) or thrombin-soaked gelfoam and cotto-
noid patties. Thorough irrigation should be com-
pleted, making sure that all bone dust is washed
out prior to opening the dura, as well as hemostasis
to prevent postoperative aseptic meningitis.
At this point, the operative microscope is
brought in. Using a Woodson dissector, planes
of the dura or scar are identified. Any bands or
sheets of tissue that can be dissected inferiorly are
done with the Woodson, above which the assis-
tant sharply incises with a 15-blade scalpel. In rare
situations, it is not possible to identify native dura
below the scar. In this case, we advise using this
entire width of tissue as essentially the new native
72  Revision suboccipital decompression for complex Chiari malformation

(a) (b) (c)

l Le
uda ft
Ca

Rig
ht

ial
an
Cr

(d) (e) (f)

Figure 10.4  Microsurgical technique for extradural exploration and suboccipital craniectomy extension
during a revision surgery for Type 1 Chiari malformation. Note that the orientation is the same for all fig-
ures as depicted in panel (a). (a) A straight curette is used to scrape soft tissue and scar from native dura.
(b) A straight curette is used to dissect out the native dura from the previous craniectomy edge. (c) A
Penfield 1 instrument is used to protect the dura during drilling for craniectomy extension. (d) The crani-
ectomy is completed using Kerrison rongeurs. (e) Any remaining soft tissue or scar tissue bands across the
dura are dissected using a slotted Woodson dissector and sharply incised with a 15-blade scalpel. (f) A
15-blade scalpel is used to perform the double-Y-shaped durotomy in a layer-by-layer fashion.

dura. A slotted Woodson dissector with a 15-blade
scalpel are used to cut a double-Y-shaped opening
in the dura (Figure 10.4e,f). Care must be taken
while retracting the dural leaflets because previous
scars may avulse vessels on the surface of the cer-
ebellum or in the subarachnoid space, depending
on the degree of prior exploration. Bipolar cautery,
microscissor sharp dissection, and combinations
of different Rhoton instruments can be used to
ensure that the cerebellar surface is not injured
during dural release and retraction. The leaflets are
tacked up using 4–0 nylon sutures.
At this point, intradural exploration should
commence. Any arachnoid adhesions should be
sharply excised using microscissors or an arach-
noid knife. In situations where the cerebellar ton-
sils have extreme inferior migration into the upper
cervical canal, tonsillopexy can be performed.
Bipolar cautery on the dorsal surface of the tonsil
while protecting the medulla is used to retract this
tissue without clinical consequence. A side-to-side
inspection of the cerebellar hemispheres should
be performed to continue resecting any arachnoid
adhesions. Once complete, the cerebellar tonsils
should be carefully dissected and spread at the
midline, where one continues to cut adhesions
as needed. It is important to visualize the fourth
ventricle with the tonsils retracted. CSF pulsatile
flow consistent with inspirations should be noted,
which confirms adequate CSF flow in this region.
Sometimes adhesions are not encountered until
deep in this area approaching the fourth ventricle,
so careful inspection needs to be performed, and
if necessary, a web or veil of arachnoid covering
 Operative technique  73

(a) (b) (c)

la Lef
t
ud
Ca

Rig
ht

Rig
ht al
ani
Cr

(d) (e) (f)

Figure 10.5 Microsurgical technique for intradural dural exploration during a revision surgery for
Type 1 Chiari malformation. Note that the orientation is the same for all figures as depicted in panel (a).
(a) Intradural exploration with lysis of adhesions tethering the cerebellar tonsils and hemispheres to the
inner layer of the dura using microscissors. (b) Dural edges tacked up and the descending cerebellar ton-
sils are directly visualized. (c) Tonsillopexy is performed, shrinking down the size of the cerebellar tonsils
with bipolar cautery. (d) Exploration of the fourth ventricle ensuring no adhesions and good pulsatile
CSF flow. (e) Final view of the posterior fossa following completed tonsillopexy and lysis of adhesions.
(f) Watertight dural closure with allogeneic dural substitute.

the obex can be identified and lysed, often in cases
with unresolved syringomyelia (Figure 10.5a–e).
Once completed, thorough irrigation is performed
and hemostasis achieved.
The choice of duraplasty at this point is at the
discretion of the surgeon and based on anatomical
factors. Autologous pericranium is preferred and
can be locally harvested from an extension of the
incision cranially or a separate incision closer to
the vertex; in cases where this is unsuccessful, an
allogeneic dural substitute can be used (e.g., bovine
pericardium and cadaveric skin). An appropriate-
sized piece is cut and tacked using interrupted
4–0 sutures. Then each leg of the graft is sutured
in a running fashion to achieve a watertight dural
closure (Figure 10.5f). Prior to completing the last
suture, the intradural space should be irrigated to
ensure that there is no bleeding requiring reex-
ploration and to reinsufflate the subarachnoid
space. For any areas where there is persistent CSF
leak, small muscle grafts can be harvested and
sutured in place. Fibrin sealant can be used over
the entirety of the dural closure for additional
support.
A dural substitute such as DuraForm or com-
pressed gel foam may be placed over the dural clo-
sure, but we do not favor this approach. Similarly,
small mesh cranioplasty can be utilized if needed
for cosmesis following revision of aggressive decom-
pressions, but more importantly, to provide struc-
tural support of the deep soft tissue, prevent scarring
of muscle on the dura, and minimize postopera-
tive pain. The deep tissue and superficial tissues are
closed with interrupted sutures using 0, 2-0, and 3-0
74  Revision suboccipital decompression for complex Chiari malformation
absorbable sutures. A running 3-0 caprosyn or nylon
suture is used for skin closure. Drains are typically
not placed to prevent the CSF-cutaneous fistula.
POSTOPERATIVE MANAGEMENT
Postoperatively, patients should be observed in an
intensive care unit (ICU) setting for hourly neuro-
logic and vital monitoring checks. Systolic blood
pressure goals should remain less than 150 mmHg
for adults or age-appropriate normotension for
pediatric patients. Any coagulopathies should be
immediately addressed. Careful monitoring of the
wound for clear fluid leaking should be undertaken.
The head of bed should be elevated to 30 degrees or
higher. For patients with preexisting dysphagia, a
formal swallow evaluation should be performed by
speech-language therapists prior to initiating diet to
prevent aspiration. Steroids (dexamethasone) should
be initiated for the prevention of aseptic meningitis,
which can occur from blood and bone dust irritation
in the subarachnoid space. Most patients can initiate
physical therapy and deep vein thrombosis (DVT)
chemoprophylaxis on the first postoperative day. For
patients with stable neurologic examination, further
inpatient imaging is usually not required.
Pain control is the primary issue that should be
addressed. At our institution, we have instituted a
postoperative pain protocol for all adult patients
undergoing first-time or revision Chiari decom-
pression surgeries, beginning with methadone
in the OR and transitioning to hydromorphone
patient-controlled analgesia (PCA) in the ICU. It
is important that this regimen is instituted only
on those with a reliable neurologic examination. A
low-dose muscle relaxer such as cyclobenzaprine
or diazepam is started as a standing dose and can
be titrated up or given additional doses as needed.
These medications should be held for any excessive
sedating side effects. The PCA narcotic require-
ment should be transitioned to an oral regimen
on postoperative day 1–2 as tolerated. Standing
Tylenol (hold for patients with preexisting hepatic
pathology), celecoxib (hold for patients with renal
pathology and start 24 hours after surgery), and
neuropathic pain medications (such as pregabalin
and gabapentin) should also be initiated. Patients
on narcotics should be discharged on a bowel regi-
men consisting of at senna and/or colace.
COMPLICATIONS
The postoperative complications that may arise
vary based on the exact revision surgery per-
formed. For revisions with or without duraplasty,
there is a risk of superficial or deep wound infec-
tions. Superficial infections can usually be treated
with observation and oral antibiotics; however,
deep or progressive infections may require surgi-
cal debridement and IV antibiotics to prevent epi-
dural abscess formation, which can compress the
posterior fossa structures. Patients that undergo
duraplasty are at risk for pseudomeningocele for-
mation, which can progress to gross CSF leak-
ing. In these cases, a CT head should be obtained
to assess for underlying hydrocephalus, in which
case CSF diversion can be used to treat both con-
ditions. Small pseudomeningoceles can remain
contained and spontaneously resolve with time if
the fascial closure is tight. However, as the collec-
tions grow, that can exert pressure on the closure
layers, impairing wound healing and leading to
superinfections and potentially meningitis. This
is especially of concern when there is obvious CSF
leaking from the incision itself. Conservative mea-
sures such as oversewing the wound are sometimes
sufficient for treatment. However, in other situa-
tions, the collection may need to be percutaneously
drained, or a lumbar drain may need to be placed
to promote wound healing. If these measures fail
to work, then exploration and identification of the
leak site may be required. For revision surgeries
that involve subarachnoid exploration, retraction
injury or iatrogenic contusions can lead to edema
and potentially infarct of the cerebellar tissue. In
a similar regard, vessel or parenchymal injury can
lead to bleeding complications and hematomas,
which can exert a mass effect on surrounding
structures. In these situations, reexploration with
potential widening of the suboccipital craniectomy
may be required for adequate decompression.
Pearls and Pitfalls
●● Given the unpredictable interfaces of hard,
bony edges with scar/dura/duraplasty,
monopolar cautery should be limited when
approaching these regions during revi-
sion surgeries. Alternatively, manual blunt

and sharp dissection with combinations of
Penfield, Rhoton, Woodson, or other instru-
ments should be used to avoid thermal
injury, which can result in durotomy and neu-
ral injury even if not directly applied to tissue.
●● MRI CSF flow sequences (e.g., CINE [short
for cinematographic] or high-resolution
T2 sequences) can demonstrate abnor-
mal CSF flow through the foramen mag-
num, confirming persistent compression
at that level. In some cases, when clinical
history suggests worse symptoms when in
extreme flexion or extension, neutral-align-
ment MRI images may not demonstrate
abnormal CSF flow. In these situations,
flexion/extension MRIs can be considered,
in which medullary compression and resul-
tant CSF flow dynamics can be assessed in
patients during these alignment changes.
Complications 75
●● Additional craniectomy is required in
some revision cases for Chiari decompres-
sion. Preoperative MRI should be carefully
assessed to exclude a low-lying torcular,
which can inadvertently be injured during
bony resection or durotomy. 3D CT recon-
struction has proven useful to counsel
­families, plan surgery, and teach in the OR.
●● Ultrasonography can be a useful adjunct
during revision surgeries prior to dural
opening. This imaging can demonstrate
the extent to which additional craniectomy
is required, how low the cerebellar tonsils
are relative to the new planned dural open-
ing, the determination for whole or partial
resection of C2 lamina, and the assessment
of CSF flow in the subarachnoid space due
to the presence of MRI occult adhesions.

How to revise a failed occipital
cervical fusion
JOSHUA T. WEWEL, MAZDA K. TUREL, JOSEPH E. MOLENDA,
AND VINCENT C. TRAYNELIS
Indications 77
Relative contraindications 78
Expectations 78
Preoperative planning and operating room
(OR) setup 79
INDICATIONS
The cranial-vertebral junction (CVJ) is a complex
structure consisting of the occiput, atlas, and axis,
along with an array of ligaments that allow mobility
and stability of the articulating surfaces. The most
common sources of pathology leading to instability
at the CVJ include congenital, infectious, trauma,
rheumatoid arthritis, malignancy, and iatrogenic
factors. CVJ instability is frequently secondary
to trauma such as atlanto-occipital dislocation
(AOD), type III occipital condyle fractures, com-
plex atlas/axis fractures, and ligamentous insta-
bility. The congenital anomalies of the CVJ that
produce instability are invariably complex lesions
that often require specific and unique strategies
to correct and stabilize. Inflammatory processes
such as rheumatoid arthritis can result not only
in translational and axial instability, often in con-
junction with deformity requiring fusion, but also
decompression at times. Anterior instrumented
fusion of the CVJ has been reported, but these
11
Operative technique 79
Postoperative management 81
Complications 82
procedures are very rarely performed, as most fixa-
tion and fusion of this segment are accomplished
via a dorsal procedure.
The CVJ is a challenging region to fuse. There
is great sagittal and axial plane rotation across the
segment, and these motions must be minimized for
a successful arthrodesis to occur. This dynamism
places increased stress on the fixation. Fixation
purchase points may be limited by factors such as a
large suboccipital craniectomy, fractured vertebra,
anomalous vascular anatomy, and poor bone qual-
ity. Every surgeon who actively manages pathol-
ogy of the CVJ will encounter patients with failed
fusions across this segment. A nonunion at the CVJ
may be detected by hardware failure, resorption of
bone graft, lucencies in bone surrounding screws,
or overt instability, as detected by flexion/extension
lateral radiographs. Nonunions that are symptom-
atic in terms of producing pain and those that are
related to instability should be surgically addressed.
Other indications for revision are infection and
prominent hardware.
77
78  How to revise a failed occipital cervical fusion
It should be noted that this chapter does not
include any discussion of revision to correct defor-
mity that persisted after the primary procedure
or that was created by the primary procedure. A
number of the points presented here may be valu-
able in these cases, but these are very rare and
unique events, each of which requires special,
highly i­ ndividualized management.
RELATIVE CONTRAINDICATIONS
The relative contraindications for revision of a CVJ
nonunion are rare, given the fact that the primary
procedure was performed for pathology that man-
dated a fusion. A few patients may be asymptom-
atic and have radiographs that show no significant
instability; these individuals can be followed with-
out surgery. Additionally, a small subset may have
developed serious comorbidities that would pre-
clude general anesthetic, which would make sur-
gery unreasonable. The remainder of patients with
CVJ nonunions should be offered surgical inter-
vention. The senior author has not seen an exter-
nal bone growth stimulator lead to a fusion in any
patient who has a nonunion (CVJ and subaxial),
and therefore, this is not recommended.
EXPECTATIONS
Patients who were doing well initially following
the primary procedure can expect to return to
that state if the reoperation is successful in obtain-
ing a solid arthrodesis. Those with instability also
should expect benefits from revision surgery in
terms of protecting the neural elements, as well as
eliminating or decreasing pain if that is part of the
symptomatology. Primary fusion rates when using
rigid fixation have been reported to be as high as
90% by multiple authors. The best opportunity for
success is with the first operation, so those need-
ing revision surgery should understand that there
is risk of persistent nonunion.
Postoperative wound infections that occur
in the early period after surgery do not require
removal of the instrumentation. Those that are
substantially delayed are more prone to be associ-
ated with the formation of biofilm, and removal
of the fixation hardware is usually necessary to
e­ radicate the infection. If the fusion is not mature,
then new instrumentation may need to be
implanted. Patients should expect that the infec-
tion can be cured.
Prominent hardware at the CVJ on very rare
occasions will produce pain. Judicious removal of
proud instrumentation in select cases of patients
who have already fused should result in decreased
pain. If the instrumentation is exposed, then it will
need to be removed to prevent (or treat) infection.
Nonunions will often require revision of the
fixation. The previously placed instrumentation
should be carefully examined, and often only
simple modifications are necessary. If screws have
become loose, then larger screws can be placed or
screws can be positioned in different locations.
For example, a loose screw in the pars interar-
ticularis of C2 could be replaced with a larger-
diameter screw, or C2 fixation could be achieved
by putting a new screw in the pedicle. Loose cra-
nial fixation can be managed in the same fash-
ion. Often, cranial plates minimize the number
of screws that can be placed and the options for
where they are placed. If cranial fixation needs
to be reestablished, it is often prudent to use
multiple single-screw/rod fixators rather than
a plate. Not only does this increase the options
for fixation, but such a technique usually allows
more of the occiput to be uncovered, which pro-
vides a larger surface area for fusion substrate to
be placed. If there has been a rod fracture, then
rods of greater diameter or one constructed with
a stronger material should be considered. In rare
occasions, a third rod could be placed.
Graft selection is an important, yet often over-
looked part of surgical planning. Broadly, two
choices exist—autograft or allograft. Allograft
is well known to heal very poorly under tension,
and if that was what was utilized in the primary
procedure, it is the most likely cause for failure.
In such cases, it is imperative to employ another
grafting strategy. We prefer to use a rib autograft,
which nicely matches the curvature of the CVJ in
all cases. The senior author has not seen great suc-
cess with calvarial autograft, although it is recog-
nized that others have reported good results with
this bone source. Iliac crest is an excellent source
of autograft. If allograft is chosen, then it should

be used in conjunction with bone morphogenetic
protein (BMP). This is an off-label use of BMP, but
it will have a good chance of producing a success-
ful fusion.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
The previous section includes information that is
important for preoperative planning, and these
issues will not be repeated. It is important to care-
fully assess the airway. Those patients with prior
CVJ fusions will usually have limited motion in
this region, even if there is a nonunion, and that
can make intubation difficult. Certainly, those
with instability will require extreme care in terms
of minimizing motion during intubation. Once
intubated, all revision patients are fixed in position
using the Mayfield three-point skeletal fixation
device and carefully turned prone.
We use neuromonitoring in a very selective
fashion. If there is instability or significant neural
compression, monitoring is critical for the posi-
tioning phase. Baseline studies are obtained and
repeated rapidly following final positioning.
Prompt radiographic evaluation of the CVJ
following the turn to prone position is also very
important to minimize neurologic injury in the
unstable patient. It is a quicker assessment than can
be achieved with electrophysiological monitoring,
and if the region is in normal alignment, the risk
of creating a neurological deficit based on patient
position approaches zero. Radiographic evalua-
tion of alignment in patients without instability or
compression is used as the sole means of monitor-
ing, and electrophysiological studies are not used
in this group. Neuromonitoring is of no value after
the position has been determined because the CVJ
will not move if using the Mayfield. This is differ-
ent than in some primary procedures, where defor-
mity correction is part of the surgical plan. When
there is no need for deformity correction, careful
and precise surgical technique will not result in a
neurological deficit. Poor operative execution can
result in deficit, but in this case, monitoring is of
no value because it will not prevent injury from
events such as inadvertent striking of the cord.
Electrophysiological monitoring can alert one to
Operative technique  79
risk due to hypotension. The more serious factor
in these cases is the anesthesiologist—monitoring
is no replacement for a skilled, experienced, and
vigilant anesthesiologist.
Intraoperative image guidance is a very use-
ful adjunct in those cases where screw fixation
needs to be changed. This is particularly impor-
tant when nonstandard fixation is desired, such
as in the occipital condyle or calvarial diploe. It
can also be helpful even in standard C2 pedicle
screws, as the surface anatomy may be altered by
the prior surgery. Use of an image guidance system
that acquires the data with a radiographic assess-
ment after positioning will minimize the errors of
­manual registration; thus, it is preferable.
If there is uncertainty about the type of instru-
mentation that is implanted, a universal cervical
instrumentation removal set should be available.
OPERATIVE TECHNIQUE
Once positioned and sterilely prepped, the original
incision is reopened. Great care is required in the
exposure if there has been a previous decompres-
sion. Firm avascular scarring will inhibit the expo-
sure at times because it can be exceedingly difficult
to retract. Resection of the medial portion of scars
in these select cases will improve exposure. If the
approach results in a dural violation, then all pos-
sible maneuvers to obtain a primary dural closure
should be employed. Reliance on the many fibrin
glue adjuncts and dural onlay grafts to prevent the
development of a pseudomeningocele without pri-
mary closure will often d­ isappoint both the patient
and the surgeon.
All the previously placed instrumentation
and the posterior occiput must be fully exposed.
Avascular, scarred encased graft material should
be removed. Any necessary decompression should
be performed once the exposure is completed.
At this point, attention is directed to the instru-
mentation, and poor screw purchase is corrected
by either using larger-diameter screws or placing
screws in new and different trajectories. Only a
single option is available for C1, but C2 can be fixed
with screws in the pars, pedicle, or lamina. If one
chooses the C2 lamina, then it is best to extend the
fixation at least one level caudally, as these screws
80  How to revise a failed occipital cervical fusion
are in line with axial rotation and thus are biome-
chanically disadvantaged to minimize movement
in that axis.
Limitation of fixation points in C2 can be
overcome by extending the fusion inferiorly, but
this is not possible if occipital fixation has failed.
Changing individual screw fixation, as described
earlier, is a good strategy. This may not be possible,
though, if there has been a large suboccipital cra-
niectomy. In these cases, establishing good cranial
fixation can be challenging. Two potential targets
for screw placement are available: the occipital
condyle and the diploe.
Occipital condyle screw placement was first
described about 10 years ago. Biomechanical
studies suggest that it provides as strong a point
of fixation as the occiput itself, but these studies
consisted of only acute testing, and it is possible
that with time, the purchase will become com-
promised. This is particularly worrisome because
the condyle is so close to the axis of rotation of
occiput–atlas sagittal plane motion, which places
it at a biomechanical disadvantage. The condyle is
relatively deep in the exposure, and the condylar
canal, through which traverses the hypoglossal
nerve, is in the anterior portion of this structure.
Despite these challenges and concerns, a number
of surgeons have reported good results with this
fixation, and although it should not be considered
a primary technique, it has great value as a second-
tier point of purchase. The technique often requires
skeletalization and mobilization of the V3 segment
of the vertebral artery (VA). The VA is traced along
the condylar fossa until the condylar foramen and
emissary vein are identified, delineating the lateral
Figure 11.1  The appropriate starting point for the condyle screw on a sawbones model.
extent of condyle exposure. The boundaries of the
condylar fossa are defined laterally by the condyle
emissary vein, inferiorly by the lateral portion of
V3, and medially by the junction of the condyle
and ­occipital bone.
The entry point for condyle screw placement
is 5 mm lateral to the posteromedial edge of
the condyle and 2 mm inferior to the skull base
floor (Figure  11.1). A pilot hole is drilled with
a 10–33-degree medial angulation and 10–30
degrees caudally, attempting to pass the screw
along the longest axis of the condyle with the
goal of staying parallel to the skull base floor
(Figure  11.2). Preoperative evaluation of the
occipital condyle dimensions will determine the
length of the screw placed, bearing in mind that
11–14 mm of the unthreaded portion of the screw
will need to remain proud, such that it can reach
the rod projecting from the C1, C2 instrumenta-
tion (Figure  11.3). It is recognized that there is
great variability in the angular drilling param-
eters, and therefore, it is optimal to utilize intra-
operative navigation to assist in achieving optimal
screw placement in the condyle. Condylar screws
do not block the occipital surface, which increases
the area available for fusion, which may be very
important if there has been a craniectomy.
The other potential technique if there has been
a large posterior fossa craniectomy is to place
screws into the diploe of the calvarium (Video
11.1). This is akin to iliac crest screw placement.
Guide holes are made through the diploic space,
and screws are placed. The screw diameter should
be tailored to each patient such that cortical bone
is engaged yet not violated by screw threads. The
 Postoperative management  81

Figure 11.2  The intraoperative planning using navigation for the placement of the condyle screw.

Figure 11.3  The successful placement of a condyle screw utilizing navigation.

diploic screws can then be fixed to the cervical
instrumentation. The procedure requires care-
ful preoperative planning and is best performed
using image guidance.
POSTOPERATIVE MANAGEMENT
Following the completion of the procedure, the
patient is turned supine and extubated. Upright
anterioposterior (AP) and lateral cervical spine
x-rays are obtained as an inpatient to establish
baseline films. Cervical radiographs are then
obtained at the 3-, 6-, and 12-month follow-up vis-
its. A computed tomography (CT) scan of the CVJ
is usually performed 1 year after surgery to verify
fusion. CT is necessary because the hardware
­frequently obscures the view of the fusion mass on
plain radiographs.
82  How to revise a failed occipital cervical fusion
COMPLICATIONS
When occipital screws are being replaced, care
must be taken to choose appropriate sites for new
screw placement, preferably below the superior
nuchal line along the occipital ridge. If screws
must be placed superior to the superior nuchal
line, dural venous structures and bleeding may
be encountered. If bleeding is encountered during
screw placement, it is best to continue with place-
ment of the screw. Minor penetration of a screw
into a venous sinus does not appear to cause any
harm. The real risk of occipital screws is a poste-
rior fossa hematoma, which can occur following a
minor cerebellar surface vein or artery injury. Any
patient who does not awaken promptly from sur-
gery should be immediately evaluated with a CT,
and if there is a posterior fossa hematoma, it should
be evaluated absolutely as quickly as possible.
The management of CSF leaks has been previ-
ously addressed. A VA injury may occur, and if
this happens, all possible maneuvers to control the
hemorrhage rapidly should be undertaken. Ideally,
the vessel is preserved, but if this is not possible,
the risk of neurological deficit with the loss of one
VA is low. If the VA injury occurs on the first side
being treated, then all possible efforts to preserve
the contralateral VA must be undertaken. In some
instances, this will mandate not operating on the
patent VA side.
Pearls and Pitfalls
●● The time invested in studying the images
preoperatively is well spent. These patients
should have plain radiographs, magnetic
resonance imaging (MRI), and CT. There
must be a clear understanding of the anat-
omy prior to surgery.
●● Verify that the tools to remove the previ-
ously implanted instrumentation are avail-
able if hardware removal is necessary.
●● Do not repeat exactly what was done
before. The best opportunity for success
lies with the first surgery, so try to deter-
mine why it failed and adjust accordingly.
●● Consider overbuilding the construct.
Additionally, if the patient’s age and body
habitus permits, consider halo immobiliza-
tion for 8–12 weeks, even if instrumenta-
tion is placed.
●● Use image guidance when incorporating
any nonstandard fixation.
●● Do not rely on allografts alone.
Video 11.1
Failed OC Fusion
(https://youtu.be/giUNd1w1mDI)

How to revise a failed C1–C2 fusion
NIZAR MOAYERI AND MICHAEL G. FEHLINGS
Indications 83
Relative contraindications 84
Expectations 84
Principles of revision surgery 84
Preoperative planning and operating
room (OR) setup 85
INDICATIONS
C1–C2 revision surgery is a technically demand-
ing procedure, as normal anatomic landmarks are
obscured, as well as the presence of vital organs: the
transition from medulla oblongata to spinal cord and
the vertebral artery (VA), with its complex geomet-
ric anatomy. A misplaced screw can result in dev-
astating neurologic and vascular complications. A
variety of surgical techniques have been utilized for
revised internal fixation to treat ongoing atlantoaxial
instability, with failure rates ranging from 5%‒50%.
Patients with rheumatoid arthritis and os odontoi-
deum have particularly high rates of nonunion after
C1–C2 fixation, necessitating a revision surgery.
The indication for revision of C1–C2 fusion is
nonunion with persistent or progressive symp-
toms, due to pseudarthrosis. The overall incidence
of atlantoaxial pseudarthrosis after atlanto-
axial fusion is estimated to be around 2%–10%.
However, the true incidence may be higher because
it can be oligosymptomatic or asymptomatic. Main
symptoms may include, but are not limited to, per-
sistent pain, progressive or limiting neurological
compromise, and instability. A wide range of other
specific indications for this surgery also exist,
12
Operative technique 86
Postoperative management 86
Complications 87
Reference 88
depending on patient and/or physician preferences
and radiological ­findings. Examples are nonunion
of odontoid fracture with development of odontoid
granuloma or retro-odontoid pannus or progres-
sive C1–C2 dislocation. In addition, pseudarthro-
sis following C1–C2 fusion is frequently seen after
wire fixation, clamps or hooks, unilateral trans-
articular screw with cable fixation, or onlay bone
graft with no internal fixation.
There are several biomechanical reasons for C1–
C2 nonunions. The C1–C2 segment has the widest
range of motion of any spinal motion segment, and
this motion is increased significantly when there
is pathological instability present. The difficulty of
achieving adequate control of C1–C2 motion dur-
ing bone healing has led to a number of strategies
to improve the fusion rate. Adjunctive use of a halo
brace or internal fixation with rigid transarticular
screws has been promoted to improve the success
rate of surgery.
Additional factors contributing to the risk of
nonunion include malnutrition and the use of
steroids, nonsteroidal anti-inflammatory drugs
(NSAIDs), and cytotoxic and immunosuppressive
drugs. Two independent risk modifiers include
smoking and osteoporosis.
83
84  How to revise a failed C1–C2 fusion
RELATIVE CONTRAINDICATIONS
A patient’s age and/or comorbidities may pose a
relative contraindication as to what invasive tech-
nique can be used or whether an internal or exter-
nal revision should be performed. The screw-rod
constructs technique for posterior atlantoaxial
fusion using C1 lateral mass screws and C2 pars/
pedicle screws, as described by Goel and Laheri
and later modified by Harms and Melcher, offers
excellent access to the C1–C2 joint and allows
decortication and packing of the joint with graft
material. However, the use of transarticular screws
involves the alignment of C1 on C2, which can be
challenging in obese patients or those with signifi-
cant thoracic kyphosis. To capture both C1 and C2,
adequate reduction in case of anterior atlantal sub-
luxation is mandatory before hardware insertion.
Moreover, many patients with fixed subluxations
or absent or fractured posterior elements of C1
and/or C2 cannot be treated with the transarticu-
lar screws technique, making the screw-rod con-
struct the technique of choice for C1–C2 revision
surgery.
EXPECTATIONS
As C1–C2 revision surgery is one of the most com-
plex procedures in spine surgery, the performing
surgeon must be aware of her or his own primary
end point and have an elaborate, detailed discussion
with the patient as to what expectations are upon
agreeing to revision surgery. A thorough patient
history and physical examination will be the first
step in establishing the patient’s needs. Questions
that should be asked include the following:
●● Why did you have your initial procedure?
●● What symptoms were you having before your
initial procedure?
●● Following the initial procedure, did you get
relief from some of or all your symptoms? If so,
how long did this relief last?
●● Are the symptoms that you are having now
similar to those you had before your initial pro-
cedure? If not, how are the symptoms different?
●● Are the symptoms related to a certain position
of the head or neck, and does that change while
sitting or lying down?
These questions will give the spine surgeon
some sense of whether the initial problem was suc-
cessfully treated and whether the current symp-
toms represent persistence of the initial problem,
recurrence of the initial problem, or a new problem
at the same or an adjacent level.
Questions regarding constitutional chills, nausea,
symptoms (i.e., fever, vomiting, unexplained weight
loss, fatigue) should also be addressed during the
history-taking to investigate whether problems such
as infection or tumor may be present. Questions per-
tinent to the nature, duration, severity, and location
of pain, numbness, and/or tingling, as well as ques-
tions relating to weakness, problems with balance
and fine motor skills, and bowel and bladder func-
tion are also essential, as is the case when assessing
any spine patient. Red flags such as progressive weak-
ness, constitutional symptoms, unrelenting pain,
weakness or numbness while the head is moved to a
certain position, and difficulty breathing or gasping
for breath without any physical effort are suggestive
of an urgent (or even emergency) situation.
PRINCIPLES OF REVISION SURGERY
The majority of C1–C2 pseudarthroses occur
between C1 and the graft and are associated with
failed hardware. Atlantoaxial instability due to
failed surgery can be successfully salvaged if the
pathological, pharmacological, biomechanical,
and technical problems are effectively resolved.
Careful exploration of the indications for surgery
through an extensive history and careful man-
agement of the patient’s expectations is key in
the decision-making phase for revision surgery.
Preoperative understanding of the altered anatomy
through imaging should be used to guide the spine
surgeon in choosing the appropriate technique.
Fusion can be achieved in a substantial proportion
of revision surgeries. The greatest success can be
gained by using autologous bone grafts, adequately
controlling C1–C2 motion (in our view, using the
C1 lateral mass screw and the C2 pars interarticu-
laris screw is the optimum technique for techni-
cal and biomechanical reasons highlighted later in
this chapter), compressing the bone graft between
the arches of C1–C2, meticulously preparing the
fusion bed, and optimizing the pharmacological
and metabolic factors for promoting bone fusion.
 Preoperative planning and operating room (OR) setup  85
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
Imaging
Appropriate imaging guides the spine surgeon in
preoperative planning. Imaging techniques that
must be present to evaluate a patient for C1–C2
revision surgery include plain radiography, com-
puted tomography (CT) scan (with or without
angiography), and magnetic resonance imaging
(MRI). Plain radiography should typically include
open-mouth view, anteroposterior, lateral, and
flexion/extension views, if deemed safe and clini-
cally possible. The status of an existing fusion
should be assessed for the presence of bridging
trabecular bone or continued motion. The location
of instrumentation, along with any subtle loosen-
ing of existing screws in the form of haloing and
implant failure in the form of screw pullout and
screw and/or rod breakage, should be noted.
Catastrophic failure of C1–C2 implants can be
seen in the setting of trauma, tumor, or infection.
Pseudarthrosis should also be considered when
subtle or overt signs of instrumentation loosening
or failure are noted on radiographs. Flexion and
extension lateral cervical radiographs are helpful
in assessing pseudarthrosis and instability. Flexion
and extension radiographs may also show the move-
ment of loosening screws and angular motion that
may suggest pseudarthrosis and/or instability.
CT scans are commonly used as the imag-
ing modality of choice to assess a patient’s possible
pseudarthrosis. Coronal and sagittal reconstructions
are particularly helpful in assessing the fusion as
well as the position and status of the C1–C2 instru-
mentation. Bridging trabecular bone in these areas
indicates a solid fusion. Lucency that is typically
linear in nature indicates a pseudarthrosis. Lytic
bony destruction may be seen in cases of infection
or tumor. In particular, when planning for a C1–C2
revision fusion, the status of the bone should be noted.
Significant bony destruction precludes the placement
of instrumentation and can alter the surgical plan,
often leading to the involvement of the occiput and/
or C3 or placing the lower distal of the instrumenta-
tion into areas of preserved bony anatomy.
CT angiography is important in planning a C1–
C2 fusion revision, especially when the anatomy
is altered or anatomic variations involving the VA
between C1 and C2 are present. In particular, V3
segment anomalies, which occur in up to 10% of
the population, should be carefully studied. These
include the persistent intersegmental artery, in
which the VA courses abnormally below the C1
arch after leaving the transverse foramen of the
C2 and enters the spinal canal without passing
through the C1 transverse foramen; a VA fenes-
trated at the atlas level; and the posterior inferior
cerebellar artery, originating from the VA between
C1 and C2 and entering the spinal canal from the
caudal side of C1. In addition, the presence of a
dominant VA must be noted to avoid introducing
any extra risks during screw placement. The pres-
ence of a high-riding VA (i.e., one that is more cra-
nial than usual and medially located in the body
of C2) occurs in up to 23% of patients and may
increase the risk of vertebral artery injury (VAI).
MRI provides great detail of the soft tissue
structures, including spinal cord compression and
epidural fluid collections that can signal infection
and tumors. MRI can be performed with and with-
out gadolinium to help differentiate recurrent dis-
ease and/or fluid collections from scar tissue. Scar
tissue is vascular, and therefore will be enhanced on
images after the intravenous (IV) administration
of gadolinium, which has high signal intensity on
T1-weighted images. In patients who cannot have
an MRI, CT myelography is helpful in assessing the
neurologic structures for evidence of compression.
If there is a concern that the patient may have an
infection in the process of working up for C1–C2
revision surgery, a complete white blood cell count
with differentiation, an erythrocyte sedimentation
rate (ESR), and determination of C-reactive pro-
tein (CRP) level is recommended. ESR and CRP
are both nonspecific markers of inflammation. The
normal concentration of CRP is 10 mg/L, which
in the setting of an infection could increase from
40 mg/L to >200 mg/L. The ESR is also a measure
of inflammation, with a normal ESR considered to
be <15‒20 mm/h. In response to inflammation,
CRP levels become elevated more rapidly than ESR.
Similarly, after the source of inflammation is suc-
cessfully treated, CRP levels return to normal more
rapidly than ESR. In the setting of an infection,
CRP levels are of value when following the response
to treatment, while ESR can remain persistently
86  How to revise a failed C1–C2 fusion
elevated despite a normal CRP level and clinical
evidence of a successfully treated infection. CRP
levels usually normalize within 1‒2 weeks, with the
ESR following suit within about 6 weeks.
Immediate preoperative setting
A careful fiberoptic endotracheal intubation without
hyperextension of the neck is important. Following
intubation, positioning of the patient should be per-
formed with careful control of the spine. Transfer
of the patient after intubation should be performed
safely and with enough support to ensure gentle
atraumatic positioning of the spine. The use of a
Jackson table and a Mayfield clamp to immobilize
the head and facilitate a smooth transition from
supine to prone is advised. A lateral radiograph
should be obtained to ensure that no additional
translation or rotation has occurred. Baseline mul-
timodality intraoperative neuromonitoring with
motor-evoked and somatosensory evoked potentials
(MEPs/SEPs) and electromyography (EMG) should
be obtained after intubation and before manipula-
tion of the patient. Neuromonitoring is continued
throughout the surgery. Hypotension can lead to
decreased cord perfusion, and therefore, the mean
arterial blood pressure should be kept at 80 mmHg
or higher. In addition, of course, adequate lighting,
magnification, and assistance should be arranged.
OPERATIVE TECHNIQUE
Our preferred technique for C1–C2 fusion revi-
sion surgery uses the C1 lateral mass screw and C2
pars/pedicle screw, based on the modified Harms
and Goel fusion technique. It does not necessitate
structural graft/wiring and can be used even in
the setting of fractured or absent C1 and C2 pos-
terior elements. In addition, it allows reduction of
C1–C2 dislocation and can be used for fixed dislo-
cations. Moreover, in the case of anomaly of the VA
course or a small pedicle or inaccessibility due to a
fractured screw in the C2 pedicle or pars interar-
ticularis, short pars screws can be used. Finally, ade-
quate decortication of the C1–C2 can be achieved.
After obtaining an intraoperative radiograph
to judge spinal alignment after positioning and
ensuring that no changes are recorded in neuro-
monitoring, the instrumentation is exposed and the
implants carefully removed. Efforts should be taken
to remove all parts of the implants, but if distal parts
are inaccessible or too risky to remove, they may be
left behind. The preferred method for revision of an
atlantoaxial fusion, in our opinion, is the Harms–
Goel screw fixation. During C1-lateral mass screw
placement, the venous vertebral plexus between C1
and C2 is exposed. Exposing the venous vertebral
plexus is often accompanied by some blood loss, but
this is usually well controlled using bipolar cautery
and application of a hemostatic matrix (Gelfoam/
Tabotamp). The C2 nerve root should be gently
displaced downward with a Penfield dissector. If
an anatomical variant is present, a preganglionic
C2 nerve root section using bipolar and scissors is
often well tolerated. A subsequent section is usually
unavoidable if joint access is needed.
Image guidance can be very helpful to guide
screw placement in a revision situation due to dis-
tortion of the anatomy. Intraoperative image guid-
ance, such as use of the O-arm, is a very useful tool
to guide the screws in an area that is already dis-
turbed by scar tissue and previous laminectomies.
After placement of the screws and rods, fluoros-
copy is performed to ensure adequate positioning.
A few points regarding bone grafting techniques
in a revision situation bear special mention. Access
to the C1–C2 facet joints allows the opportunity
to achieve direct arthrodesis. Careful stripping of
the C1–C2 joints is followed by packing the joints
with either autograft or allograft. In addition, the
use of bone morphogenic protein-2 can be a help-
ful adjunct to accelerate the fusion.
POSTOPERATIVE MANAGEMENT
The use of a rigid cervical collar is controversial, and
we do not feel that it should be considered standard
procedure. However, the decision as to whether to
apply a collar should be guided by patient-specific
characteristics such as severe osteoporosis, contin-
ued tobacco abuse or noncompliance.
In the case of a cerebrovascular fluid leak, we
recommend flat bed rest for 72 hours. Persistent
leaks should be managed with an external lumbar
drain for at least 5 days. If leaks persist, revision
surgery to close the dural leak is indicated.
Baseline radiographs are obtained after sur-
gery. Unless there is doubt about the position of
the instruments, a follow-up CT should then be
obtained after 6 weeks and 6 months.
 Complications 87

COMPLICATIONS (FIGURES 12.1
AND 12.2)
Long-term follow-up of patients is necessary in
order to record both early and late complications
accurately. As Sir William Osler, in his work The
Student Life (1905), remarked on mistakes (and
complications): “Begin early to make a threefold
category: clear cases, doubtful cases, mistakes.
And learn to play the game fair. No self-deception.
No shrinking from the truth. Mercy and consid-
eration for the other man. But none for yourself,
upon whom you have to keep an incessant watch.
It is only by getting your cases grouped in this way
that you can make any real progress in your (con-
tinuing) education; only in this way can you gain
wisdom from experience.”1
Revision of atlantoaxial fusion is associated
with an increased risk for intraoperative and post-
operative complications due to the altered anatomy.
The following complications related to surgery can
occur and may present early or late, depending on
the cause and effect: (1) operative-site hemorrhage,
either due to direct VAI or other causes; (2) cere-
brospinal fluid (CSF) leak and pseudomeningocele;
and (3) wound infection. Other immediate postop-
erative complications include occipital neuralgia,
persistent neck pain, C2 anesthesia or hypoesthe-
sia, and pain at the harvested site.
Operative-site hemorrhage is rare but can occur
in the subdural or epidural space. Hemorrhage is
usually benign and self-limited, but any patient
with hemorrhage-induced neurological deficit
has to undergo neuroimaging and careful evalu-
ation for evacuation of the hematoma if it should
enlarge. In our opinion, transarticular screw posi-
tion has a higher rate of screw malposition and VAI
compared to separate C1 and C2 screws. In the
case of VAI during drilling or tapping, the screw
should be rapidly inserted to stop the bleeding. The
procedure should be interrupted or the surgical
strategy changed to preserve the contralateral VA,
with the patient then sent for angiographic inves-
tigation. Hemostasis can be further achieved using

(b)

(a)

(c)

Figure 12.1 This is a 53-year-old female who is a heavy drug-user/smoker. She had severe neck pain due
to C1–C2 instability, subluxation, and os odontoideum. She underwent went a C1–C2 fusion (transarticular
screws with cable fixation with autogenous iliac bone). Six months after surgery she developed severe neck
pain and dysesthesia in her upper limbs. (a) is a lateral radiograph demonstrating C1/2 subluxation after screw
fracture. This is again demonstrated in an axial (b) and sagittal (c) CT scan. The patient underwent a revision
C1–C2 (C1 lateral mass/C2 pedicle/pars, supplemented by bone morphogenetic protein [BMP] and brace).
(Courtesy of Dr. Michael G Fehlings, MD, PhD, Toronto Western Hospital, University of Toronto, ON, Canada.)
88  How to revise a failed C1–C2 fusion
(a)
Figure 12.2 (a,b) The anterioposterior (AP) and lateral postoperative films. (Courtesy of Dr. Michael
G Fehlings, MD, PhD, Toronto Western Hospital, University of Toronto, ON, Canada.)
bone wax or tamponade, coagulation, ligation, or
direct suture.
CSF leak, pseudomeningocele, and wound
infection can present as both early and late com-
plications. Inadequate dural closure or gaps within
the fascial closure may allow the fluid to leak.
Pseudomeningoceles can cause CSF flow obstruc-
tion and hydrocephalus. If CSF leakage is observed,
a sterile dressing may be temporarily placed over
the site. The leakage site along the suture line,
however, should be closed using a figure-eight
stitch with either fat-autograft or dura-substitute
(Gelfoam or DuraGen) tissue. If leakage continues
or resumes, external lumbar shunt insertion should
be considered. The development of a pseudomenin-
gocele is not necessarily a problem unless there is
CSF leakage, or if the cosmetic defect is unaccept-
able to the patient. If the pseudomeningocele is sub-
stantial, revision of the closure can be undertaken.
Wound infections are particularly problematic.
Superficial wound infections may be treated with
oral or IV antibiotic agents, topical cleansing and
antibiotic ointments, and debridement if neces-
sary. If there are areas of clear necrosis, they should
be excised and reclosed. However, deep wound
infections in combination with CSF leak may
cause bacterial meningitis. In cases of question-
able or deep wound infections, a lumbar puncture
should be performed to evaluate CSF gram stain
(b)
and cultures to rule out occult infection. Any men-
ingitis should be appropriately treated. Deep infec-
tions are quite rare; osteomyelitis requires removal
of the infected instrumentation and long-term IV
antibiotic therapy.
Pearls and Pitfalls
●● Establish a clear line of communication and
express your preferences with the anes-
thesiologist regarding preoperative and
intraoperative management (i.e., method
of intubation, need for blood pressure
management).
●● The use of intraoperative neuromonitoring
and navigation is extremely helpful in tai-
loring the revision technique.
●● Begin a C1–C2 revision fusion with a clear
understanding of the altered anatomy and
the course of the VA.
●● Regaining control over the operating room
(OR) and having a backup plan in case of a
VAI is pivotal for successful management of
such an injury.
REFERENCE
1. Sir William Osler The student life: A farewell
address to Canadian and American Medical
Students. Canada Lancet 1905;39:121–138.

Treatment of postlaminectomy kyphosis
CHRISTOPHER T. MARTIN AND JOHN M. RHEE
Indications 89
Relative contraindications 90
Expectations 90
Principles of revision surgery 91
Preoperative planning and operating room
(OR) setup 91
INDICATIONS
Although patients may initially report improve-
ment in their neurologic symptoms after a cervi-
cal decompressive laminectomy, over time their
clinical results may deteriorate if postlaminec-
tomy kyphosis develops. The reason for this dete-
rioration is usually multifactorial. In the healthy
cervical spine, the center of gravity for the head
falls posterior to the upper cervical vertebrae1
(Figure  13.1). This alignment promotes a lordotic
posture, averaging 14 degrees, and places 64% of
the load through the posterior column.2 Thus, in
the healthy spine, the biomechanical demands
on the posterior musculature are lessened by the
favorable lordotic alignment.
Cervical laminectomy may alter this balance in
several ways. First, it results in the removal of the
posterior tension band, including the spinous pro-
cesses, lamina, supraspinous ligament, and inter-
spinous ligament. In the absence of these normal
soft tissue and bony restraints, the posterior mus-
culature must compensate with additional muscu-
lar tension in order to maintain a neutral or lordotic
posture. This exertion may lead to excessive muscle
13
Operative technique 95
Postoperative management 97
Complications 97
References 98
fatigue with cramping and axial neck pain. Often,
these symptoms are activity related and may be
improved with rest. Second, the surgical dissection
for a laminectomy involves stripping the posterior
cervical musculature, which can lead to scarring
and fibrosis, thus further placing the extensor
muscles at a disadvantage. This is particularly the
case if semispinalis cervicis and capitis, which are
the primary cervical extensors, are detached from
C2. Third, even with a careful dissection, some
amount of iatrogenic injury to the facet capsule
and facet joint may occur, potentially aggravat-
ing segmental instability. This is particularly likely
with overaggressive facet resection, and cadaveric
studies have demonstrated that instability is more
likely to occur with resection of more than 50% of
the facet joint.
With increasing muscle fatigue and segmental
translation, it becomes more difficult to maintain
an upright posture, and the cervical spine falls into
kyphosis. This mechanism that produces kyphosis
tends to be a self-perpetuating cycle: As the head
moves farther anteriorly, additional tensile loads
are placed onto the posterior elements and mus-
culature, leading to worsening decompensation
89
90  Treatment of postlaminectomy kyphosis
C2
C7
T1
Figure 13.1  Cervical sagittal alignment. In a per-
son with normal alignment, the center of gravity
of the head (CGH) falls posterior to the cervical
vertebrae, such that the majority of the loads are
borne by the posterior elements. The weight of
the head does not exert a kyphogenic moment
on the center of rotation of the cervical spine. The
CGH (white line), C2–C7 SVA (red line and white
arrow), and T1 slope (yellow lines) are indicated.
(Figure 13.2). With worsening malalignment, the
spinal cord can become draped over the verte-
bral bodies, leading to myelopathy. In addition,
postlaminectomy membranes can form, which
may lead to compression of the dura in extension.3
In severe cases, the patient may develop a chin-on-
chest deformity, which interferes with the normal
forward gaze during gait and poses difficulties in
hygiene, swallowing, and feeding.
Although nonoperative symptom manage-
ment can be considered, surgery is recommended
for those with refractory or progressive symp-
toms. Surgical indications for postlaminectomy
kyphosis include axial pain related to muscula-
ture fatigue, deformity that interferes with the
activities of daily living, and neurologic dysfunc-
tion due to instability or compression from the
deformity.
RELATIVE CONTRAINDICATIONS
Relative contraindications include active infec-
tion or concurrent chemotherapy or radiation,
which might place the patient at significant risk
for wound complications postoperatively. Patients
with significant osteopenia or osteoporosis are
at risk for implant-related complications such as
pullout or adjacent level fractures (Figure 13.3).
In such patients, depending on the urgency of the
neurologic situation, consideration may be given
to an endocrinology referral in order to develop a
plan for optimization of their bone quality prior
to surgery. Patients who are actively using tobacco
should be encouraged to stop and offered anti-
smoking aids or referral to a smoking cessation
program. Where possible, medical comorbidities
should be optimized prior to surgery, particularly
with regard to diabetic status, nutritional status,
and cardiopulmonary function.
EXPECTATIONS
The majority of reports on the treatment of cer-
vical deformity are small, retrospective clinical
series, with short-term follow-up. Nonetheless,
high rates of significant postoperative improve-
ment have been reported. Steinmetz et al. reported
on 10 patients, followed for a minimum of 6
months, who underwent anterior-only correction
of an iatrogenic cervical kyphosis.4 These patients
overall had relatively small deformities, with mean
preoperative kyphosis measuring +13 degrees that
was corrected to −6 degrees of lordosis postopera-
tively. All patients reported clinical improvement,
and 3 patients had a complete resolution of their
preoperative symptoms. No failures or major com-
plications were noted, and 3 patients developed
either hoarsness or dysphagia, but none had symp-
toms for more than 6 months. O’Shaughnessy et al.
reported on 16 patients with an average preopera-
tive kyphosis of +38 degrees who were treated
with circumferential procedures and followed for
a mean of 4.5 years.5 At final follow-up, the mean
lordosis had improved to −10 degrees. According
to Odom’s criteria, 88% had either good or excel-
lent outcomes; 1 patient required a late revision, 2
had durotomies, 3 had transient C5 root palsies,
 Preoperative planning and operating room (OR) setup  91

(a) (b)

Figure 13.2  Progressive postlaminectomy kyphosis. (a) A 38-year-old woman initially underwent suboc-
cipital craniectomy and C1–C2 laminectomy. (b) The same surgeon then performed a multilevel cervical
laminectomy for persistent headaches, leading to worsening, progressive postlaminectomy kyphosis.

and 1 sustained quadriplegia. Tang et al.6 reported
on 113 patients who underwent multilevel pos-
terior fusions for cervical kyphosis, cervical ste-
nosis, and myelopathy. Improved postoperative
C2–C7 sagittal vertical axis (SVA) correlated with
improved neck disability index (NDI) and Short-
Form Health Survey (SF-36) scores, demonstrating
that improvement in sagittal cervical deformity is
associated with improved patient disability.
PRINCIPLES OF REVISION SURGERY
The available surgical options vary depend-
ing on the severity of the patient’s deformity and
clinical symptoms. In general, the goals of any
surgical intervention are to decompress the neu-
rologic elements, improve the patient’s deformity,
achieve a durable fusion, and provide pain relief.
Furthermore, the correction maneuvers should
avoid stretching of the spinal cord by lengthening
the anterior column while shortening the posterior
column. This is accomplished by hinging the spine
along the posterior longitudinal ligament (PLL)
whenever possible.7
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
Measurement of cervical deformity
Proper preoperative planning requires a thorough
radiographic assessment of the deformity, includ-
ing both the magnitude and the flexibility. Upright
lateral, anterioposterior (AP), and flexion and
extension views of the cervical spine are commonly
obtained. Additional full-length standing scoliosis
radiographs may be useful in patients with global
deformities. Sagittal views in a nonweight-bearing
position can provide insight into the amount of
spontaneous correction achievable and are obtain-
able from plain supine or hyperextension x-rays,
as well as scout views from computed tomogra-
phy (CT) scans and reconstructed sagittal CT and
magnetic resonance imaging (MRI).
92  Treatment of postlaminectomy kyphosis
Figure 13.3  Distal junctional kyphosis. A 72-year-
old osteoporotic woman presented to our clinic
after multiple prior surgeries with severe distal
junctional failure and chin on chest deformity.
The thoracic pedicle screws have pulled out at the
distal end of the construct, and junctional frac-
tures have occurred in the upper thoracic spine.
Thoracic hyperkyphosis is present.
Multiple cervical measurement techniques
have been proposed.8 Cervical lordosis is mea-
sured as a Cobb angle between the inferior end
plates of C2 and C7 (Figure 13.1). The C2‒C7 SVA
is measured from a plumb line dropped from the
center of the odontoid to the posterior aspect of
the C7 vertebral body (Figure 13.1), and higher
measurements have been correlated with worse
SF-36 and NDI scores.6 For rigid cervical defor-
mities, horizontal gaze can be approximated
using the chin-brow vertical angle (CBVA), which
is defined as the angle between a line drawn from
the patient’s chin to brow and a vertical line
Figure 13.4  CBVA. Patient who underwent previ-
ous multilevel cervical laminectomy with a signifi-
cant segmental kyphosis between C5 and C7 but
a normal CBVA due to compensatory lordosis in
the supra-adjacent cervical segments.
(Figure 13.4). Lastly, recent evidence has empha-
sized the importance of T1 alignment.9 T1 slope
is measured as the angle between the superior end
plate of T1 and a horizontal reference line (Figure
13.1), and, akin to pelvic incidence in the lumbar
spine, correlates with the amount of subaxial lor-
dosis required to maintain the head in a balanced
position.
Planning for flexible and passively
correctable kyphosis
Multiple options are available for patients with
flexible deformities, including either anterior or
posterior procedures. Anterior-only surgery does
have several advantages. An anterior approach
avoids reoperation through the old posterior scar,
and it is associated with lower wound complica-
tion rates. Furthermore, the anterior approach
allows for direct decompression of the neural
elements and provides for direct height restora-
tion of the anterior column through the use of
 Preoperative planning and operating room (OR) setup  93
anterior grafts. However, anterior fixation is at
a mechanical disadvantage because it is anterior
to the axis of rotation of the kyphotic deformity.
Furthermore, the anterior screws fix into the
cancellous vertebral bodies and have less biome-
chanical stability than fixation in the posterior
elements (particularly in osteoporotic patients).
Pistoning of the anterior graft into the vertebral
end plates has been reported as the spine settles
back into its kyphotic alignment. Furthermore,
multilevel corpectomies in the setting of a prior
laminectomy severely destabilizes the spine. The
anterior corpectomy site, combined with the
prior laminectomy, effectively separates the two
lateral masses from each other, and high rates of
failure have been reported with anterior-only fix-
ation in this setting.10 If the goals of surgery allow
treatment with discectomies alone, or with short-
segment combination corpectomy-discectomy
rather than long corpectomies, anterior-only
surgery may be sufficient. Otherwise, a combined
anterior-posterior approach may be necessary. In
general, anterior-only surgery should be reserved
for those with mild to moderate kyphosis.
Posterior-only surgery can be considered in
patients who have a flexible deformity that can
correct passively with extension. Additionally,
the pattern of neurologic compression must be
amenable to decompression through a posterior
approach, or the restoration of lordosis alone
should be sufficient to achieve decompression of
the neurologic elements. In these cases, poste-
rior implants have two significant advantages.
First, posterior fixation is generally superior bio-
mechanically, particularly when pedicle screws
rather than lateral mass screws are placed at the
ends of the construct. Second, posterior implants
are at a mechanical advantage in correcting
kyphosis, in that they act posterior to the axis of
rotation. However, posterior-only surgery also has
disadvantages. In addition to an increased risk
of wound complications, the posterior approach
offers limited area for bone grafting in the setting
of a previous laminectomy and requires revision
dissection. Furthermore, the lack of anterior col-
umn support could increase the risk of implant
failure and screw pullout, leading to a recurrence
of kyphosis or construct settling.
Planning for fixed nonflexible but
nonankylosed postlaminectomy
kyphosis
Patients with a fixed but not fused deformity most
often are considered for combined AP correction,
consisting of anterior releases, interbody support,
and posterior segmental fixation for supplemental
stability. As noted previously, this is particularly
true if multilevel corpectomies are needed for
spinal cord decompression, due to the significant
instability that results from combined anterior
corpectomy in the setting of prior posterior multi-
level laminectomy.10
Planning for fixed and ankylosed
postlaminectomy kyphosis
Although in some cases osteotomies may not be
required if reasonable correction can be achieved
through the nonankylosed segments, many
patients with both a fixed and fused deformity
may require osteotomy to correct their sagittal
imbalance. The approach to correction is depen-
dent upon the location of the ankylosis. For
patients with posterior fixed and fused deformi-
ties, a posterior approach should be performed
first to release the area of ankylosis. The initial
correction is obtained through an osteotomy.
Supplemental anterior support and further cor-
rection is then usually required through anterior
release and interbody grafting. This is followed
with a second posterior approach, to lock in the
posterior instrumentation for maximal correction
(i.e., a back-front-back procedure) (Figure 13.5).
Conversely, patients with anterior fixed fused
deformities usually require an anterior approach
first. The area of ankylosis is osteotomized, and
then, contingent upon sufficient correction and
bone quality, anterior-only surgery may be con-
sidered. In most cases involving substantial global
malalignment, however, a subsequent posterior
approach is then performed to provide further
correction and supplement the fixation. Patients
with circumferential ankylosis are approached
in a similar manner as those with posterior-only
ankylosis via a back-front-back procedure.
94  Treatment of postlaminectomy kyphosis
(a) (b)
(c) (d)
Figure 13.5 Posterior-anterior-posterior correc-
tion. (a) A 65-year-old woman who underwent
multilevel ACDF and posterior laminectomy
and fusion. After posterior implant pullout, the
treating surgeon elected to remove the instru-
mentation without addressing the nonunion.
Patient subsequently developed severe kypho-
sis and chin on chest deformity. The CBVA is
demonstrated in white. (b) Intraoperative x-ray
demonstrating maximal hyperextension achiev-
able during positioning on first posterior stage.
Kyphosis is modestly improved—mostly through
the occipitocervical region—but is still significant.
Fixation points were established, and SPO was
performed. (c) After anterior osteotomy through
a previously fused disc space at C5–C6. A small
plate with single, purposely short, variable angle
screws has been placed to resist translation, while
not preventing further angular correction dur-
ing the final posterior stage. (d) After final pos-
terior instrumentation and further correction of
kyphosis.
Comparison of osteotomy options
Multiple osteotomy options are available, includ-
ing anterior column osteotomies, Smith-Petersen
osteotomies (SPOs), and pedicle subtraction oste-
otomies (PSOs). A technical description of each
is included in the subsequent sections. The choice
of osteotomy is usually dictated by the location
of ankylosis and the magnitude of correction
needed. The amount of correction achieved with
an osteotomy depends on a number of factors and
will vary from case to case. Kim et al.11 reported
that isolated SPOs with posterior fusion gener-
ated a mean angular correction of 10.1 degrees
per osteotomy. Isolated anterior osteotomy with
posterior fusion generated a mean correction of
17.1 degrees per osteotomy. Combined anterior
osteotomy with posterior SPO generated a mean
correction of 27.8 degrees per osteotomy. Isolated
PSOs with posterior fusion generated a mean cor-
rection of 34.5 degrees per PSO. However, cervi-
cal PSO is more technically demanding than the
other osteotomy types, and it may be associated
with significant blood loss,12 with risk of neu-
rologic complications as high as 23% in some
series.13 Anterior osteotomy combined with pos-
terior SPOs can provide equal correction with
significantly less blood loss.11 However, in some
cases of severe kyphosis, such as those with a chin-
on-chest deformity, an anterior approach may
be impossible. In those cases, a PSO may allow
adequate correction of the deformity through an
all-posterior approach.14
General considerations for OR setup
For both anterior and posterior procedures, it is
useful to have fluoroscopy available to evaluate
the postcorrection cervical alignment. The shoul-
ders can be lightly taped to facilitate intraoperative
imaging. Image guidance can be used but is not
routinely necessary. Gentle cranial tong traction
(5–10 pounds) can help maintain stability while
releases are being performed. After the spine is
mobile, an assistant can manipulate the tongs to
help facilitate the final correction.

Careful positioning of the cervical deformity
patient is mandatory based on the pattern of cord
compression present on imaging. In most cases of
postlaminectomy kyphosis, positioning the neck
in extension will not exacerbate cord compression
because the dorsal elements have been removed
and the compression arises anteriorly. The excep-
tion can be in the patient with a postlaminectomy
membrane. However, foraminal stenosis could
worsen with hyperextension if not decompressed,
such that a previously asymptomatic foramen
could become symptomatic when extended and
locked into that position with instrumentation.
Multimodal (motor and sensory) spinal cord
monitoring is routinely used in the correction
of thoracolumbar deformity and is also recom-
mended when correcting cervical kyphosis.15
Baseline neuromonitoring data may be obtained
prior to positioning, particularly in those with sig-
nificant myelopathy, to make sure that positioning
does not cause worsening neurologic compression.
Additionally, special care should be taken dur-
ing intubation, and an intubation plan should be
made in conjunction with the anesthesia team.
Depending on the patient’s anatomy, either a glide-
scope or fiberoptic intubation may be needed to
avoid traumatic intubation.
When performing anterior surgery, standard
supine positioning for a planned Smith-Robinson
approach is utilized. A large roll should be placed
under the scapula to allow neck extension and max-
imize the initial correction. In patients with more
fixed deformities, temporary sheets can be placed
under the occiput to support it until the correction
is performed. After the anterior releases, the sheets
can be sequentially removed to allow the head to fall
posteriorly and the neck to become more lordotic.
OPERATIVE TECHNIQUE
Anterior corrective maneuvers
The standard Smith-Robinson approach is taken and
the appropriate levels identified. If the disc spaces
are not ankylosed, complete discectomies are then
performed at each needed level. Where possible,
multilevel discectomies are preferred over multi-
level corpectomies, as segmental lordosis correction
is generally superior with multiple discectomies.
Operative technique  95
However, corpectomy should be performed when
necessary for neurologic decompression. The carti-
laginous end plates should be removed completely
to promote a good surface for fusion, but as much
bone as possible should be preserved to minimize
the risk of graft subsidence. Where possible, the
PLL should generally be left intact to act as the pivot
point for correction.7 Maintenance of the PLL also
helps limit overdistraction with the placement of
interbody grafts. However, as with corpectomies,
removal of the PLL may be performed if necessary
for adequate neurologic decompression.
In patients with ankylosis, anterior osteotomies
may be necessary. Wide lateral surgical exposure is
helpful for these osteotomies; it is accomplished by
bluntly elevating the longus colli over the uncinates
laterally and then continuing the blunt dissection
along the lateral vertebral body. With this lateral dis-
section, the risk of vertebral artery injury (VAI) is
thus increased. This risk can be minimized by care-
fully dissecting around the uncinates laterally with a
Penfield dissector to protect the vertebral arteries. In
cases of anterior pseudarthrosis or partial disc space
autofusion, identification of remnant disc material
can help to orient the surgeon and ensure that the
osteotomy is made parallel to the disc space. In cases
with significantly altered anatomy or complete anky-
losis, intraoperative fluoroscopy is helpful in deter-
mining the angle at which to create the osteotomy.
After completion of the anterior releases and
osteotomies, the correction maneuvers are then
performed by removing the sheets under the
occiput and gradually extending the neck under
neuromonitoring. The insertion of Caspar pins in
a convergent manner can facilitate further correc-
tion. Convergent pins will induce lordosis as they
are connected to the spreader and distracted.16
Ideally, the level requiring the most lordotic cor-
rection is grafted first. Subsequent grafts are then
inserted at each segment. Wedge-shaped lordotic
grafts may be considered to maximize the lordo-
sis, but careful foraminal decompression is needed
to prevent iatrogenic foraminal narrowing. Grafts
should be placed as anteriorly as possible within
the disc space to optimize lordotic angulation.
Cervical plating is necessary when anterior-only
surgery is performed for kyphosis. Rigid plating is
generally recommended when treating kyphosis
with anterior-only surgery for better maintenance
96  Treatment of postlaminectomy kyphosis
of deformity correction. The appropriate length
plate is chosen and contoured into appropriate
lordosis. The screws at the caudal and rostral seg-
ments are applied first. Doing this allows further
correction during placement of the intercalary
screws, which causes those segments to be pulled
anteriorly toward the plate.4 Screw lengths should
be maximized where possible, and bicortical screw
fixation may be considered to increase the rigidity
of fixation.
For combined AP surgery, anterior plating may
or may not be utilized depending on the overall
bone quality, the anticipated quality of the poste-
rior fixation, and the amount of instability present.
If the desired amount of lordosis is achieved dur-
ing the anterior stage, a rigid plate may be applied
to provide additional fixation in combined surgery.
However, when a highly unstable segment is sur-
gically created but the overall desired lordosis has
not yet been achieved during the anterior portion
of the case, these highly unstable segments may be
“loosely” stabilized with variable screw plates until
definitive correction and posterior fixation are
completed. Doing so can help prevent subluxation
and spinal cord injury between stages, while still
allowing angular correction during final posterior
fixation.
Posterior corrective maneuvers
In general, lateral mass screws are utilized in the
subaxial spine for posterior segmental fixation.
Subaxial pedicle screws have been described, with
the benefits of greater correction potential, shorter
constructs, and the possibility of avoiding anterior
surgery.17 However, because violation of the pedi-
cle during placement can lead to VAI or nerve root
injury, cervical pedicle screws are not commonly
used from C3‒C6. The exceptions are at C2 and
C7, as well as in the upper thoracic spine, where
the pedicular anatomy is generally large enough
for safe screw insertion in most patients.
In the majority of postlaminectomy kyphosis
cases requiring posterior surgery, consideration
should be given to extending the proximal aspect
of the posterior construct to C2. The reasons for
this are twofold. First, the proximal fixation point
is the one most prone to failure due to the tension
from the kyphotic deformity. This is particularly
true if the sagittal vertical axis is not fully restored,
and the patient is left with residual malalignment.
Extension to C2 allows the placement of C2 pedicle
or pars screws, which have better pullout strength
than lateral mass screws and thus are better able to
resist these kyphotic forces. C2 laminar screws can
also be utilized, but they are not quite as good bio-
mechanically. Similarly, many of these cases will
require distal fixation to the upper thoracic spine
to reduce the likelihood of distal junctional kypho-
sis and failure.
Smith-Petersen osteotomies (SPOs)
SPOs are performed through the facet joint and
are particularly useful in the setting of posterior
ankylosis. Approximately 5 mm of the inferior
facet and the underlying superior facet up to the
pedicle are removed with the burr until motion
is achieved bilaterally. When ankylosis is not
present, SPOs can still be considered in order to
achieve additional correction, given that anterior
mobility through the disc is already present or will
be created surgically.
Pedicle subtraction osteotomies
(PSOs)
If a PSO is needed, it is usually performed at C7
or T114 (Figure 13.6). The canal is slightly wider at
this level and the vertebral artery (VA) is usually
anterior to the transverse process. The osteotomy
is begun after placement of instrumentation above
and below, and the technique is similar to that
in the lumbar spine. A complete laminectomy of
the chosen level (C7 or T1) is performed, and the
bone is saved for later bone grafting. The facets
are completely excised, including the inferior fac-
ets of the level above and the superior facets of the
level below, such that both the caudad and cepha-
lad nerve roots are completely exposed, with the
pedicle in between. While carefully protecting the
dura, a burr is used to thin the bone of the pedicles
bilaterally. Reverse angle curretes and pituitaries
are then used to remove the cancellous bone of the
body and the walls of the pedicles. Work is contin-
ued to create a cavity in the posterior portion of

(a)
(b) (c)
Figure 13.6 Pedicle subtraction osteotomy. (a)
A 72-year-old man presented with severe chin-
on-chest deformity after multiple anterior and
posterior operations done elsewhere resulting
in postlaminectomy kyphosis. The fusion is solid
from C2–C7. (b) After T1 pedicle subtraction oste-
otomy. Chin-brow angle is improved, as is overall
sagittal alignment, but is still somewhat positive.
(c) Postop CT scan demonstrates the wedge-
shaped osteotomy through the T1 vertebral body
allowing for the sagittal plane correction.
the body until adequate decancellation is achieved.
Finally, an angled dural elevator is placed anterior
to the dura and is used to impact the dorsal cor-
tex into the newly created cavity in the body. If the
cortex does not break easily, additional cancellous
bone may need to be removed. A wedge of bone is
then removed from the lateral aspect of the verte-
bra bilaterally, with its apex in the anterior third of
the body. Overaggressive bone resection may lead
to translation rather than angular correction and
is therefore to be avoided.
Osteotomy closure
After the osteotomy is completed, closure is
then performed by loosening the cranial tongs
Complications 97
and manipulating the head and neck into lor-
dosis. If the neck does not easily extend, it may
be necessary to remove additional bone at the
osteotomy site. A precontoured rod is usually
placed to help guide the neck into position dur-
ing the correction and avoid translation. Spinal
cord monitoring should be closely referenced
during osteotomy closure, and lateral fluoros-
copy is helpful during this maneuver to verify
proper alignment. After osteotomy closure, it is
important to inspect the dura and exiting nerve
roots to verify that the neurologic elements are
not under compression.
POSTOPERATIVE MANAGEMENT
A careful neurologic exam should be obtained
immediately after the completion of the procedure.
Patients are generally placed into a postoperative
cervical collar. In the immediate postoperative
period, patients should be closely monitored for
swallowing or airway complications. A closely
monitored intensive care unit (ICU) setting may be
appropriate for many of these patients, depending
on the complexity of the surgery and preoperative
medical factors. Standard postoperative protocols
for activity modification, wound monitoring, and
regular radiographic follow-up are employed as
per the surgeon’s preference.
COMPLICATIONS
Patients should be adequately counseled about
the substantial risk of morbidity prior to under-
going correction of cervical deformities. In a
multicenter database review of 78 adult cervical
sagittal imbalance patients,18 14% were treated
with anterior only, 49% with posterior only, and
38% with circumferential procedures. Further,
28% of patients had at least one minor complica-
tion, and 24% had at least one major complica-
tion. The most common complications included
dysphagia (11.5%), deep wound infection (6.4%),
C5 motor deficit (6.4%), and respiratory failure.
The incidence of complications was significantly
higher with circumferential procedures (79%), as
compared to posterior only (68%) or anterior only
(27%).
98  Treatment of postlaminectomy kyphosis
Pearls and Pitfalls
●● Proper patient positioning is critical. The
placement of bumps preoperatively, which
are removed after releases have been
performed, can greatly facilitate lordosis
correction.
●● Multimodal neuromonitoring should be
employed and closely monitored after
positioning of the patient and during any
corrective maneuvers.
●● For anterior corrections, the placement of
convergent Caspar pins can facilitate lor-
dosis when the pins are connected to the
spreader and distracted.
●● For mild, flexible deformities, anterior
surgery may be best because it allows
direct neurologic decompression, avoids
a revision posterior approach, creates less
perioperative pain, and restores anterior
column height.
●● With severe deformities, particularly in
the setting of osteopenia, patients should
generally undergo both anterior and pos-
terior surgery, as the mechanical demands
may exceed those provided by anterior
implants alone.
●● Osteotomies are necessary when correct-
ing severe deformities with bony ankylosis
11. Kim HJ, Piyaskulkaew C, Riew KD.
in which the overall sagittal alignment can-
not be restored by correction through the
nonfused areas.
REFERENCES
1. Panjabi MM, Summers DJ, Pelker RR et  al.
Three-dimensional load-displacement curves
due to forces on the cervical spine. J Orthop
Res 1986;4:152–161.
2. Pal GP, Sherk HH. The vertical stability of the
cervical spine. Spine (Phila Pa 1976) 1988;13:​
447–449.
3. Morimoto T, Okuno S, Nakase H et  al.
Cervical myelopathy due to dynamic com-
pression by the laminectomy membrane:
Dynamic MR imaging study. J Spinal Disord
1999;12:172–173.
4. Steinmetz MP, Kager CD, Benzel EC. Ventral
correction of postsurgical cervical kyphosis.
J Neurosurg 2003;98:1–7.
5. O’Shaughnessy BA, Liu JC, Hsieh PC et al.
Surgical treatment of fixed cervical kyphosis
with myelopathy. Spine (Phila Pa 1976)
2008;33:771–778.
6. Tang JA, Scheer JK, Smith JS et  al. The
impact of standing regional cervical sagittal
alignment on outcomes in posterior cervical
fusion surgery. Neurosurgery 2015;76(Suppl
1):S14–S21.
7. Albert TJ, Vacarro A. Postlaminectomy
kyphosis. Spine 1998;23:2738–2745.
8. Ames CP, Blondel B, Scheer JK et al. Cervical
radiographical alignment: Comprehensive
assessment techniques and potential impor-
tance in cervical myelopathy. Spine (Phila Pa
1976) 2013;38:S149–S160.
9. Lee SH, Kim KT, Seo EM et al. The influence
of thoracic inlet alignment on the craniocer-
vical sagittal balance in asymptomatic
adults. J  Spinal Disord Tech 2012;25:​
E41–E47.
10. Riew KD, Hilibrand AS, Palumbo MA et  al.
Anterior cervical corpectomy in patients
­previously managed with a laminectomy:
Short-term complications. J Bone Joint Surg
Am 1999;81:950–957.
Comparison of Smith-Petersen osteotomy
versus pedicle subtraction osteotomy versus
anterior-posterior osteotomy types for the
correction of cervical spine deformi-
ties.  Spine (Phila Pa 1976) 2015;40:143–146.
12. Deviren V, Scheer JK, Ames CP. Technique of
cervicothoracic junction pedicle subtraction
osteotomy for cervical sagittal imbalance:
Report of 11 cases. J Neurosurg Spine
2011;15:174–181.
13. Etame AB, Than KD, Wang AC et al. Surgical
management of symptomatic cervical or cer-
vicothoracic kyphosis due to ankylosing
spondylitis. Spine (Phila Pa 1976) 2008;33:​
E559–E564.
14. Wollowick AL, Kelly MP, Riew KD. Pedicle
subtraction osteotomy in the cervical spine.
Spine (Phila Pa 1976) 2012;37:E342–E348.
15. Quraishi NA, Lewis SJ, Kelleher MO et  al.
Intraoperative multimodality monitoring in
adult spinal deformity: Analysis of a

prospective series of one hundred two cases
with independent evaluation. Spine (Phila Pa
1976) 2009;34:1504–1512.
16. Stewart TJ, Steinmetz MP, Benzel EC.
Techniques for the ventral correction of post-
surgical cervical kyphotic deformity.
Neurosurgery 2005;56:191–195; discussion-5.
17. Yoshihara H, Passias PG, Errico TJ. Screw-
related complications in the subaxial cervical
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Prospective multicenter assessment of early
complication rates associated with adult cer-
vical deformity surgery in 78 patients.
Neurosurgery 2015;79(3):378–388.

Revision of failed posterior
cervical fusions
TREVOR MORDHORST, VADIM GOZ, AND WILLIAM RYAN SPIKER
Introduction 101
Differential diagnosis 101
Contraindications 102
Diagnostic workup 102
Expectations 104
INTRODUCTION
Posterior cervical fusion selectively coupled with
decompression provides a reliable surgical solution to
a broad range of cervical spine issues. Unfortunately,
some patients will present with continued, recurrent,
or new pain or neurologic symptoms after posterior
cervical surgery. Successful management of failed
posterior cervical surgery relies on accurate diagno-
sis, choosing the correct surgical strategy to address
the underlying problem, and technical competency
in executing the selected surgical strategy.
The differential for pain, sensory, and/or motor
symptoms after posterior cervical surgery includes
pseudarthrosis, malpositioned hardware, inad-
equate decompression at prior surgery, poor sur-
gical level selection during prior surgery, adjacent
segment disease, infection, iatrogenic instability,
as well as poor global sagittal balance. A thorough
workup including a detailed history and physical,
imaging, and labs will help refine this differential
diagnosis. It is critical to confirm the underlying
cause of the patient’s symptoms before embarking
upon a revision posterior cervical surgery.
14
Preoperative planning 104
Operative technique 104
Postoperative management 106
Complications 107
DIFFERENTIAL DIAGNOSIS
Pseudarthrosis is a well-known etiology of recur-
rent symptoms after posterior cervical fusion
surgery, and it can necessitate revision. Both
patient-related and operative factors contribute to
the risk of developing a nonunion. Surgical factors
that affect the rates of pseudarthrosis include type
of graft and graft adjuncts used, stability/rigidity
of the construct, number of levels included in the
construct, and surgical technique of fusion bed
preparation. Reviewing these factors can help to
stratify patients based on their risk for developing
pseudarthrosis.
Radiographic pseudarthrosis in the absence of
symptoms is not an indication for revision surgery.
Asymptomatic patients with radiographic evidence
of nonunion can be closely followed and moni-
tored for the development of symptoms. However,
up to two-thirds of patients with pseudarthrosis
may experience symptoms over time. A common
symptom pattern is a brief period of symptom
resolution, followed by recurrence of pain and/or
neurologic symptoms. It is important to remember
101
102  Revision of failed posterior cervical fusions
that a nonunion can be associated with axial neck
pain, as well as radicular symptoms if nerve root
irritation occurs at the mobile segment.
Another etiology of failed posterior cervical
fusion is malpositioned hardware. Lateral mass
screws have the potential to be placed within the
facet joint, which would lead to significant axial
neck pain. Typically, this pain would be pres-
ent starting from the immediate postoperative
period, and it would not have a period of quies-
cence as is commonly seen with pseudarthrosis.
Lateral mass screws also have the potential to be
placed into the foramen, causing foraminal ste-
nosis and associated radicular symptoms. These
symptoms would include shooting pain down the
arm in a dermatomal distribution, as well as pos-
sible associated decreased sensation in the same
dermatome and potential weakness in muscles
that correspond to the same root level as the pain
and sensory changes.
Patients presenting with continued symptoms
of radiculopathy or myelopathy that are unchanged
compared to preoperative symptoms should be
evaluated for potential continued central or foram-
inal stenosis at the operative level. Another poten-
tial etiology of continued symptoms that should be
investigated in this setting is whether a symptom-
atic level may have remained unaddressed during
the index procedure. Another important etiology
to consider during the acute postoperative period
is infection. Infection can present at any time after
the index surgery, although the acute and subacute
postoperative periods are the highest risk. Pain
can be associated with systemic signs/symptoms of
fevers/chills/poor appetite and malaise. Epidural
abscess formation can result in progressive neuro-
logic deficits and is a surgical emergency that must
be monitored for carefully.
Adjacent-segment disease (ASD) is a well-
described entity in the cervical spine and occurs at
a rate of approximately 25% over 10 years. Patient
history would typically include a prolonged reso-
lution of symptoms after the index procedure,
followed by development of symptoms of radicu-
lopathy or myelopathy a number of years later.
Axial neck pain can have a variable presentation
in patients with ASD. Infection can present at any
time after the index surgery, although the acute
and subacute postoperative periods are the highest
risk. Pain can be associated with systemic signs
and symptoms of fevers, chills, poor appetite, and
malaise. Epidural abscess formation can result in
progressive neurologic deficits and is a surgical
emergency that must be monitored carefully.
CONTRAINDICATIONS
There are many patient factors that should be
taken into account before revising a failed poste-
rior cervical fusion. It is important to assess the
patient’s nutritional status and overall current state
of health, as revision surgery has significant mor-
bidity associated with it and successful revision is
less likely to occur if the patient has not been opti-
mized. Delay of surgery may be prudent until the
patient’s nutritional status and modifiable comor-
bid conditions have been optimized.
Specifically, uncontrolled diabetes, use of nico-
tine products, and severe cardiopulmonary dis-
ease are relative contraindications for revising a
failed posterior cervical fusion. Diabetic patients
with a hemoglobin A1c greater than 8% make poor
surgical candidates, as they are at greater risk for
surgical site infection, cardiac complications, and
thromboembolic complications and have worse
surgical outcomes; thus, elective revision surgery
should be avoided in these patients until improved
glucose control is achieved whenever possible.
Patients who smoke cigarettes or use other forms
of nicotine should be encouraged to stop their
use before surgery is pursued, as cigarette smok-
ing has been shown to drastically increase the
rate of pseudarthrosis. Additionally, patients with
cardiopulmonary disease or other risk factors for
intraoperative mortality should be thoroughly
evaluated before being cleared to undergo revision
surgery. It is important to note that in the presence
of severe neurologic symptoms, urgent surgery
may be warranted even in the presence of these
risk factors.
DIAGNOSTIC WORKUP
History and physical
A thorough history and physical exam are essen-
tial to narrowing down the differential diagnosis
for symptoms after a posterior cervical surgery.

Particularly important aspects of the history are
the location, character, and timing of pain, the
presence and distribution of weakness or decreased
sensation, and the presence of long tract signs,
including hyperreflexia, clonus, Hoffman’s sign,
pathologic Babinski sign, Romberg sign, changes
in balance and gait, and upper-extremity dexter-
ity. The timing of pain can be particularly infor-
mative. Pain that briefly resolved after surgery, but
recurred fairly early in the postoperative recov-
ery, is concerning for pseudarthrosis. Continued
symptoms of radiculopathy or myelopathy that
were unchanged by the index surgery suggest that
at least one of the symptomatic levels was not ade-
quately addressed by the index procedure.
Recurrence of symptoms years after the initial
surgery, with a prolonged symptom-free period,
suggests ASD as a possible etiology. Continued
severe axial neck pain or severe radiculopathy that
is significantly different in nature from preopera-
tive symptoms and present immediately after sur-
gery should raise suspicion for possible misplaced
hardware into the facet joint or neural foramen.
The patient’s signs and symptoms should be care-
fully interpreted for the presence of radiculopathy
versus myelopathy and the involved root levels.
IMAGING AND DIAGNOSTICS
A typical workup for etiology of symptoms in the
setting of prior posterior cervical fusion should
include plain x-rays, computed tomography (CT),
and magnetic resonance imaging (MRI). Plain
x-rays should include flexion and extension views
to evaluate for pseudarthrosis. Additional imaging
modalities that may help with diagnosis include
oblique x-ray, single photon emission CT, electro-
myography (EMG), or selective nerve root block
(SNRB). Plain x-rays and CT are used to assess for
presence of nonunion, as well as structural integ-
rity of the cervical spine and the prior construct.
These studies are also critical in diagnosing adja-
cent segment degeneration. CT scans can also be
helpful for presurgical planning, providing infor-
mation on the location of prior laminectomy, as
well as aiding in planning for operative fixation
options. MRI allows evaluation of any spinal cord
or nerve root compression.
When plain x-ray, CT, and MRI yield insufficient
information for diagnostic or operative measures,
Diagnostic workup  103
further imaging is available. Metallic artifact
obstruction in MRI may be avoided with the addi-
tion of myelography, allowing for the assessment of
cord structures. In the case that radicular patterns
are ambiguous, SNRB is a worthwhile addition
with potential for relief without surgical inter-
vention. EMG may differentiate peripheral nerve
entrapment from a cervical source.
Oblique x-ray views allow better visualization
of the foramen than traditional x-ray. Osteophyte
formation or hardware misplacement into the
foramen may be sources of symptoms, and oblique
x-ray provides a rapid evaluation for these issues.
Flexion/extension radiographs and CT scans are
useful tools for evaluation of union. A high suspi-
cion for nonunion must be maintained. Evaluation
of flexion/extension lateral radiographs should be
carefully evaluated under magnification. The effort
in flexion and extension is measured to ensure
that the noninstrumented spinous processes are
moving at least 4 mm. If spinous processes are in
place, there should be less than 1 mm of movement
between them on flexion/extension. The same level
of scrutiny should be applied to evaluation of a CT
scan. While intragraft spanning bone or spotweld-
ing of graft to adjacent end plates may indicate par-
tial healing, a sign of true bony union is extragraft
bridging bone.
Laboratory testing
Labs are beneficial for determining the presence
of infection and evaluating for risk factors of non-
union. Diagnostic workup prior to revision fusion
may include complete blood count (CBC), eryth-
rocyte sedimentation rate (ESR), and C-reactive
protein (CRP). ESR and CRP will be elevated in
infection, but they may be difficult to interpret in
the acute postoperative setting. CRP is the most
sensitive marker for acute postoperative infection,
while leukocytosis is not always present. Acute
spondylodiscitis is characterized by high inflam-
matory markers; however, inflammatory markers
may be normal in chronic infection.
A full metabolic/endocrine workup is useful for
determining risk factors for nonunion. Relevant
lab studies include vitamin D, calcium, phospho-
rus, alkaline phosphatase, albumin, prealbumin,
thyroid hormone panel, parathyroid hormone, and
104  Revision of failed posterior cervical fusions
sex hormones. Any metabolic abnormalities that
may predispose to risk of nonunion should be cor-
rected prior to proceeding with revision surgery.
EXPECTATIONS
Establishing realistic goals and managing patient
expectations are critical when performing any
revision surgery. Symptomatic relief after the ini-
tial surgery often predicts positive outcomes post-
revision surgery because a source of symptoms has
been identified. Diagnosis of why the initial failure
occurred can help improve the chances of success
of subsequent revisions.
Revision surgery has the potential for more
complications, pain, and a longer recovery than
the initial operation. It often requires larger expo-
sures with more extensive manipulation of stabi-
lizing structures/tissues. Infection rates are higher
and hospital stays are generally longer in revision
surgery.
Outcomes are highly dependent on patient
selection. Patients with multiple contraindications
should avoid revision surgery until modifiable
conditions are improved. Comorbidities increase
the risk of complications after revision surgery and
may decrease the chance of successful treatment.
It is critical to educate patients that persistent pain
is not always treatable with surgery, and in the
absence of an identifiable etiology, revision is not
advisable.
Expectations after revision are dependent on
the revision technique. The posterior approach
versus the anterior approach provides contrasting
revision fusion rates, with the posterior approach
having nearly double the fusion rate as the anterior.
While posterior provides higher fusion rates, the
technique is also associated with higher complica-
tion rates. Secondary revision surgery rates have
been reported higher in the anterior approach,
and the approach also carries a risk of injury to the
recurrent laryngeal nerve.
PREOPERATIVE PLANNING
Preoperative planning for revision posterior cervi-
cal fusion involves a number of key steps. The first
and most crucial of these steps is correct diagnosis
using a thorough evaluation described previously.
Beyond accurate diagnosis and careful decision-
making regarding operative levels, there are a
number of factors specific to revision surgery that
must be considered. A careful assessment of sagittal
alignment should be performed. Excessive sagittal
imbalance can increase strain on the construct and
has the potential to contribute to poor outcomes.
Imaging should be carefully reviewed to note levels
of prior laminectomy prior to any revision surgery.
Operative reports from prior procedures should
be obtained when possible so that appropriate
instruments are available for hardware removal.
Surgical fixation options should be planned.
Options for posterior cervical fixation are further
described next. Sizes of prior lateral mass screws
should be determined from the operative note,
which will determine if upsizing to a rescue screw
will be an option. The size of pedicles of the opera-
tive levels should be measured. Vertebral artery
(VA) anatomy should be carefully noted on the
MRI. Multiple contingency plans for instrumen-
tation should be established so that appropriate
hardware is available on the day of surgery.
OPERATIVE TECHNIQUE
Exposure
The prior incision is used and extended both crani-
ally and caudally. Care is taken not to create mul-
tiple dissection planes and to stay in the midline
throughout the initial exposure. Dissection is car-
ried down to the fascia overlying the cervical para-
spinal muscles using electrocautery. At this point,
it is important to note which levels had a prior
laminectomy performed, as no spinal elements are
present to protect the spinal cord. Levels without
a laminectomy are exposed first, which will guide
the depth of dissection for subsequent levels that
have had a prior laminectomy. Cross-links, when
present, are useful midline safeguards that can be
taken advantage of to determine the depth of dis-
section in a revision setting.
Alternatively, a plane can be identified between
scar tissue from the previous surgery and perios-
teum. This tissue plane is identified at the caudal
end of the lamina on the proximal aspect or cra-
nial end of the lamina on the distal aspect of the
laminectomy. Once identified, blunt dissection

with a Cobb elevator in a distal and lateral direc-
tion can further expand that plane throughout the
extent of the laminectomy until the hardware is
seen. The goal of the dissection is to leave minimal
midline tissue, dissect in a subperiosteal manner
with minimal bleeding, and minimize dead space
upon closure without injuring the dura or under-
lying neural elements. Subperiosteal dissection is
further carried laterally until the prior hardware is
fully exposed, and the medial and lateral margins
of the lateral masses of all operative levels are fully
in view without overlying tissue.
Hardware removal
Appropriate preoperative planning with identifica-
tion of prior hardware can save a significant amount
of time on this step. If operative reports from prior
surgery cannot be obtained, universal hardware
removal systems are available from a number of
companies. At this point, set screws and cross-links
are removed. Use of a countertorque during this
step is key to limiting the stress placed on the lat-
eral mass and helps to prevent fracture of the lateral
mass during hardware removal. If the set screw is
stripped, hardware removal systems typically have
a number of available tools that can reverse thread
into the stripped screw. The rods and previous lat-
eral mass screws are then removed. The size of each
screw is noted, and the tract is probed with a ball-
tip probe to ensure that there is no cortical breach.
Reinstrumentation
Levels that had prior hardware are reinstrumented
if possible, given remaining bone stock. If no corti-
cal breach is detected with a ball-tip probe, a rescue
screw can be attempted if a screw of larger diameter
than the one removed is available. Salvage options
for fixation in the cervical spine include an alterna-
tive lateral mass screw trajectory, cervical pedicle
screw, and transfacet screw, as well as a number
of wiring techniques. The fusion can be extended
proximally and distally as appropriate based on the
patient’s pathology. Pedicle screw fixation at the
caudal end of the construct is also preferred if end-
ing at C7 or in the upper thoracic spine, in order to
provide robust fixation, especially in the setting of
a long posterior construct.
Operative technique  105
Lateral mass screws have two commonly
described trajectories. The lateral mass screw tra-
jectory described by Magerl is most commonly
used for primary posterior cervical fusions. Magerl
lateral mass screws are angled 10 degrees cranially
and 25 degrees laterally. An alternative lateral mass
trajectory was described by Roy-Camille, with a
10-degree lateral angulation and flat or nearly flat
in the sagittal plane. The starting point of the two
trajectories also differs slightly. The Roy-Camille
trajectory can serve as a bailout option, although it
will lead to a shorter screw length.
Cervical pedicle screws are another option for
fixation when the lateral mass screws do not have
adequate purchase. The starting point is slightly lat-
eral to the center of the lateral mass, transverse plane
angulation varies between 15 and 25 degrees, and
the sagittal plane angulation is based off the lateral
fluoroscopy image. These screws are technically chal-
lenging to place, and pedicle anatomy can be quite
variable. In addition to fluoroscopic assistance, a
small laminoforaminotomy can be made, allowing
the surgeon to palpate the medial aspect of the pedi-
cle with a nerve hook. CT-navigation techniques have
also been described for placement of subaxial cervical
pedicle screws. Preoperative CT scan must be scruti-
nized, as placement of pedicle screws in pedicles with
a diameter of <4.5 mm is not recommended.
Transfacet screws are another historical option
for cervical fixation. These screws have a slightly
more caudal starting point compared to traditional
lateral mass screws and are angled perpendicular
to the facet joint. These screws were more com-
mon when plate fixation was used in the cervical
spine, and it would be difficult to incorporate into a
screw-rod construct. Another option for additional
fixation is wiring. A number of wiring techniques
have been described, including interspinous, sub-
laminar, triple-wire, transfacet, and oblique.
Our preferred method of wiring is interspinous
process wiring. A drill hole is made in the spinous
process of the rostral vertebra at its junction with the
lamina. An 18- or 20-gauge wire is passed through
the drill hole. The wire is looped around the spinous
process of the caudal vertebra of the level to be fused
and tightened using a tensioner-crimper tool. It is
important to use a system that is MRI compatible.
Interspinous process wiring is not an option for lev-
els where a laminectomy has been performed.
106  Revision of failed posterior cervical fusions
Decortication/fusion bed preparation
After instrumentation has been placed, atten-
tion is turned to the fusion bed. During the prior
exposure, all soft tissue has been dissected away
from the remaining bony elements in a subperi-
osteal manner. Cortical bone of the lateral mass
and remaining lamina are eburnated with a
high-speed pneumatic burr. Special attention is
focused on thorough decortication of the facet
joints. If a laminectomy was performed as part
of the revision procedure, the removed bone can
be used as local autograft and placed over the
decorticated lateral masses, and into the decor-
ticated facet joints. In the absence of sufficient
local autograft, crushed cancellous allograft can
be used.
A demineralized bone matrix (DBM) can serve
as a useful adjunct for fusion, as it has both osteo-
inductive and osteoconductive properties. Other
fusion adjuncts include bone morphogenetic pro-
tein (BMP), facet joint cages, and iliac crest auto-
graft. We do not routinely use iliac crest autograft
due to concern for morbidity of graft harvest-
ing. BMP is a powerful tool to increase fusion
rates, making it a useful addition in the setting of
pseudarthrosis. It has also been associated with
higher rates of dysphagia, prevertebral swelling,
hematoma, higher reintubation rates, and higher
infection rates when used in the cervical spine
(including anterior approaches). Due to the com-
plications associated with BMP use in the cervical
spine, the U.S. Food and Drug Association (FDA)
issued a warning regarding the procedure in 2008.
For this reason, routine use of BMP in the cervical
spine should be avoided.
Closure
A thorough closure has the potential to avoid two
key complications of posterior cervical surgery:
wound infection and webbed neck deformity due
to migration of paraspinal muscles laterally. We
prefer to close posterior cervical incisions with
multiple layers of braided absorbable suture, mini-
mizing the spacing between each suture and maxi-
mizing the number of sutures used. This creates a
well-reinforced posterior tension band, which we
believe decreases the risk of the paraspinal muscles
migrating laterally and anteriorly during the post-
operative course, although this has not been for-
mally studied. Vancomycin powder is commonly
used, as it has been demonstrated to decrease
wound infection rates in studies not specific to
the cervical spine. Drains are routinely used in the
revision setting.
POSTOPERATIVE MANAGEMENT
Patients who undergo revision surgery for failed
posterior cervical spinal fusion should expect to
spend several days in the hospital. This time will
allow staff to adequately manage the patient’s pain
and oversee any perioperative issues that may
arise. Ice chips and clear liquids can be given to
the patient in the immediate perioperative period,
with advancement to a full diet as the patient toler-
ates, as dysphagia is possible in revision posterior
spine surgery. Criteria for the patient to be dis-
charged from the hospital are adequate pain con-
trol on oral medication, return of normal bowel
function, and disposition arranged for the patient
to leave to an environment that will allow them to
continue healing.
Immediately after surgery, the patient is com-
monly placed in a cervical collar, which is to be
worn at all times until cleared by the surgeon at
a postoperative clinic visit. Patients are typically
instructed at the 6-week patient visit that they
can begin weaning out of the collar. This is done
by having patients reduce the amount of time they
spend in the collar every day until they no longer
are wearing it. The patients are advised to do this
process over a 2-week period to allow a smooth
transition.
Fusion failure after revision surgery has a
higher risk than the failure after the index pro-
cedure, and additional measures are sometimes
taken to prevent fusion failure a second time. One
such option is an external bone growth stimula-
tor. These devices are worn on the skin for sev-
eral hours a day and produce an electric field that
some studies say stimulates bone growth and
improves fusion rates. Patients are instructed to
use the external stimulator for 3–9 months after
their surgery.

COMPLICATIONS
The complications associated with revision poste-
rior cervical fusion surgery can be broken up into
three main categories of complications: immedi-
ate surgical, short term, and longer term.
As with any surgery, there is the risk of dam-
aging local neurologic or vascular structures dur-
ing the operation. In the case of posterior cervical
surgery, the most notable structures that can be
injured are the spinal cord, spinal nerves, and
vertebral arteries. Thorough neurologic exams
should be completed before and after surgery to
ensure that no new deficits have arisen. There is
also the risk of serious blood loss, with the poten-
tial of requiring a blood transfusion. The patient
should be appropriately counseled on this risk and
should consent to receiving blood in the case of an
emergency.
The short-term medical complications seen fol-
lowing revision posterior cervical fusion are the
same ones seen among all surgeries. These early
complications include stroke, heart attack, deep
vein thrombosis (DVT), and pulmonary embo-
lism. Additionally, there are the complications
associated with the subsequent hospital stay, such
as nosocomial infections.
Recurrent nonunion, loosening or breakage
of hardware, recurrent stenosis, dysphagia/dys-
phonia, adjacent segment degeneration, and the
need for additional revision surgery are the most
Complications 107
common long-term complications associated with
revision posterior cervical fusion. These compli-
cations are well known to spine surgery and are
present in all forms of spinal fusion. The rates of
these complications are higher in revision surgery,
as the procedures often are more complicated and
include additional levels, and the patient already
has some propensity for nonunion.
Pearls and Pitfalls
●● The key to successful treatment of failed
posterior cervical fusion is accurate
diagnosis.
●● The presence of a radiographic pseudar-
throsis does not always require surgical
treatment.
●● A thorough workup, including a detailed
history, physical exam, and imaging and
laboratory tests when appropriate, will help
clinicians arrive at the correct diagnosis.
●● Revision surgery can be a highly mor-
bid endeavor; for this reason, modifiable
patient risk factors/comorbidities should
be optimized preoperatively.
●● When planning a revision fusion, the sur-
geon must have a primary, secondary, and
tertiary plan for fixation options at each
level to be instrumented. This involves
a thorough evaluation of preoperative
CT scan in order to understand the best
options for fixation.

Complications necessitating surgical
intervention following cervical
laminoplasty
MICHAEL J. MOSES, AMOS Z. DAI, AND THEMISTOCLES S. PROTOPSALTIS
Introduction 109
Relative contraindications 110
Expectations 110
Principles of revision surgery 110
Preoperative setup 110
Operative techniques 110
Disc herniation or progression of OPLL
with recurrent stenosis 111
INTRODUCTION
Since the advent of laminoplasty in 1977 by
Hirabayashi et  al.,1 it has been used as an effec-
tive surgical method in the treatment of compres-
sive cervical myelopathy, typically involving three
or more levels. Cervical myelopathy most com-
monly arises due to underlying ossification of the
posterior longitudinal ligament (OPLL) or due to
cervical spondylosis, both of which are common
indications for laminoplasty. The main goal of the
procedure is to reposition the laminae to expand
the spinal canal, allowing the spinal cord to migrate
posteriorly. Laminoplasty remains an effective
method overall of treating cervical myelopathy
and relieving the symptomatology associated with
the spinal cord compression. These positive post-
operative outcomes are commonly measured by
15
Loss of alignment and kyphosis or sagittal
deformity 112
Intractable neck pain 113
Postoperative management 113
Complications 114
References 114
using the Japanese Orthopedic Association (JOA)
score. Recovery rates for patients at 10 years follow-
ing laminoplasty are generally good, with results
ranging from 50%–72%. In general, high preopera-
tive JOA scores are associated with good clinical
outcomes. Even though there are relatively good
long-term outcomes associated with laminoplasty,
there is a paucity of information in the current lit-
erature related to the treatment of failed lamino-
plasties and the resultant revision surgeries. There
are a number of causes related to the necessity for
a revision surgery following laminoplasty, includ-
ing mechanical failure of an open- or double-door
procedure, disc herniation with recurrent stenosis,
loss of alignment due to kyphotic or sagittal defor-
mity, and intractable neck pain postoperatively.
109
110  Complications necessitating surgical intervention following cervical laminoplasty
The surgical procedures for revision vary accord-
ing to the pathologic condition and the preferences
of each operating surgeon. Because the number of
patients who underwent revision surgery after cer-
vical laminoplasty was very small in the previous
reports, the optimal surgical procedures remain
controversial and case specific. The surgical pro-
cedures should thus be tailor-made for each case
according to the existing pathologic conditions.
The revision procedures all stem from analogous
methods used to treat cervical myelopathy.
RELATIVE CONTRAINDICATIONS
A multitude of factors may prevent a patient from
being able to undergo a revision surgery. Failure for
a laminoplasty may result in progressive myelopa-
thy, and in this case, surgery is rarely delayed;
however, if the patient does not have progressive
myelopathy, patients should be optimized. This
includes counseling patients to stop smoking and
optimizing nutrition.
EXPECTATIONS
The expectations are often variable depending on
the reason for failure. In general, spine surgery is
more predictive at preventing the future progres-
sion of spinal cord dysfunction rather than lead-
ing to improvement of symptoms; however, many
patients will see improvement in their symptoms.
PRINCIPLES OF REVISION SURGERY
As is the case with all revision surgery, a detailed
history and physical exam are needed. Surgical
intervention should move forward only once a com-
plete radiographic workup has been completed. In
the setting of a failed laminoplasty, patients should
undergo preoperative computed tomography (CT)
scans to determine the integrity of the hinge, as well
as magnetic resonance imaging (MRI) to deter-
mine if there is continued spinal cord compression.
PREOPERATIVE SETUP
The preoperative setup can often vary dramati-
cally for these cases, depending on the reason for
failure. A failed laminoplasty can be addressed in
a multitude of ways. However, in all cases, neuro-
monitoring is used.
OPERATIVE TECHNIQUES
Mechanical failure of open- or
double-door laminoplasty
The open- and double-door techniques are two
­surgical methods commonly employed during lam-
inoplasty. In open-door laminoplasty, bony gutters
are drilled bilaterally at the border of laminae cor-
responding to the medial portion of the pedicles.
The lamina border on one side is excised, and then
the laminae are pushed laterally toward the other
side as if to open a door, so that the spinal canal is
enlarged. The ligamentum flavum and deep mus-
cles around the facets of the hinge side are secured
with specialized plates and screws, or they are teth-
ered by sutures to prevent the laminar door from
closing. Kurokawa et  al.2 developed spinous pro-
cess-splitting laminoplasty, also known as double-
door laminoplasty, in which the spinous processes
and laminae are split in the midline and hinges
are made bilaterally along the lateral borders of the
laminae, which are lifted bilaterally as well. Failure
of the laminoplasty procedure can result from frac-
ture on the hinge side of the lamina, which may
lead to collapse of the fractured lamina, causing
either compression of the exiting nerve root in the
foramen or recurrence of the central spinal cord
compression. These complications of the hinge also
have the potential to cause restenosis, with resul-
tant progressive myelopathic symptoms. Video 15.1
for this chapter highlights the surgical intervention
utilized to correct for this presentation.
In other cases, patients require revision surgery
due to the inadequate opening of the lamina dur-
ing the index procedure. The inadequate opening
leads to neurological sequelae related to the com-
pression of the spinal cord and exiting nerve roots.
Patients may present with limb numbness and
other myelopathic symptoms that may directly
parallel their initial presenting signs. However,
there may also be cases during which the patient
presents with new neurological findings that differ
from their presentation prior to the index proce-
dure. The main goal when the patient presents fol-
lowing a laminoplasty procedure is to decompress
 Disc herniation or progression of OPLL with recurrent stenosis  111
the spinal cord and create additional space to ame-
liorate the neurologic symptoms.
REVISE WITH PLATE
One of the surgical methods that can be used as a
revision technique is revising the index procedure
with a specialized laminoplasty plate. Rigid fixa-
tion is provided with the plates and allows for the
expanded intrathecal space to be maintained and
decompress the spinal cord. Healing rates, identi-
fied by radiographic union, at 12 months follow-
ing rigid fixation were noted at 93% in a recent
study used to evaluate the effectiveness of plate-
only open-door laminoplasty in maintaining spi-
nal canal expansion. Furthermore, plate fixation
has also been shown to preserve cervical range
of motion and cervical alignment, in addition to
the expansive stability of the canal, and effectively
avoid lamina reclosure in long-term follow-up.
Thus, it is clear that surgical correction with a plate
provides the stability necessary to treat such cases
in which the index laminoplasty procedure did not
provide enough expansion for the spinal canal.
REVISE WITH LAMINECTOMY AND FUSION
Laminectomy and fusion is another surgical
method that is utilized as a revision technique
when the index procedure results in inadequate
opening of the spinal canal. Lamincetomy alone
was commonly employed as a method to treat cer-
vical myelopathy; however, numerous complica-
tions were associated with the use of laminectomy
without fusion, including kyphosis, iatrogenic
spondylolisthesis, and others, which can lead to
the subsequent compression of the spinal cord and
progression of myelopathy. The addition of fusion
to the laminectomy procedure has minimized
many of the complications commonly associated
with laminectomy alone. Laminectomy and fusion
may prevent postlaminectomy kyphosis, improve
neck pain symptoms, and prevent the development
or progression of instability (which is associated
with poorer neurological outcomes). There are a
number of complications associated with lami-
nectomy and fusion, including nonunion. There is
no evidence in the current literature as to which
procedure (laminoplasty versus laminectomy and
fusion) is more efficacious, and the risks and ben-
efits of each should be weighed and considered
in each individual case presentation. While some
studies have reported a higher complication rate
for laminectomy and fusion when compared to
laminoplasty, laminectomy and fusion still serve
as an effective means of a revision procedure in
patients who have failed prior laminoplasty.
DISC HERNIATION OR
PROGRESSION OF OPLL WITH
RECURRENT STENOSIS
Laminoplasty is an effective treatment option
for cervical myelopathy due to disc herniation.
Sakahura et  al.3 demonstrated equal neurologic
improvement for laminoplasty and anterior cer-
vical decompression and fusion. One of the com-
plications known to arise with laminoplasty is
postoperative disc herniation. Disc herniation can
occur within the laminoplasty levels or in an adja-
cent level. Another common cause of progressive
anterior compression of the spinal cord after lami-
noplasty is progression of OPLL. In either case,
symptoms of myelopathy may persist or worsen
postoperatively, and further workup, including
repeat advanced imaging with MRI and CT, will
show the progression of the anterior compression.
Revise with ACDF or anterior cervical
corpectomy and fusion
Anterior cervical discectomy and fusion (ACDF) is
an effective means of treating postlaminoplasty disc
herniation. Furthermore, in patients with OPLL,
where there is a risk of postoperative progression of
the OPLL, anterior cervical corpectomy and fusion
(ACCF) is an effective means of addressing the
progression of OPLL. The calcified anterior com-
pressive lesions of OPLL are not typically removed
during the index laminoplasty, which is an entirely
posterior-based procedure yielding a situation in
which the OPLL can propagate and restenose the
spinal canal despite the expansive laminoplasty. In
the current literature, the risk of progression of the
OPLL ranges from 70%–73%. Fibular strut grafts or
corpectomy cages may be utilized in such cases with
success rates ranging from 85%–100% in the current
literature. Therefore, ACDF and ACCF serve as via-
ble revision options when approaching patients with
postlaminoplasty recurrent anterior compression.
112  Complications necessitating surgical intervention following cervical laminoplasty
LOSS OF ALIGNMENT AND
KYPHOSIS OR SAGITTAL
DEFORMITY
One of the commonly cited benefits of lamino-
plasty as compared to laminectomy is the avoid-
ance of complications such as kyphosis or changes
in spinal alignment that were associated with
laminectomy. It is important to note, however,
that laminoplasty has been associated with nega-
tive outcomes in patients with kyphosis, due to
the limited dorsal shift that occurs in kyphotic
spines, which is necessary for the relief of symp-
toms in the laminoplasty procedure. Suda et  al.4
have noted that local segmental kyphosis greater
than 13 degrees reduces neurological outcomes in
open-door laminoplasty. Thus, the surgeon must
be prudent when indicating a patient for lamino-
plasty and accurately measure for any global or
segmental spinal deformities prior to surgery, as
these factors can negatively affect patient outcomes.
Additionally, the development of postlaminoplasty
kyphosis is a concern, as rates in the literature have
been reported from 0%–28%. Patients also tend to
lose some of their lordotic curve postoperatively as
well. Suk et al.5 noted that “the preoperative factors
affecting postoperative kyphosis are diagnosis of
myelopathy cases associated with cervical spondy-
losis, a lordosis angle of <10°, and a kyphotic angle
during flexion that is larger than a lordotic angle
during extension” (p. 656). Therefore, there appears
to be clear preoperative factors that affect the out-
come and development of postoperative kyphosis
in these patients. The pathophysiology implicated
in the development of postoperative kyphosis and
alignment changes is centered upon the paraspinal
muscles, notably the semispinalis cervicis, whose
detachment from its insertion point on C2 can lead
to the progressive loss of lordotic curvature and
alignment.6 The maintenance of these mechanical
forces between opposing muscle groups is vital to
maintain stable spinal alignment.
Deformity correction with anterior,
posterior, or combined anterior/
posterior surgery
To correct postlaminoplasty kyphosis, osteotomy
via an anterior, posterior, or combination surgeries
is utilized. Osteotomies in the cervical spine tend
to be more challenging procedures than for other
regions of the spinal column, due to the neuro-
vascular structures that may be disrupted during
the surgery. Patients are initially managed con-
servatively; if their symptoms do not improve,
however, it may be necessary to indicate surgical
intervention. It has been documented in the litera-
ture that ACDF with fibular strut grafts does not
serve as an effective means of treating postlami-
noplasty kyphosis.7 The anterior approach is typi-
cally indicated in patients whose facet joints are
stable, without any concern for posterior ankylo-
sis. The anterior approach can be advantageous,
as it allows ventral decompression and segmental
correction of kyphotic deformity, and it is associ-
ated with minimal morbidity.8 Through the ante-
rior approach, fixation with a cervical plate can
be utilized to maintain correction of the kyphotic
deformity. Results are variable in the literature
regarding the correlation between objective defor-
mity correction on radiographs and resolution of
patients’ symptomatology related to the condition.
The posterior approach is preferred in certain
scenarios, mainly in flexible cervical kyphosis and
kyphosis caused by ankylosing spondylitis. The
posterior-based osteotomies that are commonly
employed have been classified by Ames et  al.9 as
grades 1, 2, 5, or 6 in reference to the magnitude of
instability produced. These posterior-based osteot-
omies can range from partial facet joint resection,
total facet resection (Smith-Petersen osteotomy
[SPO] or Ponte type), opening wedge osteotomy,
or a closing-wedge pedicle subtraction osteotomy
(PSO) involving both the posterior and anterior
columns.
The Ames grade 1 osteotomy is notable for its
inclusion of posterior facet capsule resection or
partial facet resection. Grade 2, the SPO tech-
nique, involves resection of the superior and infe-
rior articulating facets at a given spinal segment,
without resection of the pedicles or vertebral
body. Both grades 1 and 2 require some degree
of anterior column mobility. Grade 5, the open-
ing wedge osteotomy, involves complete poste-
rior element resection with osteoclastic fracture
and open wedge creation, utilized for correcting
deformity in patients with ankylosing spondylitis.
Aside from the grade 5 osteotomy, the posterior

cervical extension osteotomy technique has also
been used in the treatment of cervical kyphosis
due to ankylosing spondylitis. It entails complete
laminectomy of C7, partial laminectomies of C6
and T1, and the removal of the spinous process of
C6, the ankylosed C7–T1 facet joints, and a por-
tion of the C6 and T1 pedicles. This procedure,
however, has been associated with significant
morbidity. Grade 6 is similar to grade 5 in terms
of the complete posterior element resection, but
it also involves pedicle resection alongside the
creation of a closing wedge. This is similar to the
posterior decancellation osteotomy, or an eggshell
procedure that is employed in the thoracolum-
bar spine for deformity correction. In addition
to osteotomies, Abumi et al.10 noted that cervical
pedicle screw fixation may be used in the approach
to correcting cervical kyphosis, but neurovascular
injury may occur.
A combination of both anterior and posterior
approaches is indicated if dorsal spinal cord com-
pression and/or facet joint ankylosis is present, or
the correction of a deformity cannot be achieved
using solely an anterior approach. The com-
bined anterior and posterior approach allows for
both ventral and dorsal osteotomies and release,
thereby removing all compression of the spinal
cord. Furthermore, it effectively corrects kypho-
sis through lengthening the anterior column and
shortening the posterior column. Lastly, it pro-
vides strong dorsal and ventral fixation, which
may assist in resisting translation and torsion
of the spine to reduce graft complications, and
increasing the fusion rate. The anterior approach
is the first-line treatment used for uncomplicated
patients, whereas the combined anterior/posterior
approach is beneficial in patients with the afore-
mentioned conditions. However, in cases of severe
cervical spinal deformity, surgical preference var-
ies widely in treating cervical spinal deformity.
INTRACTABLE NECK PAIN
The final consideration in this discussion of revision
laminoplasty is the case of patients with postopera-
tive, intractable neck pain. There is a wide range of
incidents reported for postlaminoplasty neck pain
in the current literature, ranging from 6%–60%.
Additionally, Hosono et al.11 found that there was a
Postoperative management  113
significantly higher rate of postoperative neck pain
for patients undergoing laminoplasty than ante-
rior fusion. Thus, although the evidence is quite
variable, intractable neck pain remains an impor-
tant consideration when approaching postopera-
tive laminoplasty patients. The pathophysiology
related to the neck pain seems to arise in a similar
manner as noted for the progression of kyphosis—
mainly the alteration in soft-tissue architecture.
The muscular and ligamentous changes that occur
postoperatively can affect the stability of the cer-
vical spine, thereby resulting in a greater sense of
pain. The C7 spinous process and its removal also
seem to play a role in contributing to patients’ pain.
Additionally, patients with high levels of preopera-
tive neck pain are contraindicated from undergo-
ing a laminoplasty, given the propensity to develop
worsening neck pain following surgery. The neck
disability index (NDI) serves as a means to assess
patients’ level of preoperative and postoperative
pain and may be used as an effective screening
modality to recognize when laminoplasty would
be best suited for a patient, given the specific level
of pain.
Revise with posterior fusion
Posterior fusion is an effective means to amelio-
rate intractable neck pain that occurs postopera-
tively in laminoplasty patients. Manzano et al.12
showed in a small study that laminectomy and
fusion resulted in significantly improved postop-
erative NDI scores for patients. Posterior fusion
allows stability that cannot be achieved in other
surgical measures. This stability may be one of
the factors contributing to the resolution of
intractable pain symptoms present before revi-
sion surgery, but the pathogenesis has yet to be
elucidated.
POSTOPERATIVE MANAGEMENT
The postoperative management will vary dramati-
cally depending on the extent of surgery needed to
address the failure. In general, if a laminoplasty is
able to be salvaged without fusion, often either no
collar or a soft collar is used; however in the setting
of a multilevel posterior fusion, a cervical orthosis
is often utilized.
114  Complications necessitating surgical intervention following cervical laminoplasty
COMPLICATIONS
Multiple complications can occur after a revision
laminoplasty. One common concern with repeat
posterior cervical surgery is muscle retraction. If the
soft tissue appears tenuous, a plastic surgeon often
can be invaluable to help in the mobilization of flaps.
Pearls and Pitfalls
●● As there is a paucity of information in the
current literature regarding which sur-
gical modalities are indicated for each
­complication, surgeons must utilize careful
clinical decision-making that is dependent
on each individual patient and case.
●● When revising a laminoplasty, surgeons
should be comfortable with both lami-
noplasty techniques and cervical fusion
techniques.
Video 15.1
Protopsaltis French Door Laminoplasty
(https://youtu.be/Yhy2SiA6hJ4)
REFERENCES
1. Hirabayashi K, Watanabe K, Wakano K et al.
Expansive open-door laminoplasty for cervi-
cal spinal stenotic myelopathy. Spine 1983;​
8:693–699.
2. Ryu K and Phyo K. Cervical laminoplasty: The
history and the future. Neurol Med Chir 2015;
55.7: 529–539.
3. Hironobu S, Noboru H, Yoshihiro M, Takahiro I,
Motoki I, and Hideki Y. Long-term outcome
of laminoplasty for cervical myelopathy due
to disc herniation. Spine 2005;30.7:756–759.
4. Suda K, Abumi K, Ito M et al. Local kyphosis
reduces surgical outcomes of expansive open-
door laminoplasty for cervical spondylotic
myelopathy. Spine 2003;28(12):1258–1262.
5. Kyung-Soo S, Ki-Tack K, Jung-Hee L, and
Sang-Hun L. Sagittal alignment of the cervi-
cal spine after laminoplasty. Spine 2007;
32(23):E656–E660.
6. Iizuka H, Shimizu T, Tateno K et al. Extensor
musculature of the cervical spine after lami-
noplasty: Morphologic evaluation by coronal
view of the magnetic resonance image. Spine
2001;26(20):2220–2226.
7. Nagano A, Miyamoto K, Fushimi K et  al.
Failure of reconstruction surgery using ante-
rior fibular strut grafting to correct postlami-
nectomy kyphosis. J Clin Neurosci 2007;​14:​
376–379.
8. Han K, Lu C, Li J et  al. Surgical treatment
of cervical kyphosis. Eur Spine J 2011;20(4):​
523–536.
9. Christopher PA, Justin SS, Justin KS et al. A
standardized nomenclature for cervical spine
soft-tissue release and osteotomy for defor-
mity correction. J Neurosurg Spine 2013;​
19(3): 269–278.
10. Abumi K, Shono Y, Taneichi H, Ito M, Kaneda
K. Correction of cervical kyphosis using ped-
icle screw fixation systems. Spine 1999;24(22):​
2389–2396.
11. Hosono N, Yonenobu K, Ono K. Neck and
shoulder pain after laminoplasty: A noticeable
complication. Spine 1996; 21:1969–1973.
12. Manzano GR, Casella G, Wang MY, Vanni S,
and Levi AD. A prospective, randomized trial
comparing expansile cervical laminoplasty
and cervical laminectomy and fusion for mul-
tilevel cervical myelopathy. Neurosurgery
2012;70(2):264–277.
 Part     3
Thoracic/Thoracolumbar Spine

16 Revision surgery for proximal junctional kyphosis following thoracolumbar fusion 117
Sundeep S. Saini, Daniel Cataldo, Christopher R. Cook, Hamadi Murphy,
Paul W. Millhouse, and Kris Radcliff
17 Pedicle subtraction osteotomy (PSO) nonunion revision 127
Jason W. Savage
18 Treatment of a nonunion of a thoracolumbar deformity, not at the site of a three-column
osteotomy 133
Randall B. Graham, Tyler R. Koski, and Patrick A. Sugrue
19 How to safely remove a pedicle screw abutting the aorta 145
Kevin Savage, Paul W. Millhouse, Hamadi Murphy, Gregory D. Schroeder, and
Alexander R. Vaccaro

Revision surgery for proximal junctional
kyphosis following thoracolumbar fusion
SUNDEEP S. SAINI, DANIEL CATALDO, CHRISTOPHER R. COOK,
HAMADI MURPHY, PAUL W. MILLHOUSE, AND KRIS RADCLIFF
Introduction 117
Causes of PJK 117
Indications 118
Contraindications 118
Expectations 118
Principles of revision surgery 118
INTRODUCTION
As the population has aged and the incidence of
adult spinal deformity has grown, the rate of revi-
sion surgery for proximal junctional kyphosis
(PJK) following instrumentation of the thoraco-
lumbar spine has also increased. The term PJK
refers to the progressive development of kyphosis
at the junction between the superior end plate of
the upper instrumented vertebra (UIV) and the
inferior end plate of the vertebra two levels above
(UIV+1). It is defined by a proximal junctional sag-
ittal Cobb angle (1) ≥10 degrees and (2) at least 10
degrees more than the preoperative measurement.
While PJK is largely an acute postoperative event,
it can include a spectrum of anatomical abnormal-
ities, including interval development of spondylo-
listhesis, compression or burst fractures, or disc
space collapse. Most PJK occurs within 18 months
of the index surgery.1 Studies have demonstrated
an incidence of approximately 6%–61% following
thoracolumbar fusion, with most stating a rate
16
Preoperative planning 120
Surgical technique 121
Postoperative management 123
Complications 123
References 125
of 20%–40%.1 Of this population, only 13%–55%
undergo subsequent revision surgery.1,2 Although
it is primarily a radiologic finding, PJK repre-
sents a broad range of clinical manifestations and
is multifactorial in nature The decision to pursue
corrective surgery for PJK must rely on a thorough
assessment of the patient’s risk factors, clinical pre-
sentation, and radiographic findings.
CAUSES OF PJK
There are a myriad of potential causes of PJK,
including patient factors, factors related to the
original surgery, and idiopathic factors. Patient
factors may include smoking, osteoporosis, bone
quality, neurological disorders such as Parkinson’s
disease, and the extent of preoperative defor-
mity.1,3,4 Prior to a revision surgery for PJK, the
patient’s host factors, including bone quality spe-
cifically, should be directly investigated. Reduced
bone density may present as fractures associated
with PJK. Preoperative sagittal malalignment, even
117
118  Revision surgery for proximal junctional kyphosis following thoracolumbar fusion
if corrected in the index surgery, may predispose
patients to the development of PJK.4,5 A change of
more than 30 degrees in both lumbar lordosis and
preoperative thoracic kyphosis are also risk fac-
tors for PJK.6 A postoperative proximal junctional
angle greater than 5 degrees is another risk factor.7
Correction of sagittal vertical axis to less than 5 cm
is an independent risk factor for PJK (Figure 16.1).8
There are a host of factors related to the index
surgery that may also predispose patients to PJK.
Inadequate sagittal plane alignment, represented
as a pelvic incidence–lumbar lordosis mismatch,
following an index surgery is a risk factor for PJK.5
Some surgeons perform vertebroplasties at the
cranial end of a long fusion construct in order to
prevent PJK due to compression fractures or screw
pullout. Surgeons also utilize semirigid constructs,
such as hooks or noninstrumented fusion, to
reduce the rate of PJK.9,10 Surgeons should also try
to avoid iatrogenic destruction of the facet joints
or other posterior elements at the cranial end of a
long fusion construct.11 Interestingly, there is no
difference in the incidence of PJK between distal
thoracic (e.g., T10) and proximal thoracic (e.g., T4)
fusions. Therefore, longer fusions are not neces-
sarily protective against PJK.10,12 However, PJK
presents differently depending on anatomic loca-
tion. The common scenario of PJK in the distal
thoracic spine includes UIV collapse, followed by
subluxation of the superjacent vertebra (Figure
16.2).10 In the proximal thoracic spine, subluxation
is the most common presentation.10 In most cases,
PJK results in a severe focal kyphotic deformity
(instead of a global malalignment).4
INDICATIONS
Currently, revision surgery is primarily reserved
for patients presenting with pain, disability, or
neurologic deficits, with the most severe cases
of PJK referred to as proximal junctional failure
(PJF). Fracture, instrumentation failure, and pos-
terior ligamentous complex disruption have all
been shown to be common etiologies.1,2,13 Several
additional factors have been determined to play a
role in the progression of this disease. Specifically,
increased rates of revision were found in patients
who demonstrated a postoperative lumbar lordosis
that was similar to the pelvic incidence13,14 (Figure
16.2). The use of a combined anterioposterior (AP)
approach, increased total construct rigidity, and
selection of the UIV have also been shown to be
surgical risk factors.1,2,13 Despite identification of
these considerations, no consensus has been estab-
lished on the specific criteria to guide proper man-
agement for PJK.
CONTRAINDICATIONS
Relative contraindications to revision surgery for
PJK include compromised skin or subcutaneous tis-
sues, active infection, and poor surgical candidates
with high-risk medical comorbidities. Another rel-
ative contraindication consists of patients who are
not medically optimized for treatment of PJK (e.g.,
severe osteoporosis that has not been corrected,
active smoking).
EXPECTATIONS
Revision surgery for symptomatic PJK in the
thoracolumbar spine generally carries a favor-
able prognosis.15,16 Patient selection and medical
optimization are imperative for successful results
following revision surgery. Patients with greater
comorbidities often require additional procedures
due to worsening PJK, even after revision surgery.15
It is important to recognize that PJK is primarily a
radiographic finding, and it remains unclear what
role the underlying etiology plays in determining
functional and surgical outcomes. Patients who
develop PJK after sustaining a vertebral fracture
show similar outcomes as those patients without
fracture, despite experiencing increased preopera-
tive pain.17 Greater PJK correction was also demon-
strated in patients with a pelvic incidence–lumbar
lordosis mismatch less than 11 degrees.17 Ultimately,
revision surgery for PJK has demonstrated effec-
tiveness in improving both radiologic and clinical
outcomes and should be reserved for symptomatic
patients who present with pain and instability.
PRINCIPLES OF REVISION SURGERY
PJK develops as a result of the physiologic stress
placed on the transition between fused and unfused
segments. Specifically, long-segment fusion func-
tions as a mechanical lever on the proximal unfused
 Principles of revision surgery  119

(a) (b) (c)

(d) (e) (f)

Figure 16.1  Patient with PJK at the T10 level. AP (a) and lateral images (b) of a 74-year-old female with
symptomatic spinal stenosis and a degenerative scoliosis from L1‒L5 and neurogenic claudication symp-
toms. She underwent a T10‒L5 fusion. After surgery, she developed proximal junctional kyphosis as seen
on AP (c) and lateral (d). Images at 1 year postoperatively. Because she had prominent instrumentation,
she underwent a revision fusion from T4 to the pelvis. An SPO was performed across the T10 segment. She
had good alignment postoperatively, as seen on 2-year AP (e) and lateral (f) radiographs.
120  Revision surgery for proximal junctional kyphosis following thoracolumbar fusion

(a) (b) (c)

Figure 16.2  Patient with failure at the T4 level. AP (a) and lateral images (b) of a 69-year-old female with
symptomatic spinal stenosis and a degenerative kyphoscoliosis and neurogenic claudication symptoms.
She underwent a T4‒S1 fusion. After surgery, she developed proximal junctional kyphosis at the T4 level
and ultimately underwent removal of instrumentation (c).

segments, causing unwanted loss of anterior vertebral
height and eventual kyphotic deformity. Revision
surgery should focus on correcting this deformity
and stabilizing the proximal vertebral segments.
Utilizing a posterior approach, the authors prefer the
use of multiple Smith-Petersen osteotomies (SPOs)
to restore lordosis, with subsequent extension of the
fusion to the proximal thoracic spine to restore sagit-
tal alignment. The posterior approach not only offers
familiarity, but also utilizes an extensile exposure
that grants the ability to implement rigid instrumen-
tation to multiple levels.
PREOPERATIVE PLANNING
Patients undergoing revision surgery for PJK
should undergo preoperative medical evaluation
for risk stratification and optimization. A thor-
ough clinical examination should be performed to
assess for any physical or neurological deficits.
Radiologic assessment
All patients initially obtain long-cassette, stand-
ing AP and lateral radiographs. The proximal
junctional sagittal angle is measured on these
films and compared to the preoperative measure-
ments from the index procedure, particularly if
there is focal pathology, such as a compression or
burst fracture related to the PJK. Physicians should
perform extensive measurement of known spine
radiographic angles, including sagittal vertical
axis (SVA), lumbar lordosis, thoracic kyphosis, pel-
vic incidence, and pelvic tilt. It is critical that the
surgeon does not focus only on the kyphotic seg-
ment, but rather seeks to understand the patient’s
entire sagittal balance. Additionally, if possible,
the surgeon should review the sagittal alignment
prior to the index surgery to understand if an
overcorrection or undercorrection has occurred.
Additional hyperextension films using a bolster
may be obtained in order to establish the rigidity of
the deformity. High-resolution computed tomog-
raphy (CT) of the thoracic and lumbar spine is per-
formed to evaluate the integrity of the bone and to
determine the adequacy of the pedicles for instru-
mentation. If necessary, opportunistic evaluation
of the L1 vertebral body for osteoporosis may be
­performed, even if dual-energy x-ray absorptiom-
etry (DEXA) is impossible due to artifacts from

spine instrumentation.18 Magnetic resonance
imaging (MRI) may be beneficial to determine any
previous injury to the posterior ligamentous com-
plex and to assess the integrity of the intervertebral
disc spaces.
Preoperative set-up
Prior to surgery, the anesthesia team should be
informed of any special considerations regard-
ing patient positioning, estimated length of sur-
gery, and expected blood loss. The surgeon should
advise the anesthesia team about the necessity for
large-bore intravenous (IV) access for resuscita-
tion and consideration of arterial-line monitoring
for blood pressure monitoring. The authors’ prefer-
ence is to maintain mean arterial pressure above
80 mmHg throughout the case to optimize cord
perfusion. The authors also usually administer IV
steroids prior to incision (10 mg dexamethasone)
to protect the spinal cord from injury due to trac-
tion or shortening. In our experience, prophylactic
steroid administration is more effective prior to
spinal cord manipulation than after a spinal cord
injury has occurred.
As most of the PJK surgery is around the spi-
nal cord, the authors’ preference is to use multi-
modal neuromonitoring, including motor-evoked
potentials (MEPs), somatosensory evoked poten-
tials (SSEPs), and free-running electromyography
(EMG). The surgeon should advise the anesthe-
sia team about the need for total IV anesthesia to
enable neuromonitoring. Sequential compression
devices are applied to the lower extremities once
endotracheal intubation is established. Prior to
positioning, baseline neuromonitoring profile is
obtained. The patient is then carefully placed in
the prone position on a radiolucent Jackson table.
A Mayfield holder may be used to immobilize the
head, making sure that the eyes and airway remain
unobstructed. The surgeon should check the eyes
to ensure that there is no pressure. The chest pad
should be adjusted to the level of the sternal notch.
The surgeon should also ensure that the neck is
not hyperextended. Care is taken at this point to
free the nipple from impingement in women with
ample breast tissue. The abdomen should be as free
as possible. The iliac crest pads are placed at the
level of the anterior superior iliac spines as distal as
Surgical technique  121
possible in order to maximize lordosis. It is impor-
tant to ensure that the pads do not extend into the
inguinal region, or they will compress the femoral
vessels and increase the risk of deep venous throm-
bosis (DVT). The perineum should be inspected in
men to ensure that there is no impingement of the
testicles. The upper extremities are then secured
with the shoulders and elbows in 90 degrees of
abduction and flexion, respectively. The authors
have determined that the abducted position poses a
challenge for the surgeon and may obstruct fluoros-
copy when instrumenting the upper thoracic spine.
Alternatively, the upper extremities can be secured
at the sides parallel to the body. The knees are placed
in slight flexion while being supported with gel
pads or pillows. The tibias and feet are supported on
pillows. After induction of anesthesia, sequential
compression devices should be placed on the legs
bilaterally. Neuromonitoring should include SSEPs
and MEPs, as well as dynamic-triggered EMG for
pedicle screw stimulation. The authors’ practice is
to count all neuromonitoring needles prior to the
start and at the end of the procedure. Mean arterial
pressure (MAP) is rigorously maintained through-
out the procedure at above 85 mmHg.
SURGICAL TECHNIQUE
Approach
A longitudinal, midline posterior skin incision is
created in line with the previous surgical exposure
over the spinous processes down to the level of the
fascia in a standard extensile manner (Video 16.1).
In order to aid in closure, the fascia is exposed
bilaterally with a Cobb elevator before proceeding
to any deeper exposure. At this point, the spinous
processes are identified by finger palpation to con-
firm identification of the midline. Fascial dissec-
tion via electrocautery is then performed while
cerebellar self-retaining retractors assist in visu-
alization. If there is a laminectomy defect from
the previous surgery, then the authors first ­dissect
proximal to the laminectomy defect to identify
normal anatomy and a “closed” spinal canal. Once
the authors have an appreciation of the depth of
the spinal structures and the canal, the midline
structures over the laminectomy defect region are
then dissected while trying to avoid a durotomy.
122  Revision surgery for proximal junctional kyphosis following thoracolumbar fusion
The authors prefer to follow the pars and facet
capsules distally to identify the boundaries of the
spinal canal while dissecting at the appropriate
depth. Once the pars and facets are dissected, then
the authors dissect farther laterally to identify the
existing instrumentation. Often, a Cobb elevator
is sufficient for elevating the tissues and muscles
off the pars and facet joints. A sponge and Cobb
are then used to gently protect while dissecting
the remaining paraspinal musculature off the facet
joint capsule.
Special attention should be given to electrocau-
tery hemostasis over the lateral aspect of the pars
interarticularis and the facets joints, as the perifac-
etal artery may be encountered. Electrocautery is
further utilized subperiosteally to the facet joints.
Gelpi retractors placed lateral to the facet joints
assist in exposing the transverse processes bilater-
ally. Care should be taken to stay on bone to avoid
violating the intertransverse membrane, which
could potentially result in excess bleeding and iat-
rogenic nerve root injury.
Working in a small hole or crevice should be
avoided, as bleeding can occur quickly. For this
reason, several vertebral levels are exposed all at
once. All areas not being directly manipulated
should be packed with sterile sponges to tampon-
ade any venous bleeding. Confirmation of verte-
bral levels is essential and should be done using
image-guided fluoroscopy or hard-copy x-rays.
Instrumentation
Lateral mass and pedicle screws are used in the
cervical and thoracolumbar spine, respectively, to
allow segmental, anterior, and posterior spinal col-
umn fixation of multiple segments, as well as the
potential for manipulation and correction of defor-
mities. A starting point is determined by identify-
ing the junction of two anatomic landmarks: the
transverse process and the superior articular pro-
cess. It is important to remember that the mid-
thoracic spine has not only the smallest pedicles
(T4, T5, T6), but also the most medial convergent
thoracic pedicles. Once a starting point is chosen,
it can be difficult to compensate and manipulate
the trajectory of an improperly oriented screw. For
this reason, an appropriate starting point is para-
mount. The most common reason for difficulty
in placing a pedicle screw is using an improper
starting point. Ideally, the medial-lateral starting
point for a thoracic pedicle screw is just lateral
to the superior articular process. It is essential to
have direct visualization of the lateral aspect of
the superior articular process to avoid placing the
screws in a more medial-based starting point. The
cephalocaudal thoracic starting point utilizes the
transverse processes as the anatomic landmark.
For this reason, surgeons should be familiar
with the relative location of the transverse process
in reference to the pedicles at every vertebral level.
The axial trajectory of thoracic pedicles is perpen-
dicular to the superior articular process, while
sagittal trajectory is often parallel to the transverse
process. A rongeur is used to remove the dorsal
cortex of the transverse process, allowing identi-
fication of the pedicle starting point using a high-
speed burr. Once the starting point is determined,
a curved pointed gearshift can be used for pedicle
screw insertion. The probe is advanced 15 mm,
with the tip pointing laterally. At this point, the
tip of the instrument should traverse the pedicle.
The gearshift tip is then rotated and pointed medi-
ally for 15 mm, as the tip should be in the vertebral
body. An awl is advanced a total of 35 mm, and the
hole is then palpated to rule out the existence of
any breach medially, laterally, superiorly, or infe-
riorly. Tapping is not recommended in order to
maximize screw purchase while creating a new
bony path. Trajectory should be confirmed prior to
final screw placement using a drill bit and image-
guided fluoroscopy.
In the lumbar spine, axial trajectory of screws
is straightforward. L1 typically has 5 degrees of
medial convergence, and at each level, an addi-
tional 5 degrees of convergence is typical. For
example: L2 has 10 degrees, and L3 has 15 degrees
of medial convergence. The sagittal trajectory is
typically referenced around the L3 pedicle, which
is perpendicular to the floor in most cases. L3 acts
as the apex of lumbar lordosis. Special attention
should be given to L1, as the transverse process is
commonly rudimentary, while the mammillary
bodies are typically large. Because of the minimal
medial convergence of the pedicles at this level,
care must be given not to breach the medial cor-
tex. Fortunately, the diameter of the L1 pedicles are
large, and medial penetration is rare.

The authors do not typically instrument the level
of the compression fracture in a PJK revision sur-
gery, as the bone and pedicles can be inadequate.
Correcting the PJK with a Smith-
Petersen osteotomy (SPO)
The expected deformity correction is approxi-
mately 10 degrees of kyphotic correction per ver-
tebral level. After adequate exposure, spinous
processes are removed or partially removed, leav-
ing adequate room to gain access to the laminar
interspace and central canal. The ligamentum fla-
vum is then removed, and a bilateral partial lami-
nectomy is performed. Initially, a high-speed burr
may be used to create a thinner area of bone resec-
tion to allow complete removal of the lamina, bilat-
eral inferior facets, and bilateral superior facets
in a systematic fashion using a Kerrison rongeur
and angled curettes. Ultimately, a V-shaped gut-
ter is created from the oblique nature of the oste-
otomy. After the bone has been resected, a slow and
gradual manual reduction and compression across
the osteotomy site is performed using the instru-
mented pedicle screws and instrumented posterior
fusion extension permanent rods. Permanent rods
are cut to an appropriate length and placed in the
field after the desired lordosis is accomplished.
Connectors attach the rods to the instrumented
pedicle screws for stable fixation.
With this compression, the posterior column
will be shortened, while lengthening the anterior
column through the disk space at each level where
osteotomy was performed. Very close attention
should be paid to the screw–bone interface during
the compression of the osteotomy to prevent any
loosening of the pedicle screws. Typically, the SPO
and extended posterior fusion is performed four to
six levels above the affected segments.
Depending on the specific cause of the PJK, more
advanced deformity reconstruction techniques
such as pedicle subtraction osteotomy (PSO) or
vertebral column resection may be necessary. The
authors would particularly consider PSO if there
was a significant sagittal imbalance or undercor-
rection from the index procedure. In that case, the
PSO would be performed in the low lumbar spine
through the previous fusion mass to maximize
lordosis, not at the level of the PJK. The authors’
Complications 123
preference is to avoid three-column osteotomies at
the level of the conus medullaris or spinal cord due
to the inherent risks of spinal cord injury. In the
authors’ experience, a posterior procedure, such as
a SPO, is often sufficient to mobilize the spinal ele-
ments and correct the focal deformity at the level
of the PJK.
Closure
All bony elements should be decorticated, and
local bone from the osteotomy should be debrided
of all soft tissue and morcellized for use as a bone
autograft. Autogenous iliac crest bone graft and
recombinant human bone morphogenic protein 2
(BMP2) may also be used to augment arthrodesis.
After copious irrigation and bone grafting, closure
should be undertaken in a layered fashion over a
subfascial drain. All dead space must be carefully
closed to minimize hematoma formation, espe-
cially in the subcutaneous fat layer over the fascia.
POSTOPERATIVE MANAGEMENT
Patients are instructed to wear an immobilizing
brace while out of bed for up to 12 weeks following
surgery. Comorbidities such as age, osteoporosis,
and smoking may require longer use of the brace.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
should be avoided to prevent delay in bone heal-
ing. In patients with increased risk of developing
DVT, chemoprophylaxis can be initiated, but signs
of local hematoma development must be carefully
monitored.
COMPLICATIONS
Complications can be separated into three catego-
ries: preoperative, operative, and postoperative.
Preoperative complications
Preoperative complications often entail injuries
related to patient positioning. Visual impairment or
blindness may occur if the eyes are not free of any
pressure when placed in the Mayfield head holder.
Soft-tissue injury or necrosis to the breast, abdomen,
or testicles can occur from impingement. Nerve
palsies can also result from improper placement
124  Revision surgery for proximal junctional kyphosis following thoracolumbar fusion
of arm boards or iliac crest pads. Extension of the
iliac crest pads into the inguinal region may lead to
meralgia paresthetica and femoral nerve palsy. Risk
of complications related to positioning increase
with the length of the procedure.
Operative complications
A common operative complication is wrong-level
surgery due to inadequate fluoroscopic visualiza-
tion of landmarks. Additionally, thoracic visualiza-
tion is difficult with fluoroscopy, as the machine has
to travel over several spinal segments. Screw mal-
position is also a possible intraoperative complica-
tion. Anatomic landmarks can be distorted from
the index procedure. Therefore, great care must be
taken with screw placement to avoid this complica-
tion. Medial malpositioning of pedicle screws may
result in spinal cord injury. Additionally, lateral
screw placement places the great vessels at risk. For
this reason, the authors recommend using thoracic
screws that are 5 mm shorter on the left side to pre-
vent possible vessel penetration.
Postoperative complications
Postoperative complications include DVT, surgical
site infection, atelectasis/pneumonia, decubitous
ulcers, postoperative ileus, catheter-associated uri-
nary tract infections (UTIs), or other medical com-
plications related to the patient’s comorbidities.
Video 16.1
PJK Correction Video
(https://youtu.be/9yVJRzCM1GI)
Cranial is at the bottom of the screen and
caudal is at the top of the screen. Surgeon
2 is on the left side of the screen (patient’s
right). Surgeon 1 is on the right side of the
screen (patient’s left).
00:00—Careful exposure in which
assistant holds elevator and tensions tissue
around previous instrumentation tissue
while surgeon exposes.
00:20—Surgeon 1 removes previ-
ous pedicle screw instrumentation on the
patient’s left side, while surgeon 2 exposes the
other instrumentation. Surgeon 2 uses an
Aquamantys to achieve meticulous hemo-
stasis. Notice that there is minimal bleeding
at this step so that both surgeons are able to
work independently without suctioning.
1:31—Previous instrumentation is
removed on the patient’s left side. A lateral
connector connecting to an old rod is iden-
tified and removed on the left. The end of
the old rod can be visualized still within the
connector. On the patient’s right side, sur-
geon 2 is removing locking caps and remov-
ing screw instrumentation. Additional
exposure is needed. The left-side rod and
connector are removed by surgeon 1.
2:14—Notice that the caudal aspect of
the wound is packed off with a sponge to
effect hemostasis. Screws are revised. New
screws are placed on the left side into the
existing pedicle screw holes. The old screws
are removed.
3:15—A new screw is placed on the
patient’s left side. While surgeon 1 is placing
a screw, surgeon 2 provides suction. Surgeon
1 has performed a laminoforaminotomy.
Surgeon 1 places a nerve hook (3:23) into the
laminoforaminotomy to palpate the medial
wall of the pedicle to ensure that the new
screw does not breach the pedicle.
4:10—Topical hemostatic agent is placed
into the laminoforaminotomy in order to
effect hemostasis of any bleeding epidural
vessels. The hemostatic agent will be irri-
gated out before the conclusion of the case
to prevent expansion and spinal cord injury.
4:26—A pedicle is cannulated on the
patient’s right side with a curved, pointed
gearshift awl.
4:28—The pedicle is palpated with a ball-
tip probe to determine if the internal walls
are intact.
4:34—While surgeon 2 is changing
instruments, surgeon 1 uses his suction to
illustrate the pedicle entry zone to enable
surgeon 2 to quickly reorient to the correct
starting point and trajectory.

REFERENCES
4:37—Surgeon 2 uses a rongeur to decor-
ticate the dorsal surface of the transverse
processes prior to screw placement.
4:47—Surgeon 2 places a screw down the
trajectory that he just cannulated. These are
self-tapping screws, so that a tap does not
need to be utilized. Notice that as the screw
engages the pedicle bone (around 4:55), the
entire vertebral body begins to move and
rotate (until 5:02).
5:10—Surgeon 2 paplates the medial wall
of the pedicle via a laminoforaminotomy to
ensure that he is not able to palpate screw
threads (which would imply a pedicle wall
breach). Surgeon 2 places a topical hemostatic
agent into the laminoforaminotomy (5:20).
5:42—Surgeon 2 uses the existing pedicle
screw and anatomical landmarks to identify
a starting point for the next pedicle screw
(5:40). The cortex is broken with a high-
speed burr (5:53). A gearshift is utilized to
cannulate the pedicles (6:04). The pedicle is
palpated with a ball-tipped probe (6:14). A
self-tapping screw is placed (6:26).
6:31—A new rod is introduced into the
spine. The rod has been hyperlordosed to
accommodate the most bent, lordotic seg-
ment at the level of the junctional kyphosis. A
reduction tower is affixed to one of the mid-
dle segments to obtain provisional fixation.
7:42—In situ sagittal plane benders are
utilized to contour the rod to the distal spi-
nal segments.
8:28—In situ sagittal plane benders are
utilized to contour the rod to the proximal
segments.
9:42—A reduction instrument is utilized
to contour to the most proximal segments.
9:49—The rod has been reduced to the
screws. Locking caps are affixed proximally.
11:38—Attention is directed to the distal
aspect of the construct. The left-side rod is
introduced and affixed to the most lordotic
segment. Caps are introduced, and the pro-
cedure is complete.
References 125
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spinal deformity. J Orthop Sci 2015;20(4):​
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4. Watanabe K, Lenke LG, Bridwell KH et  al.
Proximal junctional vertebral fracture in
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138–145.
5. Reames DL, Kasliwal MK, Smith JS et al. Time
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lumbar instrumented fusion for spinal defor-
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–E114.
6. Maruo K, Ha Y, Inoue S et al. Predictive fac-
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mity. Spine 2013;38(23):E1469–E1476.
7. Annis P, Lawrence BD, Spiker WR et  al.
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thoracolumbar spine. Evid Based Spine Care
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8. Smith MW, Annis P, Lawrence BD et al. Acute
proximal junctional failure in patients with
preoperative sagittal imbalance. Spine J
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9. Sengupta DK. Clinical incidence of PJK/ASD
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rigid. Spine 2016;41(Suppl 7):S37–S38.
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10. Berven SH. Clinical incidence of PJK/ASD in
adult deformity surgery: A comparison of
rigid fixation and semirigid fixation-rigid.
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11. Arlet V, Aebi M. Junctional spinal disorders in
operated adult spinal deformities: Present
understanding and future perspectives. Eur
Spine J. 2013;22(Suppl 2):S276–S295.
12. Fujimori T, Inoue S, Le H et al. Long fusion
from sacrum to thoracic spine for adult spinal
deformity with sagittal imbalance: Upper
versus lower thoracic spine as site of upper
instrumented vertebra. Neurosurg Focus
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13. Kim HJ, Iyer S. Proximal junctional kyphosis.
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14. Kim HJ, Bridwell KH, Lenke LG et al. Patients
with proximal junctional kyphosis requiring
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lumbar lordosis and larger sagittal balance
corrections. Spine 2014;39(9):E576–E580.
15. Yagi M, Rahm M, Gaines R et  al. Charact­
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junctional failure in surgically treated patients
with adult spinal deformity. Spine
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16. Mcclendon J, O’shaughnessy BA, Sugrue PA
et al. Techniques for operative correction of
proximal junctional kyphosis of the upper
thoracic spine. Spine 2012;37(4):292–303.
17. Kim YC, Lenke LG, Bridwell KH et al. Results
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Pedicle subtraction osteotomy (PSO)
nonunion revision
JASON W. SAVAGE
Indications 127
Relative contraindications 127
Expectations 128
Principles of revision surgery 128
Preoperative planning and operating
room (OR) setup (including the utility
of neuromonitoring) 128
Pedicle subtraction osteotomy (PSO) is a power-
ful technique that is used in the correction of fixed
sagittal imbalance. It is a three-column osteotomy
performed through a posterior approach and is
typically used in cases where the fixed sagittal
imbalance is greater than 10 cm. On average, it can
provide approximately 30–35 degrees of correc-
tion in lumbar lordosis. The operative technique
involves resecting a wide, V-shaped transpedicu-
lar wedge from one vertebral body, typically in the
lumbar spine, which is then closed posteriorly to
restore positive sagittal balance. This procedure
involves a wide exposure with prolonged operative
times and increased blood loss, with a high risk of
medical and mechanical complications. Common
mechanical complications include junctional
failures, nonunions, and failure of instrumenta-
tion. In the case of symptomatic nonunion and/
or construct failure, revision surgery should be
considered.
17
Operative technique 128
Postoperative management 129
Complications 129
Case example 130
INDICATIONS
●● Persistent or worsening positive sagittal plane
imbalance in patients after undergoing a previ-
ous PSO
●● Pseudarthrosis at the site of the osteotomy or at
an adjacent level to the osteotomy
●● Pseudarthrosis often associated with failure of
posterior instrumentation at or about the level
of the osteotomy
RELATIVE CONTRAINDICATIONS
●● Kyphosis caused by osteoporotic compression
fractures
●● High risk of additional compression frac-
tures in adjacent vertebrae, especially in the
lower thoracic or upper lumbar spine
●● Coagulopathy leading to increased intraopera-
tive blood loss
127
128  Pedicle subtraction osteotomy (PSO) nonunion revision
●● Active medical comorbidities: psychiatric disease,
uncontrolled diabetes mellitus (DM), cardiopul-
monary disease, poor family or social support
EXPECTATIONS
●● The goal is to restore age-appropriate sagittal
balance and spinopelvic alignment.
●● Revision surgery is typically more difficult, with
increased blood loss and distorted tissue planes.
PRINCIPLES OF REVISION SURGERY
●● If there is solid interbody fusion above and below
the osteotomy site, the mainstay of treatment is
revision posterior surgery with bone grafting
of the nonunion (autograft is best), followed by
placement of four rods across the osteotomy site.
●● If there is a nonunion at the level above or below
the PSO site, then an interbody fusion is typically
the most predictable way to achieve fusion, as it
is difficult to achieve a solid posterolateral fusion
over multiple levels (i.e., for an L3 PSO, solid pos-
terolateral bone from L2 TP‒L4 TP is needed).
●● Additional stability can be gained posteriorly
with the use of larger pedicle screws, larger rods,
in-line connectors, rod couplers, and satellite
rods. Four rods should be placed across three-
column osteotomies to prevent rod breakage
and/or nonunion at or near the osteotomy site.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
(INCLUDING THE UTILITY OF
NEUROMONITORING)
●● Tensile forces through posterior graft can
reduce chances of obtaining solid fusion, so
thorough preoperative planning is critical.
Insufficient correction of sagittal balance will
predispose the patient to greater risk of failure
and pseudarthrosis.
●● Important parameters should be considered
for preoperative planning, and age-appropriate
alignment objectives are critical.
●● Pelvic tilt (positional parameter that refers to
the orientation of the pelvis). Typically, the
goal of this is to decrease < 15–20 degrees.
●● Sagittal vertical axis (SVA), the distance of
the C7-plumbline from the posterosuperior
corner of S1. In balanced patients, this value
is under 5 cm.
●● Regional sagittal alignment can also be assessed
using the following measurements:
●● Thoracic kyphosis—typically measured
from the superior end plate of T4 to the infe-
rior end plate of T12
●● Lumbar lordosis—typically measured from
the superior end plate of L1 to the superior
end plate of S1
●● Lumbar lordosis (LL)—pelvic incidence (PI)
mismatch
●● LL = PI ±  10 degrees to prevent a
high degree of mismatch and potential for
failure
●● There are potential acute and long-term neu-
rological deficits associated with PSO surgery;
therefore, neuromonitoring, such as intraopera-
tive somatosensory evoked potentials (SSEP),
motor-evoked potentials (MEPs), and triggered
electromyography (EMG) of the upper and
lower extremities, is typically recommended,
although the efficacy of neuromonitoring for
lumbar osteotomies is controversial.
●● Adequate vascular access is a key component
and should be discussed with anesthesiologist
prior to proceeding with the case due to the
potential for high blood loss.
●● Intraoperative positioning:
●● An open Jackson frame with chest pads and
supports for the pelvis are used to properly
position the patient and ensure adequate
imaging.
●● The patient is placed in the prone posi-
tion, with slight hip and chest extension
to maximize lumbar lordosis. A pillow can
be placed underneath the thigh to increase
hip extension. The bolsters on the Jackson
frame can be adjusted to allow the desired
amount of correction.
●● Arms are positioned in 90 degrees of abduc-
tion and 90 degrees of flexion.
OPERATIVE TECHNIQUE
●● We prefer to perform lateral interbody fusions
at L1‒L2 and/or L2‒L3 and anterior lumbar

interbody fusions at L4‒L5 and L5‒S1 (when indi-
cated). Most PSO nonunions occur at L2‒L3 and/
or L3‒L4, adjacent to a previous L3 PSO. The oste-
otomy level typically heals if there is good apposi-
tion at the osteotomy site. If there is nonunion at
the osteotomy site itself, bone grafting is required.
●● For an L2‒L3 nonunion above a previous L3 PSO,
a lateral interbody fusion is performed, followed
by revision of the posterior instrumentation.
●● The patient is positioned in the lateral decu-
bitis position. A standard minimally invasive
surgical (MIS) lateral approach is then per-
­ ●●
formed with appropriate neuromonitoring to
prevent iatrogenic injury to the lumbar plexus.
●● This can be done using fluoroscopy or intraop-
erative navigation.
●● A discectomy is then performed and the disc
and end-plate cartilage is removed using a
combination of end-plate shavers, curettes, and
pituitary rongeurs.
●● The contralateral osteophyte is released using a
Cobb elevator.
●● If more correction is needed, an anterior col-
umn release can be performed; there must be
mobility in the posterior instrumentation (i.e.,
rod failure) to achieve maximal correction.
●● A lordotic cage is then placed with bone graft
(typically an iliac crest bone graft [ICBG]). The
use of a biologic is at the discretion of the treat-
ing surgeon.
●● The wound is then closed in layers.
●● The posterior instrumentation is then revised,
and additional stability is provided by placing
three or four rods across the osteotomy and
nonunion sites.
POSTOPERATIVE MANAGEMENT
●● The patient is often taken to the intensive care
unit (ICU) for frequent neuromonitoring for a
minimum of 18–24 hours.
●● Postoperative drains are left and removed at the
surgeon’s discretion when output has decreased
to less than 30 cc per 8 hours.
●● Gradual mobilization of the patient is encour-
aged. Physical therapy is a key component to
recovery. If the patient is able to sit and walk
postoperatively, use of a thoracolumbosacral
orthosis is recommended.
Complications 129
●● Deep venous thrombosis (DVT) prophylaxis
is held in the immediate postoperative period.
Subcutaneous heparin or enoxaparin can be
started at the 48-hour mark (need to balance
risk of DVT versus epidural hematoma).
●● Sutures are removed 2 weeks after surgery.
COMPLICATIONS
●● Blood loss
●● Repeat hardware failure
Pseudarthrosis
●● Acute intraoperative and postoperative neuro-
logical deficits, such as visual field deficit, quad-
riceps weakness, and urinary retention
●● Nerve root injury or dural tear
●● Spinal cord ischemia
●● Postoperative epidural hematoma
●● Postoperative infection
●● Cardiopulmonary complications (e.g., myocar-
dial infarction, pulmonary emobolism)
●● Prominent hardware at iliac screw site
Pearls and Pitfalls
Pearls
●● Detailed preoperative planning is critical to
the success of surgery.
●● Intraoperative imaging helps to confirm the
appropriate restoration of lumbar lordosis.
●● Blood products should be prepared prior
to exposure. Excessive bleeding can be
decreased by coagulating segmental ves-
sels during exposure. Bipolar cautery and
hemostatic agents are beneficial in control-
ling epidural bleeding.
●● Techniques for increasing stiffness of con-
struct include multiple rods, bone-to-bone
contact posteriorly, and fusion of adjacent
disc spaces.
●● Rod material must be matched to patient’s
bone health/density (stiff rods will increase
failure in patients with osteopenia and/or
osteoporosis).
●● Optimization of osteopenia or osteoporo-
sis prior to surgery is critical.
●● PSO provides powerful correction for
deformities requiring at least 30 degrees
of correction. Smith-Petersen osteotomy
(SPO) can be used to correct lesser defor-
mities (for 10 degrees or less per level) with
mobile disc spaces.
130  Pedicle subtraction osteotomy (PSO) nonunion revision

Pitfalls
●● There may be a failure to ensure correction of
lumbar lordosis prior to final instrumentation.
●● Neurologic deficits may not always be
identified with neuromonitoring.

CASE EXAMPLE
●● A 67-year-old male who underwent an L4‒S1
decompression and posterior spinal fusion
(Figure 17.1) and subsequent extension of fusion
from L3‒S1 (Figure 17.2).
●● He then presented, complaining of worsening
back pain and the inability to stand upright.

Figure 17.2  Lateral lumbar spine radiograph dem-

onstrating a flat-back deformity with L3 screws in
the superior end plate.

●● He then underwent a revision T10‒S1 posterior

spinal fusion with L2 PSO for severe sagittal
plane imbalance and LL‒PI mismatch (Figure
17.3).
●● The patient initially did very well postopera-
tively, with improvement in clinical symptoms
and overall alignment, but then presented to the
clinic 18 months after surgery complaining of
worsening pain and posture.
●● Computed tomography (CT) scan revealed
nonunion at L3‒L4, with failure of the instru-
mentation/rods (Figure 17.4).
●● Due to his symptomatic nonunion, he under-
went revision surgery with an L3‒L4 lat-
eral lumbar interbody fusion and revision of
Figure 17.1 Standing lateral scoliosis radiograph the posterior instrumentation (Figures 17.5
demonstrating a flat-back deformity. through 17.7).
 Case example  131

Figure 17.5  Intraoperative image of the L3–L4 lat-

eral lumbar interbody fusion.

Figure 17.3  Postoperative lateral radiograph after

the patient underwent a revision T10–S1 posterior
spinal fusion with L2 pedicle PSO.

Figure 17.4  Sagittal CT scan demonstrating PSO Figure 17.6 Lateral radiograph demonstrating
nonunion. final revision construct.
132  Pedicle subtraction osteotomy (PSO) nonunion revision

Figure 17.7 Lateral scoliosis radiograph demon-

strating final revision construct.

Treatment of a nonunion of a
thoracolumbar deformity, not at the site
of a three-column osteotomy
RANDALL B. GRAHAM, TYLER R. KOSKI, AND PATRICK A. SUGRUE
Indications 133
Relative contraindications 134
Expectations 134
Principles of revision surgery 136
INDICATIONS
Reconstructive surgery for thoracolumbar defor-
mity can be fraught with complications, one of
which is pseudarthrosis or nonunion. Patients
with pseudarthrosis typically present with a radio-
graphically apparent fracture and/or failure of
instrumentation. Computed tomography (CT)
scanning may demonstrate a fracture or disconti-
nuity in the underlying fusion mass. This can clini-
cally manifest as a painful popping or cracking
sensation at the site of the nonunion or functional
flexible focal deformity.
Not all patients with thoracolumbar pseudar-
throsis require immediate surgical intervention.
Many patients can tolerate this condition with
analgesics and activity modification. Persistent
refractory pain, neurologic symptoms, and loss
of correction resulting in recurrent sagittal and/
or coronal plane deformity are indications for sur-
gery. Similar to any other adult spinal deformity
18
Preoperative planning and operating room
(OR) setup 136
Operative technique 140
Postoperative management 141
Complications 142
operation, repair of a thoracolumbar nonunion can
be a major undertaking, with many potential com-
plications. The decision to pursue surgery requires
a thoughtful and extensive discussion in which the
amount of discomfort and disability caused by the
nonunion is weighed against the risks of a major
spinal revision operation.
It is imperative to investigate the underlying
etiology of the pseudarthrosis prior to attempting
a salvage revision. Often, the underlying factors
that lead to a nonunion fall into two general cat-
egories: metabolic and biomechanical. Metabolic
factors that can lead to poor bone healing include
smoking, renal disease, steroid use, nonsteroi-
dal anti-inflamatory drug (NSAID) use, infec-
tion, and other elements that inhibit bone growth.
Biomechanical factors include poor bone quality,
inadequate instrumentation, lack of anterior col-
umn support, sagittal or coronal malalignment,
elevated proximal or distal junctional angle, or a
combination of these. By better understanding the
133
134  Treatment of a nonunion of a thoracolumbar deformity, not at the site of a three-column osteotomy
underlying factors that may have contributed to
the failed fusion, the revision strategy can be opti-
mized for success.
RELATIVE CONTRAINDICATIONS
As mentioned earlier, surgical intervention for
a thoracolumbar pseudarthrosis can be consid-
ered a complex spinal revision operation, and the
decision to operate must be carefully considered.
Relative contraindications to surgical revision
mainly include conditions that would unreason-
ably increase the risk of morbidity or other failure
of the operation.
Certain systemic conditions can be prohibitive
to surgery from a medical standpoint. Severe active
systemic disease, such as coronary artery disease,
congestive heart failure, chronic obstructive pul-
monary disease, pulmonary hypertension, or end-
stage renal disease, can preclude a patient’s ability
to tolerate general anesthesia in the prone position
for extended periods. A thorough assessment of the
patient’s medical risk factors should be undertaken
with the assistance of an internist, a cardiologist,
and/or an anesthesiologist, preferably with experi-
ence in the care of complex spine patients prior to
the time of surgery.
Great caution should also be exercised in
patients with active malignancy. Certain osteo-
promotive grafting materials that are used with
great frequency in these revision operations, such
as recombinant human bone morphogenetic pro-
tein (BMP), can carry a risk of worsening sys-
temic malignancies. Furthermore, many of these
patients have previously undergone or are cur-
rently undergoing chemotherapeutic and/or radia-
tion treatment for their conditions, both of which
can negatively affect bony fusion and wound heal-
ing. In the setting of systemic cancer, it is of utmost
importance to prioritize the patient’s overall dis-
ease status before considering any spinal operation
of this magnitude. The patient’s long-term progno-
sis will most likely preclude the risks of a complex
spinal revision, and a thoughtful discussion with
the patient’s oncologist should take place prior to
its consideration (Figure 18.1).
Given the fact that repair of a nonunion is a
complex revision operation with manipulation of
spinal implants, the existence of a systemic or local
infection can be considered a relative contraindi-
cation. In this setting, a full aggressive course of
antibiotic therapy (and preferably clearance from
an infectious disease specialist) should take place
prior to surgery. Similarly, treatment of a local
wound or implant infection should take prece-
dence over repair of a nonunion. Depending on the
severity of the infection and the microbe involved
(i.e., Gram-negative organisms), this may neces-
sitate complete removal or replacement of some
(if not all) implants and a long course of antibiot-
ics prior to the definitive revision/reconstruction
operation (Figure 18.2).
Severe immunodeficiency (especially with high-
dose immunosuppressive medications) can unrea-
sonably increase the risks of infection, wound
breakdown, and construct failure. Whenever pos-
sible, the dosages of these medications should be
reduced and/or tapered as much as safely possible
prior to planning any type of revision spinal fusion
operation.
Severe osteopenia and osteoporosis can also be
considered relative contraindications due to the
subsequent risk of further nonunion and construct
failure. Dual-energy x-ray absorptiometry (DEXA)
scanning is an absolute requirement for preopera-
tive screening and planning. For T-scores < −2.5,
one should strongly consider treatment with either
recombinant parathyroid hormone or denosumab
(a monoclonal antibody to osteoclasts) prior to
major revision spine surgery.
EXPECTATIONS
Setting reasonable expectations for both the patient
and the surgeon is paramount prior to revision sur-
gery for thoracolumbar pseudarthrosis. Realistic
goals of surgery in this setting should include relief
of the pain, reversal or halting of neurologic symp-
toms, and correction of the focal deformity that
arises from the nonunion. It is important to stress
that any chronic pain or longstanding neurologic
deficit that existed prior to the nonunion will likely
remain postoperatively.
Patients should also understand that major spi-
nal revision surgery likely carries a higher chance
of medical and infectious complications than their
prior operations. Furthermore, because many of
these patients have risk factors for pseudarthrosis
 Expectations 135

(a) (b) (c) (d)

(e) (f ) (g)

Figure 18.1  A 65-year-old male underwent radiation treatment for renal cell carcinoma and then devel-
oped progressive pain, disability, and focal lumbar kyphosis from multiple compression fractures (a,b).
His systemic disease had achieved long-term remission, so he underwent T10–ilium posterior fusion, with
multilevel posterior column osteotomies for deformity correction (c,d). Then, 8 months later, he developed
severe pain and was found to have bilateral rod fractures and lack of bony fusion (e). He thus underwent
revision fusion with rod reconstruction and arthrodesis using rhBMP (f,g).
136  Treatment of a nonunion of a thoracolumbar deformity, not at the site of a three-column osteotomy
(e.g., obesity, smoking, and poor bone quality),
they carry a subsequent risk of further nonunion,
even after revision surgery.
PRINCIPLES OF REVISION SURGERY
The goals of pseudarthrosis repair are twofold: (1)
revision, reconstruction, and reinforcement of the
implant construct across the site of the nonunion;
and (2) adequate arthrodesis and bone grafting
across that site, which optimizes bone, reducing
the risk of further breakdown.
Revision of the existing construct often requires
thorough planning. The patient’s radiographs and
advanced imaging should be closely reviewed to
look for evidence of instrumentation failure such
as rod fracture, disconnected implants, and a halo
phenomenon around screws, suggesting loosening.
These findings can help determine which implants
need to be removed and/or replaced and can assist
the surgeon in developing a sound instrumen-
tation strategy. Close review of the patient’s CT
scan can reveal a fracture or discontinuity in the
fusion mass (Figures 18.2 and 18.3). In some cases
with long constructs (e.g., proximal thoracic spine
to the sacrum/pelvis), it may not be necessary to
expose and revise the entire construct (Figure
18.1). Careful radiographic review and planning
can help determine this. Reinforcement of the con-
struct is usually achieved via anterior column sup-
port, with the use of structural interbody grafting
and additional rods, which must always span the
site of the pseudarthrosis.
Adequate arthrodesis and bone grafting are
absolutely essential to these operations. A thorough
soft-tissue and scar dissection should be carried out
in order to expose existing fusion mass and bony
anatomy so that arthrodesis can be performed.
In doing so, the actual site of the nonunion in the
fusion mass should be identified so that graft mate-
rial and additional rods can be placed across it.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
As mentioned earlier, a thorough medical evalua-
tion and analysis of specific risk factors, especially
smoking history and overall bone health, are abso-
lutely essential parts of preoperative planning.
Radiographic evaluation is just as important.
Full-length, so-called long-cassette (14″ × 36″),
standing radiographs should be considered the
standard of care in the preoperative evaluation in
all instrumented thoracolumbar revision opera-
tions. Pseudarthrosis can result in loss of cor-
rection and/or alterations in sagittal and coronal
balance, which is best appreciated using long-cas-
sette standing radiographs.
A high-quality CT scan through the patient’s
existing construct and fusion is also important to
evaluating for implant breakage and failure. Close
inspection can reveal a halo phenomenon around
screws adjacent to the nonunion site. Sometimes
scans can also reveal a subtle fracture or discon-
tinuity in the fusion mass. Magnetic resonance
imaging (MRI) is typically not as useful due to
artifacts from these patients’ existing implants. If
the surgeon seeks to evaluate neurologic symp-
toms, CT-myelography can be more useful.
Operative planning also should focus on how
much of the existing construct needs to be exposed
and revised. In some scenarios, one can avoid
exposure of the entire construct, especially if the
pseudarthrosis is a focal issue around which the
reconstruction can occur (Figures 18.3 and 18.4).
Careful analysis of radiographs and CT scans can
reveal where rods can be cut in situ, and connec-
tors with additional rods can be linked to provide
necessary support across the nonunion site. If CT
scanning reveals the halo phenomenon around
screws several levels above the nonunion and/or
concern for lack of bony fusion throughout the
construct, one must consider complete exposure
and revision (Figure 18.1). Distal or proximal
instrumentation failure can represent an underly-
ing global spinal alignment problem, and thus the
revision strategy must also take that into account.
The setup in the operating room is similar to
any complex thoracolumbar reconstructive case.
In most cases, an open Jackson frame should be
used to mimic physiologic lumbar lordosis as
closely as possible. For cases in which a revision of
the rod construct is planned, intraoperative neu-
rophysiologic monitoring is not typically used. If,
however, multiple pedicle screws are to be removed
and replaced, or if the patient is experiencing neu-
rologic symptoms or compression due to the non-
union, it should be strongly considered.
 Preoperative planning and operating room (OR) setup  137

(a) (b) (c)

(d) (e) (f ) (g)

Figure 18.2  A 68-year-old female with rheumatoid arthritis, chronic corticosteroid use, osteopenia, and
a complex history of multiple spinal operations presented with severe pain, pseudarthrosis with bilateral
rod fractures, and partially treated osteomyelitis with severe sagittal imbalance (a,b). Note the bilateral
fusion mass fractures (c). Due to concern for incomplete treatment of infection, the patient first underwent
a distal revision from T12–S1 with repair of pseudarthrosis and use of a three-rod construct using end-to-
end and side-to side connectors as a temporizing measure while her antibiotic course was completed (d).
Of note, she fractured her existing rod just above the end-to-end connector (e) just prior to undergoing
definitive complete revision with correction of her sagittal plane deformity (f,g). Yellow arrows (b,c,e)
­indicate areas of rod fracture and/or pseudarthrosis/discontinuity.
138  Treatment of a nonunion of a thoracolumbar deformity, not at the site of a three-column osteotomy

(a) (b) (c) (d)

(e) (f ) (g)

Figure 18.3  A 68-year-old male with a previous L2–S2 instrumented fusion for lumbar scoliosis developed
severe kyphoscoliosis above this construct (a,b) and thus underwent a complex, three-stage instrumented
fusion from T2 to the sacrum/ilium with deformity correction (c,d). He then developed recurrent pain
with mild loss of correction and was found to have multiple rod fractures with a subtle gap in his fusion
mass (e,f); yellow arrows indicate areas of rod fracture and/or pseudarthrosis/discontinuity. He therefore
underwent revision from T4 to the ilium without exposure of the distal two segments, with repair of pseud-
arthrosis and complex rod revision (g). Note the overlapping reinforcing rods that bridge well above the
sites of rod fracture.
 Preoperative planning and operating room (OR) setup  139

(a) (b) (c) (d)

(e) (f ) (g)

Figure 18.4 A 77-year-old female underwent multiple prior lumbar fusions and developed progressive
pain and disability with severe sagittal plane imbalance (a,b). She underwent T4–S1/ilium instrumented
fusion with deformity correction with good symptom relief (c,d). Then, 2 years later, she developed severe
lumbar pain and was found to have a unilateral rod fracture with fracture through her fusion mass (e,f). Her
construct was thus revised from T9 to the ilium with bilateral supplemental rods and multiple connectors
spanning the site of the nonunion (g). Note the end-to-end and end-to-side connectors in the mid-thoracic
spine, where a metal cutting burr was used to cut the original rod. Yellow arrows (e,f,g) indicate areas of
rod fracture and/or pseudarthrosis/discontinuity.
140  Treatment of a nonunion of a thoracolumbar deformity, not at the site of a three-column osteotomy
OPERATIVE TECHNIQUE
As mentioned earlier, positioning is generally on
an open bed frame, such as the Jackson frame
(Mizuho OSI, Union City, California). For most
cases, a contoured face pad such as the ProneView
(Mizuho OSI) can be used, but if the construct
extends into the cervical spine or the patient has a
separate cervical spine fusion, one should strongly
consider using pin fixation for the head, including
possible cervical traction.
Upon exposure, care must be taken to use the
patient’s existing incision as much as possible to
avoid necrosis of the skin edges. Dissection is then
carried through the midline down to the implants
on either side. Great care must be taken to avoid
dissection into areas of previous decompressions
due to risk of dural breach. This is most easily done
by leaving islands of scar tissue over these sites.
This should be balanced, however, by the neces-
sity of dissecting off adequate soft tissue to provide
coverage of the new implants at the completion of
the case. Soft tissue is dissected thoroughly all the
way around the instrumentation and then carried
out in such a way that the entire dorsal extent of
the fusion mass is exposed down to the bone. This
is critical because the existing fusion mass must
serve as the main arthrodesis surface. The non-
union site should also be explored fully. Usually,
a fracture in the rod, which should also be radio-
graphically apparent, can be found. Additionally,
the fusion mass may have a fracture or gap in bone
formation. Graft material that failed to fuse should
be removed so that the underlying bone surface
can undergo repeat arthrodesis.
Once exposure is adequate, it is time to remove
and/or revise the existing instrumentation. In
some cases, removal and revision of the entire rod
length are unnecessary, and so exposure is typically
carried out from the distal end of the construct
to four or five levels above the pseudarthrosis. In
such a case, the screw-caps are removed and the
distal (i.e., broken-off) end of the rod is removed.
In many cases, there has been significant bony
overgrowth along the construct. If removal of the
implants requires resection of this bone, it is advis-
able to use osteotomes and rongeurs so that the
bone can be saved and used as autografts. An area
of rod about four or five levels above the breakage
is selected, ideally where there is an adequate gap
between adjacent pedicle screws, and a metal cut-
ting burr is used to cut the rod in situ, taking care
to leave enough proximal rod to fit an end-to-end
and/or multiple side-to-side rod connectors. If a
metal cutting burr is used, it is important to irri-
gate the wound thoroughly, both to prevent ther-
mal injury to surrounding tissues and remove the
resulting metal dust and shards. Removing rods
will reveal more soft tissue overlying the fusion
mass between the pedicle screws, which should be
removed meticulously to expose the bony surface
of the existing fusion, particularly over the pseud-
arthrosis site.
Loose or haloed pedicle screws are then removed
and replaced (typically upsizing their diameter if
safely possible), and attention is then turned to rod
reconstruction. Generally, the presence of a pseud-
arthrosis necessitates the addition of rods across
the nonunion site, which can be done by using
an end-to-end connector where the previous rod
was cut and then supplementing with another rod
using side-to-side domino connectors, taking care
to ensure that the supplemental rod spans both the
nonunion and any site where the previous rod was
cut in situ.
Longer constructs with more complex failures
(i.e., those requiring exposure and revision of the
entire construct) and those that extend into the
cervical spine require more complex interven-
tion, often requiring an overlapping and staggered
multirod construct with various connector types.
The use of so-called transitional rods can be useful
for revising constructs extending into the cervical
spine.
Before arthrodesis and bone grafting, the wound
and implants are irrigated copiously with antibi-
otic-containing solution. Many surgeons prefer
the use of a pulse lavage irrigator device, and some
have advocated using diluted iodine or hydrogen
peroxide solution. As mentioned earlier, deep sur-
gical site infection can be a devastating complica-
tion of a complex thoracolumbar spinal revision,
so copious irrigation should always be performed,
and it should take place before arthrodesis and
bone grafting to avoid washing away graft material
and osteopromotive growth factors.
Arthrodesis and bone grafting are critical
and should be done thoroughly and aggressively,

particularly across the pseudarthrosis site. In many
cases, arthrodesis and grafting should be per-
formed prior to placing supplemental rods in order
to ensure that they are done thoroughly and to
avoid damaging the new implants with the burr. A
good arthrodesis involves meticulously decorticat-
ing all exposed bony surfaces to the point of bleed-
ing. Unless a significant amount of ectopic fusion
bone was removed during exposure and removal of
the original implants, these cases typically do not
generate a great deal of autogenous graft. Unless
further autograft is removed from other sites (e.g.,
iliac crest or ribs), it is almost always necessary
to use synthetic osteopromotive materials, such
as recombinant human bone morphogenetic pro-
tein (rhBMP) and allograft as the bulk of the graft
material. Although many surgeons have decreased
their use of rhBMP in dorsal-approach cases, revi-
sion/repair of a complex pseudarthrosis should
be seen as a salvage type of operation, in which
aggressive maneuvers to encourage bony fusion
should be used.
The actual placement of graft material should be
done strategically and purposefully. In these cases,
the actual pseudarthrosis site is the most impor-
tant site to graft, and thus the most effective graft
material, such as the rhBMP or iliac crest, should be
used there. Similarly, graft material is layered onto
the arthrodesis surface in a particular order, with
the best material placed directly onto decorticated
bone followed by the lesser material layered on top.
Intraoperative radiographs should be taken
toward the end of the case for the purpose of
inspecting the new construct and the patient’s
alignment. Fluoroscopy may adequately serve this
purpose, but it is ideal to obtain an intraoperative,
long-cassette radiograph, particularly in patients
who have had changes in their sagittal or coronal
profile because of the nonunion.
Wound closure should be done systemically in
anatomic layers. This can be difficult in these cases
due to the presence of dense scar tissue from mul-
tiple previous operations, which makes the natural
tissue layers difficult to elucidate and approximate.
In such cases, the layers can be separated and then
closed more easily, usually with the assistance of
a plastic surgeon. The priority of wound closure is
to get adequate soft tissue coverage over the new
spinal implants and new fusion. This will promote
Postoperative management  141
both wound healing and bony fusion through
blood supply. Drains should almost always be
placed over the fusion bed to prevent a deep fluid
collection, which can be a nidus for infection and
can prevent healing of the deep paraspinal tissues.
POSTOPERATIVE MANAGEMENT
Management of these patients postoperatively
focuses on the prevention and avoidance of medi-
cal and infectious complications. Given the fact
that all these operations are complex revisions
involving instrumentation, the risk of infec-
tion can be significant. Avoidance of postopera-
tive infection and wound-related issues can be
brought about with painstaking attention to detail
in postoperative care. The use of intravenous (IV)
antibiotics in the perioperative period is essential
in these cases. For cases involving instrumenta-
tion, 24 hours of prophylaxis against methicillin-
resistant Staphylococcus aureus (MRSA) with
vancomycin, plus standard coverage against skin
flora with cefazolin (or a similar agent) while deep
wound drains are in place, is a typical protocol.
Continuous prophylactic antibiotics while drains
are in place is controversial and starting to fall out
of favor in some institutions, and it can potentially
be avoided if meticulous drain care and skin clean-
ing takes place postoperatively.
Early and frequent mobilization is key to
avoidance of wound breakdown. Direct pres-
sure to wounds by braces, mattresses, and other
devices should always be avoided, and patients
should remain out of bed as much as possible. If
patients are to remain on bed rest for CSF leak or
other causes, care must be taken that they remain
on their sides, with frequent logrolling to prevent
direct wound pressure.
Adequate nutrition is essential to both wound
healing and bony fusion. Patients should be tran-
sitioned to regular diets as soon as possible after
surgery. These are large open dorsal thoracolum-
bar operations with large wounds that need to
heal, so caloric requirements are likely increased
compared to other patients. Nutritional supple-
mentation with high-protein shakes and vitamins
can be helpful. Some advocate early involvement
of a nutritionist, with careful monitoring of caloric
intake during the perioperative period.
142  Treatment of a nonunion of a thoracolumbar deformity, not at the site of a three-column osteotomy
Other postoperative considerations involve
prevention of thromboembolism via early mobili-
zation, sequential compression devices, and chemo-
prophylaxis. Systemic infections such as pneumonia
and urinary tract infection (UTI) can be minimized
by incentive spirometry, early urinary catheter
removal, and, again, aggressive mobilization.
At the end of the hospitalization, a full-length,
long-cassette, standing radiograph should be
obtained to evaluate both the new construct and
the patient’s standing alignment. Patients are then
seen after discharge on an outpatient basis in reg-
ular intervals with repeat standing radiographs
throughout the period of bony fusion for a mini-
mum of 2 years.
COMPLICATIONS
As mentioned earlier, many complications of com-
plex thoracolumbar revision surgery for pseud-
arthrosis are related to infection. Infections can
occur early after surgery or in a delayed fashion.
Early infections most often occur due to some
occult contamination event during the operation
or poor wound healing with microbial contamina-
tion through a nonhealed incision. For either of
them, treatment should be early and aggressive.
Radiographic evaluation with CT and/or MRI
should take place to document the depth of the
infection. Identifiable fluid collections should be
immediately sampled for culturing with the ini-
tiation of IV antibiotics soon thereafter. Superficial
infections can often be debrided quickly and
managed expectantly. Deeper infections, how-
ever, require more extensive exploration and may
necessitate removal of instrumentation. Delayed
infections are often the result of bacterial seed-
ing of spinal implants from a primary infection at
a different site. These infections are usually deep
and quite severe, which is often the result of more
aggressive Gram-negative organisms. Similarly,
they should be treated promptly with IV antibi-
otics and surgical debridement with removal of
all bone graft material (and possibly removal and
replacement of instrumentation). Additionally, the
source of such an infection should be quickly iden-
tified and treated.
Because many of these patients are prone to
poor bony healing in the first place, it follows that
further nonunion may yet occur after attempted
revision and repair of pseudarthrosis, which is
why thorough preoperative evaluation and miti-
gation of all such risk factors such as osteope-
nia, corticosteroid use, and smoking is critical.
Nevertheless, if pseudarthrosis and/or failure of
instrumentation occur despite dorsal reconstruc-
tion and arthrodesis, one may consider an anterior
or lateral approach for the placement of interbody
grafts. This serves a dual purpose of providing
anterior column support at the site of nonunion
and increasing the fusion surface via end-plate
arthrodesis.
Systemic medical complications such as car-
diopulmonary events, thromboembolism, hospi-
tal delirium, systemic infections, and ileus occur
after these operations in similar frequency to any
complex thoracolumbar spinal reconstruction. As
described earlier, their prevention and management
rely upon thorough preoperative risk stratification
and meticulous postoperative care, both of which
often require assistance from a qualified internist.
Pearls and Pitfalls
●● Favorable outcomes following reconstruc-
tive surgery for thoracolumbar pseudar-
throsis can be obtained with thoughtful
planning and efficient execution. This
starts with careful review of the patient’s
radiographs preoperatively so that a com-
prehensive reconstruction plan can be for-
mulated prior to the incision. It is vital to
note which manufacturer’s implants were
used in the previous operation so that
appropriate instruments are readily avail-
able at the time of surgery. The decision
to expose and revise only part of the con-
struct should be made well in advance of
the time of incision so that exposure and
exploration of fusion can be carried out in
an efficient and focused manner.
●● Simply replacing a fractured rod (even if
the rod diameter is increased) will likely
end in another nonunion. The occurrence
of pseudarthrosis in long thoracolumbar
constructs implies persistent motion that
prevents bony healing. The best solution,

then, is not only to replace the primary rod,
but also to reinforce it with supplemental
rods and, when possible, anterior column
support and interbody fusion. Fashioning
such a construct with multiple connectors
can be tedious and frustrating, but if the
resulting additional strength and stiffness
leads to bony fusion and a good outcome,
the time and effort are well spent.
●● The importance of meticulous bony expo-
sure and aggressive arthrodesis and
Complications 143
grafting cannot be stressed enough. Soft
tissue remnants will likely inhibit bony
fusion, resulting in further pseudarthrosis.
It is often tempting to avoid the high costs
of osteopromotive biologic agents such
as rhBMP; however, these cases should
be considered salvage-type operations,
and once the decision to operate has been
made, expense should not be spared in
return for successful fusion.

How to safely remove a pedicle screw
abutting the aorta
KEVIN SAVAGE, PAUL W. MILLHOUSE, HAMADI MURPHY,
GREGORY D. SCHROEDER, AND ALEXANDER R. VACCARO
Indications 145
Contraindications 145
Expectation 145
Principles of revision surgery 146
Preoperative setup 146
INDICATIONS
It is the authors’ preference that all malpositioned
pedicle screws that are near the aorta be removed.
Due to normal pulsatile flow, a screw in close prox-
imity to or in contact with the aorta may lead to late
damage as a result of erosion into the tunica externa
and beyond, leading to eventual perforation of the
aortic wall. Consequently, while there are reports of
patients being safely watched with a screw abutting
the aorta, the authors routinely remove all screws
within 5 mm of the aorta (Figure 19.1).
CONTRAINDICATIONS
While pedicle screws lying close to the aorta may
pose a long-term risk to the patient, there are addi-
tional considerations. When evaluating a patient
for revision or removal of a screw, one must weigh
the relative risk and reward of such an invasive
procedure. In patients that are completely asymp-
tomatic, simple observation of screws abutting
the aorta may be an effective option. This holds
19
Operative techniques 146
Postoperative management 148
Complications 148
Reference 148
especially true if the patient is already near the
end of his or her life and does not have a promising
prognosis. Additionally, if the procedure was in the
distant past and the patient has not experienced
any concerning or worsening symptoms, simple
monitoring might be the most prudent approach.
It should be noted that if a screw is thought to
be misplaced and in contact with the aorta during
original screw placement, it should not be removed
immediately. When a patient is in the prone posi-
tion, as they would be for pedicle screw placement,
it is exceedingly difficult to control bleeding from
the aorta. In the absence of immediate hemor-
rhage, an imaging study should be performed to
confirm the location of the screw in relation to the
aorta before proceeding with a revision operation.
EXPECTATION
Most patients who undergo a removal of the pedi-
cle screw have no major sequel; however, it is criti-
cal that patients understand the risk of the surgery,
as well as the risks of leaving the screw in place.
145
146  How to safely remove a pedicle screw abutting the aorta
(a) (b)
Figure 19.1  Pedicle screw penetrating the vertebral body laterally and abutting the aorta. (a) Axial CT of a
pedicle screw abutting the aorta. (b) Coronal CT of a pedicle screw abutting the aorta; (c) is a sagittal CT
of a pedicle screw abutting the aorta.
PRINCIPLES OF REVISION SURGERY
It is critical that the surgeon have an understand-
ing of the type of aortic involvement. Is the screw
extraosseous and near the aorta, or is the screw
abutting the aorta, or is there an actual aortic wall
perforation? It is important to resolve these ques-
tions, as different surgical techniques are required in
response to each. Because of these issues, the patient
should undergo a computed tomography (CT) angi-
ography of the aorta prior to surgery. Additionally,
the patient should be evaluated by a vascular sur-
geon prior to surgery, and thus the vascular surgeon
must be a member of the surgical team.
PREOPERATIVE SETUP
It is critical that proper imaging studies (CT angio-
gram versus aortogram) are performed to ade-
quately localize the screw in relation to the aorta
and other anatomical structures. This allows a
more accurate removal of the involved screw and
minimizes risk to the patient. The operative setup
depends on the location of the pedicle screw. If the
screw is extraosseous and near the aorta, but not
in contact with the aorta, the patient can often be
placed in the supine position and the screw simply
removed. Even with the screw only near the aorta,
the authors recommend that vascular surgeon
should be consulted and on hand in the event of
hemorrhage upon removal. If the screw is abutting
the aorta, vascular surgery should be involved in the
(c)
case, and either an endovascular-assisted approach
or an open thoracotomy should be performed.
OPERATIVE TECHNIQUES
Depending on the type of aortic involvement, dif-
ferent techniques are preferable in order to encour-
age more favorable outcomes.
Endovascular-assisted approach
If the screw is abutting the aorta, an endovascular-
assisted approach is beneficial. To reduce the pos-
sibility of hemorrhage, aortography, as well as the
option to place a stent graft endovascualrly prior to
removing the screw, should be considered. If a graft
is placed (Figure 19.2), an aortogram or CT angi-
ography should be performed afterward as well to
demonstrate proper placement of the stent-graft in
relation to the screw and to ensure that there are no
leaks from the graft. Once the integrity of the aorta
has been confirmed, the patient often has to be
placed in a prone position so that the entire screw
and rod construct can be exposed. Rarely, this may
be done in the lateral decubitus position through a
paramedian incision if the surgeon thinks that it is
possible to remove the single screw without taking
the rod out of all the screws.
Thoracotomy procedure
While an endovascular aortic repair (EVAR) offers
a less invasive approach to removal of pedicle

(a)
(b)
Figure 19.2 Stent placement in the area of the
aorta around an offending screw. (a) Aortogram
before aortic stenting. (b) Aortogram after aortic
stenting. (Reprinted from J Vasc Surg, 39, Minor
ME et al., Endovascular treatment of an iatrogenic
thoracic aortic injury after spinal instrumenta-
tion: Case report, 893–896, Copyright 2004, with
­permission from Elsevier.)
screws, thoracotomy may be preferred in some
cases because it allows better visualization of the
aorta. Thoracotomy may be utilized regardless of
whether the screw tip has penetrated or is simply
abutting the aorta. This approach should be done
if the surgical team does not feel comfortable with
controlling acute hemorrhage via the endovascular
approach alone. Specifically, thoracotomy allows
excellent visualization and access to the aorta in
the event that direct clamping for hemostasis is
required. Additionally, if the screw tip is thought
to lie within the lumen of the aorta, a thoracotomy
Operative techniques  147
should be done to allow anterior preparation of
the screw using a high-speed burr, as well as direct
control and repair of the aorta.
An incision in the intercostal space at the level
of the offending screw is made. Dissection is done
down to the level of the aorta to allow for visu-
alization and confirmation of the position of the
screw. If the screw tip has been confirmed to be
penetrating the aorta, atriofemoral bypass should
be performed, along with clamping of the aorta
proximally and distally to the location of the
screw, effectively allowing isolation of this area
of the aorta for repair by the vascular team. Once
this is done, it should be retracted medially using
retractors to expose the location of the offending
screw, and just the screw tip may be removed using
a diamond burr or an equivalent modality until
the screw is level with the body of the vertebrae
in which it is placed. Depending on the amount of
damage to the wall of the aorta, the vascular team
should proceed in one of two ways: direct suture of
the aorta or replacement of the aorta in the area of
insult. If damage to the aorta is limited to a small
perforation site, it may be repaired via simple
suturing. If the damage exceeds limits for sutur-
ing, the aorta in this region will need to be replaced
with a graft to help ensure proper recovery.
Hybrid approach
While the previous two techniques are potential
solutions for posteriorly placed screws, anterior
hardware presents a different challenge, and gen-
erally a thoracotomy is required to visualize and
access it. If the offending screw is anteriorly placed
and found to be lying tangential to the aorta, it is
possible to combine a thoracotomy with an EVAR.
First, a thoracotomy is performed to visualize the
aorta and access the hardware in question. Once
this is done, a catheter should be placed via a
femoral cut-down and introduced into the aorta.
A stent graft should then be deployed in the area
surrounding the screw in order to allow exclu-
sion of this segment of the aorta. Once the aorta
has been confirmed to be excluded, the hardware
can be removed through the thoracotomy site and
follow-up aortography should be done to ensure
the proper placement of the endograft without any
extravasation.
148  How to safely remove a pedicle screw abutting the aorta
POSTOPERATIVE MANAGEMENT
In the immediate postoperative period, patients
should be evaluated to ensure that they are neu-
rologically and vascularly intact and their status
unchanged from prior to surgery. Follow-up CT
angiography is indicated to ensure that any endo-
graft placed is in the proper position and that the
patient has no new hardware-related complications.
COMPLICATIONS
The most feared complication in this surgery is
damage to the aorta. Because of this, it is critical
that a comprehensive preoperative evaluation be
completed, and that vascular surgeons are on the
surgical team.
Pearls and Pitfalls
●● Prior to the placement of thoracic instru-
mentation, template the appropriate
length of the screws.
●● Consider a laminoforaminotomy for all tho-
racic pedicle screws.
●● Always have a vascular surgeon involved in
the care of the patient if a pedicle screw is
near the aorta.
●● Inspect the position of the screw meticu-
lously on the CT angiogram. If there is any
concern about the integrity of the aorta,
do not remove the screw until the vascular
surgeons have either endovascularly evalu-
ated and possibly repaired the aorta or
directly repaired it.
REFERENCE
1. Minor ME, Morrissey NJ, Peress R, Carroccio
A, Ellozy S, Agarwal G, Teodorescu V, Hollier
LH, Marin ML. Endovascular treatment of an
iatrogenic thoracic aortic injury after spinal
instrumentation: Case report. J Vasc Surg
2004;39(4):893–896.
 Part     4
Lumbar Spine

20 Revision of an anterior lumbar interbody fusion (ALIF) nonunion 151

Edward Delsole, Rishi Sharma, and Gregory D. Schroeder
21 How to revise nonunion of a lateral interbody fusion (LLIF) through a lateral approach 155
Heeren S. Makanji, Jacqueline Koomson, Dhruv K.C. Goyal, and
Gregory D. Schroeder
22 How to surgically manage a recurrent lumbar herniated nucleus pulposus (HNP) 161
Taylor Paziuk, Matthew S. Galetta, and Jeffrey A. Rihn
23 How to perform revision lumbar decompression 167
Jacob Hoffman, Ryan Murphy, Mark L. Prasarn, and 
Shah-Nawaz M. Dodwad
24 How to perform revision lumbar decompression at the index level through a minimally
invasive (MIS) approach 173
Aaron Hillis, Christoph Wipplinger, Sertac Kirnaz, Franziska A. Schmidt, and Roger Härtl
25 How to revise a transforaminal lumbar interbody fusion (TLIF) nonunion with recurrent
stenosis at the index level (open) 183
Jesse E. Bible and Gregory Pace
26 How to revise a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF)
nonunion with recurrent stenosis at the index level through an MIS approach 191
Fady Y. Hijji, Ankur S. Narain, Gregory D. Lopez, Krishna T. Kudaravalli,
Kelly H. Yom, and Kern Singh
27 How to revise a posterior lateral decompression and fusion at the index level 199
Fadi Sweiss, Cristian Gragnaniello, Anthony J. Caputy, and Michael Rosner
28 How to revise a posterior lumbar fusion that has developed adjacent-level stenosis with
or without instability 205
Patrick Curry and Mark F. Kurd
29 Flat back deformity revision surgery 211
Jefferson Wilson, Matthew S. Galetta, and Srinivas Prassad
30 Revision high-grade spondylolisthesis surgery 217
Peter D. Angevine
31 Management of a ventrally displaced graft following ALIF, TLIF or DLIF 223
Dhruv K.C. Goyal, Heeren S. Makanji, Gregory D. Schroeder, and 
Brian W. Su

149

Revision of an anterior lumbar interbody
fusion (ALIF) nonunion
EDWARD DELSOLE, RISHI SHARMA, AND GREGORY D. SCHROEDER
Introduction 151
Indications 151
Relative contraindications 151
Expectations 152
Principles of revision surgery 152
INTRODUCTION
Anterior lumbar interbody fusion (ALIF) is a pow-
erful tool for the spine surgeon—one that affords
opportunities for direct and indirect neural decom-
pression, reduction of spondylolisthesis, and a large
surface for fusion. This technique avoids manipu-
lation of the neurologic structures to access the
interbody space, and it can allow indirect decom-
pression of the foramen and lateral recess through
disk height restoration. The approach is most com-
monly retroperitoneal and requires mobilization
and retraction of the great vessels to expose the
intervertebral disk. Some spine surgeons may feel
comfortable performing the approach indepen-
dently; however, it is our preference to work with an
approach surgeon on primary and revision cases to
limit intraoperative risk. Given the potential mor-
bidity of this surgical approach, the surgeon opting
for an anterior exposure should make every possi-
ble effort to ensure adequate disk space preparation,
thereby maximizing the likelihood of fusion.
ALIF nonunion presents a potentially chal-
lenging surgical problem, as reoperated lumbar
20
Preoperative planning 152
Operating room (OR) setup 152
Operative technique 153
Postoperative management 154
Complications 154
nonunions appear to have uniformly diminished
clinical and functional outcomes compared to
patients who do not require reoperation. Safe ret-
roperitoneal access may be challenging due to the
presence of scar tissue. The fusion bed may lack
adequate host bone stock or be overgrown with
fibrous tissue, thus commonly requiring complex
reconstruction. Here, we provide our methods
and techniques for evaluating and treating ALIF
nonunions.
INDICATIONS
Indications for revision of ALIF nonunions include
(1) pain related to the nonunion, (2) hardware fail-
ure with resultant three-column instability, and
(3) graft/cage displacement, subsidence, or resorp-
tion—the complications of which may result in
symptomatic positive sagittal balance.
RELATIVE CONTRAINDICATIONS
●● High preoperative medical risk
●● Severe osteoporosis
151
152  Revision of an anterior lumbar interbody fusion (ALIF) nonunion
●● A structurally stable interbody graft/cage and
fusion achievable from the posterior approach
alone
●● A surgical plan to extend a posterior construct
proximal or distal to the nonunion, thus bridg-
ing it with instrumentation and a posterolateral
fusion mass
EXPECTATIONS
The surgeon should anticipate all possible factors
that could influence the goals of surgery, including
the following:
●● Removal of the index interbody graft or device
●● Revision of disk space preparation to create a
structurally optimized, osseous fusion bed
●● Implantation of an interbody graft or device
that affords anterior column support and pro-
motes fusion
●● Restoration of appropriate sagittal and coronal
alignment
●● Segmental stabilization with instrumentation
PRINCIPLES OF REVISION SURGERY
Revision surgery can be fraught with challenges,
including scarred tissue planes, poorly mobile vas-
culature, bone loss, and excessive fibrous tissue
within the interbody space. Native tissue planes
should be exploited wherever possible—this can be
facilitated by extending the approach wider than
the original dissection plane and utilizing the sur-
rounding native tissue as anatomical landmarks.
Great care should be taken to mobilize the great ves-
sels prior to retraction to avoid inadvertent injury.
PREOPERATIVE PLANNING
Preoperative planning begins with a focused
assessment of the patient’s complaints and correla-
tion with the lumbar level of concern. Nonunion
should be demonstrated radiographically with the
use of flexion-extension lateral lumbar plain radio-
graphs, as well as with thin-cut (2 mm) computed
tomography (CT). Magnetic resonance imaging
(MRI) and nuclear imaging studies play a limited
role in the assessment of bony healing, especially
in the presence of adjacent hardware.
The etiology of nonunion should be ascertained,
and, if possible, optimized prior to undertaking a
revision operation. The authors of this technique
recommend preoperative smoking cessation at least
2 weeks prior to reoperation with maintenance of a
smoke-free lifestyle for at least 2 months postopera-
tively. Patients with diabetes should have a baseline
hemoglobin A1c measured to assess historical gly-
cemic control. Tight glycemic control is suggested
in the perioperative period. Osteoporosis may be
an important factor to optimize in certain patients,
and preoperative recombinant human parathy-
roid hormone (i.e., teriparatide) may be a valuable
adjunct. As a rule, infection should always be ruled
out with laboratory testing or preoperative image-
guided biopsy and culture.
Prior operative reports should be reviewed for
details related to the index approach. All prior
abdominal scars should be assessed. Our pref-
erence is to work closely with a surgeon experi-
enced with anterior lumbar procedures. A careful
assessment of preoperative vascular and uro-
genital function is warranted to ensure that there
are no residual complications from the index
procedure.
OPERATING ROOM (OR) SETUP
●● The patient is placed in a supine position on a
radiolucent table to allow the use of fluoroscopy
if needed. Our preference is a flat, radiolucent
Jackson table (Mizuho, Union City, California)
for this approach.
●● The patient should be prepped and draped
widely from the top of the pubic symphysis to
the manubrium of the sternum to facilitate ade-
quate exposure.
●● To optimize access to the L4‒L5 and L5‒S1
disk spaces, lordosis should be slightly empha-
sized by placing a bump beneath the lumbar
spine. This can be accomplished with towels,
gel rolls, or an inflatable bag. For patients with
high pelvic tilt, access to the L5‒S1 disk space
can be challenging due to the angle of approach
and the encroaching pubic symphysis. In these
cases, the bump can be moved to beneath the
sacrum to optimize the angle.
●● Intraoperative neuromonitoring (IONM) is
controversial in ALIF procedures. Theoretically,
if reduction of a spondylolisthesis is performed,
there may be observable changes to baseline
somatosensory evoked potentials (SSEPs) and
 Operative technique  153

electromyography (EMG); however, we do not (a)

routinely use IONM during the index or the
revision ALIF unless we are concerned about
nerve root traction.
●● Image intensification can be utilized as needed
to assist in the safe placement of interbody graft
or device.

OPERATIVE TECHNIQUE
●● The patient is prepped and draped in the usual
sterile fashion.
●● When possible, it is our preference to approach the
spine from the contralateral side of the index sur-
gery to diminish the influence of scar tissue on
the development of a surgical plane.
●● The index hardware and residual graft should
be removed upon reaching the appropriate disk-
space level.
●● Attention should be paid to any existing bone (b)
loss, which may compromise the structural
integrity of the interbody space and inhibit graft
stability postoperatively (Figure 20.1).
●● Using a series of curettes and pituitary rongeurs,
the interbody space is cleared of fibrous tissue
down to a bed of bleeding bone. End plates, if
present, are maintained for structural support.
If the end plates are compromised from the
index operation or subsequent complications,
then the remaining bone is contoured appropri-
ately using curettes or a high-speed burr.
●● Once the disk space is prepared, the inter-
body graft or device is appropriately sized and
inserted. Our preference is to use femoral ring
allograft due to its structural properties and
historically good fusion rates (Figure 20.2).
●● Bone morphogenetic protein (BMP), such as
INFUSE (Medtronic, Minneapolis), can be
added to the femoral ring to augment host biol-
ogy and optimize fusion rates. It is important to
discuss this preoperatively with the patient, as
this is an off-label use of the product.
●● Internal fixation of the graft is not strictly
required; however, if there is difficulty obtain-
Figure 20.1 (a,b) demonstrate a lateral and an
ing stable fixation due to host bone loss, one
anteroposterior (AP) radiograph of a patient pre-
may apply an anterior plate to the operated level. senting with severe back and leg pain. Imaging
●● The wound is then checked to ensure adequate demonstrates nonunion of prior ALIF with bone
hemostasis, copiously irrigated in a standard loss and progressive spondylolisthesis at the L4–L5
fashion, and subsequently closed in a layered level. The previously placed interbody device likely
manner—all of which should prevent wound encroaches upon the neurologic elements.
154  Revision of an anterior lumbar interbody fusion (ALIF) nonunion

(a) dehiscence and minimize the risk of surgical

site infection.

POSTOPERATIVE MANAGEMENT
●● The patient should be started on a clear liquid
diet and advanced as tolerated.
●● The patient should be mobilized early to opti­
mize functional outcomes and decrease the risk
of venous thromboembolic complications.
●● Our preference is to begin subcutaneous hepa-
rin on postoperative day 1 for procedures at the
level of the cauda equina, and postoperative
day 2 for procedures at the level of the conus
medullaris.
●● A thoracic lumbar sacral orthosis (TLSO)
brace  may be useful in certain cases, mostly
for patient comfort. However, we recommend
this type of brace for patients who  have long
instrumentation constructs, as these con-
­
structs generate large cantilever forces.

COMPLICATIONS
(b)
●● Intraoperative vascular injury
●● Thromboembolic disease secondary to exces-
sive traction of the great vessels
●● Hypogastric plexus injury, resulting in retro-
grade ejaculation
●● Peritoneal perforation, resulting in visceral
herniation
●● Graft displacement
●● Persistent nonunion
●● Surgical site infection

Pearls and Pitfalls

Figure 20.2 (a,b) are the post-operative images
following revision surgery. The patient underwent
posterior decompression with placement of ped-
icle screws, followed by revision anterior recon-
struction with removal of interbody cage, partial
corpectomy, and iliac crest autograft. The patient
was then returned to prone position, and rods were
placed.
●● A bump may be used beneath the lumbar
spine or sacrum to facilitate better access
to the interbody space of interest.
●● A diagnosis of infection should be ruled out
preoperatively, as revision in the setting of
active infection may influence graft choice,
intraoperative cultures, and postoperative
antibiotics.
●● An approach through the contralateral ret-
roperitoneal space is recommended, as it
avoids navigation through scar tissue in the
original dissection plane.
●● Complete resection of the fibrous union is
essential in preparing an optimal fusion bed
during revision.

How to revise nonunion of a lateral
lumbar interbody fusion (LLIF) through
a lateral approach
HEEREN S. MAKANJI, JACQUELINE KOOMSON, DHRUV K.C. GOYAL, AND
GREGORY D. SCHROEDER
Introduction 155
Indications 155
Relative contraindications 156
Expectations 156
Principles of revision surgery 156
Preoperative planning 156
INTRODUCTION
Lateral lumbar interbody fusion (LLIF) allows
fusion between vertebral body end plates and
indirect decompression of neural elements, and
depending on the pathology, it can be done through
a minimally invasive tubular retractor or, often in
revision cases, through a slightly bigger incision.
This technique has demonstrated promising results
in patients with spondylolisthesis, degenerative
scoliosis, foraminal stenosis, and adjacent segment
disease. LLIF offers the advantages of a retroperito-
neal approach, which keeps the abdominal viscera,
sympathetic plexus, and great vessels unexposed.
The anterior and posterior longitudinal ligaments
are also spared, which maintains segmental sta-
bility. While the technique has gained significant
popularity in recent years, there is a scarcity of
literature regarding management following an
21
Operating room (OR) setup 156
Operative technique 157
Surgical technique 157
Postoperative management 158
Complications 158
unsuccessful surgery. Revision surgeries are asso-
ciated with an increased risk of perioperative com-
plications, longer postoperative stays, and greater
hospital costs. In the revision setting, both altered
anatomical planes and scar tissue can increase the
difficulty of achieving adequate and safe exposure
and maintaining the ability to execute the surgical
plan. Here, we aim to provide basic guidelines for
the management of revision lateral lumbar inter-
body fusion surgery for nonunion.
INDICATIONS
●● Pseudarthrosis
●● Graft subsidence
●● Graft extrusion
●● Graft misplacement
●● Persistent radiculopathy or other neurological
complications
155
156  How to revise nonunion of a lateral lumbar interbody fusion (LLIF) through a lateral approach

RELATIVE CONTRAINDICATIONS ●● Identification of modifiable risk factors for

nonunion such as smoking, and address as
●● Bilateral retroperitoneal scarring appropriate
●● Active tumor or infection ●● Upright posterior-anterior (PA) and lateral spine
●● Anatomic location of the great vessels and radiographs with flexion/extension views to
l­ umbar plexus assess residual instability—a comparison with
●● Cardiopulmonary compromise prior radiographs can help determine if there is
●● Need for direct nerve decompression—in this new instability, subsidence, etc. (hardware loos-
situation, a revision lateral lumbar interbody ening is typically first sign of nonunion)
fusion would need to be combined with a pos- ●● Determination of nonunion via computed
terior approach tomography (CT) scan—looking for bridging
bone between segments and assessing signs of
EXPECTATIONS hardware loosening
●● Evaluation of the degree of residual neural
●● Restoration of disc height compression, if present, via magnetic resonance
●● Resolution of back pain imaging (MRI), which will also help determine
●● Fusion of the involved segments the location of the great vessels and lumbar
●● Indirect decompression of neural elements, plexus for planning a safe lateral approach
depending on anatomical factors—combining ●● Consideration of a general surgeon for extended
with a posterior approach may be necessary for lateral approach may be appropriate, depend-
complete decompression ing on degree of scarring and surgeon comfort/
familiarity with anatomy during the revision
PRINCIPLES OF REVISION SURGERY
OPERATING ROOM (OR) SETUP
●● Extensive preoperative assessment, including
cardiac and medical clearance ●● The patient is positioned in the lateral decubitus
●● Preparation of the patient for surgery and post- position with approach side up.
operative expectations ●● A bump is placed between the contralateral infe-
●● Adequate neural decompression rior rib and iliac crest to expand the approach
●● Stabilization of involved segments plan (Figure 21.1)—alternatively, the table break
●● Maintenance of spinal alignment when at the same level can provide a similar effect.
applicable ●● Standard prepping and draping.
●● Postoperative bracing/rehabilitation ●● The use of fluoroscopy to determine skin
incision (if on the different side than prior
PREOPERATIVE PLANNING approach).
●● Biplanar fluoroscopy using two c-arms elimi-
●● Thorough history and physical examination nates the need for C-arm movement and loss of
to determine the timeframe of symptoms adequate imaging intraoperatively (Figure 21.2).
after initial surgery (i.e., improvement for ●● Each manufacturer will have a minimally inva-
short period of time and then return of pain/ sive tubular retractor system that may be used;
worsening pain) and associated neurological however, often in revision cases, having a gen-
symptoms eral surgeon to perform the exposure can allow
●● Full neurological examination with a focus on for better access and exposure.
muscles and dermatome supplied by nerve roots ●● Neuromonitoring with triggered electromyog-
near the zone of interest raphy (EMG) is necessary to provide informa-
●● Assessment of upright alignment/posture tion regarding position of the lumbar plexus
●● Assessment of hip joints, sacroiliac joints, and relative to the retractor, which encourages safe
prior bone graft sites docking on the lateral spine.

Figure 21.1  Example of patient positioning for lat-
eral lumbar interbody fusion. The bump is placed
just above the contralateral iliac crest to allow max-
imal opening of the operative window between
the lowest rib and iliac crest. (Photograph from
SpineUniverse.com.)
Figure 21.2 Biplanar fluoroscopy setup for lat-
eral lumbar interbody fusion. Using two C-arms
ensures that images remain unchanged and there
is no movement of the intensifier.
OPERATIVE TECHNIQUE
●● Although the lateral lumbar interbody fusion
procedure spares the paraspinal muscles of the
back, careful attention must be paid to the loca-
tion of the great vessels and lumbar plexus.
Surgical technique  157
●● Approach-related hip pain and hip flexion
weakness are quite common.
●● Vascular or true nerve injury are rare, but their
consequences can be disastrous.
●● A nonunion bed may have associated scar tis-
sue, and thus safe removal of the prior inter-
body graft with special attention to nearby
vasculature is necessary.
●● Placement of the new graft should be supple-
mented with lateral plate/screws or posterior
percutaneous screws—we recommend against
stand-alone LLIF for revision.
●● If direct decompression of neural elements is
necessary, a standard posterior approach is then
utilized after repositioning the patient.
●● Intraoperative fluoroscopy is useful for proper
graft positioning.
SURGICAL TECHNIQUE
Step 1: Exposure
1. Use of the prior incision site is likely adequate
for revision fusion; however, use lateral fluoros-
copy to confirm that prior incision will be in
line with disc space of interest. The approach
can be done with single or two-incision tech-
nique based on surgeon preference and comfort.
2 . Start by incising the skin in a standard fashion,
followed by carefully dissecting the abdominal
oblique muscles and underlying transversalis
fascia.
3. Once in the retroperitoneum, use blunt fin-
ger dissection to create a plane for dilator
placement.
4. Place the first dilator into the incision. Using
lateral fluoroscopy, aim the dilator at the junc-
tion of the anterior and middle third of the disc
space. At the same time, employ dynamic neu-
romonitoring to ensure safe passage through
the psoas major.
5. Once the dilator is seated on the disc space and
appropriate neuromonitoring readings have
been taken, place a threaded wire into the disc
space. This serves as a marker for subsequent
dilators to be placed.
6. Widen the working space using dilators with
­progressively larger diameters. Neuromonitoring
158  How to revise nonunion of a lateral lumbar interbody fusion (LLIF) through a lateral approach
should be used during each dilator placement to
ensure safe passage.
7. Once final dilator has been placed, determine
the length of retractor blades for insertion. Dock
the retractor firmly with the docking station.
Check the final EMG before final docking to
ensure nerve safety. Triggered EMG responses
greater than 10 mA are typically considered
safe.
8. Check placement of the retractor and AP
and lateral fluoroscopy prior to starting graft
removal.
9. Identify the anterior aspect of the vertebral
body and place a retractor here. The majority of
the case is going to be done utilizing AP radio-
graphs. The combination of AP images and a
retractor at the anterior aspect of the vertebral
body should allow the surgeon to have medial/
lateral and anterior/posterior references.
Step 2: Removal of previous graft
1. Identification of the previous graft may be dif-
ficult due to overlying scar tissue. Use of fluo-
roscopy at short intervals is helpful to ensure
localization.
2 . Use long-handled curettes, both angled and
straight, to free up the graft from the surround-
ing scar tissue end plates.
3. Kerrison and pituitary rongeurs can be used
to further remove excess tissue and free up the
graft.
4. Use of a scalpel may also be necessary to cut
through scar tissue that can often adhere to
graft.
5. Once graft is adequately freed, remove it with a
pituitary rongeur.
Step 3: End-plate/fusion bed
preparation and graft placement
1. Use a scalpel to widen the window through the
remaining annulus fibrosis and scar tissue.
2 . Use disc space shavers, distractors, and curettes
to removal all remaining disc and cartilage,
graft remnants, and scar tissue. Use angled
curettes to create bleeding bony surfaces for
graft placement. Be careful not to violate the
end plate, especially in osteopenic bone.
3. Determine the appropriate size and length of
the graft using manufacturer-provided mea-
surement tools.
4. Pack the selected cage with bone graft. Autograft,
allograft, and synthetics are all appropriate and
will vary based on surgeon preference. Iliac
crest bone graft (ICBG) may be considered in
patients at high risk of recurrent nonunion. The
use of bone morphogenetic  ­protein (BMP)-2
in this setting is  ­off-label, but it is commonly
employed in LLIF.
5. Place the cage carefully using fluoroscopic guid-
ance. Once the disc space is entered, use the AP
view to determine the appropriate depth of cage
placement to ensure that there is no extrusion
on the contralateral side.
6. In the case of revision fusion, we recom-
mend against stand-alone LLIF. The authors’
­preference is to use percutaneous pedicle screws
for supplementary fixation.
POSTOPERATIVE MANAGEMENT
●● Lateral lumbar interbody fusion allows quick
recovery time due to reduced blood loss and tis-
sue disruption
●● In a revision setting, expectations for post-
operative mobility and hospital length of
stay will vary based on the degree of surgical
invasiveness.
●● When combined with a posterior approach for
more direct neural element decompression or
percutaneous screw fixation, blood loss may be
higher and recovery duration delayed.
●● Patient comorbidities and pain management
considerations (especially in the setting of opi-
oid use prior to revision surgery) may limit
immediate postoperative rehabilitation.
●● External brace support is typically not neces-
sary, but may be provided for comfort or at the
surgeon’s discretion.
COMPLICATIONS
●● Recurrent nonunion
●● Graft subsidence/extrusion
●● Major vessel injury during approach, removal
of the prior graft, or insertion of the new graft
●● Lumbar plexus/femoral nerve injury

●● Approach-related hip pain and hip flexion
weakness
●● Infection
●● Persistent neurologic deficits
Pearls and Pitfalls
●● Most patients with degenerative lumbar
spine conditions can be treated without
surgery. A risk/benefit analysis should be
performed before each successive opera-
tion because of increased complication
rates. Careful evaluation of the patient’s
history, physical examination, and imaging
must be done to decide whether a revision
surgery should be performed.
●● Identify and improve modifiable risk fac-
tors for nonunion to maximize chances of
success following revision surgery.
●● Careful scrutiny of CT and MRI is neces-
sary to plan a safe approach to the lumbar
Complications 159
spine, especially in the revision setting; the
use of a general surgeon for the approach
is recommended in many revision cases.
●● Scar tissue from prior operations and irri-
tation of anatomic structures increases the
difficulty of adequate exposure and indi-
rect decompression.
●● Prior graft removal can be difficult, so care-
ful use of curettes and pituitary rongeurs
allows safe extraction.
●● Meticulous end-plate preparation with
removal of all intervening scar tissue will
increase the likelihood of union after
surgery.
●● Stand-alone constructs are not recom-
mended in the revision setting; supplemen-
tation with lateral plate/screws or posterior
screws should be employed.
●● Radiographic indication of fusion may not
always lead to good clinical outcomes;
therefore, patient education and manage-
ment of expectations after surgery are key.

How to surgically manage a recurrent
lumbar herniated nucleus pulposus
(HNP)
TAYLOR PAZIUK, MATTHEW S. GALETTA, AND JEFFREY A. RIHN
Introduction 161
Indications 161
Contraindications 162
Expectations 162
INTRODUCTION
Recurrent lumbar herniated nucleus pulposus
(HNP) is often associated with severe, disabling
symptoms. With the incidence of lumbar disc her-
niation among the population being between 1%
and 3%, and the risk of recurrence being reported
between 6% and 24%, recurrent lumbar disc her-
niation represents a significant clinical problem.
Symptomatic recurrent lumbar HNP is defined as
the onset of clinical symptoms, following a win-
dow of pain-free time postoperatively, which can
be confirmed upon imaging, typically using mag-
netic resonance imaging (MRI), with and without
contrast, to be associated with reherniation of the
nucleus pulposus through the annulus fibrosis at
the site of the index procedure. Certain patient-
related factors and characteristics of the involved
disc may affect the risk of sustaining a recurrent
herniation. The prevention and treatment of recur-
rent lumbar disc herniation present a significant
clinical challenge.
22
Principles of revision surgery 162
Preoperative planning 162
Complications 164
INDICATIONS
The occurrence of a recurrent lumbar disc hernia-
tion is a multifactorial process. Therefore, assess-
ment of which patients are at greatest risk for
reherniation requires a systematic approach that
addresses not only patient-related factors, such
as obesity, age, intervertebral disc characteristics,
and pathology, but also environmental factors
such as index surgeon experience and the extent
of annulotomy.
Much like the treatment of symptomatic
primary lumbar disc herniation, conservative
treatment options, including nonsteroidal anti-
inflammatory drugs (NSAIDs), oral steroids,
physical therapy, and epidural injections, should
be used for the initial management of recurrent
lumbar disc herniation. Surgical treatment for
recurrent lumbar disc herniation should be con-
sidered in patients whose radicular symptoms
persist beyond a period of 6 weeks despite conser-
vative treatment or in patients who demonstrate
161
162  How to surgically manage a recurrent lumbar herniated nucleus pulposus (HNP)
progressive weakness, signs or symptoms of cauda
equina syndrome, and/or intractable pain that
does not respond to conventional pain manage-
ment techniques and medications.
CONTRAINDICATIONS
Contraindications for lumbar discectomy are lim-
ited. Patients with back pain without radicular
symptoms are not good candidates for surgery.
Contraindications include the presence of spinal
stenosis, spondylolisthesis, and significant com-
promise of the spinal canal caused by the recurrent
herniated disc.
EXPECTATIONS
There are several surgical approaches to treating
a recurrent lumbar disc herniation. Generally, the
primary significant differences between the index
procedure and the subsequent revision procedure,
assuming that the same approach is employed,
include a longer operative time, increased risk of
dural tear and nerve injury, and the potential for a
relative decrease in satisfaction with the outcome
relative to the index procedure. Nonetheless,
when compared to treating primary lumbar disc
herniation, similar improvement rates in terms
of pain and function can be achieved with the
surgical management of recurrent lumbar disc
herniation.
PRINCIPLES OF REVISION SURGERY
The approach and operation performed for
addressing recurrent lumbar disc herniation are
largely based on whether this was the initial reher-
niation, the approach to the initial procedure, and
the surgeon’s preference. Surgical treatment should
be individualized to the patient based on the symp-
toms (e.g., back pain versus leg pain), findings on
imaging studies (e.g., presence of instability, severe
disc collapse, Modic changes), and patient expecta-
tions (e.g., whether a patient is OK with the ongo-
ing risk of recurrent disc herniation after a revision
microdiscectomy, or prefer a fusion, despite the
added risk and recovery time associated with
fusion surgery).
PREOPERATIVE PLANNING
Patients presenting with symptoms of recurrent
disc herniation should be worked up for potential
infection/abscess, epidural fibrosis, scar tissue, a
second primary herniation, and ultimately reher-
niation. Assessment of a patient’s complete blood
count (CBC) with a differential erythrocyte sedi-
mentation rate (ESR) and C-reactive protein are
very sensitive, albeit not very specific, tests for rul-
ing out infection.
Imaging—specifically gadolinium contrast
and noncontrast magnetic resonance imaging
(MRI)—is the modality of choice for differentiat-
ing fibrosis, epidural abscess, and potentially scar
tissue from reherniation. Although MRI without
contrast has about a 90% accuracy rate for diag-
nosing reherniation, gadolinium contrast is often
employed to differentiate postoperative fibrosis
from herniated nucleus pulposus. Additionally, the
extent to which fibrosis is portrayed via imaging
tends to vary based on time from index procedure
and degree of tissue manipulation (Figures 22.1a,b
and 22.2a,b). Nonetheless, it is common to order
both contrast and noncontrast MRI such that the
accuracy of diagnoses exceeds 90%. Computed
tomography (CT) (with or without myelography)
can be employed as the imaging modality of choice
in patients with specific contraindications to an
MRI.
Operative technique
For a traditional revision microdiscectomy, the
patient is positioned in the prone position on a
Jackson table or Andrews frame, allowing the
abdomen to be free and the hips to be flexed in
order to open the posterior lumbar interspaces. In
most cases, the original incision site can be used.
The incision should be a vertical incision in the
midline over the involved levels. Dissection is per-
formed through the subcutaneous tissue and deep
fascia using electrocautery. Intraoperative fluo-
roscopy or traditional x-ray is used to confirm the
correct levels by placing a metal clamp on the spi-
nous process. Dissection is then continued using
electrocautery in a subperiosteal fashion down the
lamina of the involved levels.
 Preoperative planning  163

(a) (a)

(b)

(b)

Figure 22.1  (a) Axial T2 MRI image without con-

trast at the L4–L5 level and (b) axial T1 MRI image
with contrast at the L4–L5 level, demonstrating a
recurrent disc herniation. The contrast enhances
around the extruded disc fragment (white arrow).
With the contrast, it is difficult to differentiate
between epidural fibrosis and herniated disc
material (white arrow, panel a).

Due to scar tissue and the presence of a prior

laminotomy, great care should be taken not to
bovie through the involved interspace, which can
result in a dural tear and spinal fluid leak. To pre-
vent this, great care should be taken to make sure
that the soft tissues are elevated off the lamina
bone. A Cobb can be used to scrape the scar tissue
off the remaining lamina to better identify the bone
and the site of prior surgery. The Cobb can also be Figure 22.2  (a) Sagittal T2 MRI image of the lum-
bar spine without contrast and (b) sagittal T1 MRI
used to dissect through the scar tissue and out over
image with contrast, demonstrating recurrent
the facet joint of the involved levels, taking great disc herniation at the L4–L5 level. The contrast
care not to damage the facet capsule. Following this enhances around the extruded disc fragment
dissection, the preferred soft tissue retractor can (white arrow, b). With the contrast, it is difficult to
be put in place. The authors prefer to use a Taylor differentiate between epidural fibrosis and herni-
retractor, which is placed over the facet joint. ated disc material (white arrow, panel a).
164  How to surgically manage a recurrent lumbar herniated nucleus pulposus (HNP)
After placement, this retractor can be secured
using a Kerlex-type dressing that is clipped around
the Taylor retractor. The surgeon’s foot can then
hold the loop of the Kerlex-type dressing that is
allowed to hang to the floor. After the retractor is
in place, a small, curved curette is used to dissect
the scar tissue from the edge of the previous lami-
notomy site. A high-speed burr can be used to per-
form an additional laminotomy, removing slightly
more bone and thinning the inferior and superior
lamina that borders the involved levels. Following
this, a 3-mm Kerrison rongeur can be used to com-
plete the revision laminotomy and perform a par-
tial medial facetectomy of the involved level, which
will allow access to the exiting and traversing nerve
root of the level. There is often a significant amount
of scar tissue around the nerve roots that must be
dissected through carefully using a small, curved
curette, a Woodson, and a nerve hook. The pedicle
is a good landmark when performing a revision
discectomy. Once the pedicle of the inferior ver-
tebra of the involved level is identified, dissection
can be performed safely to identify the traversing
nerve root as it passes and then exits beneath the
pedicle.
Due to scar tissue, it is often difficult to retract
the traversing nerve root to assess the disc hernia-
tion. A reverse-angled curette can be used to gain
this mobility. The curette can be passed under-
neath the traversing nerve root along the inferior
vertebra of the involved level, following the verte-
bra superiorly until the disc space is reached. The
curette can then be passed under the traversing
nerve root and over the disc in order to free up the
nerve root and better identify the disc herniation.
Once the traversing nerve root can be adequately
retracted, a nerve root retractor can be placed and
held by the surgical assistant. The disc herniation
can then be fully visualized and removed.
If the disc is extruded, it can be removed with
a pituitary rongeur. If there is still annulus cover-
ing the protruded disc, a number 15 blade scalpel
can be used to make an annulotomy to remove
the underlying protruded disc. Occasionally, an
extruded fragment will be difficult to retrieve
from its location ventral to the thecal sac and
traversing nerve root. A nerve hook can be used
to hook the extruded fragment and pull it out of
its ventral location. Once the discectomy is felt
to be complete, the adequacy of discectomy and
decompression should be confirmed with a nerve
hook and/or Woodson, making sure to check that
both the exiting and traversing nerve roots of the
involved level are free of compression. Hemostasis
is best obtained with bipolar electrocautery and
a hemostatic agent such as Floseal. The wound
should be copiously irrigated prior to closure, and
the anesthesiologist should perform a Valsalva
maneuver to ensure adequate hemostasis and the
absence of spinal fluid leakage.
COMPLICATIONS
The most common complication during this pro-
cedure is a dural tear, which is most often caused
by the Woodson, nerve hook, or curette during
the attempt to dissect through the scar tissue and
free up the nerve roots. Dural tears in this area
and through this small incision can be difficult to
repair. If a dural tear is encountered, it is often nec-
essary to extend the laminotomy and partial fac-
etectomy to identify the entire tear and perform a
repair adequately. The authors prefer to use a 6–0
Gortex suture for repair of the dural tear.
Small tears can be closed in a figure-of-eight
fashion, where longer tears can be closed using a
running-locking suture technique. If a watertight
repair is obtained, then no drain is necessary and
the patient can be mobilized after the surgery. If
a watertight repair is questionable, then a subfa-
cial drain should be left in place to protect the fas-
cia and skin from the caustic cerebrospinal fluid
(CSF) for 3–4 days. The drain can then be pulled
and the drain hole sutured shut. The patient can
be mobilized on the first postoperative day, so long
as he or she does not experience positional head-
aches in the postoperative period. If the patient
does experience positional headaches, flat bed
rest is recommended. Once the drain is pulled
and the drain hole is sutured closed (i.e., after 3‒4
days from the day of surgery), headaches typically
resolve and the patient can be fully mobilized and
discharged to home. If headaches persist and/or
there is CSF leakage through the incision, then a
lumbar drain can be placed and bed rest can be
implemented for an additional 4–5 days, or the
patient can be taken back to the operating room
(OR) for a better repair.

Pearls and Pitfalls
●● An MRI with contrast can better help dif-
ferentiate between a recurrent disc hernia-
tion and epidural fibrosis.
●● Nonoperative care is often successful for
revision disc herniations, especially if a
laminotomy was performed with the index
surgery.
Complications 165
●● The authors will generally attempt only one
revision discectomy. If a patient continues
to have recurrent disc herniations, consider
having an interbody fusion.
●● No annular closure method has been con-
sistently demonstrated to decrease the risk
of recurrence.

How to perform revision lumbar
decompression
JACOB HOFFMAN, RYAN MURPHY, MARK L. PRASARN,
AND SHAH-NAWAZ M. DODWAD
Introduction 167
Indications 167
Relative contraindications 167
Expectations 168
Preoperative planning 168
INTRODUCTION
The rate of revision lumbar decompression is
increasing with the growth of the aging popula-
tion. As more lumbar decompressions are per-
formed, there inevitably will be a growing number
of revision cases. Approximately 10% of patients
will develop persistent low back pain and radicular
pain due to recurrent stenosis after laminectomy.
Lumbar decompression may fail for a variety of
reasons, including inadequate bony or soft tis-
sue decompression, epidural fibrosis, recurrent
disc herniation, infection, instability, deformity,
or a combination of these factors. A systematic
approach to obtain the correct diagnosis will aid
the surgeon in selecting the best treatment option,
whether it is surgical or nonoperative manage-
ment. Surgical therapy requires close attention to
detail, as well as understanding and anticipating
potential postoperative issues. This chapter will
discuss the preoperative, operative, and postopera-
tive management of patients undergoing revision
lumbar decompression.
23
Operating room (OR) setup 169
Operative technique 169
Postoperative management 171
Complications 171
INDICATIONS
Patients who often require revision lumbar decom-
pression will present with progressive recurrent
symptoms of radicular leg pain in the setting of
recurrent stenosis. Upon imaging, these patients
will have either recurrent central, lateral recess,
or foraminal stenosis. Also, neurogenic claudica-
tion presenting as progressive bilateral thigh pain
that is worse with standing and activity due to ste-
nosis may benefit from decompression. A neuro-
logic deficit, such as cauda equina syndrome, is an
absolute indication for emergent revision lumbar
laminectomy.
RELATIVE CONTRAINDICATIONS
In the event of recurrent stenosis, the surgeon must
carefully consider the patient’s overall medical sta-
tus, including the presence of uncontrolled diabe-
tes mellitus (DM), smoking, increased body mass
index (BMI), and nutritional status. These factors
increase the risk of postoperative infection. Patients
167
168  How to perform revision lumbar decompression
with hemoglobin A1C (HbA1C) >7.0 should have
surgery delayed until there is improved glycemic
control. Smoking cessation should occur at least 1
month prior to operative intervention. A decom-
pression should not proceed in a patient with a
BMI >40 due to increased risk of postoperative
complications, including wound complications.
Additionally, in the setting of stable neurologic sta-
tus without significant weakness, the patient may
benefit from nonoperative management, including
nonsteroidal anti-inflammatory drugs (NSAIDs),
physical therapy, and fluoroscopically guided epi-
dural and transforaminal injections. Other relative
contraindications include the presence of pain due
to peripheral neuropathy or early discitis that can
be managed medically with antibiotic treatment.
Isolated axial lumbar pain without leg symptoms
or neurogenic claudication should not be treated
with repeat laminectomy.
EXPECTATIONS
After careful evaluation of the patient’s history
and physical examination findings and correlation
with advanced imaging, a discussion should be
held with the patient regarding the risks, benefits,
and alternatives to nonoperative versus operative
intervention. Patients are counseled that treat-
ment would maximize improvement of leg pain
and neurologic symptoms with equivocal relief of
back pain. The increased risks of a revision sur-
gery should be discussed with the patient. In the
revision setting, there is an increased risk of dural
tear, neurologic injury, epidural hematoma, and
infection.
PREOPERATIVE PLANNING
The surgeon should consider revision decompres-
sion in the setting of recurrent, progressive neu-
rologic symptoms that have failed all nonoperative
modalities. Careful history and physical exami-
nation with the aid of advanced imaging guide
the surgeon in making the correct diagnosis. The
location of residual stenosis should be noted and
addressed at the time of the operation. If there
is presence of spondylolisthesis, hypermobility
on flexion-extension radiographs, retrolisthe-
sis, or rotatory listhesis combined with recurrent
stenosis, the surgeon should consider fusion in
addition to decompression.
Prior to obtaining advanced imaging or labo-
ratory testing, a history should be taken and a
detailed physical exam performed at the initial
evaluation. The patient should be questioned
regarding the exact nature of the symptoms to
identify radiculopathy or neurogenic claudica-
tion. A detailed review of the patient’s past spinal
surgery should be obtained. Inspection of the pre-
vious surgical incision may reveal subcutaneous
fullness and fluctuance, indicating a postopera-
tive pseudomeningocele. The presence of a drain-
ing wound at the previous surgical site indicates
an infection that must be addressed with surgical
debridement. Sagittal balance may be assessed
with the patient standing. Significant stenosis
may result in positive sagittal balance or lean-
ing forward to decompress the neural elements.
Peripheral pulses should be palpated to rule out
vascular claudication. In office, ankle-brachial
index may be utilized to evaluate for peripheral
vascular disease. Hip joints are ranged to rule out
pain from hip arthropathy, primarily with inter-
nal/external rotation. The neurologic status of the
patient is evaluated and graded with sensory test-
ing, motor strength testing, deep tendon reflexes,
and assessment of gait.
After a differential is formed from the his-
tory and physical examination, advanced imag-
ing should be obtained for confirmation of the
diagnosis and planning of operative intervention.
Plain, upright anterioposterior (AP) and lateral
radiographs of the lumbar spine are generally
sufficient unless the patient is suspected to have
sagittal imbalance, where full-length scoliosis
films are performed. Radiographs showing spon-
dylolisthesis may require a fusion procedure in
addition to the decompression. A fine-cut com-
puted tomography (CT) scan with axial, sagit-
tal, and coronal reconstructions assesses bony
anatomy, including any defects after previous
laminectomy. The CT may reveal presences of
iatrogenic pars or facet defects. Previous instru-
mentation or presences of a pacemaker may make
magnetic resonance imaging (MRI) not feasible,
and a CT myelogram could be used to evaluate
these patients. In patients with previous lum-
bar surgery, MRIs with and without gadolinium

enhancement show increased uptake in vascular
tissues such as epidural scars from laminectomy.
The surgeon should carefully review the imag-
ing to note the exact location of the stenosis.
Typically, recurrent stenosis occurs at the central-
cranial aspect of the index level. However recur-
rence can also occur at the foraminal and lateral
recesses. The presence of bony bridging over the
site of the previous laminectomy should be noted.
Recognizing if the cranial or caudal spinous pro-
cesses have been removed can provide insight into
anatomical landmarks during the exposure. The
level of the dura should be compared to the local
bony anatomy to aid the surgeon during dissection
to prevent inadvertent dural violation. Presence
of a pseudomeningocele on imaging alters the
surgeon’s treatment plan. Patients with equivo-
cal advanced imaging may benefit from epidural
steroid injections, such as interlaminar, trans-
foraminal, or facet joint injections, to serve both
diagnostic and therapeutic purposes.
OPERATING ROOM (OR) SETUP
In the majority of cases, general anesthesia is
preferred. Alternatively, spinal anesthesia may
be used in one- or two-level revision laminec-
tomy. Appropriate intravenous (IV) access is
placed by the anesthesiology and nursing team in
the operating room (OR). An arterial line and a
Foley catheter are placed depending on the over-
all medical status of the patient. The patient is
then carefully logrolled prone on a radiolucent
open-frame Jackson table (Mizuho OSI, Union
City, California). The open frame allows the abdo-
men to hang free, thereby decreasing the epidural
venous pressure and potentially reducing intraop-
erative bleeding. Pads are placed just distal to the
anterior superior iliac spine and on the thighs. If
the desired level of decompression is the caudal
lumbar spine, a sling may be used to allow flex-
ion of the lumbar spine, which increases the inter-
laminar space. In the sling, the patient’s thigh and
knee should be flexed to facilitate lumbar flexion.
Only the pads for the pelvis are placed when a
sling is used. The arms are placed forward with the
shoulders and elbows bent at less than 90 degrees
each. A chest pad should be placed just distal to
the sternal notch.
Operative technique  169
For confirmation of the surgical level, intraop-
erative fluoroscopy is used. Appropriate personal
radiation protection should be utilized by all OR
staff. A mobile glass lead barrier and personal lead
apron with a thyroid shield will help reduce radia-
tion exposure. In most cases of revision lumbar
decompression, neuromonitoring is not necessary.
OPERATIVE TECHNIQUE
After appropriate patient positioning, the patient’s
skin over the planned surgical site is cleansed
with isopropyl alcohol and allowed to dry prior
to squaring off the surgical field with 1010 drapes
(3M, Maplewood, Minnesota). The drapes should
be placed wide. For lumbar spine surgery, draping
includes the cranial aspect of the intergluteal cleft,
which may be used as a midline landmark. An
alcohol-based prep is then used for sterilization of
the surgical field. After sterile prep, a spinal needle
is placed at the desired surgical level with the use
of lateral intraoperative fluoroscopy. The level is
then marked out and the spinal needle removed.
A second alcohol-based prep is used for final skin
sterilization.
Prior to skin incision, 10 mL of 0.25% bupiva-
caine hydrochloric acid (HCL) with an epineph-
rine local is injected along the planned incision.
The surgeon must not place the needle too deep in
the skin due to the potential of dural penetration.
After preoperative IV antibiotics, an incision with
a number 10 blade scalpel is made with a poste-
rior midline vertical approach utilizing the previ-
ous surgical scarring with extension of the incision
beyond the margins of the prior incision to facili-
tate visualization and identify more normal anat-
omy. In previous single-level decompressions, a
slightly larger incision incorporating normal tissue
may be used. The scalpel incision should be deep
enough to incise the majority of superficial fat, but
not past plane deep to the fascia. If fascia is intact
from the previous surgery, a Cobb elevator or blunt
dissection with a sponge can be used to define the
fascial layer clearly, which assists with fascial clo-
sure at the end of the procedure. Meticulous hemo-
stasis is maintained throughout the dissection, as
it is carried deep to the fascia with electrocautery.
Due to the surgical scar encountered, the desired
level of decompression should be approached with
170  How to perform revision lumbar decompression
great care from caudal to cranial area. The dura
can often be closely adherent to the surgical scar.
In general, revision surgical dissection should pro-
ceed from known to unknown and from normal
tissue to scar tissue. Approaching from normal tis-
sue can aid the surgeon in clearly defining the layer
of the epidural scars. Also in cases of a previous
single-level decompression, the inferior aspect of
the spinous process cranial to the desired decom-
pression level and superior aspect of the spinous
process of the caudal level may be palpated and
used as a guide. In some cases, the adjacent spinous
process may have been removed and should be
identified on preoperative imaging. Caution must
be taken until the cranial and caudal bones are
exposed. Once bone of the desired level has been
identified, the dissection should be carried out to
the remaining lamina. The lateral 50% of the facet
joint capsules should be protected throughout the
dissection. If adjacent virgin levels are stenotic and
require decompression, it is recommended that
these levels are dissected out first in a standard
fashion. This will help guide the surgeon to the
level that underwent previous decompression.
Once the level is fully exposed, a small, curved
curette is placed against the bone-epidural scar
interface to mark the level. An intraoperative lat-
eral image is obtained to validate the appropriate
level. In the revision setting, the stenosis is often
most severe at the cranial-central end of the scar.
Elevation of the scar is performed with a sharp,
curved microcurette at the lateral aspect of the
cranial bone‒epidural scar interface. The sharp
end of the microcurette is placed flush against the
bone, just superficial to the scar. With gentle pres-
sure in the cranial direction parallel to the bone,
the curette undercuts the bone-scar junction cre-
ating a surgical plane between the scar, dura, and
bone. The elevation is carried out lateral to medial
toward the central portion in this fashion.
After a clear margin is obtained with a microcu-
rette, a Penfield No. 4 elevator is used to gradually
increase the plane between the dura and epidural
scar. To further develop this plane, a cottonoid is
placed between the epidural scar and the dura.
Depending on exposure or levels involved, some
surgeons may use a microscope. Decompression
is now performed. If the bone edge is broad and
deep, a high-speed burr may be used to decrease the
thickness of bone prior to removal with a rongeur.
The burr is used in circular, sweeping movements
along the superficial bone. Once burr use is com-
pleted, bone removal with Kerrison rongeur can be
carried out in a more controlled and precise manner.
In some cases, the stenosis from the epidural
scar is so severe at the central-cranial aspect that
surgeons may begin with the caudal or cranial
aspect of the level, leaving the most adherent part
of the scar for removal last. The spinous process is
removed with a rongeur or lamina cutter. A high-
speed burr is used initially to thin the bone and
allow controlled removal by the Kerrison rongeur.
Once a plane is created between the bone and dura,
the surgeon works laterally to centrally. A curved
microcurette or Penfield elevator is used to create a
plane, releasing the remainder of the scar from the
dura to complete the decompression.
The lateral recess, from superior articular facet
hypertrophy, may be the source of stenosis in the
setting of previous inadequate decompression. The
Kerrison rongeur can be used to undercut up to 50%
of the medial aspect of the superior facet, ensuring
decompression of the lateral recess and preservation
of stability. Often, epidural venous bleeding can be
encountered during decompression of the lateral
recess. Hemostasis is achieved with topical human
thrombin-gelatin hemostatic matrix (Surgiflo),
bipolar electrocautery, or thrombin soaked gelatin
sponges (Gelfoam). The laminectomy is carried out
caudal to cranial until the caudal and cranial pedicle
can be palpated with a dural or Woodson elevator.
Any sharp spikes of bone along the decompres-
sion should be removed with a Kerrison rongeur to
­prevent inadvertent durotomy.
The foramina need to be inspected for the pres-
ence of stenosis or scarring. The exiting nerve root
can be traced along its path as it exits inferior to
the pedicle into the foramen with a Woodson ele-
vator or 4-mm ball-tip probe. Any bony spurs or
scar tissue should be removed. The Kerrison ron-
geur is used parallel and dorsal to the path of the
nerve root to cut out any remaining scar tissue or
bone. The surgeon should stand on the contralat-
eral aspect of the table to maximize visualization
of the dura during Kerrison use. After adequate
decompression, a 4-mm ball-tip probe or Woodson
elevator should pass unencumbered through the
foramina.

A disc herniation is usually recognized upon
imaging prior to the operation. However, after
appropriate decompression, the ventral spinal
canal should be inspected for any unidentified
protruded disc material. Inspection begins by
slightly displacing the thecal sac medially with a
Penfield elevator. The ventral aspect of the canal
is examined with another Penfield elevator or a
ball-tip probe for any extruded disc herniation.
Any fragments of disc visualized can be removed
with a micropituitary rongeur. Depending on the
amount of dural scar/adhesion, this maneuver may
prove difficult and may be abandoned due to risk
of durotomy. Once the surgeon believes that the
decompression is adequate, confirmation is made
with a lateral radiograph by placing a Penfield
number 4 and a Woodson elevator by the cranial
and caudal pedicle.
At the conclusion of the decompression, hemo-
stasis is achieved in the manner described here,
and the wound is thoroughly irrigated with nor-
mal saline. If significant bleeding was encountered
during the procedure, a medium-size Hemovac
drain is placed deep into the fascia. Some surgeons
place vancomycin powder in the wound prior to
closure. The risk/benefit ratio should be evaluated
for potential associated complications, including
seroma/wound complications with vancomycin
use in low-risk-infection patients. The fascia is then
closed in an interrupted, figure-of-eight fashion
with 0 braided, absorbable suture. Subcutaneous
tissue is closed in a buried, interrupted fashion
with 2–0 absorbable sutures, and skin is closed
with 3–0 nylon in a horizontal mattress fashion or
3–0 absorbable subcuticular suture, followed by a
skin sealant and sterile dressing.
POSTOPERATIVE MANAGEMENT
Revision one-level decompression patients may
be discharged home the same day as surgery. If a
drain is placed, the patient should be admitted for
1 night of observation. Oral multimodal pain regi-
men is initiated prior to the procedure for adequate
postoperative analgesia. Narcotic medication
should be minimized. Patients are encouraged to
mobilize the day of surgery with physical therapy.
Patients with dural tears are restricted to bed rest
for 24 hours postoperatively. While the patient is
Complications 171
in the hospital, the nutrition status is optimized,
with continued vitamin D and protein supplement
drinks. Patients are again counseled regarding
optimization of home nutrition prior to discharge.
Lumbosacral orthosis are not required after revi-
sion decompression cases. However, patients are
advised against heavy lifting, bending, or twisting
for the first 6 weeks after surgery to allow wound
healing. The first postoperative visit is 2‒3 weeks
after surgery, when incision evaluation is per-
formed. The patient is prescribed core-strength-
ening physical therapy at the 6-week postoperative
visit. Patients are generally followed for a mini-
mum of 3 months postoperatively.
COMPLICATIONS
There can be a myriad of complications following
revision decompression, including those related to
patient positioning, dural tear, nerve root injury,
infection, thromboembolic events, epidural hema-
toma, and pars interarticular or facet fractures.
Dural tears are well-known complications. In
revision surgery, these can be more common than
at the index operation due to the adherent epi-
dural scarring. Typically, the dural tear is created
by aberrant use of the Kerrison rongeur. Then the
dural scar is separated and mobilized away from
the bone, and it is kept clear using a Penfield eleva-
tor prior to using the Kerrison rongeur. If an inci-
dental durotomy is created, a primary repair is
performed with running nonabsorbable 6–0 non-
absorbable monofilament suture. Following suture
closure, a spinal sealant system such as DuraSeal
may be used. A Valsalva maneuver is performed to
test the adequacy of the repair. Patients are placed
on flat-bed rest for 24 hours postoperatively. After
the patient lies flat, the head of bed is slowly pro-
gressed and the patient is allowed to mobilize if
asymptomatic.
Infections typically present with increased
induration, erythema, and a draining wound in
the postoperative period. It is critical to address
the infection in an expeditious manner. Prior to
operative debridement and irrigation, a complete
blood count (CBC), erythrocyte sedimentation
rate (ESR), and C-reative protein (CRP) should be
obtained to aid the diagnosis and follow the clini-
cal course of the infection. Surgical debridement
172  How to perform revision lumbar decompression
is carried out deep to the fascia, and the wound is
thoroughly irrigated with normal saline.
If the patient is hemodynamically stable, antibi-
otics should be held prior to intraoperative culture
obtainment. After cultures are taken, broad-spec-
trum IV antibiotics are started. Closure may be
performed at the first debridement over a drain.
However, multiple factors may require a second
debridement, including the patient’s medical con-
dition, nutritional status, and presence of gross
purulence. If a second debridement is planned, a
negative pressure wound vacuum device might be
used.
Following spinal surgery, patients are at risk for
thromboembolic events, including deep venous
thrombosis (DVT) and pulmonary embolism.
Surgeons must weigh the risk of epidural hema-
toma with the risk of a thromboembolic event in
terms of chemoprophylaxis. In the preoperative
holding area, thigh-high compressive stockings
and sequential compressive device sleeves are
placed on the patient and used throughout the
procedure. In elective decompressions, patients
are encouraged to mobilize and use incentive spi-
rometry during the postoperative period. Venous
thromboembolic chemoprophylaxis is used in
high-risk patients approximately 24 hours post-
operatively. A symptomatic epidural hematoma
should be diagnosed promptly and the patient
emergently returned to the OR for decompression.
If the decompression is carried out too laterally,
the surgeon can cause an iatrogenic pars defect
or complete facetectomy with resultant instabil-
ity. Unrecognized defects may lead to progressive
deformity or increased lumbar pain postopera-
tively, with possible recurrent stenosis. Patients
may require a stabilization procedure depending
on pathology.
Pearls and Pitfalls
●● Assessment of recurrent stenosis includes
obtaining a detailed history and physical
exam and confirming the diagnosis with
an MRI, with and without contrast. CT is
often  useful in revision setting to identify
bony anatomy.
●● Segments of hypermobility or stenosis due
to spondylolisthesis may require fusion, in
addition to revision decompression.
●● Dissection to the epidural scar should
start from normal tissue and then extend
cranially and caudally over the scar tis-
sue. Always work from known to unknown
anatomy.
●● Scar is often adherent to the dura at the
central-cranial aspect of the level, and
decompression can begin at less-­adherent
areas. The surgeon may have to start
from inferior lamina or superior lamina to
develop an appropriate decompression
plan.
●● Always counsel patients and their fami-
lies of the increased risk of durotomy and
infection in the revision setting.

How to perform revision lumbar
decompression at the index level
through a minimally invasive (MIS)
approach
AARON HILLIS, CHRISTOPH WIPPLINGER, SERTAC KIRNAZ,
FRANZISKA A. SCHMIDT, AND ROGER HÄRTL
Indications 173
Relative contraindications 174
Expectations 175
Principles of revision surgery 175
Preoperative planning and operating
room (OR) setup (including the utility of
neuromonitoring) 175
INDICATIONS
History and physical examination
An appropriate patient selection for minimally inva-
sive (MIS) revision surgery is critical to achieving
good clinical outcomes. The indications for revision
surgery are related, but not limited to, residual or
recurrent radicular symptoms (Table 24.1). A thor-
ough physical examination is mandatory and plays
an important role in assessing symptoms caused by
recurrent disc herniation or lumbar stenosis symp-
toms. A detailed history is also crucial to properly
evaluate whether a patient’s neurological symp-
toms are persistent, recurrent, or new after pri-
mary spinal surgery, which may guide the surgeon’s
24
Surgical technique 176
Postoperative management 180
Complications 181
Reference 181
decision-making process. A pain-free period of
at least several months after discectomy, severely
reduced walking capacity, radicular pain distribu-
tion consistent with previously operated disc level,
radiating leg pain, and positive straight leg raising-
test of more than 30 degrees increases the likelihood
for true symptomatic ipsilateral recurrent disc herni-
ation. If the primary surgery was not performed on
the contralateral side of the disc, the clinical symp-
toms of the contralateral radiation leg pain often
resemble symptomatic first-time disc herniation.
Imaging studies
Imaging studies are key to minimally invasive revi-
sion surgery and should be carefully evaluated in
173
174  How to perform revision lumbar decompression at the index level

Table 24.1  Indications for patient selection for minimally invasive lumbar revision surgery

Indications for minimally invasive revision decompression surgery

• Patients with recurrent claudication or radicular symptoms
• Patients with a radiologically confirmed pathology, correlating with the current symptoms
• Patients with stable alignment in the sagittal and coronal plane
• Index level is stable on dynamic x-ray (flexion/extension)

relation to the clinical symptoms. Valuable informa-
tion can be gained by imaging modalities such as
plain radiographs, computed tomography (CT) scan,
and magnetic resonance imaging (MRI). Therefore,
the reevaluation protocol should include as many
studies as needed. Both MRI and CT scan are able to
accurately assess the degree of spinal canal narrow-
ing or foraminal stenosis after prior lumbar surgery.
MRI, with or without contrast, allows distinction of
disc material from postoperative scarring in recur-
rent disc herniation and provides valuable infor-
mation about the amount of intraspinal fibrosis in
recurrent herniated discs (Figure 24.1). However, CT
scans offer additional information about the config-
uration of the facet joints, as well as the osseous bor-
ders of the spinal canal. Additionally, they delineate
the extent of previous bony decompression.
Biplanar lumbar spine radiographs provide
valuable information about lumbar spine align-
ment and local deformity. Flexion-extension radio-
graphs should be analyzed for the presence of gross
instability involving previously operated segments,
as well as levels adjacent to the previous surgery.
Lumbar myelography should be reserved for
special cases in which MRI cannot be performed
safely. We do not see an indication for discography
or scoliosis films in revision decompression sur-
gery without fusion.
RELATIVE CONTRAINDICATIONS
While there are no absolute contraindications,
there are circumstances where minimally inva-
sive revision surgery is relatively contraindicated,
mainly due to the need for a wide decompression.
It would be inadvisable to use a minimally inva-
sive approach for treatment of severe neurologi-
cal deficits due to a massive central sequestrated
disc, which entails a wide decompression. In this
case, a minimally invasive unilateral fenestration
and microdiscectomy seems difficult and may
risk worsening of neurological deficits. In case of
an overt instability in dynamic imaging studies, a
simple revision may not address the main problem,
and a stabilization procedure may be necessary
(Table 24.2).

Figure 24.1  MRI image of left recurrent L5–S1 disc herniation after microdiscectomy.
 Preoperative planning and operating room (OR) setup (including the utility of neuromonitoring)  175
Table 24.2  Contraindications for minimally
invasive lumbar revision surgery
Contraindication of minimally invasive lumbar
revision decompression surgery
• Significant instability or deformity that may
require additional fusion surgery
• Significant bilateral scarring after previous
bilateral decompression surgery that makes
a unilateral MIS approach difficult
EXPECTATIONS
The goals of revision surgery are pain relief and
restoration of function. However, due to scar for-
mation, epidural adhesions, and an altered anat-
omy, revision surgeries are associated with worse
prognoses than primary surgery. Among other
factors, this is based on a higher rate of compli-
cations. However, tubular minimally invasive
approaches offer the advantages of less soft-tissue
trauma, reduced blood loss, and limited bony
resection, which leads to shorter hospital stays
and quicker recovery (Table 24.3). This advantage
holds true especially in recurrent cases and obese
patients.
PRINCIPLES OF REVISION SURGERY
The rationale and final goal for the MIS revision
decompression surgery is similar to that of the
primary surgery, which is decompression of the
neural structures without extensive bone and
muscle disruption. The main difference between
revision surgery and primary surgery lies in the
altered spinal anatomy due to a significant amount
Table 24.3 Advantages of minimally invasive
spine revision surgery
• Minimize muscle and soft-tissue disruption
• Decrease blood loss
• Limit bone resection
• Shorter inpatient hospital stays
• Faster return to regular activities
• Less risk of symptomatic CSF leaking
of epidural and/or periradicular fibrosis on the
side of primary surgery. Regardless of fibrosis or a
reherniated disk, this scarring may trigger radicu-
lar pain itself.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
(INCLUDING THE UTILITY OF
NEUROMONITORING)
Equipment
●● Operating table with Wilson frame
●● Fluoroscopy/navigation
●● Operative microscope or surgical loupes
●● Tubular set (high-speed drill—Kerrison rongeurs)
●● Monopolar/bipolar cautery
Patient positioning/preparation
After induction of anesthesia, the patient is usu-
ally placed in prone position, with knees and hips
slightly flexed. A Wilson frame is adequate if no
instrumentation is planned. Otherwise, a Jackson
table (Mizuho OSI, Union City, California) is gen-
erally used (Figure 24.2a). Care should be taken that
no compression is on the abdomen in order to avoid
an increase of central venous pressure and poten-
tially higher intraoperative blood loss. For level
localization, we do not rely on the location of the
scar from the previous surgery, which may be supe-
rior or inferior to the target disc space. Therefore,
we strongly recommend localization of the target
level with fluoroscopy or navigation (Figure 24.2b).
Intraoperative neuromonitoring
(IONM)
Intraoperative neuromonitoring (IONM) is com-
monly used in complex spinal procedures. In these
scenarios, methods like somatosensory evoked
potentials (SSEPs) and motor-evoked potentials
(MEPs), as well as free-run and triggered elec-
tromyography (frEMG and tEMG, respectively)
have helped to reduce complications by identify-
ing neural structures and avoiding neural injury.
Use of frEMG and tEMG in order to identify
176  How to perform revision lumbar decompression at the index level
Figure 24.2  Patient positioning (a) and fluoroscopy localization (b).
neural structures or verify nerve root decompres-
sion offers a potential field of application for IONM
in revision cases, and yet the literature regarding
this topic is scarce.
The monitoring of neural function may help
guide decompression in cases of severe neural com-
pression, or even conus/cauda compression, which
is often regarded as a contraindication to MIS. In
the case of redo spinal operations, the anatomy is
altered and may sometimes benefit from the use of
IONM. However, in our experience, it was not nec-
essary for visualization of the neural structures.
Therefore, IONM should be reserved for more
complex cases, where its use may be beneficial.
SURGICAL TECHNIQUE
MIS revision discectomy
A skin incision is usually made overlying the previ-
ous scar and target level, for which localization was
determined by fluoroscopy or navigation. The inci-
sion sometimes has to be slightly larger to accom-
modate a larger tubular retractor. Blunt dissection
is used to expose the lumbosacral fascia, which is
opened longitudinally. The smallest cannulated
dilator is advanced past the fascia and docked onto
the lamina of the target segment. The dilator is
then used to gently separate the soft tissues from
the dorsal aspect of the lamina and to palpate the
base of the spinous process medially, the facet joint
laterally and the inferior edge of the lamina. These
are the most reliable anatomical landmarks. The
target area is the zone of transition between scar
tissue and lamina. The final tubular retractor is
placed, and fluoroscopy is used to confirm its cor-
rect position (Figure 24.3).
For tubular revision decompression, it should
be taken into consideration that the lamina is not
as wide in the upper lumbar levels (L1‒L4) as in the
lower lumbar levels. In addition, the facet joints
are oriented more sagittally and the pars is thin-
ner, which makes it more vulnerable to potential
iatrogenic injury. Therefore, the tube should be
positioned more medially and vertically—about
1 cm from the midline (as opposed to 2 or 3 cm
from the midline in lower levels; see Figure 24.4).
This will avoid excessive ipsilateral facet removal
and potential instability. At the lower levels of (L4‒
S1), the tube should be docked more laterally from
the midline (2 or 3 cm) and at a greater angle to
achieve adequate decompression.
The working tube is then secured with a rigid
holding arm and directed slightly medially toward
the lamina ascending toward the spinous process.
From this point onward, the operating microscope
is used. Often, a small portion of the deep layer of
the multifidus muscle or postoperative scar tissue
overlays the lamina and interlaminar space (Figure
24.5a). A monopolar cauterizer can be used to thin
out the scar tissue layer by layer down to the level
of the laminae. Care should be taken not to go
deeper than the laminar level to avoid dural lac-
eration. It is of utmost importance to expose the
lamina clearly before continuing with further steps
of the operation (Figure 24.5b).

Figure 24.3 Intraoperative lateral fluoroscopy view showing the ideal placement of the working tube
retractor over the disc space (a). Illustration of fixed diameter retractor systems placed with a flex arm (b).
The next step depends on the intraoperative
findings. Usually, at least some degree of bony
removal is required to gain access into the spinal
≈1 cm ≈3 cm
(a)
(b)
Figure 24.4  Tube positioning at L1–L2, L2–L3, or
L3–L4. The tubular retractor should be positioned
more medially, about 1 cm from the midline
(a), instead of the customary 2–3 cm (b), to avoid
excessive ipsilateral facet removal.
Surgical technique  177
channel to find normal anatomy. To achieve this,
parts of the lamina have to be removed. A 3-mm
matchstick bone drill is used by positioning the
blunt tip on the scar tissue and the drilling side
on the edge of the bone (Figure 24.6). The drill-
ing starts at the inferior edge of the lamina and is
performed cranially, and from medially to later-
ally. The side-drilling technique essentially entails
removal of the bone that is covering the remnant
ligamentum flavum, with the blunt tip of the drill
bit always sitting on the scar tissue (Figure 24.6).
Once a few millimeters of bone have been removed,
the scar tissue is dissected from the inner surface of
the lamina with a blunt-tipped dissector or curette,
and an entrance for a small (2-mm) Kerrison ron-
geur is created. Stepwise resection of the inferior
parts of the lamina will then expose healthy dura.
Afterward, bone removal is carried out laterally
until the lateral edge of the transversing nerve root
is found (Figure 24.7). In the case of severe scar-
ring, identifying the nerve root can be difficult, so
removal of covering parts of the medial edge of the
superior facet may be necessary to achieve better
visualization. If the anatomy still remains obscure,
it is important to follow a basic rule: nerve roots
are intimately related to pedicles, so if a nerve root
cannot be found, find the pedicle and the root will
be immediately beside it.
After clear identification of the nerve root,
adhesions should be loosened between the nerve
178  How to perform revision lumbar decompression at the index level

Medial Medial

Scar tissue

Cranial Caudal Cranial Caudal

Lamina

(a) Lateral (b) Lateral

Figure 24.5  Intraoperative microscope image of remaining tissue after docking the final retractor tube (a).
Monopolar electrocautery is used over the residual lamina to dissect over the scar tissue (b).

root and dorsal dura and the surrounding scar
tissue if necessary, using an instrument such as a
blunt nerve hook. If the disc herniation has entered
into the epidural space, it can often be mobilized
with a ball-tip nerve hook and removed hereafter.
However, in the case of a subligamentous hernia-
tion or protrusion, the dorsal ligament has to be
opened carefully while retracting the dura and
nerve root medially. The nerve root is now exposed
and decompressed from its root sleeve exit to its

Medial

Scar tissue

Scar tissue Lamina

Ligamentum flavum

Cranial Caudal
L5 S1
Lamina
3-mm matchstick
bone drill

Lateral

(a)
(b)

Figure 24.6  (a) Intraoperative microscope image of lamina removal using a side-cutting match-stick bone
drill. (b) Schematic illustration showing the recommended use of a side-cutting matchstick bone drill.
The  blunt tip can be rested safely on soft tissues during drilling while drilling in the horizontal plane.
Vertical drilling is not recommended with this type of drill.
 Surgical technique  179

Medial minimum necessary. After removal of the herni-

Nerve root
Cranial
Lateral
Figure Identification
24.7  and exposure
of the nerve root and dural sac following
laminoforaminotomy.
entrance into the foramen. However, it might still
be covered with scar tissue. Nevertheless, we do
not recommend performing peeling (i.e., neuroly-
sis) of the fibrous tissue from the nerve, as it carries
a high risk of injuring the dura and does not pro-
vide a better clinical outcome.
Afterward, the herniated disc material can be
mobilized and removed (Figure 24.8). To reduce
the extent of nerve root manipulation, we limit
the removal of the herniated disc material to the
ated disc, the nerve root and dura should be free
from pressure in all directions, which is confirmed
by palpation with a ball-tip nerve hook.
Meticulous hemostasis must be achieved by
Caudal
using bipolar cautery or by tamponading the veins
temporarily with Gelfoam or Surgicel. Irrigation
with cold saline solution often helps achieving
hemostasis. Most epidural bleeding will stop after
a few minutes. In case of severe bleeding from the
epidural venous plexus, Batson gel- or powder-
type hemostatic agents can be used (e.g., FloSeal;
Baxter Healthcare Inc., San Juan, Puerto Rico).
The tubular retractor is removed slowly, with care-
ful evaluation of the soft tissue along the site of the
operative tract to ensure that no significant bleed-
ers are missed. Any bleeding encountered during
tube withdrawal is controlled by bipolar cautery.
The fascia and skin are then closed with absorbable
sutures. The subcutaneous tissues are injected with
local anesthetic to reduce postoperative pain, and
a small bandage is applied.
MIS revision lumbar laminectomy
An ipsilateral decompression is utilized when
symptomatic recurrent compression is confined to
only one side of the spinal canal. The first steps are

Medial Medial

Nerve root Nerve root

Disc
material
Cranial Caudal Cranial Caudal
Disc space

Disc space

(a) Lateral (b) Lateral

Figure 24.8  Intraoperative microscope image of the recurrent disc material, which can now be seen and
removed in the standard fashion with a pituitary rongeur (a). Intraoperative image showing satisfactory
decompression of ipsilateral nerve root after discectomy (b).
180  How to perform revision lumbar decompression at the index level
similar to the procedure of recurrent disc hernia-
tion described previously. After creating the tubu-
lar surgical portal, it is again of utmost importance
that the transition zone between scar tissue and
lamina be correctly identified. The 3-mm blunt
matchstick bone drill is used on the scar-bone
interface to extend the bony decompression in the
mediocephalad direction until the ligamentum fla-
vum is exposed or a plane between scar tissue and
bone can be developed (Figure 24.6). The remain-
ing cranial lamina is thinned out with the drill.
Hereafter, medial parts of the thinned lamina
are removed with Kerrison rongeurs until the
attachment of the ligamentum flavum is reached.
Remnants of the ligamentum flavum are then
removed, and the healthy dura can be identified.
The bony decompression is now extended later-
ally, but again take care not to violate the pars
interarticularis. The scar tissue overlying the dura
can hereby be used as a protection against dural
or even neural injury and therefore should not be
resected.
In patients whose symptoms can be related to
lateral recess stenosis, the medial portion of the
superior articular process is drilled and resected.
However, care should be taken not to remove too
much of the inferior articular process to avoid an
iatrogenic fracture or secondary instability. In the
next step, a Kerrison rongeur is used to trim the
medial portion of the superior articular process
until it is vertically flush with the medial border of
the pedicle. The foramen can be opened up with the
use of a curved-tip foraminotomy Kerrison ron-
geur. The ipsilateral side can be difficult to visualize
directly, so it is important to establish a dissection
plane above the nerve root by initial palpation with
a blunt probe, and then to continue to work in the
established plane using Kerrison rongeurs.
For patients with bilateral stenosis, a unilat-
eral approach to decompress the contralateral
side might be difficult due to severe scarring and
altered anatomy. Therefore, we recommend a bilat-
eral approach.
POSTOPERATIVE MANAGEMENT
In our practice, we begin pain management intra-
operatively by applying epidural steroids, such
as 40 mg of Solu-Medrol (methyl-prednisolone).
Furthermore, local anesthetic Marcaine (buvic-
aine) is administered intramuscularly. In order
to achieve immediate postoperative pain control,
patients are treated with a combination of nonste-
roidal anti-inflammatory drugs (NSAIDs), such
as ibuprofen) and opioids, such as Vicodin. Due
to the reduced muscle trauma in minimally inva-
sive spine surgery, the administration of additional
opioids is often not required. Nevertheless, care
should be taken to administer proton pump inhibi-
tors (PPIs) in the case of prolonged NSAID treat-
ment, and also to discontinue opioid treatment as
soon as possible. In our experience, analgesic treat-
ment is generally not required for more than 2–3
weeks postoperatively for minimally invasive redo
lumbar surgery.
In a normal course, we advise for early mobi-
lization after minimally invasive surgeries of redo
cases for lumbar herniated disc or lumbar stenosis.
Usually, patients are allowed to mobilize 2–4 hours
following surgery. However, in the case of an acci-
dental durotomy, bed rest is extended until the
next morning. In younger, healthier individuals,
discharge from the hospital is often possible on
the same day; however, in older, morbid patients,
a prolonged stay of 1–3 days is sometimes justified.
Typically, we do not place drains unless unusual
bleeding occurred intraoperatively. In these cases,
the drain is removed on the first postoperative day.
After initial mobilization, we advise our patients
to stay active and recommend a walking routine
of approximately 1 hour per day. A general restric-
tion in patients’ activity is not warranted, but
bending or twisting, as well as heavy lifting, should
be avoided for the first 6 weeks postoperatively.
While we advise our patients to start exercises
for improving flexibility and strength of the erec-
tor spinae as early as 2 weeks postoperatively, we
do not recommend starting physiotherapy earlier
than 6 weeks postoperatively in order to allow the
soft tissue to heal adequately. How quickly a patient
can return to work mainly depends on the speed of
the patient’s recovery and on the type of work that
the patient does. Usually, a gradual return to nor-
mal activities is advised.
Because wound closure is performed intracu-
taneously, removal of sutures is not necessary.

However, we schedule an early follow-up on day
7 for wound inspection and removal of steristrips.
Further follow-up is not required, so long as the
patient is free of symptoms.
COMPLICATIONS
The basic principle of minimally invasive treat-
ment of lumbar spine stenosis and disc hernia-
tion redo cases is avoidance of scar tissue. Thus, in
order to reach healthy tissue while avoiding scar
tissue, an enlargement of the bony decompres-
sion is required as described previously. The most
common complications associated with minimally
invasive redo surgeries—durotomy and risk of
secondary instability—are likely to occur during
bony decompression. However, in our experience,
the risk for intraoperative durotomy and second-
ary instability was still lower than in open decom-
pression or discectomy, as we were able to achieve
adequate decompression with minimal disruption
of the integrity of the pars interarticularis.
In the occurrence of a dural tear, our manage-
ment strategy depends on the size of the defect and
whether nerve roots protrude through the defect.
Recently, we published our technique for closure of
dural tears in a paper called “Ten-Step MIS Lumbar
Decompression and Dural Repair Through
Tubular Retractors” in Operative Neurosurgery.1 In
most cases, the defect is small and the nerve roots
are contained in the thecal sac, and this can nor-
mally be treated by covering the defect with a seal-
ant (e.g., fibrin glue or DuraSeal). In the case of a
large defect and nerve root protrusion, we aim at a
primary repair, for which we use the Scanlan endo-
scopic dural repair set and a 4–0 Nurolon TF-5
suture. After confirming the closure by perform-
ing a Valsalva maneuver, we cover the repaired
Reference 181
defect with an additional sealant. Patients with an
accidental durotomy are usually then placed on flat
bed rest until the next morning. Sequelae such as of
cerebrospinal fluid (CSF) fistula, severe headache,
and pseudocysts occur very rarely. Other compli-
cations are also extremely rare. The occurrence of
significant blood loss, wound infection, and neural
injury are negligible with our minimally invasive
technique.
Pearls and Pitfalls
●● Careful preservation of stabilizing struc-
tures (pars interarticularis and facet joints).
●● Blunt probe identification of anatomical
references is key in MIS surgery and revi-
sion surgery to avoid nerve injury or seg-
mental instability (lamina, pedicles, facets,
disc space).
●● Postoperative scar tissue that is densely
attached to dura is preferentially left in
place to avoid dura or nerve damage.
●● In upper lumbar levels, the tubular retrac-
tor should be positioned more medially
and vertically (1 cm from midline) to avoid
excessive ipsilateral facet removal and
potential instability. At lower lumbar levels
such as L4–L5 or L5–S1, a more lateral posi-
tion of the tubular retractor is advisable
(2–3 cm from midline).
REFERENCE
1. Boukebir MA, Berlin CD, Navarro-Ramirez R
et al. Ten-Step Minimally Invasive Spine
Lumbar Decompression and Dural Repair
Through Tubular Retractors. Oper Neurosurg
(Hagerstown) 2017;13(2):232–245.
doi:10.1227/NEU.0000000000001407

How to revise a transforaminal lumbar
interbody fusion (TLIF) nonunion with
recurrent stenosis at the index level
(open)
JESSE E. BIBLE AND GREGORY PACE
Indications 183
Relative contraindications 185
Expectations 185
Principles of revision surgery 185
INDICATIONS
Symptomatic nonunion...
Nonunion, or pseudarthrosis, should always be
included in the differential for any patient with pro-
gressive pain following an attempted prior fusion
procedure. Important points to extract from the
patient’s history include initial symptoms prior to
the original surgery (i.e., leg versus back pain) and
any change in symptoms following surgery (i.e.,
magnitude and duration). Patients with a symp-
tomatic nonunion frequently describe a honey-
moon period of approximately 4–6 months before
the onset of progressive low back pain, opposed to
someone who had predominantly preoperative back
pain, with continued back pain following surgery.
Likewise, a patient may also present with leg
symptoms in the setting of a lumbar nonunion.
25
Preoperative planning and operating
room (OR) setup 185
Operative technique 187
Postoperative management 189
Complications 189
Again, history is key to teasing out the potential
etiology of their leg symptoms. Lack of relief fol-
lowing surgery may suggest incorrect preoperative
diagnosis, inadequate decompression, or wrong-
level surgery. Immediate postoperative leg symp-
toms can be due to iatrogenic injury at the time of
surgery. Lastly, recurrence of symptoms can be a
result of adjacent-segment compressive pathology
or recurrent stenosis at the index level. The latter
can come in the form of static compression from
persistent pathology that has now become symp-
tomatic due to recurrent segmental motion or from
dynamic compression itself.
...Confirmed on imaging...
Along with determining if the patient is symp-
tomatic from a potential nonunion, further imag-
ing should be used to verify the presence of a
183
184  How to revise a TLIF

nonunion. This process commonly involves radio-
graphs and computed tomography (CT) scans.
Unlike the cervical spine, there remains a lack of
consensus of radiographic criteria for a nonunion.
Findings suggestive of nonunion include screw
haloing, significant osteolysis around the inter-
body cage, and minimal to no posterolateral or
interbody bone formation. Furthermore, dynamic
flexion and extension radiographs can be specific
for nonunion if segmental motion is noted, but not
if such motion is not seen. Frequently, a CT scan
is warranted to assess further for bridging bone.
The sagittal, coronal, and axial reconstructions are
closely scrutinized for bridging bone within the
facet joints, disc space, and posterolateral gutters.
Instrumentation is analyzed for its original posi-
tioning (malpositioning and/or change from screw
tract) and for any surrounding haloing.
After a nonunion has been confirmed via imag-
ing, areas of persistent or recurrent neural com-
pression are assessed via CT and/or magnetic
resonance imaging (MRI), especially in patients
with concurrent leg symptoms. Potential sources
of compression include foraminal stenosis from
remaining articular processes, hypertrophied tis-
sue from osteolysis, bone formation within the
path of interbody cage insertion, and malposi-
tioned instrumentation (Figure 25.1). Again, the
latter can be cage or screw malpositioning at the
time of index procedure, or subsequent migration
as micromotion develops from nonunion.
...Modifiable risk factors optimized
After a symptomatic nonunion has been con-
firmed via history, physical, and imaging workup,
it should be determined if the patient has any
modifiable factors that potentially increased their
risk for developing a nonunion. These may include
nicotine use, osteoporosis, malnutrition, infec-
tion, and noncompliance with temporary activity
restrictions.

(a) (b) (c)

Figure 25.1  A malpositioned cage with hypertrophic bone: CT imaging (sagittal [a, b] and axial [c]) from
a patient with recurrent left leg radiculopathy following a left-sided TLIF performed 2 years earlier at an
outside hospital. The interbody cage remains in prominent position, with hypertrophic bone formation in
the path of cage insertion.
 Preoperative planning and operating room (OR) setup  185
RELATIVE CONTRAINDICATIONS
●● Active infection (local or systemic)
●● Untreated osteoporosis/osteopenia
●● Active nicotine use
●● Malnutrition
●● Inability to follow temporary postoperative
restrictions
EXPECTATIONS
Setting appropriate expectations for revision non-
union surgery cannot be overemphasized. This is
especially true with patients for which their index
procedure was done predominantly for mechani-
cal back pain. Similar to most primary surgeries
for low back pain, revision nonunion surgery is
unlikely to cure them of their back pain. However,
if patients endorse a clear progression of symptoms
(i.e., back and/or leg) related to abnormal nonunion
motion and/or recurrent stenosis, revision surgery
has a high probability of relieving such symptoms.
Patients should also be counseled that revision
surgery is frequently more invasive, is riskier, and
has longer recovery. Pertinent risks include nerve
injury, given abnormal bony anatomy and epidural
fibrous tissue; durotomies; adjacent segment insta-
bility; and persistent nonunion.
PRINCIPLES OF REVISION SURGERY
For any revision surgery, obtaining original pre-
operative imaging and operative reports can be
helpful in putting a story together for a patient.
This includes trying to determine if the nonunion
occurred due to technical failure, biological fail-
ure, or both. When assessing the mechanical
environment on preoperative imaging, one needs
to address honestly if the construct used was suf-
ficient enough to provide immediate stability until
biological fusion. Examples could include isolated
L5/S1 pedicle fixation for high-grade isthmic spon-
dylolisthesis in the setting of high pelvic incidence.
Next, the biological environment is assessed
both locally and systemically. Local assess-
ment includes what type of bone graft was used
(iliac crest autograft, local autograft, allograft,
bone morphogenetic protein [BMP], etc.) and
where it was placed. An example might include
percutaneous transforaminal lumbar interbody
fusion (TLIF), with allograft placed only within
the interbody cage without further disc removal or
the use of more osteoinductive material. Although
a persistent deep infection frequently would have
manifested itself clearly, a prior history of infection
to the surgical site can be deleterious for any local
fusion environment.
Lastly, as discussed previously, systemic risk
factors for nonunion need be closely assessed.
Although some of these may not be able to be elim-
inated, they should be optimized as much as pos-
sible. A dual-energy x-ray absorptiometry (DEXA)
scan and metabolic labs are ordered for any patient
with risk factors for osteopenia/osteoporosis (age,
family history, steroid use, chronic renal failure,
rheumatoid arthritis, etc.). If abnormal, calcium
and vitamin D supplementation and pharma-
cologic agents (teriparatide or denosumab) are
initiated prior to any revision surgery, preferably
for a minimum of 3 months earlier. Malnutrition,
as assessed via prealbumin, albumin, and total
lymphocyte count, is optimized with the aid of
a certified nutritionist. Nicotine cessation is a
requirement before any revision nonunion sur-
gery, as this remains the greatest risk factor for
nonunion within a patient’s control. All patients
are clearly informed that replacing cigarettes for a
nicotine patch, gum, or vaporizer is not sufficient.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
Preoperative planning starts with clearly defin-
ing the following goals for the revision surgery:
(1) immediate stability with instrumentation,
(2) subsequent bony fusion, and (3) ± neural
decompression.
Immediate stability with
instrumentation
PEDICLE SCREWS
If easily obtainable, old operative reports are help-
ful in determining what company and size of
instrumentation were used. Preoperative imaging
(most notably CT) is closely reviewed to see if any
pedicle screw tracts need to be redirected. Similarly,
186  How to revise a TLIF

the extent to which each screw can be upsized in
diameter and length should be templated to obtain
the greatest possible bony purchase.
INTERBODY CAGE
The location of the prior interbody cage is evalu-
ated. If a single bullet cage was placed in an off-cen-
ter location, a contralateral TLIF can be performed
using an additional bullet cage, as opposed to a
banana-shaped cage. Extreme caution should be
taken when considering removing a prior posterior
lumbar interbody fusion (PLIF)/TLIF cage from a
posterior approach, given the risk of nerve/dura
injury.
If a single TLIF cage appears to be well centered
or focal end-plate violation is seen via imaging, an
anterior lumbar interbody fusion (ALIF) should
be considered, as opposed to a revision TLIF. This
approach allows for the old interbody material to
be meticulously removed and a large structural
cage/graft placed, spanning most end-plate defects
by seating along the apophyseal ring (Figure
25.2). Revision posterior instrumentation is also
performed in the setting of ALIF for nonunion,
especially if prior posterior instrumentation is
clearly loose on preoperative imaging.
Bony fusion
All potential areas of bony fusion are closely
assessed on radiograph, CT, and MRI. Not infre-
quently, when a prior TLIF has been performed,
the posterolateral gutters, dorsal to the inter-
transverse membrane, remain virgin territory for
a traditional posterolateral fusion (Figure 25.3). A
contralateral facet joint can also be used as a focal
area of fusion, with articular cartilage and cortical
bone removal and bone graft placement.
Along with additional mechanical stability
provided by interbody cages/grafts, the interbody
space can provide additional surface area for bony
fusion. Again, a contralateral TLIF approach can
be used in the setting of prior asymmetric cage
placement, or an ALIF can be performed to pro-
vide a larger interbody surface area for bony fusion
(Figure 25.4).
Given the biological hurdles for bony fusion
during revision nonunion surgery (i.e., avascu-
lar tissue), iliac crest autograft or BMP is strongly
encouraged due to the osteoinductive potential.

(a) (b) (c)

Figure 25.2  ALIF with removal of well-centered TLIF cage: Active smoker with symptomatic nonunion and
L5 foraminal stenosis following minimally invasive TLIF and percutaneous screw placement at outside facil-
ity for isthmic spondylolisthesis. An anteroposterior (AP) radiograph (a) shows a well-centered single bul-
let cage with surrounding osteolysis/end-plate violation on sagittal CT (b). Following smoking cessation,
the patient was treated with allograft ALIF and revision posterior laminectomy/foraminatomies and fusion
with iliac crest autograft. Postoperative lateral radiograph at 3 months (c).
 Operative technique  187

(a) (b)

(c) (d)

Figure 25.3  Missing bilateral pars and rudimentary transverse processes: Lateral radiograph (a) and coro-
nal CT image (b) from a patient with two-level nonunion following TLIF. Given that the prior surgeon had
resected bilateral L4 facets/pars and the patient had very rudimentary transverse processes at L4 (limiting
posterolateral fusion potential), ALIF was performed by burring out prior TLIF cage at L4/5, followed by
revision posterior fusion with iliac autograft. AP (c) and lateral (d) radiographs at 6 months postoperatively.

Neural decompression Preoperative CT imaging can be helpful in determin-

In the setting of recurrent leg symptoms, sources of
static and dynamic compression need to be correlated
with symptom distribution. In the setting of clear
static compression (i.e., articular processes, malposi-
tioned cage, hypertrophic bone formation), revision
direct posterior decompression is the most reliable
procedure for obtaining symptom relief. However,
this holds some increased risk for nerve injury,
especially if on the side of the prior TLIF approach.
ing what bony landmarks remain (i.e., pedicles and
articular processes) and in nerve root dissection.
OPERATIVE TECHNIQUE
Anterior lumbar interbody fusion
(ALIF)
The standard approach to the desired disc space
is used. Using a knife and pituitary rongeur,
188  How to revise a TLIF

anterior longitudinal ligament and disc material
are removed back to the anterior aspect of the
cage. The edges of the cage are then clearly demar-
cated. If minimal bone or fibrous tissue has formed
within the cage, it can frequently be removed with
just a Kocher clamp. If this does not work, but
some toggle is noted at the cage/bone interface, a
thin osteotome can gently be tapped between sur-
faces; however, extreme caution should be used not
to further disrupt the endplate. Lastly, if the cage is
polyetheretherketone (PEEK) or bone, a burr can
be used to gradually burr down the cage. The pre-
operative imaging is closely assessed to determine
if the posterior aspect of the thecal sac is in contact
with the posterior cage.
Similar to a primary ALIF procedure, the tallest
and widest cage is used to get the best fit. It should
span across any end-plate defects onto the periph-
eral apophyseal ring in order to prevent subsidence.
Revision posterior instrumented
fusion ± transforaminal interbody
fusion
Posterior instrumentation is dissected out and
removed, taking note of the amount of torque
required for removal. The remaining articular and
transverse processes are meticulously dissected
free of soft tissue, down to the intertransverse
membrane bilaterally, for later planned standard
posterolateral arthrodesis. Junctional facet cap-
sules from noninstrumented segments should be
preserved. New pedicle screws are placed. Larger-
diameter and longer screws are used based on the
torque required for the removal of prior instrumen-
tation, as well as preoperative image templating.
If neural decompression or a contralateral
TLIF approach is required, the medial edge of the
remaining pars is identified and a plane is created
between the epidural fibrous tissue using Cobb,
curette, and Kerrison rongeurs. The medial edges
of both superior and inferior pedicles are clearly
identified, allowing the corresponding exiting and
traversing nerve roots to be safely visualized.
If a contralateral TLIF is planned, the pars is
transected and articular processes are removed
in a standard fashion. After the existing and tra-
versing roots are visualized and protected, a
meticulous discectomy and interbody fusion are
performed, keeping in mind that there likely will
be fibrous tissue throughout the interbody space to
be removed (Figure 25.4). The anterior interbody

(a) (b) (c)

Figure 25.4  Contralateral TLIF: Gross nonunion with recurrent L5 radiculopathy after prior broken hard-
ware was removed by an outside surgeon due to the patient’s pain. Sagittal (a) and coronal (b) CT imaging
shows clear nonunion with severe L5 foraminal stenosis and lateral TLIF cage placement with surrounding
osteolysis. Due to concern about harming a well-functioning transplanted kidney within the pelvis, the
patient refused any anterior approach. Therefore, after negative infection workup and denosumab treat-
ment, the patient was treated with revision foraminotomies, contralateral TLIF, and instrumented fusion
with iliac crest autograft. (c) Immediate postoperative radiograph. Fusion was extended up to L4 due to
prior resected articular processes at junctional facet joint noted on preoperative CT imaging.

space is then packed with iliac crest autograft prior
to cage placement.
In the setting of prior TLIF cage malposition-
ing causing neural compression, the nerve roots
are safely identified by following the medial and
inferior edges of the pedicles. The residual disc
space is identified laterally in line with the superior
and inferior pedicles and followed medially until a
prominent cage is palpated. The thecal sac is gently
cleared off ventrally and medially using a Penfield
elevator and curettes. If the cage is clearly loose,
attempts can be made to remove it with a Kocher
clamp after all surrounding dural adhesions have
been released. More frequently, the cage is well
fixed; in this case, a burr can be used to burr down
the prominent aspect of the cage carefully, leaving
the remaining anterior portion intact.
POSTOPERATIVE MANAGEMENT
A standard postoperative regimen is initiated fol-
lowing surgery. For short-segment fusion con-
structs, a lumbar brace or corset is not commonly
prescribed. The surgeon should emphasize to the
patient the importance of continued calcium and
vitamin D supplementation and pharmacologic
agents if initiated preoperatively, along with nico-
tine cessation.
COMPLICATIONS
●● Nerve injury: This is an increased risk, espe-
cially if the prior TLIF path is being dis-
sected again for revision foraminotomy or a
Complications 189
prominent cage. The medial and lateral walls
of the cephalad and caudal pedicles are used
to safely identify exiting and traversing nerve
roots. A low-energy trigger EMG probe can also
be utilized to help differentiate scar and neural
tissue. The respective roots can also be identi-
fied lateral to the pedicle and followed medially.
●● Dural injury: Patients are at increased risk of
dural tear given epidural fibrosis. Some basics
of dural repair around a revision tissue bed
include (1) freeing surrounding adhesions to
limit tension on the primary repair, (2) using a
stiff needle to pass through scar tissue, and (3)
limiting subfascial dead space with paraspinal
muscle reapproximation prior to tight fascial
closure.
Pearls and Pitfalls
●● Risk factors for lumbar nonunion should be
identified and successfully treated before
any revision nonunion surgery is consid-
ered. This most frequently entails smoking
cessation and osteoporosis pharmacologic
agents.
●● Prior TLIF cage positioning should be
closely evaluated via preoperative CT
imaging to determine if contralateral TLIF
can be performed, as opposed to ALIF.
●● All remaining areas for potential fusion
beds should be evaluated via preoperative
imaging and utilized during the revision
procedure.
●● In the setting of clear nonunion, an isolated
ALIF without revision posterior instru-
mented fusion is discouraged.

How to revise a minimally invasive
transforaminal lumbar interbody fusion
(MIS TLIF) nonunion with recurrent
stenosis at the index level through an
MIS approach
FADY Y. HIJJI, ANKUR S. NARAIN, GREGORY D. LOPEZ, KRISHNA
T. KUDARAVALLI, KELLY H. YOM, AND KERN SINGH
Indications 191
Radiographic evidence 191
Principles and expectations of revision surgery 192
Preoperative planning and contraindications 193
INDICATIONS
Multiple indications exist, which may necessitate
a revision fusion following minimally invasive
transforaminal lumbar interbody fusion (MIS
TLIF). Predominantly, patients with persistent low
back pain who exhibit radiographic evidence of
pseudarthrosis at a minimum of 1 year following
MIS TLIF should be considered candidates for a
revision procedure. Additionally, patients exhibit-
ing implant failure, including cage migration and
subsidence with subsequent neurologic symptoms,
should be considered for a revision fusion. While
not necessarily requiring a revision fusion, pedicle
screw malposition may also be an indication for a
revision procedure.
26
Operating room (OR) setup and operative
technique 195
Postoperative management 197
Complications 197
RADIOGRAPHIC EVIDENCE
Radiographic imaging is necessary to identify
the occurrence of pseudarthrosis following MIS
TLIF and the necessity for a revision procedure.
Anterioposterior (AP) and lateral radiographs,
as well as sagittal and axial magnetic resonance
imaging (MRI), of the lumbar spine are obtained.
Coronal and sagittal computed tomography
(CT) images are also obtained to better eluci-
date existing pseudarthrosis. Radiographic signs
of pseudarthrosis include subchondral sclerosis,
subchondral cyst formation, and pedicle screw
loosening. Interbody graft subsidence may also
be present, along with evidence of interbody cage
migration (Figure 26.1). Upon MRI, subchondral
191
192  How to revise a minimally invasive transforaminal lumbar interbody fusion

(a) (b)

Figure 26.1  (a) AP and (b) lateral radiographs demonstrating pseudarthrosis at the L4–L5 vertebral level
following MIS TLIF.

and pedicle edema are indicative signs of pseud-

arthrosis (Figure 26.2). Characteristics of pseud-
arthrosis on CT will be similar to that found on
radiographs. In addition, cystic changes around
the interbody device margins or lucency through
the fusion mass may be identified on the coronal
view. The absence of bony bridging within the
interbody space in sagittal or coronal views is also
pathognomonic of pseudarthrosis following MIS
TLIF (Figure 26.3).

PRINCIPLES AND EXPECTATIONS

OF REVISION SURGERY
A revision MIS TLIF is performed to revise any
technical errors, insert additional or more effi-
cacious graft material, and improve the biome-
chanical environment created by the initial fusion
procedure. This is achieved through the revision Figure 26.2 Sagittal magnetic resonance imag-
and adjustment of implant positioning and size to ing (MRI) demonstrating pseudarthrosis following
improve the amount of surface area contact between MIS TLIF.

(a)
(b)
Figure 26.3 (a) Sagittal and (b) axial CT of the
lumbar spine demonstrating pseudarthrosis, with
cystic changes around the interbody cage.
Preoperative planning and contraindications  193
the graft and vertebral end plates. Additionally,
readjustment of screw size and positioning can
increase the strength of vertebral fixation, thereby
minimizing vertebral motion and subsequently
reducing the biomechanical stress at the fusion
site. By adjusting these parameters, a surgeon will
be able to provide the best environment to facilitate
lumbar fusion. As such, it is expected that revision
MIS TLIF will allow fusion to occur in those who
have previously failed to fuse, thereby eliminating
the continuing symptoms associated with motion
at the fusion site.
PREOPERATIVE PLANNING AND
CONTRAINDICATIONS
The preoperative planning phase for a revision
MIS TLIF is crucial to identifying the feasibility
and any potential contraindications for the pro-
cedure. Based on particular imaging findings,
the surgeon can determine whether an MIS TLIF
or another approach should be utilized. Upon
meeting the indications for a revision fusion, CT
scans are initially reviewed to assess the position-
ing and strength of previous screw fixations. This
will determine the necessity for screw adjust-
ment, screw replacement, or large interbody cage
placement (Figure 26.4). If screw positioning is
adequate with minimal loosening, screws will
require removal and an increase in size. If screw
malpositioning is evident with minimal loosen-
ing, screw removal, screw redirection, and screw
size adjustment are necessary. If gross screw loos-
ening is apparent, the revision fusion may require
the placement of an interbody implant with a large
footprint, in addition to screw readjustment.
Following the assessment of screw placement,
a detailed analysis of the interbody cage position-
ing, size, and type is performed. Cage position-
ing will frequently determine the approach to be
utilized for the revision procedure. If there is evi-
dence of cage migration posteriorly into neural
elements, an anterior approach for the revision
procedure will often be utilized. However, if pos-
terior cage migration is not present, a revision MIS
TLIF can feasibly be performed. In this scenario,
the type of cage previously utilized must then be
evaluated. If a straight-bullet style interbody cage
has been previously inserted, a revision MIS TLIF
194  How to revise a minimally invasive transforaminal lumbar interbody fusion

Clinical and radiographic evidence of pseudarthrosis 1 year

postoperatively following MIS TLIF

Review lumbar coronal and sagittal CT scan

Screw malpositioning or loosening?

Screw position Screw Screw

adequate with malposition malposition with
minimal loosening with minimal gross loosening
loosening
Remove screws and Remove screws, redirect
Remove screws, redirect
reinsert in similar malpositioned screws, and increase
malpositioned screws, and
position with increased size of all screws. Increase footprint
increase size of all screws
screw size of interbody cage

Cage migration in posterior

neural structures?

Yes No

Not a candidate for revision

Possible candidate for revision
MIS TLIF. Utilize anterior
MIS TLIF. Review type of
approach and remove
interbody cage.
previous interbody cage

Type of interbody cage?

Other type of cage or multiple

Straight bullet
Banana shape TLIF cages placed at 1 level
shape

Not a candidate for

Candidate for Room for
revision MIS TLIF.
revision MIS TLIF. contralateral or
Utilize anterior approach
Place cage on ipsilateral interbody
with removal of previous
contralateral side cage?
interbody cages

Contralateral Contralateral
or ipsilateral and ipsilateral
interbody interbody cages

Candidate for Candidate for

revision MIS TLIF. revision MIS TLIF.
Utilize 1 interbody Utilize 2 interbody
cage cages

Figure 26.4  Preoperative decision-making flowchart for revision MIS TLIF.

 Operating room (OR) setup and operative technique  195
with cage placement on the contralateral side can
be utilized. If a banana style of interbody cage is
present, an assessment of the available interbody
space is required. If there is adequate space avail-
able in either the contralateral or ipsilateral side,
a revision MIS TLIF can be performed with the
utilization of 1 interbody cage. If room is available
on both the contralateral and ipsilateral sides, two
interbody cages can be inserted. If no space exists
or another type of interbody cage has been uti-
lized, then an anterior approach with removal of
the previous interbody cages must be performed.
Once the feasibility of a revision MIS TLIF has
been confirmed, the interbody graft choice and
fusion type is determined. For revision MIS TLIF
procedures, the senior author frequently utilizes
iliac crest bone graft (ICBG) with an interbody
cage, with or without posterolateral fusion.
OPERATING ROOM (OR) SETUP
AND OPERATIVE TECHNIQUE
Patient positioning
The patient undergoing revision MIS TLIF is posi-
tioned in a fashion similar to that of a primary
MIS TLIF. Initially, the patient will undergo anes-
thesia and endotracheal intubation. The patient is
then placed in the prone position on a radiolucent
table, including a standard table with chest rolls
or a Jackson table with chest and hip pads. Chest
pads are placed on the manubrium, and hip pads
are placed inferior to the anterior superior iliac
spine (ASIS) to maintain lumbar lordosis and
reduce venous pressure around the lumbar spine.
Following pad placement, the patient’s arms are
positioned in 90 degrees of shoulder and elbow
flexion, with foam padding underneath to prevent
ulnar nerve compression. Following final position-
ing, the iliac crest and lumbar spinous processes
are readily palpable. Lateral and AP fluoroscopic
images are then obtained to ensure appropriate
positioning, with adequate visibility of the pedi-
cles. The skin is then prepared and draped.
Screw removal and replacement
Previously inserted percutaneous pedicle screws
are initially removed. Following removal, a
Jamshidi trocar is centered on the vertebral pedicle
using fluoroscopic guidance. A guide wire is then
inserted and advanced until the medial pedicle
wall is reached, as identified by AP fluoroscopy.
This is repeated for the contralateral pedicle and
the pedicles of the adjacent vertebral level (Figure
26.5a). It is crucial to ensure that the spinous pro-
cesses are centered in the AP fluoroscopic view
to facilitate accurate screw placement. Following
guide-wire placement, a lateral image is obtained
to ensure placement of the guide wires beyond
the posterior vertebral body wall and within the
medial pedicle wall. Once appropriate placement
of the guide wires has been confirmed, the pedicle
screws on the contralateral side of the revision MIS
TLIF (the ipsilateral side of the original MIS TLIF)
can be placed over the guide wires. The guide wires
of the inserted pedicle screws can then be removed,
and a rod is placed submuscularly into the pedicle
screws’ tulips (Figure 26.5b).
Incision and exposure
A 22-gauge spinal needle is inserted toward the
facet joint at the level to be revised. The needle
will be inserted on the side contralateral to that of
the previously performed interbody fusion. Once
the appropriate vertebral level is confirmed via
fluoroscopy, the needle is removed, and a parame-
dian incision is made approximately 4–5 cm lat-
eral to the midline on the same side as the needle.
In larger patients, a more laterally placed incision
may be necessary. The incision is frequently made
to be equivalent to the diameter of the final tubu-
lar retractor (approximately 2.5 cm). A K-wire
or initial dilator is inserted through the fascia
and erector spinae musculature toward the facet
complex in a lateral-to-medial direction using
fluoroscopy. Serial dilators are then continuously
passed over the initial wire or dilator to expand
the working portal. The dilators are frequently
swept to remove any creeping muscle or soft tis-
sue. Once the final dilator is placed, a tubular
retractor is placed and docked over the facet, and
serial dilators are removed. The tubular retractor
system is then firmly affixed to the table frame,
and fluoroscopic images are obtained to confirm
the correct positioning and orientation of the sur-
gical corridor.
196  How to revise a minimally invasive transforaminal lumbar interbody fusion

(a) (b)

Figure 26.5 (a) Intraoperative AP fluoroscopic image demonstrating guide-wire placement within the
pedicles of the fusion site. (b) Intraoperative lateral fluoroscopic image demonstrating pedicle-screw
placement and guide-wire removal on the contralateral side of the intended revision MIS TLIF.

Procedure drill until the ligamentum flavum is visualized.

The remainder of the procedure is performed by
utilizing an operating microscope or under illu-
mination with loupe magnification (Figure 26.6).
Using electrocautery and pituitary instruments,
any residual soft tissue within the surgical corri-
dor is cleared from the lamina and facet joint. A
laminectomy is then performed using a high-speed
Figure 26.6  Image demonstrating visualization of
the facet joint through the tubular retractor.
Bone removed during this process can be saved as
autograft material for use later in the procedure.
The laminectomy is then extended cranially until
the insertion of the ligamentum flavum. A facec-
tomy is then performed, taking care to first remove
the pars interarticularis and inferior articular pro-
cess. During the laminectomy and facectomy, it is
crucial to avoid drill breach into the pedicle, as this
may affect pedicle integrity. The ligamentum fla-
vum is then removed, subsequently exposing the
nerve roots. During flavum removal, the venous
plexus contained within the epidural space can
cause substantial bleeding. Appropriate hemosta-
sis with bipolar cautery or Gelfoam is necessary to
visualize the disc space and nerve roots adequately.
Following adequate hemostasis, further end-
plate preparation is performed by utilizing end-plate
shavers and paddle distractors. The interbody cage
with morcellized bone fragments is then passed
into the midline of the disc space. Caution must
be taken to protect the nearby nerve root during
cage placement. Once adequate cage placement is
achieved, the remaining two screws can be inserted
over the guide wires with subsequent guide-wire
removal and rod placement (Figure 26.7).

Figure 26.7 Lateral intraoperative fluoroscopic
image demonstrating contralateral cage and
bilateral screw placement.
(a)
Figure 26.8  AP and lateral lumbar radiographs at 10 weeks postoperatively, demonstrating placement of
the contralateral cage with appropriate screw readjustment.
Complications 197
POSTOPERATIVE MANAGEMENT
Following revision MIS TLIF, patients are fre-
quently discharged on postoperative day 0 or 1.
During the inpatient stay, a multimodal analgesia
regimen is utilized to provide adequate pain con-
trol and minimize the risk for narcotics-associated
side effects. Dressing placed over the patient’s
wounds can be removed on postoperative day 3.
Postoperative radiographs are obtained immedi-
ately postoperatively, in addition to all follow-up
time points (Figure 26.8).
COMPLICATIONS
The complications associated with revision
MIS TLIF are similar to that of a primary MIS or
open TLIF. The overall complication rate follow-
ing MIS TLIF ranges from 0%‒33%, with the most
significant complications including intraoperative
durotomy, cerebrospinal fluid (CSF) leak, hemor-
rhage, new neurologic deficits, and continuing
pseudarthrosis. Due to the small size and foot-
print of implants utilized in MIS TLIF, the risk
for pseudarthrosis is theorized to be greater than
that of open TLIF. However, ensuring adequate
visualization through appropriate hemostasis and
(b)
198  How to revise a minimally invasive transforaminal lumbar interbody fusion
proper size of the surgical field is necessary to
minimize the risk of many of these other surgical
complications.
Pearls and Pitfalls
Revision MIS TLIF can be a particularly ben-
eficial procedure in the setting of pseudar-
throsis. By allowing for the readjustment of
posterior instrumentation and increases in
bone graft material and implant-end-plate
surface area contact, this procedure can
improve the biomechanical and biological
environment needed to facilitate interbody
fusion. However, particular attention must be
given to preoperative planning, as these steps
will determine the efficacy and feasibility of a
revision MIS TLIF. Specifically, it is important
for surgeons to note any potential implant
and instrument malpositioning or misplace-
ment. The identification of these errors may
highlight possible causes of the vertebral non-
union, and as such, they can be appropriately
corrected to prevent future complications.
Additionally, significant posterior cage migra-
tion may be a contraindication for revision
MIS TLIF. This highlights the importance of a
detailed analysis of medical imaging to pre-
vent unnecessary operations and reduce the
risk of iatrogenic neural injury.
Finally, assessing the amount of space
remaining between the vertebral end plates
can help a surgeon determine whether multiple
implants can be utilized in order to increase the
likelihood for subsequent fusion. Limited space
can also indicate the need for cage removal,
which will require an anterior approach rather
than the posterior approach utilized in MIS
TLIF. By preoperatively identifying potential
hardware failure and assessing the remaining
intervertebral space, a surgeon can determine
the feasibility and efficacy of a revision MIS
TLIF and maximize its potential benefits.

How to revise a posterior lateral
decompression and fusion at the
index level
FADI SWEISS, CRISTIAN GRAGNANIELLO, ANTHONY J. CAPUTY, AND
MICHAEL ROSNER
Indications 199
Relative contraindications 200
Expectations 200
Principles of revision surgery 200
INDICATIONS
There are several reasons why a spinal fusion is
considered failed, and posterolateral fusions are no
exception. This particular type of fusion holds an
intrinsic risk of failure at the index level, related to
the fact that the disc has not been removed, which
keeps the anterior column viable while the middle
and posterior columns are locked in place. In this
chapter, we discuss ­failure of posterolateral fusion
solely at the index level.
Continued back pain, radiculopathy, and weak-
ness or sensory deficits, especially those that were
present prior to initial posterolateral fusion per-
formed, should warrant further investigation to
evaluate the success of the previous fusion. The
causes of these findings are numerous, and in most
cases, they will be identified as further workup is
undertaken.
27
Preoperative planning and operating room
(OR) setup 201
Operative technique 201
Postoperative management 202
Complications 202
The failure of fusion with continued motion at
the index level or subsequent levels can be evalu-
ated with computed tomography (CT) scans, as
well as plain films with flexion and extension
images. The failure of fusion can lead to further
facet joint hypertrophy, leading to neurologi-
cal complaints including back pain. The extent of
motion with increasing forces on hardware will
lead to overt failure. This includes loosened screws,
pedicle screw pull-outs, pedicle screw fractures,
and rod fractures, all of which will be easily identi-
fied via imaging and likely warrant revision.
If further workup does not yield adequate find-
ings, one should consider whether the fusion pro-
vided adequate alignment and balance. In recent
years, many have stressed the importance of pro-
viding correction of lordosis, sagittal balance, and
pelvic parameters in the success of fusion surgeries
(Figure 27.4, see later).
199
200  How to revise a posterior lateral decompression and fusion at the index level

Without achieving overall spinal balance, PRINCIPLES OF REVISION SURGERY

compensatory factors lead to added stresses
on constructs and adjacent levels. These may
lead to pseudarthrosis, which presents rela-
tively early after the initial corrective surgery.
This is another indication for revision surgery
and should always be considered with fusion
surgeries.
RELATIVE CONTRAINDICATIONS
Surgical correction of a previously failed postero-
lateral fusion has an increased risk of intraopera-
tive complications. There is an increase in both
operative time and intraoperative blood loss. All
patients need to be medically optimized to pro-
ceed with revision surgery. An interdisciplinary
approach is required, especially in cases where
a patient has multiple medical comorbidities.
Decisions must be made as to the safety with which
the surgeon can proceed with the procedure. With
the need of instrumentation, active infection is an
absolute contraindication to surgery.
Revision surgery should be completed by a spine
specialist with experience in revisions, as they
are more complex and involve added risks. As
previously stated, a multidisciplinary approach is
required to optimize all patients prior to under-
going such a procedure, especially those with
significant medical comorbidities. An extensive
workup, including anterioposterior (AP)/lateral
plain films (Figure 27.1), standing scoliosis films
(Figure 27.2) including side-bending images,
flexion/extension images, magnetic resonance
imaging (MRI) of the spine with and without gad-
olinium, computed tomography (CT) scan, and
possibly including a CT myelogram, is needed for
the surgeon to determine the most beneficial and
safe revision surgery.

EXPECTATIONS
With revision of a failed posterolateral decom-
pressive and fusion procedure, the goal is to see
an overall improvement in preoperative symp-
toms. Back pain secondary to failure of fusion
should significantly improve after the construct
is repaired and fusion is achieved. After place-
ment of an interbody graft and removal of bilat-
eral facet joints, radiculopathies and motor and
sensory symptoms are also expected to improve.
Although revisions are more difficult techni-
cally, improvement of symptoms and successful
fusion should be achieved, with a majority of
patients reporting improvements in functional
outcomes.
The goal of the revision procedure should also
be directed toward achieving and maintaining
adequate lordosis and proper alignment. These
factors are now expected outcomes that should be
obtained in all fusion procedures. By maintaining
and correcting sagittal balance and proper lumbar Figure 27.1  Lateral plain film of the L-spine, show-
lordosis, a successful fusion procedure is expected ing previous posterolateral instrumentation and
to decrease the likelihood for future construct fail- fusion. Anterior spondylolisthesis noted for L4 on
ure and adjacent-level disease. L5, with lucency of the L4 pedicle screw.

Figure 27.2  AP and lateral standing scoliosis plain
films. The patient has overall coronal and sagittal
balance.
The surgeon must also consider whether a min-
imally invasive approach is possible to avoid scar
tissue and to ease exposure. This may not always be
the case, given the extent of previous instrumen-
tation and fusion that was achieved. The ultimate
goal in revising failed posterolateral fusions is to
provide corrective and adequate fixation to allow
fusion and optimal spinal alignment.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
Preoperative planning is essential to revise a failed
posterolateral fusion. Evaluation of preoperative
imaging and patient symptomatology must be
done to provide the patient with the most benefi-
cial corrective procedure. In most cases, the need
for interbody graft can allow a minimal access sur-
gical technology/transforaminal lumbar interbody
Operative technique  201
fusion (MAST TLIF) approach (Figure 27.5, see
later), which can shorten exposure time, blood
loss, and most important, avoid scar tissue from
the previous midline approach. This will also allow
access to instrumentation, which can be replaced
and extended as needed.
Patients are placed prone on a Jackson table,
with six posts to limit intra-abdominal pressure
during the surgery. Chest padding should be opti-
mized with maximal extension of hips to allow
maximum lordosis and an adequate degree of cor-
rection with positioning alone. The face should be
well padded, with C-spine in neutral position, and
all tubes and lines properly placed to prevent skin
breakdown during the procedure. All extremities
should be in neutral position, and bony promi-
nences should also be well padded. All lines should
be positioned to prevent interference with intraop-
erative imaging.
A C-arm should be readily available for con-
firmation of level, screw placement, and interbody
graft placement if needed. An O-arm can also
be utilized (if available) after instrumentation
placement to confirm proper screw and inter-
body placement. The use of neuromonitoring
is strongly advised, including stimulus-evoked
electromyography (EMG)/triggered electromyog-
raphy (tEMG). This will allow the monitoring of
individual nerve roots and pedicle screw breaches,
respectively.
OPERATIVE TECHNIQUE
Our choice of a transforaminal lumbar interbody
fusion (TLIF) approach to revise a posterolateral
fusion is related to the fact that this approach is
truly versatile. It can be done through tubular
retractors for a single level and two levels, with
expandable tubes, and it also can be mini-open or
open depending on the pathology at hand.
●● A C-arm is used to locate the facet complex at
the index level and mark it on the skin.
●● The skin incision is usually placed 3.5–4.5 cm
off the midline and vertical along the cranio-
caudal axis. The length of the incision var-
ies depending on the number of levels to be
approached and the decision to use one r­ etractor
on each side or more than one on a side.
202  How to revise a posterior lateral decompression and fusion at the index level
●● After the skin is incised, the Wiltse plane is
developed with the first tube, which is kept “not
hollow” and used as a dissector.
●● When the plane is found and developed, the
sequential dilation does not differ from a fresh
case, with the largest dilator essentially docked
around the screw head already present at the
index level, or over the facet complex in a new
or additional level.
●● The next step is the same no matter what the
cause for the failure is; it involves unlocking the
screw caps and removal of caps and rods, fol-
lowed by removal of the screws.
●● At this stage, the screws are removed so that
the facetectomy can be performed with either
small osteotomes or a high-speed drill to deliver
appropriate decompression of neural elements
and to allow access to the disc.
●● If screws from the previous fusion were placed
with good trajectory, having appropriate entry
points and with good purchase in the pedicle,
and if there were no violations or breaches any-
where along the medial or lateral border, the
holes can be reutilized at the end by placing
larger-diameter screws through them. If this is
not the case, new entry points are chosen, and
the procedure is the same as for a new case.
●● Discectomy is carried out in the usual fashion
if the disc is still present and the reason for the
failure was nonunion, but even if this is the case,
the use of a high-speed drill or osteotomy may
be necessary to enter the disc space, as Sharpie’s
fibers around the disc margins are usually one
of the first places to fuse when a spinal segment
is immobilized.
●● Distraction of the disc space is performed, one
side at a time, so that discectomy can be com-
pleted and optimal end-plate preparation can be
achieved.
●● At this point, as in a fresh case, implants are
tried until adequate height and lordosis is
achieved, with good restoration of foraminal
height.
POSTOPERATIVE MANAGEMENT
Postoperatively, the patient should be moni-
tored in a postanesthesia care unit (PACU). Pain
should be adequately controlled, and if needed,
acute pain management consultation should
be obtained. The patient should be monitored
for hemodynamic instability and a complete
blood count (CBC), bone morphogenetic pro-
tein (BMP), and coags should be drawn and cor-
rected as needed.
Drains, if placed, should be monitored for sud-
den increases in output and removed on postop-
erative day 1.
If stable, patients should be placed in a surgi-
cal care unit, with nurses experienced in dealing
with this subset of patients. Frequent neurological
assessment should be obtained, and a surgical team
should be notified immediately about any changes.
Adequate pain control should be provided, as early
ambulation is required to improve recovery times.
Standing AP/lateral plain films (Figure 27.3)
should be obtained prior to discharge.
COMPLICATIONS
●● Immediate complications include subsidence
of the end plates when inserting the cages and
breach of the cortical surface of the pedicle.
●● Delayed complications include infections and
residual/new onset of pain and sensory distur-
bances. Nonunion is still a possibility in a small
subset of patients, including osteopenic and
osteoporotic patients.
 Complications 203

Figure 27.3  Correction of failed posterolateral instrumentation and fusion with L3–4, L4–5, L5–S1 MAST
TLIF, with adequate lumbar lordosis and correction of L4 on L5 spondylolisthesis.

Figure 27.4  CT of the L-spine sagittal view, show- Figure 27.5  Intraoperative fluoroscopy of the MAST
ing properly placed pedicle screws. Again what is TLIF approach, with appropriate interbody place-
shown here is adequate lumbar lordosis. ment providing adequate disc height and lordosis.
204  How to revise a posterior lateral decompression and fusion at the index level
Pearls and Pitfalls
●● In replacing the screws, if the same path is
used, it is appropriate to increase the diam-
eter by one size.
●● If the initial posterolateral fusion failed,
it necessarily warrants another approach
to the case, including a different surgical
strategy, as well as the use of different
biologics.
●● New biologics should be considered, as
previously mentioned, especially in cases
where none were used at the initial surgery,
or that failed because of poor bone qual-
ity and insufficient filling of the initial scaf-
fold—that is, off-label recombinant human
bone morphogenetic protein (rhBMP)-2.
●● In revision surgery, it is imperative to adhere
to and respect all the principles of spine
surgery, especially the “balanced spine” in
both the coronal and sagittal plane.
●● Revising an instrumented spine requires
surgeons to be aware of what system was
used in the first operation so that the nec-
essary instruments for the removal of the
existing hardware can be retrieved.
●● CT with myelogram is essential, as it allows
for careful preoperative planning of bone
removal to achieve the necessary decom-
pression of neural elements and appropri-
ate segmental alignment of the spine.
●● A frank discussion with the patient and the
family about the potential risks of redo sur-
gery, including the higher risk of CSF leak,
as well as counseling about potential out-
comes and patient expectations and the
potential need for ongoing pain manage-
ment, are of paramount importance.

How to revise a posterior lumbar fusion
that has developed adjacent-level
stenosis with or without instability
PATRICK CURRY AND MARK F. KURD
Indications 205
Relative contraindications 206
Expectations 206
Principles of revision surgery 207
INDICATIONS
The number of lumbar spine fusions performed
each year is rapidly increasing. Many of these
patients experience excellent pain relief and
recovery of function. However a significant num-
ber experience recurrent symptoms secondary to
adjacent segment stenosis. Treating these patients
will be a significant burden for the healthcare
system as a whole, as well as for individual sur-
geons. Revision surgery can be successful but
requires meticulous attention to detail in order to
obtain a good outcome. The chances of a success-
ful outcome decrease with each surgical interven-
tion. Each revision procedure should be carefully
planned to address new pathology, as well as any
iatrogenic issue present from prior surgery.
Estimates of the incidence of adjacent segment
degeneration vary widely, depending on the defi-
nition and length of follow-up. The incidence may
be as high as 30%. The available literature does not
28
Preoperative planning and operating room
(OR) setup (including neuromonitoring) 207
Operative technique 208
Postoperative management 208
Complications 209
always distinguish between asymptomatic degen-
eration and symptomatic adjacent-segment disease
(ASD), which most likely has a significantly lower
incidence. Most evidence indicates that the risk of
developing ASD increases with the number of lev-
els fused.
Revision surgery for adjacent-level stenosis,
with or without instability, should be approached
cautiously and considered only when an appropri-
ate course of nonoperative management has failed
to treat the patients symptoms. Nonoperative
treatment can include activity modification, physi-
cal therapy, anti-inflammatory or neuromodula-
tory medications, and epidural steroid injections.
Patients with adjacent-level stenosis above a
prior fusion may present with back pain, neuro-
genic claudication, radiculopathy, or a combina-
tion of symptoms. They may also have sagittal or
coronal deformities due to ongoing degeneration
or as a result of their prior surgery.
205
206  How to revise a posterior lumbar fusion that has developed adjacent-level stenosis
If symptoms are not responsive to nonop-
erative management, revision surgery should be
approached in an algorithmic fashion. First, the
details of the patient’s prior procedure should be
investigated. The indication for the index pro-
cedure should be determined utilizing previous
operative reports and office notes. Other critical
information includes the patient’s reported preop-
erative symptoms and degree of disability, as well
as the degree of symptom relief following the index
procedure. Patients who did not experience any
interval of symptom relief may have undergone a
wrong site, inappropriately indicated surgery, or
inadequate decompression.
Nonspinal pathology must also be considered
in patients who had no relief from their prior sur-
gery. Patients with low back pain may be suffering
from malignancy or other nonspinal pathology.
Those who appear to have neurogenic claudica-
tion or radiculopathy in fact may be suffering
from vascular claudication or peripheral nerve
pathology.
A preoperative physical exam must include
careful attention to motor and sensory characteris-
tics, deep tendon reflexes, long tract signs, and gait.
The patient’s standing balance should be carefully
evaluated, both clinically and radiographically.
Any compensatory mechanisms like knee flexion
should be corrected so that the full extent of imbal-
ance, if present, can be evaluated. Lower extrem-
ity flexion contractures, especially at the hip, can
exacerbate sagittal imbalance.
A careful history and physical exam should be
augmented by advanced imaging studies to evalu-
ate previously operated levels and adjacent levels.
Computed tomography (CT) scan can be used
to assess the prior construct and fusion mass.
Magnetic resonance imaging (MRI), with and
without contrast, can determine the degree of ste-
nosis adjacent to the fusion, as well as determine if
there is an active infection or malignancy. If neces-
sary, a CT myelogram can be used to evaluate the
decompression at levels where MRI is obscured by
artifacts.
When imaging studies confirm pathology
consistent with the patient’s symptoms and non-
operative management fails to give the patient
adequate symptom relief, revision surgery should
be considered.
RELATIVE CONTRAINDICATIONS
Adjacent-level degeneration is a common finding
after lumbar spine fusion. For revision surgery to
be effective, the patient’s current pathology must
be carefully correlated with current symptoms.
In addition to imaging studies, electromyogra-
phy/nerve conduction study (EMG/NCS) can give
insight into the cause of the patient’s recurrent
symptoms.
There are a number of patient factors that have
been identified as predictors of poor outcomes.
They fall into the following broad categories: bio-
medical factors, occupational factors, and psycho-
social or cognitive factors.
Biomedical factors, which can compromise out-
come, include diffuse pain, comorbidities, prior
episodes of spine pain, poor sleep, and severe limb
pain. Occupational factors include demanding
physical labor, poor job satisfaction, and extensive
time off work due to injury. Psychosocial/cognitive
factors include depression anxiety, history of phys-
ical abuse, and history of substance abuse.
If a patient has multiple findings predictive of
a poor outcome, surgical intervention may not be
effective.
Patients who fail to achieve any symptom-free
interval after an appropriately indicated index
procedure should be approached with extreme
caution.
EXPECTATIONS
Patients should be advised that the outcome of
revision spine surgery is not as reliable as the out-
come from primary procedures. There is no level
I evidence to guide clinicians when counseling
patients regarding the outcome of revision sur-
gery. Some small series have shown good patient
outcomes; however, others have reported less than
50% success.
A subset of patients will likely have baseline
chronic pain that increased significantly prior to
presentation. When counseling these patients pre-
operatively, surgeons must be careful to explain
that the likelihood of eliminating their chronic
pain is low.
Appropriate counseling is critical for success
when revision surgery is considered. When patients
 Preoperative planning and operating room (OR) setup (including neuromonitoring)  207
had good relief from an index procedure and have
clear pathology that correlates well with their cur-
rent symptoms, the chances of successful revision
are good. If a patient failed to have significant relief
following an appropriate index procedure, he or
she may not benefit from revision. Patients who
have chronic pain that has increased or changed
may benefit from surgery if the new symptoms cor-
relate with imaging findings.
PRINCIPLES OF REVISION SURGERY
A detailed history and physical is required prior
to consideration of revision surgery. This must
include the patient’s chief complaint prior to the
index procedure. Operative reports should be
obtained if possible. Careful review may reveal
an incorrect prior diagnosis. Patients should be
questioned about relief of their initial symptoms.
Patients who report good relief initially, followed
by the return of symptoms, have a better progno-
sis. If patients report that they did not have pain
relief at any time, prior records should be carefully
scrutinized to determine if the patients underwent
an incorrect procedure or inadequate decompres-
sion. If patients can recall a specific inciting event
or moment when symptoms returned abruptly,
recurrent disk herniation or hardware failure
should be considered. When symptoms return
insidiously more than 6 months postoperatively,
nonunion should be considered as well as adjacent-
level disease.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
(INCLUDING NEUROMONITORING)
Preoperative planning occurs in several areas.
The patient’s functional status and comorbidities
should be optimized. Patients who smoke should
be required to quit and be nicotine free for 4–6
weeks prior to surgery. Nutritional parameters
should be evaluated and supplemented if deficient.
Many patients will have low or borderline vita-
min D levels. This should be supplemented with
1,000–2,000 IU vitamin D3 for patients with mild
deficiency. For patients with severe deficiency,
vitamin D2 50,000 IU weekly for 3 months is also
an option. Many elderly patients will have poor
protein intake. This should be addressed with sup-
plemental nutrition. Hemoglobin A1C is a good
indicator of average blood glucose, and if it is ele-
vated, the risk of perioperative complications, par-
ticularly postoperative wound infection, increases.
Preoperative imaging should begin with ante-
rioposterior (AP), lateral, and flexion/extension
views. These will determine whether the patient
has instability adjacent to the prior fusion. Also,
36-inch AP and lateral standing films should be
used to assess the patient’s coronal and sagittal
balance.
Planning for patients with back pain and ASD
secondary to sagittal imbalance or flat back must
include osteotomies or other techniques directed
at increasing lordosis and harmonizing sagittal
parameters. Multiple studies have shown that cor-
rection of sagittal parameters is closely associated
with increased quality of life.
CT scans with fine cuts and coronal and sag-
ittal reconstructions allow evaluation of the prior
construct and fusion mass, as well as the degree of
bony degeneration adjacent to the previous fusion.
MRIs with and without contrast can delineate scar
(enhancing) from recurrent disk herniations or
ligament flavum hypertrophy (nonenhancing). CT
myelograms are appropriate when patients have
contraindications to undergoing MRI. It can also
provide information about areas obscured by arti-
fact from prior instrumentation.
If possible, the previous instrumentation sys-
tem should be identified from operative reports
or by examination of x-rays. A well-stocked revi-
sion instrumentation set should be available. Plain
films and advanced imaging should be scrutinized
to identify hardware failure or nonunion, hard-
ware loosening, or misplaced hardware.
Preoperatively, the surgeon should evaluate the
prior construct and determine if the entire prior
construct should be removed or if the new con-
struct should be tied into the prior construct.
Pedicle screw fracture may require trephine
for removal or if possible broken screws may be
bypassed. Measurements should be taken of loose
screws and bone loss, and large, nonstandard
diameter screws should be available.
Neuromonitoring can be especially useful in
revision surgery. For the process to be as benefi-
cial as possible, the surgeon must be familiar with
208  How to revise a posterior lumbar fusion that has developed adjacent-level stenosis
the various modalities available, as well as the
indications for their use. Somatosensory evoked
potentials (SSEPs) monitor primarily the dorsal
columns. The condition of the dorsal columns
can be used as a proxy for the condition of the
entire cord. Transcranial motor-evoked poten-
tials (MEPs) allow monitoring of the corticospi-
nal tracts. Pedicle screw simulation can help to
evaluate the position of pedicle screws. This can be
particularly useful in the revision setting, where
anatomic landmarks are absent. In addition to
chasing modalities, the surgeon must know and
understand the threshold for an alert, as well as the
numerous causes of false positives.
OPERATIVE TECHNIQUE
The operative technique should be chosen based
on the patient’s pathology and chief complaint.
A variety of approaches are available for revision
surgery. If possible, it is best to turn a revision sur-
gery into a primary or partial primary surgery, but
using a different approach.
Patients with back pain and/or radiculopathy
secondary to stenosis and disk degeneration adja-
cent to a prior fusion can be treated with anterior,
posterior, lateral, or combined approaches. For the
posterior approach, preoperative imaging studies
should be reviewed carefully to determine stenotic
areas and their relationship to the prior surgical
site. Often, the most severe stenosis occurs adjacent
to the prior decompression. This area typically has
a significant amount of scarring, which compli-
cates dissection and increases the risk of dural tear.
The patient’s prior incision should be carefully
marked. Dissection should begin through virgin
tissue and facet capsules should be preserved until
a marker film has been taken to verify the exact
level of the dissection. Dissection at the virgin level
can then proceed as normal. The transition zone
between scar and virgin dissection requires care-
ful attention. Curettes can be utilized to detach
scar and pseudomembrane bluntly from the neural
elements.
The depth of the lamina at the virgin level
can guide the dissection through the scar. Care
should be taken to raise full-thickness soft-tis-
sue flaps without violating the dura. This can be
achieved by directing dissection laterally when the
level of the virgin lamina is reached. Exposure of
the prior hardware and fusion mass can then be
accomplished.
Patients who have primarily leg pain may be
appropriate for decompression only. Traditionally,
ASD above a fusion has been treated with exten-
sion of the fusion. However, patients with an adja-
cent segment disk herniation and no instability
may benefit from microdiskectomy. If patients
with leg pain have significant facet hypertrophy
that causes central and lateral recess disease, and
do not have instability, they can also be considered
for decompression only, although they should be
counseled that there is a risk of recurrent stenosis
at that level. If there is instability at the adjacent
level, the fusion should be extended.
POSTOPERATIVE MANAGEMENT
Postoperative management begins in the operating
room (OR). Prior to leaving the OR, the team should
conduct a sign-out. The World Health Organization
(WHO) advocates the use of a Surgical Safety
Checklist. This checklist is intended to ensure that
critical information is relayed from the OR to the
postanesthesia care unit (PACU) or intensive care
unit (ICU). This information should include the
name of the procedure, verification that sponge
and instrument counts are correct, and any critical
or unexpected events, as well as the patient’s cur-
rent hemodynamic status. Some patients may need
to remain intubated in the immediate postopera-
tive period. If this is the case, a motor exam should
be obtained as soon as possible.
Once the patient is extubated, he or she should
be mobilized with physical therapy. In order to
mobilize patients, they must have adequate pain
control. Appropriate pain control can be chal-
lenging in the revision setting. Patients who have
been on chronic narcotics may require high doses
of intravenous (IV) narcotics, and acute pain
management service can be useful when manag-
ing these patients. Patients must be comfortable
enough to mobilize with physical therapy.
Deep venous thrombosis (DVT) prophylaxis is
an area of controversy. Due to the low incidence
of postoperative DVT and the potentially cata-
strophic consequences of an epidural hematoma,
chemoprophylaxis is not routinely used in most

centers. Early mobilization and sequential com-
pression devices are sufficient in most cases. For
patients who have significant difficulty mobilizing
or those who have undergone an anterior approach
with manipulation of the iliac vessels or aorta che-
moprophylaxis may be considered.
Some surgeons routinely use postoperative brac-
ing. There is no strong evidence for or against the
use of braces. Some patients may benefit from the
sense of stability that a brace provides. However,
there is a risk of skin breakdown, particularly for
older, more fragile patients.
Many patients will require a short stay at a
skilled nursing facility or rehab hospital. If patients
cannot return home safely by the time they are sta-
ble from a surgical standpoint, it is advisable that
they be discharged to a facility where more inten-
sive therapy is available.
COMPLICATIONS
The incidence of complications is significantly
increased in the revision setting. Surgical compli-
cations range from incidental durotomy to large-
volume blood loss. Incidental durotomy occurs
with frequency during revision surgery. Patients
who require decompression where the scar will be
present from the index procedure should be coun-
seled that the likelihood of durotomy is 15%–20%.
Many of these tears will be large and may not be
amenable to direct repair. Surgeons should be
Complications 209
comfortable with the use of a fascial graft or sub-
arachnoid drains to manage these issues.
Significant bleeding can be encountered during
revision surgery. This should be discussed with the
anesthesia providers preoperatively, and appropri-
ate IV access should be obtained preoperatively.
In many cases, particularly for medically frail
patients, an arterial line and central venous cath-
eter should be carefully considered. Depending on
the magnitude of the surgery, crossmatched red
cells, as well as platelets and fresh frozen plasma,
should be available. Surgeons should also consider
using tranexemic acid intraoperatively to reduce
blood loss.
Pearls and Pitfalls
●● Preoperative planning is the key to a suc-
cessful outcome. Determine why the
patient had the index procedure, the result
of the index procedure (including any com-
plications), and what instrumentation was
used.
●● Turn a revision procedure into a primary
procedure. Whenever possible, use a dif-
ferent approach or technique to avoid scar
tissue and the associated complications.
●● Manage patient expectations. Patients
need to be aware that the outcomes of
revision procedures are not as high as pri-
mary procedures, and the complication
rate is higher as well.

Flat back deformity revision surgery
JEFFERSON WILSON, MATTHEW S. GALETTA, AND SRINIVAS PRASAD
Indications 211
Relative contraindications 211
Expectations 211
Principles of revision surgery 211
INDICATIONS
Iatrogenic flat back deformity is a well-known,
long-term sequela of lumbar fusion, particularly
multilevel lumbar fusions performed in the remote
past, when there was less sensitivity to the preser-
vation and restoration of sagittal balance. The risk
of developing loss of lordosis is increased when
either distraction is applied across pedicle screws,
or insufficient restoration of anterior height is
achieved during the initial surgery.
Indications for revision surgery include pseu-
doarthrosis, persistent back and neck pain
attributable to loss of lordosis, and inability of
compensatory knee flexion and hip extension to
restore sagittal balance. Patients may develop adja-
cent-level degeneration, with resultant radicular
pain and claudicant symptoms.
RELATIVE CONTRAINDICATIONS
Patients who are not medically stable to undergo
operative treatment and those with ongoing tobacco
use. Presence of significant medical comorbidties and
ongoing tobacco use are relative contraindications
29
Preoperative planning and operating
room (OR) setup 212
Operative technique 212
Postoperative management 215
Complications 215
as these may lead to increased short- and long-term
postoperative complication rates.
EXPECTATIONS
Patients with poor sagittal balance and resultant
back and neck pain are counseled that the goal of
surgery is to improve global alignment, improve
their symptoms, and reduce the need for narcotic
pain medications, but achieving a completely pain-
free state is not a reasonable expectation.
The importance of preoperative and postop-
erative nutrition, smoking/tobacco cessation, and
compliance with a rigid brace for 6–12 weeks post-
operatively are emphasized.
PRINCIPLES OF REVISION SURGERY
The goal of revision surgery is to decompress the
neural elements, restore sagittal balance and lum-
bar lordosis, and obtain adequate fusion along
the construct. Generally, the aim of correction is
to achieve sagittal vertical axis (SVA) <5 cm and
pelvic tilt (PT) <20 degrees. If pseudoarthrosis is
the reason for revision, specific attention is paid to
211
212  Flat back deformity revision surgery
smoking cessation counseling if relevant, and plan-
ning for iliac crest bone graft (ICBG) harvesting.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
During preoperative assessment, anterioposterior
(AP) and lateral spine x-rays, including flexion
and extension films, are obtained to assess instru-
mentation, graft position, and fusion mass (Figure
29.1). Supine x-rays, with and without a bolster,
are done to define how much lordosis would be
achieved by simple positioning. Full-length sco-
liosis x-rays are obtained with the patient stand-
ing upright, and sagittal balance is assessed with
a standard C7 plumb line and associated spino-
pelvic measurements. Thoracolumbar computed
tomography (CT) scans are obtained to assess
bony anatomy, osteophytes, fusion mass, and ped-
icle-screw positions and measurements. Magnetic
resonance imaging (MRI) is used to assess the
thecal sac and nerve roots. Patients may require
combined or staged anterior, posterior, and/or
lateral approaches to adequately restore lordosis
Figure 29.1  Preoperative imaging: 63M with mul-
tiple thoracolumbar fusions, including placement
of a spinal cord stimulator for pain management,
who presented with a chief complaint of inability
to stand for longer than 1 minute.
and extend the instrumentation. When there is a
hip contracture deformity, it should be addressed
before any corrective surgery to the lumbar spine
because it might affect the overall sagittal align-
ment. Based on the rigidity of the deformity and
prior circumferential fusion, the surgical scenario
would be anterior only, posterior only (including
vertebral column resection), combined AP or com-
bined lateral-posterior approaches.
For patients undergoing AP procedures, posi-
tioning is on a Jackson table, which allows more
efficient and safe turning from the supine to prone
position. The type of osteotomy (Smith-Petersen
osteotomy [SPO] or pedicle subtraction osteotomy
[PSO]) is primarily determined by the presence
of fixed sagittal deformity and prior circumfer-
ential fusion. Other significant influences include
the extent of the correction necessary, whether
the kyphosis is smooth or acute, and concerns for
intraoperative blood loss.
Motor-evoked potentials (MEPs) and somato-
sensory evoked potentials (SSEPs) are obtained at
baseline, after turning prone, and after final posi-
tioning. If the iliac crest is to be harvested, the side
contralateral to the surgeon is prepared, unless
contraindicated, to optimize the operating room
(OR) flow.
Patients receive an arterial line for intraopera-
tive monitoring. All patients have preoperative labs
drawn, and a type and crossmatch are obtained for
these cases. Unless infection or tumor is involved,
an autologous blood recovery system is used to
minimize the need for additional blood products
intraoperatively.
OPERATIVE TECHNIQUE
For anterior approaches, our general surgery col-
leagues provide exposure and closure. Care is
taken to protect the iliac veins and ureters. In
patients who have had prior anterior exposures,
ureteral stents may be placed preoperatively by the
urology team to aid in identifying and protecting
these structures.
In revision posterior exposures, the hips are
fully extended in the prone position to allow as
much lumbar lordosis to be achieved with posi-
tioning. The prior incision is opened and extended
as required, and attention is paid to locating and

respecting surgical planes within the scar tissues.
Undisturbed landmarks are used to assist in dis-
section down to spinous processes at the levels
above or below the previous fusion, and this level
is followed to expose the prior laminectomy levels
and the lateral instrumentation.
During anterior discectomy and graft place-
ment, lordotic grafts provide some correction of
alignment, and they also may be directed to one
side to achieve some correction of coronal imbal-
ance (Figure 29.2). During posterior revisions,
PSOs provide approximately 30 degrees of lordotic
correction (Figure 29.3), while posterior column
osteotomies provide approximately 10 degrees
of correction per level (Figure 29.4). If additional
structural stability is required, because of pseu-
doarthrosis at low lumbar levels, poor bone qual-
ity, or multiple prior revisions, sacral screws and
iliac bolts may be added to the construct. For these
cases, the use of S2-Alar iliac (S2AI) screws may be
considered.
Achieving appropriate curvature in the rods
is paramount to preserve the lordosis achieved
through allograft and wedge osteotomies. Further
compression along the pedicle screw construct
may provide additional lordotic correction.
Figure 29.2  CT scan of after-first-stage revision surgery. Staged operative treatment: first-stage removal
of prior hardware, removal of spinal cord stimulation (SCS), placement of new screws.
Operative technique  213
Combined lateral lumbar interbody fusion
(LLIF) and posterior lumbar interbody fusion
is another option to address coronal and sagittal
deformity in the lumbar spine. Lordotic LLIF cages
also help to restore lumbar lordosis. The limitation
of the lateral approach is access to the L5‒S1 disk
space, which is often obstructed by the iliac crest
and obscured by the complexity of the lumbosacral
plexus and adjacent vasculature.
MEPs and SSEPs are obtained throughout the
stages of decompression, instrumentation place-
ment, and distraction. When all manipulation of
the spine and instrumentation is completed, final
signals are obtained. AP and lateral spine x-rays
are obtained to ensure appropriate hardware posi-
tioning (Figure 29.5).
Generally, two posterior drains are left to bulb
suction. Occasionally, an anterior JP is left at the
discretion of the general surgery team. Muscle
and fascia are closed with interrupted 0 vicryl
sutures, deep dermal tissue is approximated with
buried interrupted 2–0 vicryl sutures, and the skin
is closed with running nylon suture. Interrupted
mattress sutures are used in cases with concern
for approximation or tissue quality. The drains are
secured with a nylon suture.
214  Flat back deformity revision surgery

Figure 29.3  Schematic of PSO in lateral and coronal plane. Arrow indicates results of osteotomy.

Figure 29.4  Schematic of SPO/Ponte osteotomy in the lateral and coronal plane. Arrow indicates results
of osteotomy.

Figure 29.5 Final postoperative imaging after
second-stage surgery: L3–L4 SPO with placement
of rods and screws for instrumented fusion.
POSTOPERATIVE MANAGEMENT
Patients are admitted to either the neurological
intensive care unit (ICU), surgical ICU, or spine
telemetry unit. Higher levels of care postopera-
tively are generally reserved for patients with high
blood loss, long operative times, difficulty extu-
bating at the conclusion of the case, or multiple
medical comorbidities requiring close monitoring.
Those patients with planned staged procedures are
generally (though not always) kept on spine pre-
cautions and bed rest until the conclusion of the
second-stage operation.
Custom thoracolumbar orthotics are obtained;
if the patient has the initial brace, it may be refit to
minimize duplicate work and costs. When able, AP
and lateral x-rays are obtained standing upright
in the brace. Physical therapy evaluates patients
beginning on the first postoperative day.
Patients are seen in the clinic at 2 weeks and 6
weeks for incision checks and review of repeat AP
and lateral x-rays. Subsequent follow-up is gener-
ally recommended out to a minimum of 2 years,
Complications 215
although the appointment intervals are at the dis-
cretion of the individual surgeon.
COMPLICATIONS
In anterior exposures, the iliac vessels may be
injured during exposure or by excessive retrac-
tion. In these cases, general surgery should
return to assess the injury, and a vascular sur-
gery consultation may be warranted intraop-
eratively. To minimize the risk of thrombosis
postoperatively, intravenous (IV) fluids should
be given, and 81 mg aspirin or a heparin drip
may be warranted.
Scar tissue increases the risk of durotomy dur-
ing exposure and decompression. If possible, dural
tears should be primarily repaired, but dural sub-
stitute, muscle, and surgical glue may be consid-
ered. If a dural tear is inaccessible from a posterior
approach or adequate repair is not achievable,
the placement of a lumbar drain is highly recom-
mended to prevent the formation of postoperative
large-volume pseudomeningocele at the laminec-
tomy site.
Injury to the lumbosacral plexus and its
branches may occur during lateral approaches to
the lumbar spine. Care should be taken in retract-
ing and dilating the psoas muscle to protect these
neural structures. In particular, care should be
taken to restrict retractor opening to the mini-
mal amount needed for exposure and graft place-
ment. The femoral nerve should be retracted from
anterior to posterior, and care should be taken
that positioning of the patient does not put the
femoral nerve under tension, reducing its ability
to withstand intraoperative retraction. Finally,
the duration of trans-psoas retraction should be
minimized.
Pearls and Pitfalls
Because surgery to correct iatrogenic flat-
back deformity is, by definition, revision sur-
gery, attention must be paid to the unique
characteristics of each patient’s prior sur-
gery, decompression, and construct. Anterior
osteophytes, facet fusion, and circumferen-
tial fusion on preoperative CT and MRI may
warrant anterior or posterior releases to fully
216  Flat back deformity revision surgery
achieve the planned correction. Selection
of an appropriate osteotomy level is cru-
cial to the success of deformity correction.
Adequate fixation, sensitive to bone density
and any existing screw lucencies, is imperative
for adequate stabilization and achievement of
arthrodesis.
Scar tissue from prior surgery can compli-
cate dissection and increase the risk of injury
to anterior and posterior structures, including
the iliac veins, ureters, and dura. Care should
be taken to avoid excessive retraction or inad-
vertent injury during exposure.
Although lateral approaches are a useful
adjunct, the iliac prominence and lumbosa-
cral plexus may make dissection and retrac-
tion challenging, and an anterior approach in
these instances may be preferred.

Revision high-grade spondylolisthesis
surgery
PETER D. ANGEVINE
Indications 217
Relative contraindications 217
Expectations 218
Principles of revision surgery 218
INDICATIONS
As for most surgery for spinal deformity, there
are few absolute indications for revision surgery
for high-grade spondylolisthesis. Any new or pro-
gressive neurological deficit should be thoroughly
investigated for an underlying cause amenable
to surgery, as this would be a rare (but possibly
urgent) indication for intervention.
The two most common indications for revi-
sion high-grade spondylolisthesis surgery are the
presence of symptoms (primarily pain) and radio-
graphic findings including implant failure (loosen-
ing or fracture) or loss of correction. Within these
categories, however, are a spectrum of severity
and a range of possible appropriate management
options. The clearest indication for revision sur-
gery might be early postoperative implant failure,
with loss of correction and intractable back pain.
At the other end of the spectrum would be bother-
some but nondisabling back pain 2 or more years
postoperatively, with questionable fusion status.
Radicular leg pain, primarily in an L5 distribu-
tion, with compressive pathology is often a strong
30
Preoperative planning and operating
room (OR) setup 218
Operative technique 219
Postoperative management 222
Complications 222
indication for surgery, particularly if there is also
likely fixation failure. Such symptoms are unlikely
to respond to nonoperative measures such as phys-
ical therapy, anti-inflammatories, or epidural ste-
roid injections.
Early (i.e., <6 months postoperatively) implant
failure in a patient with a high-grade spondylolis-
thesis and high slip angle likely portends a poor
long-term outcome without revision. In these cir-
cumstances, revision is indicated both for symp-
tom management and for prevention of continued
loss of correction and deformity progression that
would make subsequent surgery more difficult,
with greater risk and likely poorer outcomes.
In situations of relative indications, a careful
evaluation of the patient and discussion with her
or him and, if appropriate, the family, is essential
to confirming the appropriateness of a potentially
formidable procedure.
RELATIVE CONTRAINDICATIONS
The stronger the indications for surgery in general,
the fewer the relative contraindications are. The
217
218  Revision high-grade spondylolisthesis surgery
patient must be able to withstand general anesthe-
sia in the prone position, perhaps for a prolonged
period of time. A large volume of blood loss is not
generally expected for these procedures, but the
possibility certainly exists, and the patient must be
able to withstand it should it occur.
Particularly given the limited points of fixation
available at the lumbosacral junction, bone quality
is a key consideration. While osteopenia or osteo-
porosis may not be a contraindication for surgery,
it may limit the amount of correction, if any, that
may be obtainable. Revision surgery in a patient
with severe osteoporosis, indicated by a T score
<–4, should be given very careful consideration,
given the high likelihood of implant failure.
As for any elective spinal fusion surgery, cur-
rent smoking should be considered to be at least
a relative contraindication. In order to reduce the
probability of a nonunion, a urine cotinine test
may be obtained to document successful cessation
of nicotine intake for at least the last 30 days.
EXPECTATIONS
Reasonable expectations on the part of both the
patient and the surgeon are a key element in achiev-
ing a good outcome. Depending on the chronicity,
intensity, and underlying cause of a patient’s pain,
even a flawless surgery may not lead to complete
symptomatic relief. Radicular pain due to ongoing
physical irritation is likely to improve significantly
or completely with surgical decompression unless
it is chronic. Response to epidural or nerve root
injections and, to a lesser degree, oral medications
such as ibuprofen or gabapentin can help with
prognostication of the outcome.
Axial back pain may improve significantly, mod-
erately, or not at all. One helpful predictor of a good
response to surgery in a patient with predominantly
back pain is significant or complete relief with
recumbency. Radiographically, a clearly mobile
nonunion with implant loosening, is an indication
that successful revision instrumentation and fusion
is likely to give the patient a substantial benefit.
PRINCIPLES OF REVISION SURGERY
As implied previously, a key principle of revi-
sion surgery is that the recommendation of and
decision for a repeat procedure is based largely
on the patient’s symptoms, in combination with
radiographic and other information. Once the rec-
ommendation and decision for surgery have been
made, there are important principles to guide the
planning and execution of the procedure.
The likelihood of achieving a good outcome
with various surgical options should be considered
along with the risks of the procedures. Given that
the patient has already undergone at least one pro-
cedure without an optimal result, the calculus may
shift to prioritize outcome maximization over risk
minimization.
Understanding the mode of failure of the prior
procedure or procedures and planning a surgery to
address that failure directly is a primary principle
of revision surgery. For example, if the failure was
an incomplete neural decompression, the revision
must be performed in a manner that ensures, to
the degree possible, that no remaining compres-
sive pathology exists. Distal implant failure, such
as sacral screw pullout or fracture, may be due to
several possible underlying causes, including use
of screws that were too short, too narrow, or both;
lack of lumbosacral interbody support; lack of iliac
fixation to back up the sacral screws; and failure
to achieve a rapid, robust arthrodesis. In this and
similar multifactorial situations, the greater the
number of possible causes that are addressed by
the revision surgery, the greater the probability of
a good outcome is.
Improving on the index surgical execution
while avoiding unnecessary risks is another
important tenet. For example, lumbosacral pseud-
arthrosis without neurological symptoms, and
in the setting of a prior transforaminal lumbar
interbody fusion (TLIF) or posterior lumbar inter-
body fusion (PLIF), is often best addressed via an
anterior approach to avoid operating in proxim-
ity to nerve roots that may be encased in surgical
scarring. On the other hand, prior decompression
alone may not obviate a PLIF or TLIF procedure in
a patient with lumbosacral nonunion.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
The surgeon must carefully consider the patient’s
anatomy prior to revision surgery. Doing so

requires obtaining the appropriate preopera-
tive radiographic studies. These generally include
upright AP and lateral long-cassette radiographs
that clearly demonstrate the sacropelvic anatomy,
lumbar flexion/extension radiographs, a lumbosa-
cral CT scan, and a lumbar MRI scan. A myelo-
gram with a postmyelo CT scan may be necessary
in some cases. Bone densitometry may be indicated
in some patients.
A spine-specific radiolucent open-frame oper-
ating table facilitates the positioning of the patient
and obtaining intraoperative images. Selection
of a flat board or a sling depends on the patient’s
hip flexibility and pelvic alignment; maintenance
or achievement of appropriate lumbar lordosis is
important to obtaining a good outcome. As these
may be lengthy procedures, the operating room
(OR) staff must ensure that all pressure points
are padded adequately and joints are positioned
appropriately.
Intraoperative imaging should be readily avail-
able, including the ability to obtain fluoroscopic
images, plain radiographs, and intraoperative CT
images as necessary. If image guidance is to be used
for placement of instrumentation, the appropriate
equipment and personnel need to be accessible.
Neurophysiological monitoring is routinely
used to increase the safety of these procedures.
As the main neurological structures at risk are
radicular, however, the utility of monitoring is
generally lower than for procedures involving
the spinal cord. Free-running electromyography
(frEMG) may indicate nerve root irritation, but it
is not highly specific for postoperative radicular
deficit. For this reason, if a substantial correction
is planned, or if the patient is otherwise at high
risk for a postoperative neurological deficit, the
patient and the anesthesiology team should be
prepared to perform an intraoperative wake-up
test. Patient preparation includes using the spe-
cific language that will be used during the proce-
dure and having the patient practice the required
movements. The anesthesiologists should be
notified prior to the surgery that a wake-up test
may be necessary, and given notice as early as
possible during the surgery once the decision has
been made to minimize any delay in having the
patient sufficiently awake to perform the neuro-
logical exam.
Operative technique  219
OPERATIVE TECHNIQUE
Mastery of several operative techniques is essential
to be able to address the variety of possible clinical
scenarios discussed here. In general, when anterior
and posterior approaches are to be performed on
the same day, performing the anterior stage first
is preferred. The exception to this is if posterior
instrumentation is in place and anterior correction
is planned. In this circumstance, a posterior-ante-
rior-posterior sequence is used.
A vascular or other general surgeon is used
for the anterior lumbosacral exposure. Typically,
a retroperitoneal paramedian approach is pre-
ferred, but a transperitoneal approach may be a
better option if an extensive retroperitoneal scar
is expected. Either a low transverse incision or a
vertical paramedian incision may be used. Access
to the L5‒S1 disc space is generally achieved in
the bifurcation between the iliac vessels. A table-
mounted retractor is used to maintain retraction
of the abdominal wall and viscera. The vessels may
be best protected with retractors held by an assis-
tant or by Steinman pins secured into the L5 ver-
tebra. Standard techniques are used to perform an
L5‒S1 anterior lumbar interbody fusion. Removal
of a previously placed TLIF or PLIF device can be
difficult; judicious use of osteotomes along the end
plates can help to mobilize these devices. In some
circumstances, it may be more expedient to drill
a polyetheretherketone (PEEK) device into frag-
ments that are then removed individually.
An anterior Bohlman procedure is performed
under AP and lateral fluoroscopic guidance. A
Kirschner wire is passed through the L5 body
and into S1, stopping before the dorsal sacral cor-
tex is breached. A fibular allograft is selected and
the appropriately sized cannulated tibial reamer
is used to drill a channel through L5 and into S1,
with fluoroscopy used to ensure the guide wire is
not inadvertently advanced into the spinal canal.
The fibular strut is packed with graft material; fen-
estrations may be made to allow ingrowth of bone.
Alternatively, a titanium mesh cage may be used.
The structural or device graft is then tapped into
position with fluoroscopic control (Figure 30.1).
The posterior techniques depend on the surgi-
cal goals and specific nature of the prior surgery.
In general, old instrumentation is removed, any
220  Revision high-grade spondylolisthesis surgery

(a) (b) (c)

(d) (e)

Figure 30.1  AP (a) and lateral (b) preoperative radiographs showing fractured S1 screws and steep L5−S1
disc angle. The patient had only back pain and therefore did not need posterior decompression. We
therefore decided to perform an anterior Bohlman procedure with fibular strut allograft, followed by pos-
terior revision instrumented fusion L4−S1 with pelvic fixation. Postoperative sagittal CT (c) showing fibular
allograft. A 2-year postoperative AP (d) and lateral (e) radiographs are shown as well.

necessary decompression and interbody work per-
formed, and new instrumentation placed. Distal
fragments of fractured transpedicular sacral
screws are removed only if it is possible to do so
without removal of a significant amount of bone.
Often, there is sufficient room in the sacral pedi-
cles to place new transpedicular screws adjacent to
retained fragments (Figure 30.2).
A wake-up test may offer some protection
against neurological deficit if substantial reduction
is performed. The need for a wake-up test must be
communicated as early as possible to the anesthe-
siologist so that the patient is awake and examin-
able as soon as possible after reduction is achieved.
The surgeon or assistant should scrub out of the
case and directly observe or perform the exami-
nation. If a satisfactory motor examination is per-
formed, the patient is put back to sleep and the
case is completed. If there is a significant loss of
function, the patient should be sedated, necessary
 Operative technique  221

(a) (b) (c) (d)

(e) (f ) (g)

Figure 30.2  AP (a), lateral (b), and posterior oblique (c) preoperative radiographs showing haloing around
L5 screws and lack of bridging arthrodesis. The patient had back and radicular pain. We performed an
all-posterior revision surgery with decompression, transforaminal lumbar interbody fusion, and L4−S1
posterior instrumented arthrodesis with iliac fixation. Also, a 2-year posteroperative AP (d) and lateral (e)
are shown. The patient had no back pain but had difficulty running. A CT scan was performed that docu-
mented solid arthrodesis. The iliac screws were therefore removed. AP (f) and lateral (g) 3-year postopera-
tive films are shown as well.

changes made, and then the patient is reawakened
and reexamined.
Either standard iliac screw fixation or S2‒AI
screws may be used to achieve distal fixation and
to back up the sacral screws to reduce the probabil-
ity of them loosening or pulling out. In younger
patients, I prefer to use standard iliac screw fixa-
tion, as their subsequent removal is generally
easier than for S2‒AI screws. S2‒AI screws have
the advantage of a lower profile and are therefore
preferable in very thin patients who might feel iliac
screws through their skin.
222  Revision high-grade spondylolisthesis surgery
Intraoperative stereotactic navigation is use-
ful for posterior instrumentation in patients with
significantly abnormal anatomy, or who have large
fusion masses that obscure the dorsal bony land-
marks that normally guide freehand placement of
pedicle screw fixation. Postinstrumentation intra-
operative CT scans may be obtained to ensure
proper placement of fixation and spinal alignment
prior to closure.
POSTOPERATIVE MANAGEMENT
Standard postoperative spinal fusion protocols
are followed. If an anterior procedure was per-
formed, the general surgeon makes recommenda-
tions regarding dietary advancement. A urinary
bladder catheter is maintained until the patient is
able to use a bedside commode or toilet. Wound
drains are removed once acceptably low outputs
are recorded. An external orthosis is not used; a
lumbosacral corset may help with mobilization
and is used based on patient preference.
COMPLICATIONS
The possible complications include all the stan-
dard possibilities for anterior and posterior spi-
nal surgery. Reoperations typically are expected
to have a higher likelihood of complications.
Intraoperatively, nerve root injury, incidental
durotomy, or instrumentation complications may
occur. In the early postoperative period, careful
neurological examinations are performed with
particular attention paid to lumbosacral nerve root
function, as subtle or delayed deficits may present.
In the absence of ongoing radiographic nerve root
compression or a progressive weakness, reopera-
tion is seldom indicated, but the individual cir-
cumstances dictate the appropriate course. Early
upright baseline radiographs are obtained as soon
as the patient is able to ambulate approximately 50
feet (15 meters) or more. These serve as compari-
son films for all subsequent radiographs.
Pearls and Pitfalls
●● Iliac fixation provides critical backup for
sacral fixation and should be considered
strongly in any revision for L5–S1 pseud-
arthrosis, particularly in the setting of pro-
gressive deformity.
●● If an anterior approach is not possible or
highly risky and the patient had previous
interbody fusion, it may be possible to
perform revision TLIF contralaterally to the
prior approach, with or without removal of
the existing device.
●● The slip angle and rigidity of deformity are
key considerations in deciding whether
to perform ALIF or the anterior Bohlman
procedure.

Management of a ventrally displaced
graft following ALIF, TLIF or DLIF
DHRUV K.C. GOYAL, HEEREN S. MAKANJI, GREGORY D. SCHROEDER,
AND BRIAN W. SU
Introduction 223
Indications for revision surgery for ventral
graft extrusion 223
Relative contraindications 224
Expectations 224
Principles of revision surgery 224
INTRODUCTION
Interbody fusion is an effective technique for sta-
bilization of the lumbar spine, leading to higher
fusion rates compared to traditional posterolat-
eral fusion. Increasing intradiscal height also has
the advantages of increasing foraminal height,
correcting coronal deformity, and improving
saggital alignment. The most common interbody
fusion techniques include anterior lumbar inter-
body fusion (ALIF), oblique lateral interbody
fusion (OLIF), transforaminal lumbar interbody
fusion (TLIF), posterior lumbar interbody fusion
(PLIF), and direct lateral interbody fusion (DLIF).
Anterior approaches require manipulation of the
great vessels but decrease the likelihood of durot-
omy, neurological injury, and epidural scarring.
Similarly, DLIF avoids manipulation of neural
structures, but it has the added risks of transient
hip flexor weakness due to psoas manipulation and
injury to the lumbar plexus.
31
Preoperative planning 224
Operating room (OR) setup 225
Operative technique 225
Surgical technique 225
Complications 227
There is a paucity of literature surround-
ing one of the rarer complications of interbody
fusion: extrusion of the interbody graft. The rate
and implications of dorsally extruded grafts are
relatively well studied (1%–3%); however, there are
much less data on ventrally extruded grafts. Here,
we aim to provide a basic framework to assess
and manage the rare complication of ventrally
extruded grafts.
INDICATIONS FOR REVISION
SURGERY FOR VENTRAL GRAFT
EXTRUSION (ALIF, TLIF, DLIF)
●● Symptomatic vascular compromise
●● Asymptomatic vascular compromise assessed
by computed tomography angiography/mag-
netic resonance angiogram (CTA/MRA); con-
sultation with a vascular surgeon regarding
the risks and benefits of intervention may be
needed
223
224  Management of a ventrally displaced graft following ALIF, TLIF or DLIF

●● Neurological compromise secondary to dis-

placement of the graft into the foramen or loss
of disc height leading to foraminal collapse
●● Symptomatic pseudarthrosis
●● Loss of regional and/or overall coronal and sag-
ittal alignment

RELATIVE CONTRAINDICATIONS
●● Active infection or tumor
●● Vertebral body fracture at revision site
●● Severe osteoporosis
●● Cardiopulmonary compromise
●● Late-stage peripheral vascular disease; calcifi-
cation of the great vessels makes retraction of
the inferior vena cava (IVC) difficult

EXPECTATIONS
●● Removal of extruded graft, with planned
replacement of graft (unless contraindicated)
●● Restoration of disc height and regional/overall
sagittal alignment
●● Resolution of neurological and/or vascular
compromise Figure 31.1 A preoperative lateral radiograph
●● Fusion of the involved segment demonstrating an L5–S1 isthmic spondylolithesis.

PRINCIPLES OF REVISION SURGERY

●● Any surgery requires both safe dissection tech-
niques and proper exposure. Scar tissue from
prior dissection obscures normal anatomical
landmarks that can be quite useful for a sur-
geon to maintain proper orientation; therefore,
if possible, using contralateral side approach (if
revising for ALIF) is advised.
●● Recognize potential reasons for the failure of
the initial surgery, such as improper graft siz-
ing, improper graft location, and compromise
of the vertebral end plates to optimize outcomes
following the revision.
PREOPERATIVE PLANNING
●● Standard upright AP and lateral radiographs
are helpful to determine extent of graft extru-
sion, overall spinal alignment, and degree of
inclination of the disc space (to determine ease
of access, most notably at L5‒S1) (Figure 31.1).
●● Advanced cross-sectional-imaging with CT
scan or magnetic resonance imaging (MRI) can
be helpful to determine the degree of impinge-
ment from the graft on surrounding structures,
such as the great vessels. Data from cross-sec-
tional images can also help guide the exposure
and show potential areas of difficulty.
●● A CT scan is helpful in assessing the status of
the fusion, as the disc space may have already
fused, depending on the time delay with which
graft extrusion occurred.
●● If there is a nonunion, the revision plan should
include a new type of bone graft that includes
autogenous bone graft or recombinant human
bone morphogenic protein-2 (rhBMP-2), the
latter of which is preferred due to its increased
efficacy.
●● Use of a polyetheretherketone (PEEK) anterior
interbody graft is recommended, as it typically
has greater lordosis and a larger footprint than
structural allograft.

OPERATING ROOM (OR) SETUP
●● Ensure that the patient is properly prepped and
draped in a supine position on a radiolucent
table to allow the use of fluoroscopy. Ensure that
all bony prominences and soft tissues are prop-
erly padded in a standard fashion.
●● If accessing the L5‒S1 disc space, place a blanket
or towels underneath the pelvis to allow retro-
version of the pelvis for easier access.
●● Placing the patient in the Trendelenberg posi-
tion to be able to directly visualize a lordotic
space such as L5‒S1 is recommended.
●● Draping generously to allow extension of the
incision cranially is critical, in anticipation of
potential vascular injury.
●● Instruments such as narrow osteotomes should
be available to intentionally fracture a wide
DLIF cage for removal.
●● Expandable lumbar corpectomy cages should
be available in the situation where a hemicor-
pectomy needs to be performed to remove a dis-
placed implant.
●● Neuromonitoring should be used in cases
involving neurological compromise or need for
revision fusion. Baseline somatosensory evoked
potentials (SSEPs) and transcranial electric
motor-evoked potentials (tcMEPs) are typically
sufficient for this procedure.
OPERATIVE TECHNIQUE
●● Ventral graft extrusion is most effectively
addressed by an anterior approach, as it allows
direct visualization of the graft and careful dis-
section for removal.
●● In the case of prior ALIF and multiple abdomi-
nal surgeries, an approach from the contralat-
eral side may allow native dissection planes and
a safer exposure.
●● Posterior-only approaches will not allow graft
retrieval, and thus they are not recommended
●● In the case of revision fusion, a stand-alone
ALIF is not recommended. Formal posterior
fixation with pedicle screw instrumentation,
cortical screw fixation, or spinous process plat-
ing is recommended.
●● A lateral fluoroscopic image used to guide inci-
sion location and angle of approach is critical.
Surgical technique  225
Based on the lateral image, a radiopaque instru-
ment should then be placed on the abdomen
over the intended incision. An anterioposterior
(AP) fluoroscopic image with the C-arm angled
(Fergusson) in line with the lateral angle can be
used to double-check incision location.
SURGICAL TECHNIQUE
Contralateral revision ALIF
Step 1: Exposure
1. Make a longitudinal or transverse incision
1–2 cm to the right of the midline at the disk
level, which had been marked during fluoro-
scopic imaging. Ensure that this incision is in
line with the disk space angle to avoid an awk-
ward trajectory.
2 . Incise the anterior rectus sheath in an oblique
extensile fashion, carefully preserving the
underlying rectus abdominus muscle.
3. Find the avascular midline between the two
rectus muscles and retract the right rectus and
its underlying epigastric vessels. The retroperi-
toneal space is easier to delineate caudally.
4. Retract the peritoneum and its contents to the
right before attempting to bluntly dissect the
retroperitoneal space.
5. For L4‒L5, the transversalis fascia should be
incised with scissors.
6. Sponge sticks and peanuts are used to bluntly
dissect into the retroperitoneal space. Once the
anterior disk space of interest has been exposed
self-retaining retractors are placed. At L4‒L5,
the aorta and IVC should be gently retracted.
At L5‒S1, the middle sacral artery/vein should
have been ligated during the index procedure. If
this has not been done, then ensure these vessels
are ligated at L5‒S1 and retract the iliac veins
away from the midline.
Step 2: Removal of previous graft
1. Subsidence of the implant into the adjacent ver-
tebral bodies is common. The extent to which
the graft to be removed has been ventrally
extruded or impacted into the adjacent bodies
should be studied on the CT (Figure 31.2).
226  Management of a ventrally displaced graft following ALIF, TLIF or DLIF

Figure 31.2 Conclusion of the anterior lumbar

interbody fusion with structural allograft.

2 . Exposing the maximum medial lateral extent of

the disc is important to be able to work on each
side of the graft to be removed.
3. Use a long-handled scalpel to incise the annulus
to obtain a symmetric window.
4. A pituitary is used to remove any allograft
material that has extruded (Figure 31.3).
5. Continue removing graft material until reach-
ing the interbody spacer. At this point, the
interbody spacer can typically be removed with
a pituitary rongeur. If the implant is impacted
into the vertebral body, a long-handled curved
curette should be used to deliver the PEEK
spacer out of the interspace. Care should be
taken to preserve as much cancellous bone
and end plate as possible. The new PEEK ALIF
spacer should span the defect.
6. DLIF cages span the apophyses and are difficult
to remove through the anterior approach. A
small (1/8-inch) osteotome can be used to frac-
ture the cage in the middle. A curved curette is
then used to deliver each half of the DLIF cage
through the ALIF defect.
7. Typically, preparation of the interspace is more
thorough from an ALIF approach compared to
a posterior or lateral approach. It is important to
Figure 31.3 The postoperative film demonstrat-
ing migration of the ALIF graft.
perform a thorough discectomy with curettes,
pituitary ronguers, and rasps, back to the poste-
rior longitudinal ligament. Again, preservation
of the end plate is critical to allow the new ALIF
graft to sit level.
Step 3: Revised graft placement
1. Subsequently larger trials should be used until a
tight fit is obtained in the disc space. It is impor-
tant not to overstuff the space as that could lead
to nerve traction injury, posterior facet distrac-
tion, or compression fracture of the adjacent
vertebral body. The authors of this chapter rec-
ommend using a PEEK or titanium cage, as they
typically are available in larger footprints and
varying lordotic angles.
2 . If there is a vertebral body defect, cancellous
allograft can be affected with a Cobb elevator
into the defect.

3. The authors of this chapter recommend using
BMP-2 to maximize fusion rates. A small (4.2-
mg) package of BMP rolled around a ceramic
carrier such as mastergraft is recommended.
4. The spacer is then impacted into the interverte-
bral space.
5. Use fluoroscopic imaging to ensure the spacer is
properly placed within the intervertebral space.
6. If a stand-alone device with integrated screws is
being used, screws are then placed through the
cage into the vertebral body.
7. Posterior fixation is recommended following
ALIF (Figure 31.4).
Postoperative management
●● Start patients on clear liquids, continually
advancing the diet as tolerated.
●● Encourage ambulation as early as the first post-
operative day, assuming the patient can tolerate
mobilization.
●● Patients are encouraged to use a lumbar corset
brace for 6 weeks postoperatively. A lumbar
sacral orthosis (LSO) with thigh extension is
used in patients who have tenuous fixation at
L5‒S1.
Figure 31.4  The postoperative films after the ven-
trally displaced graft was revised with a screw and
washer placed as a buttress.
Complications 227
COMPLICATIONS
●● Because this approach requires a right-sided
retroperitoneal approach, there is increased risk
of injury to the vena cava and the liver (depend-
ing on the disk level).
●● Also, 2 units of packed red blood cells should be
in the room prior to starting the case, as well as
access through a central line should the rapid
transfusion protocol be required.
●● While it is preferable to gain access to the disk
space via a retroperitoneal approach, surgeons
may opt to use the transperitoneal approach in
situations where the anatomical plane of the
retroperitoneal space has been obliterated by
prior surgery/pathology in this area.
●● Retrograde ejaculation from injury to the supe-
rior hypogastric plexus (found near the aortic
bifurcation) can occur from both mechanical
(i.e., aggressive retraction of the great vessel
during exposure) and inflammatory reactions
near the plexus (i.e., healing during fusion after
previous ALIF).
●● Although rare, it may be possible to injure lym-
phatic vessels—which run adjacent to the vas-
culature of the spine—during exposure and
cause lymphedema or lymphocele formation in
the retroperitoneum.
Pearls and pitfalls
General
●● Intraoperative neurophysiological monitor-
ing should be used to avoid traction injury
during graft placement.
●● Creating a wide discectomy allows the ALIF
graft to span any defect created by the
prior disc prep.
●● Use smooth-edged retractors to avoid any
unintended injuries to the surrounding vas-
culature once the anterior disk space has
been exposed.
●● When correcting ventral graft extrusion
for TLIF or DLIF, one may be able to use a
standard left-sided approach ALIF, as the
planes of dissection are free of scar tissue.
During Exposure
●● Bifurcation of the vena cava tends to be
superior to the disk space at L5–S1 and
228  Management of a ventrally displaced graft following ALIF, TLIF or DLIF
often lies over the vertebral body of L5, lat-
eral to the midline on the right side; how-
ever, a small number of individuals have this
bifurcation inferior to the L5–S1 disk level.
●● Vasculature: Some individuals may exhibit
rare bridging veins between the iliac vein
and venous plexus lying anterior to the
vertebrae. Additionally, some patients
may have an absence of the iliolumbar
vein, which is usually easy to identify when
exposing the L4–L5 disk space, as it often
branches off the common iliac vein at L5.
●● Nerves: The superior hypogastric plexus
communicates with the inferior hypogas-
tric plexus via left and right hypogastric
nerves. To avoid retrograde ejaculation,
one may leave these nerves adherent to
the peritoneum, along with the ureter and
associated vessels, to avoid accidental
injury during mobilization of this serosal
layer for exposure. The risk of retrograde
ejaculation can also be reduced with the
use of bipolar cautery for any hemostasis
that needs to be achieved.
●● The ureter travels with gonadal vessels
up until the level of the common iliac
bifurcation (L4), where it then travels over
the iliac vessels to reach the bladder.
To avoid devascularization of the ureter
from excessive traction, it is important to
leave the ureter and its associated ves-
sels attached to the peritoneum during
retraction.
 5
Part    

Special Cases

32 Treatment of symptomatic cervical and lumbar pseudomeningocoeles 231

Joshua E. Heller and George Rymarczuk
33 Treatment of a persistent cervical dural tear 241
Jessica L. Block and D. Greg Anderson
34 Treatment of a ventral thoracic dural defect 245
Ibrahim Hussain, Peter F. Morgenstern, and Ali A. Baaj
35 Treatment of a persistent lumbar dural tear 251
Joseph S. Butler, Matthew S. Galetta, and Barrett I. Woods
36 Treatment of a chronic postoperative cervical and lumbar spine infection 255
Kamil Okroj and Christopher Kepler

Treatment of symptomatic cervical and
lumbar pseudomeningocoeles
JOSHUA E. HELLER AND GEORGE RYMARCZUK
Indications 231
Relative contraindications 231
Expectations 232
Principles of revision surgery 232
INDICATIONS
Cerebrospinal fluid (CSF) leaks are an inevitabil-
ity in spine surgery. An attempt should be made
to repair any dural tear when noticed intraopera-
tively. Tears that extend ventrally, track along a
nerve root sleeve, or are large and stellate in nature
can be particularly challenging to repair. In these
instances, primary repair is often not possible
without stenosing the thecal sac to a degree that
may impinge upon neural elements. Patch-grafting
or on-lay material used in conjunction with lum-
bar subarachnoid drainage is often necessary in
these situations.
It is not uncommon for dural tears to go unno-
ticed at the time of surgery and present in a delayed
manner, or perhaps even occur in the postoperative
phase. In these instances, the CSF leak is typically
heralded by postural headaches, wound fluctu-
ance from pseudomeningocoele formation, or
frank wound drainage. A draining wound should
be considered an urgent matter and addressed as
soon as is feasible, for the patient risks developing
32
Preoperative planning and operating room
(OR) setup 232
Operative technique 235
Postoperative management 238
Complications 239
meningitis. Postural headaches can be severe, and
there is the possibility for sequelae of this low-pres-
sure phenomenon such as subdural hematomas
from torn bridging veins or remote cerebellar or
supratentorial hematomas.
RELATIVE CONTRAINDICATIONS
The most conservative approach is to address a CSF
leak surgically. An asymptomatic pseudomenin-
gocoele may be considered one that is unaccom-
panied by a postural headache or wound swelling
that is cosmetically distressing to the patient. A
truly asymptomatic pseudomeningocoele can be
observed and often will typically resolve given
enough time. For a minimally symptomatic pseu-
domeningocoele, one that is characterized by a tol-
erable postural headache and an intact wound, it
is not unreasonable to attempt a trial of bed rest
and hydration; however, this is most often ineffec-
tive. Caffeine, in conjunction with hydration, can
be particularly effective in treating the postural
headache. Medications such as acetazolamide may
231
232  Treatment of symptomatic cervical and lumbar pseudomeningocoeles
reduce the production of CSF and help facilitate
resolution in some instances.
EXPECTATIONS
All patients undergoing spinal surgery should
be counseled regarding the possibility of durot-
omy as part of the informed consent process.
Managing this expectation can be the single most
important factor in ensuring patient satisfac-
tion. Certain procedures, such as instrumented
fusions, revision or deformity surgery, decom-
pression of facet cysts, and ossification of the
posterior longitudinal ligament (OPLL), carry
particularly high rates of durotomy and should
be discussed preoperatively. Fortunately, most
long-term studies have found that ultimate out-
come is unaffected by the presence of durotomy
at the time of surgery.
PRINCIPLES OF REVISION SURGERY
The principles of durotomy repair are to obtain
adequate exposure of the leak, repair the dural
defect as completely as possible, and perform a
multilayered tissue closure to contain any pseu-
domeningocoele. CSF leaks often occur at the
periphery of the exposure. It is often necessary
to enlarge the bony exposure to fully delineate
the dural tear and to find normal native dura on
all sides of the defect. This can involve extend-
ing a laminectomy or facetectomy. Care should
be taken not to unduly destabilize the segment.
An attempt should be made to close the defect
primarily, although at times, this may not be
possible. Performing a Valsalva maneuver to
30–40 mm Hg can confirm the integrity of the
closure or indicate the need for an additional
stitch. Dural patches or on-lay grafts may be nec-
essary for inaccessible leaks such as those that
extend ventrally, or those that cannot be closed
without stenosing the dura, including dura tears
that extend along a nerve root sleeve. Once the
dural tear has been addressed, a multilayer clo-
sure of the subcutaneous tissues and skin should
be performed. A watertight closure of the fascia
and skin can serve to contain difficult-to-close
durotomies and a pseudomeningocoele in the
subfacial compartment.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
Concerns for anesthesia
A smooth emergence from general anesthesia
can mean the difference between a successful and
unsuccessful surgery. The Valsalva effect from the
ventilator may cause a fresh dural repair to leak.
This should be discussed with the anesthesiolo-
gist at the beginning of the case. It may be prefer-
able to extubate the patient while still comfortably
sedated. If all else fails and the patient begins to
emerge at an undesirable time, the anesthesiolo-
gist should disconnect the patient from the venti-
latory circuit until sedation can be reestablished,
allowing them to freely expire through the endo-
tracheal tube only with no resistance to the pas-
sage of air.
An additional concern is the patient’s head-of-
bed position postoperatively. Conventional wisdom
dictates that CSF leaks in the cervical pine should
be treated with elevated head of bed, whereas leaks
in the lumbar spine should be treated with flat bed
rest. This optimizes the hydrostatic pressure that
opposes the repair at each site. The surgeon’s desire
for head-of-bed height should be clearly commu-
nicated to the anesthesiologist at the beginning of
the procedure to avoid mistakes.
Wound cultures
An old neurosurgical adage is that a wound leak-
ing CSF is due to infection or hydrocephalus until
proven otherwise. Strong consideration should
be given to culturing the wound, particularly if it
has been leaking. If there is concern for meningi-
tis and the patient is hemodynamically unstable,
antibiotics should not be withheld. However, if
the patient is not in extremis, it may be prefer-
able to withhold perioperative antibiotics until
wound cultures have been taken. This may provide
 Preoperative planning and operating room (OR) setup  233
the best chance to obtain an identification of the
organism that is responsible for the infection, and
therefore allow therapy to be tailored. Along the
same line, an open wound should not be cleansed
with chlorhexidine.
Instruments and cottonoids
Certain microsurgical instruments that are not
typically included on spinal fusion trays can be
particularly useful for the precise nature of dural
repair. One should remember to call for these
additional instruments so that they are available
when repairing a durotomy. Castro-Viejo needle
drivers are well suited to maneuvering and sutur-
ing in the long, dark corridors that are typical
during durotomy repair. Pediatric-sized Frazier
suction tubes less than 10 Fr in size, as well as the
full complement of Rhoton dissectors, are often
necessary for the delicate work around exposed
neural elements. Small cottonoids, such as those
that are ½ inch × ½ inch or even ¼ inch × ¼
inch, are useful to cover or tamponade the durot-
omy site. In the event that nerve rootlets have
herniated through the defect, it may be desirable
to use Merocel neurosurgical patties (Medtronic,
Minneapolis). Merocel patties are less traumatic
to delicate neural structures and are frequently
used to protect cranial nerves during skull base
procedures.
Choice of suture and needle
Many different options for suture choice exist for
closing both the dura and the overlying tissue.
When closing the dura, an important consider-
ation is the use of a tapered needle, rather than a
cutting or reverse cutting needle. Cutting needles
make larger holes in the dura, each one a possible
point of egress for CSF. The tapered needle will
serve to pierce and spread the thin dural tissue,
and allow is to close down over the suture as it
passes through the tissue with minimal trauma.
For intradural surgery, neurosurgeons often use a
small nonabsorbable monofilament such as a 6–0
Prolene (Ethicon, Somerville, New Jersey) suture.
A clean surgical incision that was carefully and
intentionally made in the dura heals very nicely
with this choice of suture. Another very commonly
used option is Nurolon (Ethicon), a nonabsorbable
braided nylon polymer most typically used in the
4-0 size. At our institution, our practice pattern
has shifted such that we use almost exclusively
Gore-Tex (W.L. Gore, Flagstaff, Arizona), typi-
cally 5-0 in size, for repair of our durotomies[10].
This nonabsorbable monofilament comes with a
needle that closely approximates the suture diam-
eter, which leads to less leakage from the needle
holes. We have found this suture has offered the
best performance profile in terms of success at
leak repair.
When closing the overlying tissues, we advo-
cate a multilayered watertight closure that will
confine any psuedomeningocoele that might
form in the subfacial compartment, and abso-
lutely prevent leakage from the wound through
the skin. We follow a different algorithm if the
wound is infected versus sterile. For a sterile
wound, we advocate use of a large #0 or #1 Vicryl
(Ethicon) suture for the muscle and fascial lay-
ers, followed by smaller (2-0 or 3-0) Vicryl for
the immediately subcutaneous tissue and the
dermis. For an infected wound, we advocate the
use of a large, absorbable monofilament such PDS
(Ethicon) for fascia. A relatively new arrival is the
quilled polydioxanone (PDS) suture marketed as
Stratafix (Ethicon). This is a knotless device that
allows the facial layer to be run continuously. In
either instance, we typically close the skin with a
nonabsorbable nylon suture such as 2-0 Ethilon
(Ethicon) or Prolene; this can be done in either
a running fashion or with interrupted inverted
mattresses.
For anterior cervical surgery, we close the pla-
tysma and dermis in separate layers with 2-0 or
3-0 Vicryl suture, followed by a subcuticular stitch
using a small Monocryl (Ethicon), such as a 4-0.
Operative microscope
An operative microscope can be a useful adjunct
when repairing a CSF leak. The magnification and
234  Treatment of symptomatic cervical and lumbar pseudomeningocoeles
illumination are unparalleled and can significantly
aid the surgeon when placing precise sutures in
close proximity to neural elements. It can be very
easy to inadvertently ensnare underlying arach-
noid or even epineurium with a carelessly placed
suture.
Choice of patch graft material and
fibrin sealants
If the dural defect is large, one may not be able
to close it primarily. In these instances, it may be
desirable to suture a graft in place, or else use it as
an on-lay material that can be secures to the sur-
rounding bony edges of particularly large defects.
Many substrates are available, ranging from syn-
thetic dural substitutes, to processed biological
materials such as bovine pericardium, to various
forms of autograft. Fat, muscle, and fascia are all
potentially useful autografts. One should have
an idea of the preferred graft material and make
appropriate arrangements to obtain it. Muscle or
fat can usually be readily obtained locally from the
wound.
Multiple options exist when a dural patch is
deemed necessary. Autologous material includes
local fascia that may be harvested. Common
choices include local lumbodorsal of trape-
zius fascia, as well as fascia lata, and perhaps
even pericranium for posterior cervical defects.
Harvesting facsia from the lumbodorsal mus-
culature or the trapezius will require one to
dissect out laterally in the layer of the subcuta-
neous to obtain the material. This is easily done
with monopolar electrocautery. Use of fascia lata
would require one to have previously prepped
and draped the patient’s anterolateral thigh.
Pericranium is another excellent material, and it
can be readily obtained at the time of posterior
cervical surgery by extending the incision above
the hairline and dissecting in the plane just deep
to the galea aponeurosis.
If autologous material is unavailable or is not
desired, multiple other materials exist, including
bovine pericardium and dural substitutes such as
DuraGen (Integra, Plainsboro, NJ). Once the patch
has been performed, it may be desirable to on-lay
additional autologous material such as fat or mus-
cle plus, or apply dural sealant such as fibrin glue.
The use of DermaBond (Ethicon) along the suture
line has even been described.
Various dural sealants are available and can be
used to as a thin application on the suture line to
reinforce the watertight closure. It should be kept
in mind that many of these sealants expand as they
become hydrated, so they should be used with care.
Applying too liberally can lead to compression of
neural elements.
Lumbar subarachnoid drainage
Inserting a lumbar drain at the completion of
the operation can be challenging, when the CSF
has been drained and the turgor of the thecal sac
diminished. The authors have found that placing
the lumbar drain first, before opening the wound
and draining the pseudomeningocoele, provides
the best opportunity to easily and successfully
insert the lumbar drain. This is best accomplished
by placing the patient in the lateral decubitus posi-
tion immediately after intubation, inserting the
lumbar drain off the field, and then proceeding
with positioning for the repair.
Special considerations: intrathecal
medications
A CSF leak in the presence of an intrathecal device
such as a morphine pump or baclofen pump will
lower the concentration of that drug in the CSF
and disrupt the steady state of the closed system
of the subarachnoid space. This can be particularly
problematic with baclofen, as the patient may go
into a life-threatening withdrawal. This scenario
requires close observation of the patient’s hemo-
dynamic parameters, with repletion of intrathe-
cal baclofen or conversion to oral baclofen. Often,

neurology consultation can be obtained to help
guide repletion.
Arachnoid blebs?
In some cases, the dural may be violated, but the
underlying arachnoid mater may remain intact.
Frequently, blebbing of arachnoid can be seen her-
niating through the dural defect. No high-quality
literature exists regarding the treatment of this.
With the dural violation, there probably is a higher
rate of CSF leakage through a rupture of the arach-
noid, and thus the authors recommend that this
entity be repaired. It is very easy to instigate a CSF
leak through the careless placement of an instru-
ment of suction device when managing an arach-
noid bleb.
OPERATIVE TECHNIQUE
The most important piece of advice to remember is
not to become frustrated when a CSF leak occurs.
Durotomies are inevitable in spinal surgery, par-
ticularly in revision or deformity cases. While an
inconvenience, they have no bearing on the overall
outcome if addressed appropriately. The last thing
the surgeon wants is for a series of misfortunes to
snowball into a larger problem.
The first step is to fully expose and understand
the configuration of the dural tear. This often
involves enlarging the degree of soft-tissue dis-
section, as well as the bony exposure. One should
also ensure that instruments are able to be freely
maneuvered within the confines of the surgical
site. As always, further exposure should proceed
from areas of normal anatomy to areas of abnor-
mal anatomy. Does the tear extend ventrally? Does
it extend under a bony margin? Once the defect has
been fully exposed, it is often possible to suture the
durotomy site primarily.
As in any surgical procedure, we recommend
beginning by completely exposing the area of
interest and working from normal anatomy to
abnormal anatomy. Durotomy sites are often at
Operative technique  235
the periphery of an exposure, and thus additional
bony removal is frequently necessary to both
fully expose the defect and allow oneself enough
room to maneuver needles, needle drivers, and
other instruments in what are typically narrow
corridors. This can be particularly challenging
in the anterior cervical spine. Care should be
taken not to enlarge the existing defect unless it
becomes necessary to do so (i.e., in the case of
herniated nerve rootlets). The defect should be
covered with a cottonoid to prevent bone, blood,
or other undesirable material to enter the sub-
arachnoid space.
Nerve roots and rootlets that herniate through
the dural defect are common in instances of
CSF leak. When this is noted, the first step is to
remove your finger from the suction instrument
to decrease the inwardly directed force produced
by the vacuum effect. This will prevent the nerve
rootlets from being trapped in the ostium of the
device, which could potentially damage them.
Next, exposed rootlets should be covered with a
cottonoid patty for protection. This also serves
to prevent blood and other material from enter-
ing the subarachnoid space, which may cause
chemical meningitis. Merocel is a particularly
useful cottonoid for this. With imminent danger
averted, now is a good time to call for microin-
struments, suture material, and other adjuncts
necessary for repair. At this time, it is often nec-
essary to release more CSF from the durotomy
site to decrease the outwardly directed hydro-
static pressure, which opposes one’s attempts to
gently return the herniated rootlets to the sub-
arachnoid space. This may occur to such a degree
that enlarging the dural defect is sometimes the
best way to address this.
Refractory CSF leaks
Nearly all CSF leaks can be addressed with a direct
repair in conjunction with lumbar subarach-
noid drainage. However, very rarely, particularly
236  Treatment of symptomatic cervical and lumbar pseudomeningocoeles

CASE  32.1

A 58-year-old male with a history of L3–L5 decompression and L4–L5 TLIF. Index surgery complicated
by CSF leak. Postoperatively, he developed headaches and new lower-extremity radicular symptoms.
He subsequently underwent exploration and closure of his CSF leak using 6-0 Gore-Tex suture with
DuraGen and Tisseel.

Figure 32.1 T2-weighted MRI in the sagittal (Right) and axial (Left) planes demonstrating lumbar
pseudo­meningocele.
 Operative technique  237

CASE  32.2

A 72-year-old female with a history of prior L4–L5 instrumented fusion, who subsequently developed
adjacent-segment disease (ASD). She underwent revision of her L4–L5 fusion with extension to L3.
Her case was complicated by a CSF leak with persistent headaches. She returned to the operating
room (OR) for complex closure of her CSF leak using 6-0 Gore-Tex and microsurgical techniques.

Figure 32.2  Preoperative T2-weighted MRI in the sagittal (right) and axial (left) planes demonstrating
lumbar pseudomeningocele.

Figure 32.3  Postoperative T2-weighted MRI in the sagittal (right) and axial (left) planes demonstrating
lumbar pseudomeningocele.
238  Treatment of symptomatic cervical and lumbar pseudomeningocoeles
troublesome leaks may require a ventriculostomy
or even a more long-term solution, such as a per-
manent CSF shunt. In these instances, permanent
CSF shunts might be needed. The most common
options include lumboperitoneal and ventriculo-
peritoneal catheters.
POSTOPERATIVE MANAGEMENT
Smooth wake-up and bed position
The postoperative management of CSF leak repair
begins with a smooth wake-up that places no
undue pressure on the repair. Next is consideration
of the patient’s head-of-bed height. Conventional
wisdom would indicate that the hydrostatic pres-
sure exerted on the repair site by the column of
CSF is exacerbated by the effect of gravity. This has
led many authors to recommend that patients with
cervical and upper thoracic leaks be maintained
upright at all times, whereas leaks in the lower
thoracic, as well as lumbosacral spines, are treated
with flat bed rest. More extreme measures might
even include placing the patient with a dorsal lum-
bar durotomy supine and in the Trendelenburg
position to ensure that the site of the leak is at the
highest portion of the field. While this has been
described, it is probably not necessary for a suc-
cessful repair.
No high-quality data exists to provide rec-
ommendations that guide how to maintain the
patient’s head of bed.
Use of a closed-suction drain
A closed-suction drain left in the wound has the
potential to compromise the integrity of the dural
repair. Nonetheless, surgical drains are often nec-
essary to prevent hematoma formation, particular
in the context of large deformity corrections. One
option is to apply only a modest degree of suc-
tion through use of only thumbprint force on the
collection bulb. The force may be less intense if a
bulb-type drain such as a Jackson-Pratt is used in
lieu of a spring-loaded device such as a hemovac.
An additional option is to forgo suction altogether
and use a drain to gravity. This can be achieved
through connection of the drainage to a device
such as a bile bag.
Regardless of the device chosen, a high drain
output, particularly of clear-appearing fluid,
should raise alarm that the repair has not been
successful. Such a drain should at the very least
be taken off suction, and consideration should be
given to drain removal. We do recommend that in
instances when a drain has been removed, a suture
should be used to close the site through which the
drain was tunneled in order to prevent formation
of a cutaneous fistula. Overdrainage may cause a
positional headache, and in severe examples may
result in subdural or intraparenchymal hematoma
formation. Severe headache or change in mental
status may signal development of these entities,
and should aggressively be worked up.
Lumbar subarachnoid drainage:
amount and duration
There is no clear answer to this dilemma. A trial
of lumbar drainage lasting 48–72 hours is usually
sufficient to address most leaks. However, some
instances have taken up to 7–10 days, or even lon-
ger. Trialing the patient with a clamp and slow
head-of-bed elevation, while being vigilant for the
onset of postural headaches, is often a good way to
assess for the persistence of leak. The manner in
which the CSF is drained, along with the amount,
is also open for debate. Most authors typically
drain a set volume to be drained each hour, and 10
cc is typical. This amount can be titrated to 12, 15,
18, or even 20 cc/hour to achieve the best reduc-
tion in turgor and facilitate watertight healing. It is
our experience that very few patients can tolerate
the positional headache that normally accompa-
nies aggressively draining 20 cc/hour of CSF; how-
ever, a slight headache may indicate the drainage is
achieving the goal.
An alternative to draining a predetermined vol-
ume each hour is to treat the lumbar subarachnoid
catheter as you would a ventriculostomy, in which
the site of the transducer is leveled at the tragus
and CSF is drained at a pressure, perhaps between
zero and 5 cm of water. This would allow for a
constant, uniform maintenance of CSF turgor at
the durotomy site; however, this method is more

labor-intensive for nursing staff, and therefore is
not recommended.
COMPLICATIONS
Overdrainage of CSF can have severe conse-
quences, including formation of subdural hema-
tomas from tearing of bridging veins, as well as
formation of remote cerebellar of supratentorial
hematomas. The onset of a severe headache, altered
mental status, seizure, or focal neurologic deficit
in a patient with the loss of a high volume of CSF,
whether through the lumbar drain, the surgical
drain, or elsewhere, should prompt investigation
for the development of these entities.
Complications 239
Pearls and Pitfalls
●● Every maneuver carries a risk of CSF leak.
Don’t gild the lily—perform adequate
decompression and move on.
●● Don’t lose composure—CSF leaks are
inevitable.
●● Always rule out infection and hydrocepha-
lus in the presence of a persistent leak.
●● Maintain leaks in the cervical spine upright,
and keep the head of the bed flat for lum-
bosacral leaks.
●● Consider inserting the lumbar drain first,
before CSF is drained from the pseudome-
ningocoele and turgor is lost.

Treatment of a persistent cervical
dural tear
JESSICA L. BLOCK AND D. GREG ANDERSON
Introduction 241
Indications for treatment 241
Relative contraindications for treatment 241
Expectations 242
INTRODUCTION
Intraoperative incidental durotomies may occur
in as many as 1% of cervical spine surgeries.
Although watertight primary closure is the goal
of treating a dural tear, due to anatomic con-
straints, this may not be possible. We will focus
on the management of dural tears in the cervical
region, where a watertight primary closure is not
feasible.
INDICATIONS FOR TREATMENT
(FIGURE 33.1)
In cases where there is spinal fluid emanating from
the surgical incision or cases with symptoms of
spinal fluid leakage (headaches, nausea, vomiting,
photophobia, changes in hearing, or imbalance),
treatment is indicated. If only mild symptoms (e.g.,
mild headache) are present, conservative manage-
ment may be undertaken with hydration and the
intake of caffeinated beverages. Cases with more
severe symptoms are candidates for wound explo-
ration and repair.
33
Pre-operative planning and operating
room (OR) setup 242
Operative technique 242
Postoperative management 242
Complications 243
Postoperative recognition of cervical dural insufficiency
Conservative management:
- Bedrest with head elevated, compression dressing
- Lumbar drain if CSF leakage persists
- Possible fine needle aspiration
Operative management:
- Irrigation and debridement of surgical site, replace hardware
- Repair durotomy with gel, sealants and autologous graft
- Lumbar drain, possible wound/peritoneal or
lumbar/peritoneal shunting
Novel operative treatments:
- Use of aneurism clips to repair dura
- Sternocleidomastoid (SCM) flap to reduce free space
Figure 33.1  Treatment algorithm for cervical dural
tears.
RELATIVE CONTRAINDICATIONS
FOR TREATMENT
The only strong contraindication for surgical
intervention in cases of a severe persistent cervi-
cal dural tear is a medical condition that would not
241
242  Treatment of a persistent cervical dural tear
allow the patient to be treated safely under general
anesthesia.
EXPECTATIONS
The expectation of treatment is healing of the dural
tear with resolution of the symptoms.
PRE-OPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
The surgical field should have the necessary fine
suture material and microinstruments that are
required to perform direct repair of a dural tear
and should have the onlay graft materials and dural
sealants that may be required as part of the repair
strategy. The operative team may also benefit from
having a kit for placement of a subarachnoid drain
in the event that cerebrospinal fluid (CSF) diver-
sion is required.
The patient is positioned prone on a spinal
frame, with the head secure and pressure relieved
from the eye region. Slight neck flexion and down-
ward taping of the shoulders are used to prepare
a stable surgical site. Introperative spinal cord
monitoring with SSEM and motor-evoked poten-
tials (MEPs) may be helpful in confirming that
the operative position is tolerated by the patient
and that the spinal cord function remains intact
through the surgical intervention.
OPERATIVE TECHNIQUE
The surgical wound should be opened and the
exposed regions of the dural tissues from the index
operation should be carefully examined. Use of a
short Valsava maneuver (40 cm of water) by the
anesthesia staff can be useful in promoting leak-
age in order to assist in identification of the leakage
site. Once the site of the leak has been identified,
a repair strategy should be determined. If pos-
sible, direct suture repair is preferred. Fine 4-0,
5-0, or 6-0 suture made of Gortex, polypropylene,
or braided nylon is typically used according to the
surgeon’s preference. Stitches can be either simple
interrupted or running/locking, depending on the
size and accessibility of the tear site. The spacing of
each suture pass should be 2–3 mm apart.
Depending on the location of the tear, acces-
sibility, size, and tissue quality, additional onlay
materials may be considered. One option is to sew
a patch over the repair site or into a gap in the dural
tissues that is not able to be reapproximated. Tissue
graft options that have been described include
autologous tissues (fat, muscle, or fascia), allografts
(dura, pericardium) or xenografts (bovine peri-
cardium). Synthetic grafts (collagen matrix) have
also become popular recently. The technique for
attaching a dural graft can include passing dural
tag sutures through the graft material and tying
onto or into the repair site.
Depending on the nature of the repair and
the preferences of the surgeon, a dural seal-
ant may also be utilized. Available dural seal-
ants include fibrin glue (autologous or allogenic),
hydrogels (Duraseal), or cyanoacrylic, which has
not been approved by the U.S. Food and Drug
Administration (FDA) for dural applications. A
dural sealant may help to occlude small defects in
the repair, such as around the sutures to reduce the
risk of CSF leakage in the postoperative period.
At the conclusion of the repair, a Valsava maneu-
ver (40 cm of water) can be requested to assess the
integrity of the repair. The surgical wound is closed
tightly in multiple layers. Subfascial drains may be
utilized according to the surgeon’s preference and
should be tracked some distance from the surgical
incision site.
The use of a CSF diversion technique such as
subarachnoid drainage may also be considered
according to the surgeon’s preference. The goals of
subsrachnoid drainage are to reduce the intrathe-
cal pressure against the inner surface of the repair
site and to promote healing of the repair. These
benefits must be weighed against the risks of sub-
dural hematomas and meningitis.
In extreme cases, irreparable dural defects have
been treated with CSF shunting such as lumbar/
peritoneal or wound/peritoneal shunts.
POSTOPERATIVE MANAGEMENT
Upright positioning following the repair of cervi-
cal dural tears is useful to reduce the intrathecal
pressure at the repair site. Aggressive nutritional
support to promote good tissue healing is rec-
ommended during the healing phase. The use of
 Complications 243

antibiotic prophylaxis is recommended if indwell- lethargy) should also be sought. If a subarachnoid

ing catheters (subarachnoid drain) or wound drain is utilized, samples of CSF should be sent for
drains are in place. cell count on a daily basis to monitor for evidence
of meningitis.

COMPLICATIONS
Pearls and Pitfalls
Patients should be watched for signs of further
CSF leakage (e.g., clear wound drainage, head- These factors should be emphasized during
the treatment of a persistent cervical dural
aches, nausea, vomiting, photophobia, changes in
tear: watertight closure, tight wound closure,
hearing, and imbalance). Additionally, symptoms upright positioning, and optimal nutrition.
of meningitis (e.g., fevers, stiff neck, and confusion

Treatment of a ventral thoracic
dural defect
IBRAHIM HUSSAIN, PETER F. MORGENSTERN, AND
ALI A. BAAJ
Indications 245
Relative contraindications 245
Expectations 246
Principles of revision surgery 246
INDICATIONS
Ventral thoracic pathologies are considered among
the most treacherous spinal cases to address surgi-
cally, especially due to the difficulty in repairing
dural defects in this region. The most common
causes of ventral thoracic spinal cord compres-
sion are calcified herniated discs and ossification
of the posterior longitudinal ligament (OPLL),
which can cause significant scarring and damage
to the underlying dura. Ventrally situated, intra-
dural, extramedullary tumors, including schwan-
nomas, meningiomas, and neurofibromas, are
other masses occurring in this region that may
necessitate wide durotomy. These pathologies often
require lateral transthoracic approaches with post-
operative placement of chest tubes to reexpand the
lung. The negative pressure generated by chest tube
suction can exacerbate and prevent adequate heal-
ing of a ventral thoracic durotomy. Complications
related to persistent cerebrospinal fluid (CSF) leak
34
Preoperative planning and operating
room (OR) setup 246
Operative technique 247
Postoperative management 247
Complications 247
from these defects can clinically manifest simi-
larly to their sentinel pathology with symptoms
of myelopathy, including lower-extremity paresis,
spasticity, gait incoordination, and bowel-bladder
dysfunction. Often, there is initial improvement
after surgery, with rapid decompensation once the
leak has reached a critical point. This situation is
nearly always an indication for revision surgery
because the patient’s neurologic status will con-
tinue to deteriorate secondary to spinal cord her-
niation, CSF fluid collection with mass effect, or
intracranial hypotension.
RELATIVE CONTRAINDICATIONS
There are few contraindications for this type
of revision surgery. Typically, patients who are
unstable from a hemodynamic, cardiopulmonary,
coagulopathic, or intracranial pressure standpoint
should be stabilized before surgical intervention.
245
246  Treatment of a ventral thoracic dural defect
EXPECTATIONS
Realistic expectations need to be fully discussed
with the patient preoperatively, which requires
highlighting the risk of requiring subsequent
interventions, given the high rate of dural viola-
tions with calcified herniated disks and OPLL.
A clear understanding of the delicate balance
between negative pressure chest tube management
and the exacerbation of ventral dural defect is also
paramount and requires constant communication
between the spine and thoracic approach surgeons.
Achieving a watertight dural closure in this region
is extremely difficult; therefore, secondary maneu-
vers for dural repair are relied upon. This includes
CSF diversion, usually in the form of a lumbar
drain, with a variable time frame based on the size
and response of the defect. The surgeon should
also note that a combination of lower-extremity
paresis, frequently encountered as a result of these
pathologies, and extended periods of bed rest to
facilitate dural repair increases the risk of other
nonsystemic complications, including pneumonia,
deep venous thrombosis (DVT), and pulmonary
emboli.
PRINCIPLES OF REVISION
SURGERY
The principles of revision surgery for cases of ven-
tral thoracic dural defects are threefold. The first
is appropriate identification of the exact level and
laterality of the defect based on known previous
surgical details, preoperative imaging (magnetic
resonance imaging [MRI] or computed tomogra-
phy [CT] myelogram), and intraoperative imag-
ing (fluoroscopy or intraoperative CT scan). The
second principle is to obtain closure of the defect
in multiple layers using various strategies detailed
later in this chapter. Using a single technique has a
high rate of failure, so an aggressive and definitive
repair is recommended at the time of initial revi-
sion to prevent subsequent takebacks. The third
principle is that even a superior intraoperative
repair strategy can fail if the postoperative man-
agement is not closely regulated. This includes
constant communication between thoracic
surgery teams if a chest tube is present, as well as
nursing staff handling chest tubes or lumbar drain
devices.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
As mentioned previously, radiographic evidence
of the location and consequences of the ventral
defect is paramount to the approach strategy.
MRI is an effective modality for diagnosis, as the
T2-weighted images can clearly identify extra-
spinal fluid collections that are isointense to CSF
signals. Furthermore, evaluation of the spinal
cord on MRI is superior to other imaging modali-
ties, so that spinal cord herniation, degree of cord
compression, and/or spinal cord edema can be
appropriately evaluated. For patients who cannot
undergo MRIs, or those with instrumentation that
causes significant artifact-limiting visualization,
CT myelogram should be considered. This modal-
ity can also identify the source of the CSF leak, as
signified by contrast extravasation, but it is lim-
ited in its ability to evaluate intrinsic spinal cord
pathology. Once a CSF leak is identified, either by
imaging or clinically based on high-volume out-
put from chest tube drainage, immediate lumbar
drainage should be considered to prevent worsen-
ing neurologic deterioration.
If the dural defect is encountered during an
anterior approach, attempt to repair it is made
in that position. For defects secondary to ventral
cord herniations, a posterior approach is favored.
This allows complete bilateral visualization of the
defect and appropriate management. The patient
should be positioned prone on an open Jackson
radiolucent table to minimize venous hyperten-
sion, as well as allowing adequate localization with
fluoroscopy. Arterial lines should be placed on all
patients by anesthesia staff so that mean arterial
pressure can be monitored to mitigate the conse-
quences of systemic hypotension-induced spinal
cord hypoperfusion and ischemia. We strongly
recommend the use of intraoperative monitor-
ing—specifically, continuous somatosensory
evoked potentials (SSEPs) and motor-evoked
potentials (MEPs), which can immediately identify

any reversible mechanical causes of spinal cord
damage intraoperatively.
OPERATIVE TECHNIQUE
For ventral defects with cord herniation, a poste-
rior midline incision centered about the level of the
defect is made. In revision-posterior-approach sur-
geries, the same incision can be used. Dissection
is carried down to the dorsal thecal sac in the
region of the defect. In some cases, it is neces-
sary to extend the incision cranially and caudally
to perform additional laminectomies to identify
normal dural edges first, and then work toward the
abnormal area of the thecal sac. Once the dura is
exposed, the operative microscope is brought into
the field.
Next, a midline durotomy or opening of a pre-
vious dorsal dural repair using a scalpel and/or
microscissors is made. The dural edges are tacked
up with 4-0 Nurolon (Ethicon, Somerville, New
Jersey) sutures and patties put in place (Figure
34.1a). The arachnoid is opened with a nerve hook,
scalpel, or microscissors, and cottonoids are placed
around the edges to prevent blood from drip-
ping into the subarachnoid space (Figure 34.1b).
Dentate ligaments and thoracic nerve roots can
be cauterized and cut with microscissors to allow
for cord mobilization and visualization of the ven-
tral dura as needed (Figure 34.1c). Once the ven-
tral cord is untethered from any ventral adhesions
(Figure 34.1d), the dural defect should be entirely
visible (Figure 34.1e). Attempt is made at primary
repair using 5-0 or 6-0 Prolene (Ethicon) inter-
rupted suture (Figure 34.1f). With the dissection
and suturing, care must be taken to avoid anterior
spinal artery injury, which can cause catastrophic
spinal cord infarction.
If primary closure is not possible, a dural graft
substitute is used, such as DuraGuard (Baxter,
Deerfield, Illinois) or Alloderm (Allergan,
Dublin). These grafts should be sized to cover
the entire defect and are carefully slung around
the ventral surface of the spinal cord. Then 6-0
Prolene sutures are used to tack the inlay graft to
the inner layer of the dura at four corners. Once
this step is completed, we ensure that the spinal
Complications 247
cord is back in its normal position and the dor-
sal durotomy is closed with running 4-0 Nurolon
suture. A very thin layer of dural sealant is sprayed
over the closure.
POSTOPERATIVE MANAGEMENT
A lumbar drain should be placed either preopera-
tively or intraoperatively following ventral tho-
racic dural defect repair. Because our technique
does not achieve a watertight closure, high-vol-
ume drainage should be considered initially. We
typically start draining immediately following
surgery at 15 mL/hour, or the maximum volume
tolerated by the patient (whichever is greater). At
minimum, we will continue draining for 5 days,
with strict bed rest. Postoperative imaging (MRI
or CT myelogram) can be considered to confirm
closure of the defect (Figure 34.2). If at that point
there is no clinical or radiographic evidence of
CSF leak, then a clamp trial for a minimum of 24
hours is performed. At that point, if there is still
no evidence of a leak, then the drain is removed. If
there is low concern for hematoma and no under-
lying coagulopathy, then all patients should be
started on DVT chemoprophylaxis in addition to
lower-extremity sequential compression devices.
Incentive spirometry should be encouraged hourly
while patients are awake to prevent atelectasis.
COMPLICATIONS
Complications from this revision surgery can
be catastrophic if not appropriately avoided or
addressed. First, failure to prevent further CSF
drainage from the defect can lead to intracranial
hypotension and subsequent intracranial hemor-
rhages. Persistent spinal cord herniation can cause
rapid deterioration of distal neurologic function.
Intraoperatively, damage to the spinal cord itself
or the anterior spinal artery during manipulation
and passing of the inlay graft can cause perma-
nent spinal cord injury and paralysis. Persistent
CSF drainage into the thoracic cavity can also
contribute to pulmonary edema and inadequate
oxygenation.
248  Treatment of a ventral thoracic dural defect

(a) (b)

(c) (d)

(e) (f )

Figure 34.1  Intraoperative photographs of ventral dural defect repair. (a) Dural opening with edges tacked
up using 4-0 Nurolon sutures. (b) Arachnoid opening with nerve hook and microscissors, exposing the
spinal cord. (c) Cauterization of the dentate ligament before being cut to allow easier mobilization of the
spinal cord. (d) Releasing spinal cord adhesions from the edge of the ventral dural defect using microscis-
sors. (e) Complete visualization of the ventral dural defect. (f) Primary closure of the ventral dural defect
using 6-0 Prolene suture.
 Complications 249

(a) (b)

(c) (d)

Figure 34.2  T2-weighted MR images. (a,b) Preoperative sagittal and axial images, respectively, demon-
strating thoracic spinal cord herniation secondary to ventral dural defects. Note the ventral epidural CSF
collection. (c,d) Postoperative sagittal and axial images, respectively, demonstrating two-level laminec-
tomy and reduction of the ventral spinal cord herniation along with reduction in a ventral CSF epidural
collection.

destabilize the spine and may require subse-

Pearls and Pitfalls
When rotating the spinal cord using cut den-
tate ligaments to identify the dural defect
intradurally, neuromonitoring is paramount.
Abrupt changes in monitoring require a less
aggressive rotation maneuver. If the decrease
in amplitude persists on subsequent attempts,
then the surgeon must consider a more lateral
approach to the ventral spinal cord, requiring
additional bony resection, such as facetectomy
or transpedicular approach. These maneuvers
quent stabilization with instrumented fusion.
Care must be taken to limit excessive amounts
of sealant gels, given that these agents can
expand and themselves cause mass effects
on the adjacent spinal cord. Finally, postop-
erative patient positioning is an important
adjunct to facilitate dural repair. Typically,
for upper thoracic dural defects, patients are
kept at  30  degrees, whereas for midthoracic
and  low-thoracic dural defects, they are kept
flat.

Treatment of a persistent lumbar
dural tear
JOSEPH S. BUTLER, MATTHEW S. GALETTA, AND BARRETT I. WOODS
Indications 251
Relative contraindications 251
Expectations 251
Principles of revision surgery 251
Preoperative planning and operating
room (OR) setup (including utility of
neuromonitoring) 252
INDICATIONS
Although dural injury can occur by a number of
mechanisms, it is most frequently an unintended
complication of lumbar spine surgery and can have
significant clinical and medicolegal consequences.
Patients with acute or persistent cerebrospinal fluid
(CSF) leaks commonly present with severe, pro-
longed headaches, which may even be complicated by
meningitis at the time of presentation. Furthermore,
these patients may present with a palpable fluctuant
fluid collection over the lumbar spine, a spinocuta-
neous fistula, or a wound infection. If left untreated,
the situation may give rise to worsening back pain,
arachnoiditis, and poor functional outcome.
Other symptoms include vertigo, posterior neck
pain, neck stiffness, nausea, diplopia, photophobia,
tinnitus, and blurred vision. These symptoms are
due to loss of buoyancy and caudal displacement of
the intracranial contents from reduced CSF pressure,
following persistent CSF leak from the subarachnoid
35
Operative technique 252
Postoperative management 253
Complications 253
Reference 254
space. In very rare cases, it has also been associated
with the development of pneumocephalus.
RELATIVE CONTRAINDICATIONS
Patients who are not medically stable to undergo
operative treatment should not have this procedure.
EXPECTATIONS
Patients are counseled that the goals of surgery will
be the termination of CSF leakage and a rapid reso-
lution of their neurological symptoms, with low to
minimal risk of long-term consequences.
PRINCIPLES OF REVISION SURGERY
Prompt primary repair of dural tears is crucial
to prevent the complications of a persistent dural
tear, including CSF fistula or formation of a pseu-
docyst, which places patients at risk of meningitis.
251
252  Treatment of a persistent lumbar dural tear

Furthermore a watertight primary repair can pre-

vent the fluid collection associated with a persis-
tent CSF leak, which significantly impairs wound
healing.
Durotomies can range in size from nonleak-
ing pinhole sized defects to much large defects
requiring dural reconstruction. Although it may
be tempting not to repair a small tear when the
two inner layers of the meninges remain intact
and there is no CSF leak, we recommend that such
tears be repaired, if possible, because increased
intra-abdominal pressure postoperatively can
cause the arachnoid to burst, resulting in a persis-
tent CSF leak.

PREOPERATIVE PLANNING
AND OPERATING ROOM (OR)
SETUP (INCLUDING UTILITY OF
NEUROMONITORING)
When determining preoperative planning of
a ­lumbar durotomy, the mechanism of injury,
setting, and location of the dural tear must be
considered.
Magnetic resonance imaging (MRI) is used to
investigate for evidence of a persistent CSF leak in
the postoperative setting. Computed tomography
(CT) myelography can be used to demonstrate the
subarachnoid space and identify the site of the leak.
It can also help predict which patients may ben-
efit from percutaneous treatment. If the site of the
leak is not demonstrated, further evaluation with
isotope scanning can be performed. Investigation
strategies used to confirm that any fluid draining is
CSF include using reagent urinary destrostix strips
to assess for the presence of dextrose, or using elec-
trophoresis to assess for beta-2 transferrin.
For patients undergoing posterior lumbar dural
tear repair, positioning is prone on a Jackson table.
For patients undergoing anterior lumbar dural tear
repair, positioning on the table is supine.
Motor-evoked potentials (MEPS) and somato-
sensory evoked potentials (SSEPs) are obtained at
baseline and after final positioning.
OPERATIVE TECHNIQUE
Circumferential exposure of the durotomy is
critical if watertight closure is to be achieved. The
Figure 35.1  Schematic of dural closure with a run-
ning locking technique. (From Eismont FJ et  al.
J Bone Joint Surg Am 1981;63(7):1132–1136. With
permission.)
borders and extent of the tear, if complex, can be
explored and defined with a nerve hook. Primary
repair is typically achieved using a 6-0 Gore-Tex
suture, whereas for revision cases when scar is
present, 4-0 silk is more commonly used. A variety
of suture techniques can be used, including a run-
ning, locked suture or multiple simple, interrupted
sutures (Figure 35.1).
Which technique to deploy should depend
upon the location of the durotomy, complexity of
the tear, integrity and visualization of surround-
ing dura, and surgeon comfort. For elliptical
durotomies in a dorsal or dorsal lateral location
with healthy surrounding dura, a running, lock-
ing suture is preferred. In complex durotomies,
located ventrally or in the axilla of an exiting nerve
root, or in patients with particularly friable dura,
simple interrupted sutures may better approximate
the dura edges. Applying the appropriate tension
to the suture during repair, particularly when per-
forming a running, locking stitch, is critical so as
not to propagate an existing tear or create a new
durotomy.

Several techniques can be used to augment the
primary repair. Multifidus muscle or fat can be
harvested and incorporated into the repair once
the durotomy has been closed. The free ends of the
suture are passed through the muscle and the tis-
sue, slide down over the primary repair, and are
secured with a locking knot. Fat harvested from the
subcutaneous tissue can be used to cover the entire
exposed dura and tucked into the lateral recess
to prevent migration. Adjuvants to suture repair
such as Dermabond, fibrin, and collagen-based
products can be critical to the successful operative
management of a durotomy. If the dural defect is
ventral or adjacent to an exiting root suture, repair
may not be feasible, making these products neces-
sary to halt the egress of CSF.
POSTOPERATIVE MANAGEMENT
For durotomies in which the repair was question-
able, or in patients who are symptomatic postop-
eratively, flat bed rest is the initial management.
The duration of bed rest is typically between 24
and 48 hours, after which elevation of the head
to 30 degrees is performed. If the patient remains
asymptomatic while the head of the bed is ele-
vated, then activity progresses to being out of bed
in a chair. Mechanical deep venous thrombosis
(DVT) prophylaxis with thrombo-embolic deter-
rent (TED) hose and sequential compression
devices (SCDs) should be placed on all bed-rest
patients unless significant contraindications exist.
Chemoprophylaxis is typically not considered
until 48 hours postoperatively.
Jackson Pratt drains are typically left in to suc-
tion for the first 24–48 hours postoperatively. If
there is a significant volume of CSF in the drain
after 24 hours, often the drain will be placed to
gravity. Drains are typically removed when there is
less than 50 cc of drainage per 8-hour period. This
is not standardized, though, and significant vari-
ability in drain management exists.
A bowel regimen is critical in patients who had
a durotomy following spinal surgery. Constipation
can cause significant increases in intra-abdominal
pressure when the patient attempts to defecate,
which can jeopardize the integrity of the dural
repair. Some advocate for the use of abdominal
binders postoperatively in these patients.
Complications 253
Subarachnoid drainage is an option for irrep-
arable durotomies, CSF fistulas, and pseudo-
menigoceles and function by diversion of CSF
from the defect while decreasing the pressure gra-
dient between the intradura and extradural space.
Subarachnoid drainage at a rate of approximately
10 cc/hour or up to 360 cc/day for 3–5 days has
been shown to be an effective way to treat complex
or persistent CSF leaks.
COMPLICATIONS
Pseudomeningocele and myelocutaneous fistula
are possible sequelae of a missed dural tear or
persistent CSF leak, and they can have significant
functional and cosmetic implications. These com-
plications can lead to superficial or deep infec-
tion, or even to meningitis. Nerve root entrapment
secondary to adhesions and arachnoiditis also
has been described in patients with chronic pseu-
domenigoceles. The treatment options for such
patients with persistent radicular symptoms in this
setting are somewhat limited.
Pearls and Pitfalls
Wound closure
A watertight closure of the fascia and subcu-
taneous tissue may be even more important
than the primary repair. Typically, the fascia
layer is closed with a 0 vicryl suture using a
figure of eight suture. The approximation of
the fascia is then reinforced with a locked run-
ning 1-0 ethibon suture. The subcutaneous
tissue is then closed with a 2-0 vicryl followed
by a 3-0 nylon suture. There are many varia-
tions to closure that are acceptable. However,
the principal tenet is a watertight closure of
the fascial layer to prevent wound drainage,
fistula formation, and infection.
Deep drains
Deep drains are often placed following lumbar
procedures in which a durotomy has occurred.
Using a 10 or 15 blade, a 1-cm incision is made
cephalad and lateral to the proximal aspect of
the midline incision. A figure-of-eight suture
is then placed across this incision using 3-0
nylon. A pituitary is then used to retrieve
254  Treatment of a persistent lumbar dural tear
the drain, and the ends of the suture are left
long and wrapped around the drainage tube.
When the drain tube is removed on the floor
when output has sufficiently subsided, the
suture is tied, preventing the possibly of CSF
leakage from the drainage tube site.
Tissue glues
Tisseel (Baxter, Deerfield, Ilinois) is a fibrin
glue containing aprotinin, an inhibitor of fibri-
nolysis, in conjunction with thrombin. The
combination is sprayed over a dural closure
REFERENCE
to reinforce a repair. In addition to supporting
a watertight closure, it promotes hemostasis.
Although it is very popular, there have been
documented instances of neural compression
and neurotoxicity associated with fibrin glue
use, so surgeons should be mindful of this.1
Valsalva manuever
After repairing a durotomy, the patient should
be placed in reverse Trendelenburg positon
and Valsalva performed to increase the intra-
thecal pressure, hence stimulating CSF leak-
age, to identify any incompletely repaired
areas. The repair should be inspected for
signs of extravasation.
1. Neuman BJ, Kristen R, Jeffery R. Cauda
equina syndrome after a TLIF resulting from
postoperative expansion of a hydrogel dural
sealant. Clin Orthop Relat R, 2012;470(6):​
1640–1645.

Treatment of a chronic postoperative
cervical and lumbar spine infection
KAMIL OKROJ AND CHRISTOPHER KEPLER
Indications 255
Relative contraindications 255
Expectations 255
Principles of revision surgery 256
Preoperative planning and operating room
(OR) setup 256
INDICATIONS
Patients with surgical site infections that are readily
apparent on initial examination will nearly always
undergo irrigation and debridement (I&D) as soon
as possible unless there is compelling evidence via
imaging that the infection is limited to cellulitis.
In this sense, the indication for surgery in this
patient population is an infection in the superficial
or deep compartment confirmed via imaging. This
is true for both anterior- and posterior-based index
surgery. The presence of infection in a part of the
spine not exposed during index surgery is some-
what more complicated. Patients with anterior
discitis and/or osteomyelitis after posterior-based
surgery that does not include an abscess can often
be treated with antibiotics, although surveillance
imaging is necessary after posterior I&D to ensure
that medical treatment alone is sufficient. Surgeons
must have a low threshold to perform anterior I&D
if the infection progresses. The presence of an ante-
rior abscess or progressive infection, even with-
out a collection, indicates the need for additional
36
Operative technique 257
Postoperative management 257
Complications 258
Case presentation 258
anterior-approach surgery. The development of
posterior-based infection after an anterior-only
approach is rare but would follow the same pattern
of decision-making about treatment.
RELATIVE CONTRAINDICATIONS
High-risk patients with evidence of a postoperative
infection but no worsening neurologic deficits can
be treated nonsurgically with a course of intrave-
nous (IV) antibiotics, followed by suppressive oral
antibiotics. Serial imaging and bloodwork must
be ordered to track the success of the antibiotic
therapy, as failure is common and will indicate the
need for patient counseling and I&D, followed by
continued antibiotic therapy.
EXPECTATIONS
The expectations about surgery in the setting of
chronic infection are to eradicate the infection to
allow successful fusion and/or to allow the patient
to clear the infection and come off antibiotics.
255
256  Treatment of a chronic postoperative cervical and lumbar spine infection
When these are unobtainable, secondary goals
include achieving fusion while on a suppressive
regiment with delayed removal of instrumentation
after fusion is confirmed with computed tomogra-
phy (CT) and cessation of antibiotic therapy. When
fusion cannot be achieved or antibiotics cannot be
stopped due to recurrence of infection, a tertiary
goal is suppression of infection through lifelong
antibiotic therapy.
PRINCIPLES OF REVISION SURGERY
The goals of revision spine surgery for chronic
postoperative infections are to remove devital-
ized tissue, including bone, muscle, and/or fascia;
prevent the use of unnecessary instrumentation;
replace necessary instrumentation; and release
abscesses that will likely not be successfully
treated with antibiotic therapy alone. Due to the
tendency to form biofilm, instrumentation that is
unnecessary based on the successful achievement
of fusion should be removed. For patients who
underwent instrumented fusion, it is important
to consider the time elapsed since index surgery
to I&D. Acute infections that present 6 weeks or
less from the index procedure are unlikely to have
formed biofilm on the implants. Instrumentation
can be left in place after thorough irrigation.
When infection presents 6 weeks or more after
index surgery, one must assume that a biofilm
has formed and the instrumentation should be
removed or replaced. As the time since index
surgery increases, so does the likelihood that the
patient has achieved fusion. In this setting, CT
scanning should be obtained to assess for fusion
status. If the patient has achieved adequate fusion,
then any hardware can be removed as part of the
debridement procedure and does not need to be
replaced. However, if the patient has not achieved
fusion, then the hardware will need to be replaced
accordingly.
PREOPERATIVE PLANNING AND
OPERATING ROOM (OR) SETUP
Patients who have undergone previous cervical
or lumbar spine surgery who present with a fever
should first undergo a standard fever workup
(i.e., basic labs, chest radiographs, urinalysis,
bilateral lower extremity ultrasound) to rule out
the most common causes of postoperative infec-
tions or unrelated infection if the history of sur-
gery is remote. Patients presenting with persistent
wound drainage, purulent drainage, and fever,
particularly more than 2 weeks after surgery, are
at much higher risk of having postoperative infec-
tion, and the workup should reflect this, immedi-
ately focusing on confirming surgical site infection
(SSI). Laboratory studies should include erythro-
cyte sedimentation rate (ESR), C-reactive protein
(CRP), and white blood cell count, although the
latter can be misleading.
As the entire wound will be opened, it is tempt-
ing to proceed without advanced imaging. In the
setting of chronic infection, however, imaging is
important to confirm that the infection has not
spread beyond the boundaries of the original sur-
gery. Magnetic resonance imaging (MRI), with and
without contrast, will allow definition of the scope
of infection and CT scanning is often valuable
to identify instrumentation failure and evaluate
fusion status. Patients with evidence of osteodis-
citis and no associated epidural abscess shown via
MRI should first undergo a trial of IV antibiotics.
Patients with osteodiscitis who fail a trial of anti-
biotics, epidural abscesses, or rim-enhancing fluid
collection require surgical intervention to help
eradicate the infection.
Unless the patient has a history of previous
spinal infection or presents with a disseminated
infection, the infectious disease team is typically
not consulted until after operating room (OR)
cultures have been obtained. Patients with poor
general medical health should undergo presurgi-
cal labs to identify nutritional deficiencies that
can be addressed simultaneously to decrease the
likelihood of wound-healing problems. Unless
the patient has a disseminated infection and there
is concern about sepsis, preoperative antibiotics
should be held to maximize the yield of intraop-
erative cultures. This is a consideration that should
also be taken into account when seeing patients in
the office who are at high risk based on the clini-
cal picture or history for infection; routine use of
oral antibiotics for erythematous wounds without
further investigation can lower the yield of cul-
tures should patients be found later to have a deep
wound infection.

OPERATIVE TECHNIQUE
The operative technique is heavily dependent
on the index surgery. Particularly for posterior-
approach surgery, the superficial compartment
is opened and then cultures are taken. If there is
not compelling evidence that the infection extends
deep to the fascia, the suprafascial compartment
should be debrided and irrigated with 3 L of antibi-
otic-containing crystalloid after cultures are taken.
Only once this is completed should the fascia be
opened to avoid exposing a potentially sterile
region to infection. If the deep fascia is obviously
open on initial inspection, there is no need to wash
out the superficial compartment separately.
The deep region is then opened, taking care to
remove fascial sutures. A thorough I&D is per-
formed after deep cultures are taken. After instru-
mentation is removed, the screw holes should be
curetted out to remove any leftover devitalized tis-
sue. Avoid the use of bone wax if possible, as foreign
objects can be a reservoir for bacteria. The use of
a thrombin product (SURGIFLO or FLOWSEAL)
is preferable. Bone graft that is obviously infected
should be removed, as should all loose bone graft
material in the setting of a chronic infection.
Patients who require second-look I&Ds can have
a bone graft placed at the time of the final planned
procedure. Patients who are unlikely to require a
second procedure can either be bone-grafted with
new material or can undergo a second procedure
for the express purpose of placing bone graft once
several weeks of antibiotics have been adminis-
tered. Surgeons should consider the use of autolo-
gous bone graft, as there may be some advantages
over putting allograft into an infected wound bed.
At the discretion of the surgeon, intraoperative
consultation with plastic surgery is often taken to
evaluate tissue loss and the need for staged clo-
sure utilizing advancement paraspinal flaps. More
invasive soft-tissue coverage options are available
but rarely necessary, given the robust nature of the
paraspinal muscles. Decisions regarding primary
closure versus delayed closure and temporization
using a vacuum-assisted closure (VAC) device can
be made in consultation with the plastic surgeon.
Prior to closure using flaps, the plastic surgeon
may require a second debridement by the primary
surgeon to demonstrate negative cultures before
Postoperative management  257
performing a complex closure that could fail if
there is a continued infection.
Antibiotic eluding cement beads are utilized from
time to time when a staged procedure is planned. Out
of fear of bead migration, this option is typically lim-
ited to noncord-level surgery such as posterior lum-
bar approaches. All patients who undergo surgery
for infection will have either drainage tubes (often
multiple) or a VAC device. Finally, patients who
are septic on presentation may worsen immediately
following I&D due to bacteremia and often benefit
from planned overnight intubation and monitoring
in an intensive care unit (ICU)‒level ward.
POSTOPERATIVE MANAGEMENT
Similar to the index procedures, postoperative
management for these patients involves providing
adequate pain management and early mobiliza-
tion with physical therapy. Drains should be main-
tained longer than usual, ideally until the output is
less than 10 cc over a 24-hour period. If a VAC is
used, the patient will typically return to the OR two
days later for repeat I&D and either VAC exchange
or primary closure. Each return to the OR should
prompt repeat cultures to demonstrate the eradica-
tion of infection. A consultation with the infectious
disease team will be requested after the index sur-
gery. While antibiotic selection will typically follow
from the results of OR cultures, presurgical treat-
ment with antibiotics, which could skew the culture
results or patient-specific risk factors, may change
the choice of antibiotic to some extent.
Patients without instrumentation are typi-
cally treated with 6 weeks of IV antibiotics, while
patients with instrumentation are often treated for
6 weeks with IV antibiotics followed by up to a year
of oral suppressive antibiotics. Nearly all patients
will receive a peripherally inserted central catheter
(PICC) line. Patients with positive blood cultures
prior to surgery will have to wait until daily blood
cultures are negative prior to PICC placement.
Patients are usually seen at regular follow-up peri-
ods by the spine surgeon and plastic surgeon (e.g., 2
weeks, 6–8 weeks, 3–6 months). Follow-up with the
infectious disease team varies, but patients should
be seen no later than 6 weeks after initial I&D, and
laboratory studies should be obtained and reviewed
before that time to monitor the treatment response.
258  Treatment of a chronic postoperative cervical and lumbar spine infection

COMPLICATIONS
Patients undergoing revision procedures that require
further decompression or I&D of the epidural space
are at increased risk of dural injury due to inflamma-
tion and adhesions near the dura. Dural tears in the
setting of an active infection should cause concern,
as they increase the patient’s risk of developing men-
ingitis; appropriate antibiotic coverage with an agent
that crosses the blood‒brain barrier is necessary in
such cases. Many factors can contribute to failure
to eradicate infection, including bacterial antibiotic
resistance, patient-specific factors related to general
health or immune deficiency, failure to pursue an
aggressive debridement strategy or multiple surgical
approaches when indicated, and insufficiently long
antibiotic regimens. Although treatment failures
will occasionally happen despite the surgeon’s best
efforts, the impact of treatment failure can be limited
by maintaining a high index of suspicion for persis-
tent infection so it can be caught early.
Pearls and Pitfalls
Maintaining an open dialogue with the infec-
tious disease team will allow communication
regarding patient-specific risk factors, antici-
pated duration of antibiotic treatment, and
likely patient compliance in order to optimize
success rates.
  There is little downside to doing several
iterations of I&D for severe infections, and the
benefits of treating the infection in a ­single
episode of care far outweigh the inconve-
nience of taking a patient back repeatedly
until the wound and all remaining tissue
appear healthy.
  Similarly, recognize bone graft as a nidus for
infection. Repeat takeback for revision bone-
grafting after antibiotic treatment is initiated
is superior to placing new allograft bone at
the time of initial I&D.

CASE PRESENTATION

A 65-year-old male patient underwent an L2–S1 decompression and fusion about 8 years ago. The
patient presented septic, with severe back pain, and was found to have osteodiscitis at L1–L2, T12–L1
and T11–T12 with an epidural abscess extending from L3–T10 (Figure 36.1a,b). He underwent a revision
T10–L3 decompression with extension of his fusion up to T11 (Figure 36.2a). In a staged manor, he
underwent anterior interbody fusion with tricortical iliac crest autograft at L1–L2, L1–T12 and T12–T11.

(a) (b)

Figure 36.1  (a) The preoperative sagittal T2 image demonstrating osteodiscitis at L1–L2, T12–L1 and
T11–T12. (b) A T1 postcontrast axial image demonstrating an epidural abscess.
 Complications 259

(a) (b)

Figure 36.2  (a) A postoperative lateral radiograph after the first stage. (b) The intraopertive radio-
graph clearly demonstrating the interbody fusion with iliac crest autograft.
Index

A expectations, 53 contralateral revision, 225–227

indications, 51–52 migration of ALIF graft, 226
ACCF, see Anterior cervical
operative technique, 55–56 Anterior superior iliac spine
corpectomy and fusion
pitfalls, 57 (ASIS), 195
ACDF, see Anterior cervical
postoperative management, 56–57 AOD, see Atlanto-occipital
discectomy and fusion
preoperative planning and OR dislocation
Adjacent-level degeneration, 206
setup, 53–55 AP, see Anterioposterior
Adjacent-level stenosis revision
relative contraindications, 52–53 ASA, see American Society of
surgery, 205
revision surgery principles, 53 Anesthesiologists
complications, 209
Anterior cervical discectomy and ASIS, see Anterior superior
expectations, 206–207
fusion (ACDF), 41, 59, iliac spine
indications, 205–206
111; see also Anterior Asymptomatic
operative technique, 208
cervical discectomy pseudomeningocoele, 231
pitfalls, 209
and disc replacement; Atlanto-occipital dislocation
postoperative management,
Revision surgery of ACDF (AOD), 77
208–209
nonunion
preoperative planning and
anterior revision of same-level,
operating room setup, B
43–44
207–208
complications, 45 Baseline upright radiographs, 54
relative contraindications, 206
expectations from revision BMI, see Body mass index
revision surgery principle, 207
surgery, 43 BMP, see Bone morphogenetic
Adjacent-segment disease (ASD),
indications for, 41–42 protein
41, 102, 205; see also
pitfalls, 46 Body mass index (BMI), 7, 63
Cervical TDR; Total disc
posterior revision, 44–45, 46 Bone morphogenetic protein (BMP),
replacement
postoperative management, 45 79, 134, 153, 158
treatment, 59
preoperative planning, 43 Bone morphogenic protein 2
American Society of
revision surgery, 42–43 (BMP2), 123
Anesthesiologists (ASA), 7
Anterior cervical fusion, 51
Anterioposterior (AP), 14, 36, 48, 54
Anterior cervical spine surgery, 51
Anterior cervical corpectomy and C
Anterior decompressions in cervical
fusion (ACCF), 111
spine, 51 C1–C2 Revision surgery, 83
Anterior cervical discectomy and
Anterior lumbar interbody fusion AP and lateral postoperative
disc replacement, 51; see
(ALIF), 151, 186, 187, 223; films, 88
also Anterior cervical
see also Revision surgery complications, 87
discectomy and fusion;
of ALIF nonunion; expectations, 84
Cervical disc replacement
Revision surgery of TLIF imaging, 85–86
complications, 57
nonunion indications, 83

261
262   Index
C1–C2 Revision surgery
(Continued)
operative technique, 86
pitfalls, 88
postoperative management, 86
preoperative planning, 85
preoperative setting, 86
relative contraindications, 84
revision surgery principles, 84
screw-rod constructs
technique, 84
CBVA, see Chin-brow vertical angle
Central nervous system (CNS), 68
Cerebrospinal fluid (CSF), 24,
27, 56, 67, 87; see also
Persistent lumbar dural
tear treatment; Ventral
thoracic dural defect
treatment
leakage, 88, 231, 245, 251
Cervical disc replacement; see
also Anterior cervical
discectomy and disc
replacement
catastrophic failure of, 52
goal of, 51
posterior fusion following
failed, 52
Cervical laminectomy, 89
Cervical laminoplasty failure, 109
complications, 114
deformity correction, 112
disc herniation or OPLL
progression, 111–112
expectations, 110
intractable neck pain, 113
loss of alignment and kyphosis,
112–113
mechanical failure of
laminoplasty, 110
operative techniques, 110–111
osteotomies in cervical spine, 112
pitfalls, 114
postoperative management, 113
preoperative setup, 110
relative contraindications, 110
revise with ACDF or ACCF, 111
revise with laminectomy and
fusion, 111
revise with plate, 111
revise with posterior fusion, 113
revision surgery principle, 110
Cervical myelopathy, 109; see also
Cervical laminoplasty
failure
Cervical TDR, 59
complications, 63–64
contraindications for cervical
TDR, 61
expectations, 61
indications, 60
operative technique, 62–63
pitfalls, 64
postoperative management, 63
preoperative planning, 62
radiographs, 60
relative contraindications, 61
revision surgery principle, 61–62
Chiari malformation, 67
Chin-brow vertical angle (CBVA), 92
Chronic postoperative cervical and
lumbar spine infection
treatment, 255
case presentation, 258–259
complications, 258
expectations, 255–256
indications, 255
operative technique, 257
pitfalls, 258
postoperative management, 257
preoperative planning, 256
relative contraindications, 255
revision surgery principle, 256
Clivo-axial angle (CXA), 69
Clivus-canal angle, see Clivo-axial
angle
Closed-suction drain, 238; see
also Symptomatic
cervical and lumbar
pseudomeningocoeles
treatment
CNS, see Central nervous system
Complete blood count (CBC), 5, 103,
162, 171
Computed tomography (CT), 5, 14,
21, 36, 48, 54
Computed tomography angiography
(CTA), 223
Cranial-vertebral junction (CVJ),
77; see also Revision
surgery of CVJ nonunion
Craniocervical instability (CCI)
with, 68
C-reactive protein (CRP), 5, 85, 103,
171, 256
CSF, see Cerebrospinal fluid
CT, see Computed tomography
CTA, see Computed tomography
angiography
CVJ, see Cranial-vertebral junction
CXA, see Clivo-axial angle
D
DBM, see Demineralized bone matrix
Deep drains, 253–254
Deep vein thrombosis (DVT), 25,
74, 107, 121, 129, 172
prophylaxis, 208
Deep venous thrombosis, see Deep
vein thrombosis
Demineralized bone matrix
(DBM), 106
Denosumab, 134
Diabetes mellitus (DM), 7–8, 27,
41, 128
Direct lateral interbody fusion
(DLIF), 223
DLIF, see Direct lateral interbody
fusion
DM, see Diabetes mellitus
Double-door laminoplasty, 110; see
also Cervical laminoplasty
failure
Dual-energy x-ray absorptiometry
(DEXA), 54, 120, 134, 185
Dural tears, 258
Durotomy repair, 232
DVT, see Deep vein thrombosis
E
Ear, nose, and throat (ENT), 62
EDS, see Ehlers–Danlos syndrome
Ehlers–Danlos syndrome (EDS), 68
Electromyography (EMG), 15, 22,
35, 44, 86, 206

EMG, see Electromyography
Endovascular aortic repair
(EVAR), 146
ENT, see Ear, nose, and throat
Erythrocyte sedimentation rate
(ESR), 5, 85, 103, 162,
171, 256
EVAR, see Endovascular aortic repair
F
Fast Imaging Employing Steady-state
Acquisition (FIESTA), 70
FDA, see U.S. Food and Drug
Administration
FIESTA, see Fast Imaging
Employing Steady-state
Acquisition
Flat back deformity revision
surgery, 211
complications, 215
CT scan of after-first-stage
revision surgery, 213
expectations, 211
final postoperative imaging, 215
indications, 211
operative technique, 212–213
pitfalls, 215–216
postoperative management, 215
preoperative imaging, 212
PSO in lateral and coronal
plane, 214
relative contraindications, 211
revision surgery principle,
211–212
SPO/Ponte osteotomy in lateral
and coronal plane, 214
Free-run electromyography
(frEMG), 175, 219
frEMG, see Free-run
electromyography
H
HCL, see Hydrochloric acid
Herniated nucleus pulposus (HNP),
161; see also Recurrent
lumbar herniated nucleus
pulposus
Heterotopic ossification (HO), 63
HNP, see Herniated nucleus
pulposus
HO, see Heterotopic ossification
Hydrochloric acid (HCL), 169
I
I&D, see Irrigation and debridement
Iatrogenic flat back deformity,
211; see also Flat back
deformity revision surgery
ICBG, see Iliac crest bone graft
IDE, see Investigational device
exemption
Idiopathic intracranial hypertension
(IIH), 68
IIH, see Idiopathic intracranial
hypertension
Iliac crest bone graft (ICBG), 129,
158, 195, 212
Implantable pulse generator
(IPG), 36
Inferior vena cava (IVC), 224
Intensive care unit (ICU), 53, 74, 97,
129, 208, 257
Interbody fusion techniques,
223; see also Ventrally
displaced graft
management
Intraoperative incidental
durotomies, 241; see also
Persistent cervical dural
tear treatment
Intraoperative neuromonitoring
(IONM), 152, 175–176
Intraoperative neurophysiological
monitoring, 62
Intravenous (IV), 6, 15, 20, 70, 85,
208, 255
Investigational device exemption
(IDE), 59
IONM, see Intraoperative
neuromonitoring
IPG, see Implantable pulse
generator
Irrigation and debridement
(I&D), 255
IVC, see Inferior vena cava
Index 263
J
Japanese Orthopedic Association
(JOA), 109
JOA, see Japanese Orthopedic
Association
L
Laminectomies, thoracic and
lumbar, 19
bone-scar interface, 23
complications, 24–25
expectations, 20
indications, 19
membrane of, 19, 20
operative technique, 22–24
pitfalls, 25
postoperative management, 24
preoperative planning, 21–22
radiograph and MRIs, 22
relative contraindications, 20
revision surgery principle, 20
scar of, 24
Laminectomy membrane, 19; see
also Laminectomies,
thoracic and lumbar
Laminoplasty, 109; see also Cervical
laminoplasty failure
Lateral lumbar interbody fusion
(LLIF), 155, 213; see
also Minimal access
surgical technology/
transforaminal lumbar
interbody fusion; Revision
surgery of lateral lumbar
interbody fusion
LL, see Lumbar lordosis
LLIF, see Lateral lumbar interbody
fusion
LSO, see Lumbar sacral orthosis
Lumbar; see also Adjacent-level
stenosis revision surgery;
Revision surgery of TLIF
nonunion; Symptomatic
cervical and lumbar
pseudomeningocoeles
treatment
nonunion, 183
264   Index
Lumbar (Continued)
spine fusions, 205
subarachnoid drainage, 238–239
Lumbar lordosis (LL), 128
Lumbar sacral orthosis (LSO), 227
M
Magnetic resonance angiogram
(MRA), 223
Magnetic resonance imaging (MRI),
6, 14, 21, 43, 48, 54, 70
MAP, see Mean arterial pressure
MAST TLIF, see Minimal access
surgical technology/
transforaminal lumbar
interbody fusion
Mean arterial pressure (MAP), 121
MEPs, see Motor-evoked potentials
MEP/SSEPs, see Motor-evoked and
somatosensory evoked
potentials
Methicillin-resistant Staphylococcus
aureus (MRSA), 21, 62, 141
Methicillin-susceptible S. aureus
(MSSA), 62
Minimal access surgical technology/
transforaminal lumbar
interbody fusion (MAST
TLIF), 201
Minimally invasive lumbar revision
surgery, 173; see also
Revision surgery of
lumbar decompression
advantages of, 175
complications, 181
decompression of ipsilateral
nerve root after
discectomy, 179
equipment, 175
expectations, 175
fluoroscopy localization, 176
history and physical
examination, 173
identification and exposure
of nerve root and
dural sac, 179
imaging studies, 173
indications, 173–174
intraoperative lateral
fluoroscopy, 177
intraoperative neuromonitoring,
175–176
lamina removal using side-
cutting match-stick bone
drill, 178
left recurrent L5–S1 disc
herniation after
microdiscectomy, 174
MIS revision discectomy,
176–179
MIS revision lumbar
laminectomy, 179–180
monopolar electrocautery, 178
patient positioning, 175
pitfalls, 181
postoperative management,
180–181
preoperative planning, 175–176
recurrent disc material, 179
relative contraindications,
174, 175
remaining tissue after docking
final retractor tube, 178
revision surgery principle, 175
surgical technique, 176–180
tube positioning at L1–L2, L2–
L3, or L3–L4, 177
Minimally invasive surgery (MIS),
129, 173; see also Revision
surgery of MIS TLIF
Minimally invasive transforaminal
lumbar interbody fusion
(MIS TLIF), 191; see also
Revision surgery of MIS
TLIF
MIS, see Minimally invasive surgery
MIS TLIF, see Minimal access
surgical technology/
transforaminal lumbar
interbody fusion
Motor-evoked and somatosensory
evoked potentials (MEP/
SSEPs), 44
Motor-evoked potentials (MEPs),
22, 48, 54
MRA, see Magnetic resonance
angiogram
MRSA, see Methicillin-resistant
Staphylococcus aureus
MSSA, see Methicillin-susceptible
S. aureus
Muscle flaps, local, 27
complications, 32–33
deep muscle flap, 30
deep paraspinous muscle
layer, 31
expectations, 28
indications, 27
open spinal wound with
hardware in place, 31
operative technique, 30–32
pitfalls, 33
posterior view of superficial and
deep muscles of back, 28
postoperative management, 32
preoperative planning, 29–30
relative contraindications, 27
relaxing incision through lateral
muscle fascia, 29
revision surgery principle, 28–29
superficial dehiscence, 32
superficial muscle flap, 30
superficial muscle layer, 31
visualization of both superficial
and deep dissected muscle
layers, 30
Myelocutaneous fistula, 253
N
NCS, see Nerve conduction study
NDI, see Neck disability index
Neck disability index (NDI),
91, 113
Nerve conduction study
(NCS), 206
Neurolysis, 179
Neuromonitoring, 54, 207
Nil per os (NPO), 25
Nonsteroidal anti-inflammatory
drug (NSAID), 37, 53, 63,
83, 133, 123
Nonunion, 183
NPO, see Nil per os
NSAID, see Nonsteroidal anti-
inflammatory drug
 Index 265

O stent placement around PJF, see Proximal junctional failure

Oblique lateral interbody fusion
(OLIF), 223
Occipital condyle screw
placement, 80
condyle screw, 80, 81
intraoperative planning for, 81
ODI, see Owesty Disability Index
OLIF, see Oblique lateral interbody
fusion
Operating room (OR), 6, 21, 36, 49,
53, 62, 208
Ossification of posterior
longitudinal ligament
(OPLL), 109, 232, 245
Osteotomies in cervical
spine, 112
Owesty Disability Index (ODI), 3
P
PA, see Posterior-anterior
Paddle lead placement, 35
Patient-controlled analgesia
(PCA), 74
PCA, see Patient-controlled
analgesia
PCDF, see Posterior cervical
discectomy and fusion
PCM, see Porous coated motion
PDS, see Polydioxanone
PE, see Pulmonary embolism
Pedicle screw, 185–186
Pedicle screw removal, 145
complications, 148
contraindications, 145
endovascular-assisted
approach, 146
expectation, 145
hybrid approach, 147
indications, 145
operative techniques, 146
pedicle screw penetrating
vertebral body, 146
pitfalls, 148
postoperative management, 148
preoperative setup, 146
revision surgery principle, 146
offending screw, 147
thoracotomy procedure,
146–147
Pedicle subtraction osteotomies
(PSOs), 94, 96–97, 112;
see also Postlaminectomy
kyphosis treatment
in lateral and coronal plane, 214
PEEK, see Polyetheretherketone
Pelvic incidence (PI), 128
Pelvic tilt (PT), 211
Percutaneous surgery, 35
Peripherally inserted central
catheter (PICC), 257
Persistent cervical dural tear
treatment, 241
complications, 243
expectations, 242
indications for, 241
operative technique, 242
pitfalls, 243
postoperative management,
242–243
pre-operative planning, 242
relative contraindications for,
241–242
treatment algorithm, 241
Persistent lumbar dural tear
treatment, 251
complications, 253
deep drains, 253–254
dural closure with running
locking technique, 252
expectations, 251
indications, 251
operative technique, 252–253
pitfalls, 253–254
postoperative management, 253
preoperative planning, 252
relative contraindications, 251
revision surgery principle,
251–252
tissue glues, 254
valsalva manuever, 254
wound closure, 253
PI, see Pelvic incidence
PICC, see Peripherally inserted
central catheter
PJK, see Proximal junctional
kyphosis
PLIF, see Posterior lumbar
interbody fusion
PLL, see Posterior longitudinal
ligament
Polydioxanone (PDS), 233
Polyetheretherketone (PEEK),
188, 219
Ponte osteotomy, 214
Porous coated motion (PCM), 60
Postanesthesia care unit (PACU),
53, 202, 208
Posterior-anterior (PA), 156
Posterior cervical discectomy and
fusion (PCDF), 47
Posterior cervical fusion, 101
Posterior cervical fusion failure
revision, 101
closure, 106
complications, 107
contraindications, 102
decortication/fusion bed
preparation, 106
diagnostic workup, 102–104
differential diagnosis, 101–102
expectations, 104
exposure, 104–105
hardware removal, 105
history and physical exam,
102–103
imaging and diagnostics, 103
laboratory testing, 103–104
operative technique, 104–106
pitfalls, 107
postoperative management, 106
preoperative planning, 104
reinstrumentation, 105
Posterior cervical laminectomy
revision, 13
complications, 17–18
expectations, 14
exposure of area, 16, 17
operative technique, 15–17
pitfalls, 18
postoperative management, 17
preoperative planning, 14–15
relative contraindications, 13
266   Index
Posterior cervical laminectomy
revision (Continued)
revision surgery principle, 14
T2-weighed sagittal and axial
MRIs, 15
Posterior longitudinal ligament
(PLL), 91
Posterior lumbar interbody fusion
(PLIF), 186, 218, 223; see
also Revision surgery of
TLIF nonunion
Posterolateral decompressive and
fusion failure revision, 199
AP and lateral standing scoliosis
plain films, 201
AP/lateral plain films, 203
complications, 202
expectations, 200
indications, 199–200
intraoperative fluoroscopy
of MAST TLIF
approach, 203
operative technique, 201–202
pedicle screws, 203
pitfalls, 204
posterolateral instrumentation
and fusion, 200
postoperative management, 202
preoperative planning and
operating room setup, 201
relative contraindications, 200
revision surgery principle,
200–201
Postlaminectomy kyphosis
treatment, 89
anterior corrective maneuvers,
95–96
CBVA, 92
cervical sagittal alignment, 90
comparison of osteotomy
options, 94
complications, 97
considerations for OR setup,
94–95
distal junctional kyphosis, 92
expectations, 90–91
indications, 89–90
measurement of cervical
deformity, 91–92
operative technique, 95
osteotomy closure, 97
pedicle subtraction osteotomies,
96–97
pitfalls, 98
planning for fixed and ankylosed
postlaminectomy
kyphosis, 93
planning for fixed nonflexible, 93
planning for flexible and
passively correctable
kyphosis, 92–93
posterior-anterior-posterior
correction, 94
posterior corrective
maneuvers, 96
postoperative management, 97
preoperative planning, 91–95
progressive postlaminectomy
kyphosis, 91
relative contraindications, 90
revision surgery principle, 91
Smith-Petersen osteotomies, 96
Postoperative care, 53
Posttraumatic stress disorder
(PTSD), 4
PPIs, see Proton pump inhibitors
Proton pump inhibitors (PPIs), 180
Proximal junctional failure (PJF),
118; see also Proximal
junctional kyphosis
revision
Proximal junctional kyphosis
(PJK), 117
Proximal junctional kyphosis
revision, 117
causes of PJK, 117–118
closure, 123
complications, 123–124
contraindications, 118
correcting PJK with SPO, 123
expectations, 118
indications, 118
instrumentation, 122–123
operative complication, 124
patient with failure at T4 level, 120
patient with PJK at T10 level, 119
postoperative complications, 124
postoperative management, 123
preoperative complications,
123–124
preoperative planning, 120–121
radiologic assessment, 120–121
revision surgery principle,
118–120
surgical technique, 121–123
Pseudarthrosis, 101
repair, 136
Pseudomeningocele, 253
PSOs, see Pedicle subtraction
osteotomies
Psychiatric illness, 8
PT, see Pelvic tilt
PTSD, see Posttraumatic stress
disorder
Pulmonary embolism (PE), 25
R
Recombinant human bone
morphogenetic protein
(rhBMP), 141
Recombinant human bone
morphogenic protein-2
(rhBMP-2), 224
Recurrent lumbar herniated nucleus
pulposus, 161
axial MRI image, 163
complications, 164
contraindications, 162
expectations, 162
indications, 161–162
operative technique, 162
pitfalls, 165
preoperative planning, 162–164
revision surgery principle, 162
sagittal MRI image, 163
Repeat suboccipital decompression
in Chiari, 67
complications, 74
dural substitute, 73
expectations, 69
indications, 67–68
microsurgical technique, 72, 73
operative technique, 71–74
pitfalls, 74–75
postoperative management, 74
preoperative planning, 70–71

relative contraindications, 68–69
revision surgery principle, 70
sagittal T2 MRI scans of Type
1 Chiari malformation,
68, 69
3D-printed subocciputal and
upper cervical spine, 70
Revision surgery, 3; see also
Adjacent-level stenosis
revision surgery
cigarette smoking and
pseudarthrosis, 6
clinical considerations, 5
diabetes mellitus and, 7–8
goals of, 256
imaging studies and, 4–5
laboratory evaluation, 5
obesity, 7
patient evaluation, 3
patient history, 3–4
patients with ongoing infection,
5–6
physical exam, 4
psychiatric illness, 8
vitamin D deficiency, 6–7
Waddell criteria of non-organic
back pain, 4
Revision surgery for PSOs
nonunion, 127; see also
Pedicle subtraction
osteotomies
case example, 130
complications, 129
expectations, 128
final revision construct, 131, 132
flat-back deformity, 130
indications, 127
L3–L4 lateral lumbar interbody
fusion, 131
mechanical complications, 127
operative technique, 128–129
pitfalls, 129–130
postoperative management, 129
preoperative planning, 128
relative contraindications,
127–128
revision surgery principle, 128
T10–S1 posterior spinal fusion
revision, 131
Revision surgery of ACDF
nonunion, 47; see
also Anterior cervical
discectomy and fusion
complications, 50
cord compression with mild cord
changes, 49
expectations, 47
final postoperative x-ray
imaging, 50
indications, 47
operative technique, 49
pitfalls, 50
postoperative management,
49–50
preoperative planning, 48–49
preoperative spine x-rays, 48
relative contraindications, 47
revision surgery principle, 47–48
Revision surgery of ALIF
nonunion, 151
complications, 154
expectations, 152
indications, 151
operating room setup, 152–153
operative technique, 153–154
pitfalls, 154
post-operative images following
revision surgery, 154
postoperative management, 154
preoperative planning, 152
principles of revision
surgery, 152
relative contraindications,
151–152
Revision surgery of CVJ
nonunion, 77
complications, 81
condyle screw, 80, 81
expectations, 78
indications, 77–78
intraoperative planning, 81
occipital condyle screw
placement, 80
operative technique, 79–81
pitfalls, 82
postoperative management, 81
preoperative planning, 79
relative contraindications, 78
Index 267
Revision surgery of high-grade
spondylolisthesis, 217
complications, 222
expectations, 218
fibular allograft, 220
fractured S1 screws and steep
L5−S1 disc angle, 220
haloing around L5 screws
and lack of bridging
arthrodesis, 221
indications, 217
operative technique, 219–222
pitfalls, 222
postoperative management, 222
preoperative planning, 218–219
relative contraindications,
217–218
revision surgery principle, 218
Revision surgery of lateral lumbar
interbody fusion, 155
biplanar fluoroscopy setup, 157
complications, 158
end-plate/fusion bed preparation
and graft placement, 158
expectations, 156
exposure, 157–158
indications, 155
operating room setup, 156–157
operative technique, 157
patient positioning, 157
pitfalls, 159
postoperative management, 158
preoperative planning, 156
relative contraindications, 156
removal of previous graft, 158
revision surgery principle, 156
surgical technique, 157–158
Revision surgery of lumbar
decompression, 167; see
also Minimally invasive
lumbar revision surgery
complications, 171–172
expectations, 168
at index level through MIS
approach, 173–181
indications, 167
operating room setup, 169
operative technique, 169–171
pitfalls, 172
268   Index
Revision surgery of lumbar
decompression
(Continued)
postoperative management, 171
preoperative planning, 168–169
relative contraindications,
167–168
Revision surgery of MIS TLIF, 191
complications, 197–198
contralateral cage and bilateral
screw placement, 197
incision and exposure, 195
indications, 191
operating room setup, 195–196
patient positioning, 195
pedicle-screw placement, 196
pitfalls, 198
postoperative management, 197
preoperative decision-making
flowchart for, 194
preoperative planning and
contraindications,
193–195
procedure, 196
pseudarthrosis, 192, 193
radiographic evidence, 191–192
revision surgery principle,
192–193
sagittal magnetic resonance
imaging, 192
screw removal and
replacement, 195
visualization of facet joint, 196
Revision surgery of TLIF nonunion,
183; see also Revision
surgery of MIS TLIF
ALIF with removal of
TLIF cage, 186
anterior lumbar interbody
fusion, 187–188
bony fusion, 186
complications, 189
contralateral TLIF, 188
expectations, 185
imaging, 183–184
immediate stability, 185
indications, 183–184
interbody cage, 186
malpositioned cage, 184
missing bilateral pars and
rudimentary transverse
processes, 187
modifiable risk factors
optimized, 184
neural decompression, 187
operative technique, 187–189
pedicle screws, 185–186
pitfalls, 189
postoperative management, 189
preoperative planning, 185
relative contraindications, 185
revision of instrumented fusion,
188–189
revision surgery principle, 185
symptomatic nonunion, 183
rhBMP, see Recombinant human
bone morphogenetic
protein
rhBMP-2, see Recombinant human
bone morphogenic
protein-2
S
S2AI, see S2-Alar iliac
S2-Alar iliac (S2AI), 213
Sagittal vertical axis (SVA), 91, 120,
128, 211
SCDs, see Sequential compression
devices
Screw-rod constructs technique, 84
SCS, see Spinal cord stimulation
Selective nerve root block
(SNRB), 103
Sequential compression devices
(SCDs), 253
SF-36, see Short-Form Health
Survey
Short-Form Health Survey
(SF-36), 91
Smith-Petersen osteotomies (SPOs),
94, 96, 112, 120; see
also Postlaminectomy
kyphosis treatment
correcting PJK with, 123
in lateral and coronal plane, 214
SNRB, see Selective nerve root
block
Somatosensory evoked potentials
(SSEPs), 16, 22, 36, 48,
54, 225
Spinal cord stimulation (SCS), 35
Spinal cord stimulator device, 35
complications, 37
contraindications, 36
expectation, 36
indications for revision, 36
operating room setup, 36
operative technique, 36–37
paddle lead placement, 35
pitfalls, 37–38
postoperative management, 37
preoperative planning, 36
revision surgery principle, 36
Spinal deformity surgery, 217
Spine surgery, 3
SPOs, see Smith-Petersen
osteotomies
SSI, see Surgical site infection
Surgical site infection (SSI), 256
SVA, see Sagittal vertical axis
Symptomatic cervical and lumbar
pseudomeningocoeles
treatment, 231
arachnoid blebs, 235
case study, 236–237
choice of patch and sealants, 234
choice of suture and needle, 233
closed-suction drain, 238
complications, 239
concerns for anesthesia, 232
expectations, 232
indications, 231
instruments and cottonoids, 233
intrathecal medications, 234–235
lumbar subarachnoid drainage,
234, 238
operative microscope, 233–234
operative technique, 235, 238
pitfalls, 239
postoperative management,
238–239
preoperative planning, 232–235
refractory CSF leaks, 235
relative contraindications,
231–232
revision surgery principle, 232

smooth wake-up and bed
position, 238
wound cultures, 232–233
Symptomatic nonunion, 183
T
TDR, see Total disc replacement
TED, see Thrombo-embolic
deterrent
tEMG, see Triggered
electromyography
Thoracic lumbar sacral orthosis
(TLSO), 154
Thoracolumbar deformity
reconstructive
surgery, 133
arthrodesis and bone
grafting, 140
bilateral fusion mass
fractures, 137
complications, 142
end-to-end and end-to-side
connectors, 139
expectations, 134, 136
indications, 133–134
kyphoscoliosis above L2–S2, 138
multiple compression
fractures, 135
multiple prior lumbar
fusions, 139
operative technique, 140–141
overlapping reinforcing rods, 138
pitfalls, 142–143
postoperative management,
141–142
preoperative planning, 136
pseudarthrosis repair, 136
relative contraindications, 134
revision surgery principle, 136
rod fracture and/or
pseudarthrosis, 137, 139
sagittal plane imbalance, 139
Thrombo-embolic deterrent
(TED), 253
Thromboembolic events, 172
Tissue glues, 254
TLIF, see Transforaminal lumbar
interbody fusion
TLSO, see Thoracic lumbar sacral
orthosis
Total disc replacement (TDR), 59;
see also Adjacent-segment
disease; Cervical TDR
contraindications for
cervical, 61
radiographs, 60
Transcranial electric motor-evoked
potentials (tcMEPs),
16, 225
Transforaminal lumbar interbody
fusion (TLIF), 183, 218,
223; see also Revision
surgery of MIS TLIF;
Revision surgery of TLIF
nonunion
Triggered electromyography
(tEMG), 175
U
UIV, see Upper instrumented
vertebra
Upper instrumented vertebra
(UIV), 117
Urinary tract infections (UTIs),
124, 142
U.S. Food and Drug Administration
(FDA), 5, 51, 59, 106, 242
UTIs, see Urinary tract infections
V
VA, see Vertebral artery
VAC, see Vacuum-assisted closure
Vacuum-assisted closure (VAC),
6, 257
VAI, see Vertebral artery injury
Valsalva
effect, 232
manuever, 254
VAS, see Visual Analog Scale
Ventrally displaced graft
management, 223
anterior lumbar interbody
fusion with structural
allograft, 226
complications, 227
Index 269
contralateral revision ALIF,
225–227
expectations, 224
indications for revision surgery,
223–224
L5–S1 isthmic
spondylolithesis, 224
migration of ALIF graft, 226
operating room setup, 225
operative technique, 225
pitfalls, 227–228
postoperative films, 227
postoperative management, 227
preoperative planning, 224
relative contraindications, 224
revision surgery principle, 224
surgical technique, 226–227
Ventral thoracic dural defect
treatment, 245
complications, 247
expectations, 246
indications, 245
intraoperative photographs, 248
operative technique, 247
pitfalls, 249
postoperative management, 247
preoperative planning, 246–247
relative contraindications, 245
revision surgery principle, 246
T2-weighted MR images, 249
Ventral thoracic pathologies, 245;
see also Ventral thoracic
dural defect treatment
Vertebral artery (VA), 80, 83
high-riding, 85
Vertebral artery injury (VAI), 85
Visual Analog Scale (VAS), 3
W
Waddell criteria of non-organic
back pain, 4
WBC, see White blood count
White blood count (WBC), 6
WHO, see World Health
Organization
World Health Organization
(WHO), 208
Wound closure, 253