SECTION
Trauma
CHAPTER
127
Trauma State of the Art
CLASSIFICATION AND MANAGEMENT
OF SPINAL INJURIES
The classification and treatment of spine fractures remains a
controversial area of modern spinal surgery. Despite a large
number of publications on this topic, there is still a lack of level
I and II evidence supporting the various treatment options.
Furthermore, there are a multitude of classification systems,
none of which have yet to gain universal acceptance. The Denis
classification, although widely accepted, is perhaps overly sim-
plistic and fails to recognize many fracture patterns. Ferguson
and Allen and the AO classification, on the other hand, are too
complex, minimizing the daily utility of these systems. Perhaps
one of the most significant advances over the past several years
is the advent of new classification systems for both cervical and
thoracolumbar fractures. They appear to be gaining wide
acceptance.14--16,19 In this chapter, we will review the current
classifications and management of spinal injuries.
THORACOLUMBAR INJURIES
Since Bohler first described thoracolumbar injuries in 1929,
not even one classification system has gained universal accep-
tance. Historically, these schemes have lacked reproducibility
and validity. Furthermore, previous classifications have failed to
guide treatment or predict outcomes of given injury patterns.
Recently, Vaccaro et al introduced the Thoracolumabr Injury
Classification and Severity Score (TLICS) in an attempt to pro-
vide a more clinically relevant system. This new system is unique
in several respects. TLICS focuses on three injury characteris-
tics: morphology, integrity of the posterior ligamentous com-
plex (PLC), and the neurologic status. A point value is assigned
to each category based on severity, and the total score guides
treatment as well as being predictive of outcomes.
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XII
Ronald A. Lehman, Jr.
Tobin Eckel
Injury morphology is divided into one of three categories:
(1) compression, (2) rotation/translation, and (3) distraction.
Compression injuries are assigned one point, with an additional
point assigned for a burst component, translation/rotation
injuries are assigned three points, and distraction injuries are
assigned four points.15,18
The supraspinous ligament, interspinous ligament, ligamen-
tum flavum, and facet joint capsules constitute the PLC.
Disruption of the PLC generally leads to spinal instability
requiring surgical intervention. It can be identified with inters-
pinous widening, facet subluxation, discontinuity of the black
stripe on T1-weighted magnetic resonance imaging (MRI), or
high signal intensity of the interspinous space on T2-weighted
MRI.12 An intact PLC is assigned zero points, an indeterminate
injury received two points, and three points are assigned to a
PLC disruption.
Neurologic status is indicative of severity of spinal column
injury. Incomplete neurologic injury is often an indication for
surgical decompression, as a result, more points are assigned
for incomplete injuries.
Management is then based on cumulative score, with scores
less than 3 managed nonoperatively, while scores greater than 5
suggesting a benefit from surgical intervention. A score of 4
could often be managed either way, depending on additional
clinical qualifiers. In addition to directing surgical versus non-
surgical management, TLICS also guides surgical approach. In
general, incomplete neurologic injury with evidence of com-
pression from anterior spinal elements should be approached
anteriorly to achieve direct decompression, while PLC disrup-
tion requires a posterior approach for stabilization and recre-
ation of the posterior tension band. When there is both ante-
rior compression with neurologic injury and PLC injury, a
combined anterior and posterior approach is necessary.15 One
study demonstrated that surgeons agreed with the treatment
recommended by the TLICS greater than 96% of the time.12
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 1378 Section XII Trauma
The advantage of this new classification system lies in its sim-
plicity. Injuries are easily classified, avoiding other burdensome
schemes already in use, and it facilitates clinical decision mak-
ing. However, there still remains a lack of evidence-based stan-
dards to guide treatment of thoracolumbar injuries. A recent
consensus panel, the Spine Trauma Study Group (STSG),
which consisted of 22 leading spinal surgeons at 20 level I
trauma centers, met to establish practical guidelines to the
management of these injuries. The STSG reaffirmed that the
three most important factors in determining management of
thoracolumbar injuries were injury morphology, neurologic
status, and the integrity of the PLC. There was a general con-
sensus on the management of several injury patterns. For
instance, neurologically intact patients with intact PLC can be
treated nonoperatively with bracing, while 91% of the panel
agreed that a PLC disruption with no neurologic injury should
be approached posteriorly. Similarly, an incomplete neurologic
injury with intact PLC should be managed via an anterior
approach. When there is complete neurologic injury, decom-
pression becomes unnecessary, and treatment is aimed at
restoring alignment and stabilizing the spine. When the PLC is
disrupted, 73% of the panel recommended a posterior
approach. However, when the PLC is intact, it is largely surgeon
preference, as evidenced by 55% of the panel choosing a poste-
rior approach, while the other 45% preferred an anterior
approach.16
There are several treatment principles reinforced by the
STSG. Thoracolumbar fractures often present with anterior
neural compression, thus decompression is best accomplished
through an anterior approach. The anterior approach facili-
tates direct canal decompression while also restoring sagittal
alignment and anterior column stability. The anterior approach
also minimizes the loss of motion segments to one above and
below the fractured vertebra, avoids further trauma to paraspi-
nal musculature, and is associated with fewer wound infections.
Direct posterior decompression is possible through transpedic-
ular or extracavitary approaches, yet these are technically
demanding and not routinely performed. Decompression can
occur indirectly through a posterior approach via ligamento-
taxis. In fact, this technique has been shown to reduce canal
compromise by 50%. However, posterior distraction and liga-
mentotaxis are not effective when greater than 67% of canal is
compromised, as the annular ligament attachments to the
extruded fragments are less likely to be intact.7,8,16,20 The poste-
rior approach has the advantage of being more familiar to
spine surgeons, and it avoids abdominal viscera and major ves-
sels encountered through an anterior approach. The posterior
approach is also necessary in high thoracic and low lumbar
injuries, where the position of the major vessels inhibits ante-
rior fixation. Circumferential procedures are indicated when
there is incomplete neurologic injury along with PLC disrup-
tion. The decompression should take precedence over stabili-
zation, except for distraction and translation injuries, which
should be stabilized posteriorly first, then decompressed anteri-
orly if necessary.16
There remains significant morbidity associated with these
open procedures. Average blood loss for both anterior and pos-
terior procedures was greater than 1000 mL, while infection
rates are 0.7% and 3.1% for anterior and posterior approaches,
respectively. This has led to the advancement of minimally inva-
sive techniques over the past several years for thoracolumbar
decompression and stabilization, such as endoscopy for ante-
LWBK836_Ch127_p1377-1380.indd 1378
rior approaches, and percutaneous fixation for posterior
approaches. Endoscopic techniques have been shown to reduce
intraoperative blood loss, perioperative pain, time to mobiliza-
tion, and length of hospital stay; however, there is a steep learn-
ing curve to these procedures and long-term outcomes are
unchanged, not to mention that sample sizes to date have been
small. Similarly, the percutaneous posterior approach has been
shown to have decreased blood loss, infection, and operative
time.10 One study which looked at open versus percutaneous
posterior stabilization of thoracolumbar fractures found no dif-
ference in functional outcomes at 5 years.21 Another recently
described technique for lumbar burst fractures includes a pos-
terior corpectomy through two keyhole incisions, with the assis-
tance of a surgical microscope. This technique avoids the com-
plications associated with an anterior approach, as well as
sparing the posterior spinal elements along with minimal para-
vertebral dissection.6
CERVICAL INJURIES
Only 2% to 3% of all blunt trauma sustain a cervical spine injury,
but the potential for neurologic injury make its prompt recogni-
tion and treatment critical. The subaxial cervical spine (C3-C7)
accounts for two thirds of all cervical fractures and three fourth
of all cervical dislocations. Like the thoracolumbar spine, clas-
sification of subaxial cervical injuries has been problematic,
often focusing on mechanism of injury, and not accounting for
ligamentous stability or neurologic injury. A recent classification
system has also been developed, similar to the thoracolumbar
injury classification (TLIC), known as the subaxial injury classi-
fication (SLIC), which also focuses on injury morphology, integ-
rity of the discoligamentous complex (DLC), and neurologic
status to guide management of these injuries.9,13
The injury morphology of the SLIC is the same as with tho-
racolumbar injuries: compression, distraction, and rotation/
translation, with the points assigned for increasing severity.
Neurologic injury is also classified in the same manner. The
DLC differs from the aforementioned PLC in that in the cervi-
cal spine, the anterior longitudinal ligament (ALL) and inter-
vertebral disc are also included along with the posterior longi-
tudinal ligament, ligamentum flavum, interspinous and
supraspinous ligaments, and facet capsules. Any abnormal facet
alignment or anterior disc space widening is indicative of
DLC disruption. On the other hand, the interspinous ligament
is the weakest component of the DLC, thus interspace
widening alone does not represent DLC compromise in the
cervical spine. A total score of 3 or less is managed nonopera-
tively, whereas a score of 5 or greater requires surgical
intervention.13
Whether to perform anterior or posterior surgery remains a
common debate with subaxial cervical spine injuries. The pos-
terior approach is biomechanically stronger when used to stabi-
lize primarily posterior injuries. It also allows for direct reduc-
tion of posterior elements, is a more familiar approach to
surgeons, and has a high union rate. However, there is a higher
rate of wound infection, and the concern for progressive
kyphotic deformity if there is anterior settling. Proponents of
anterior surgery favor the avoidance of prone positioning,
direct decompression of a disc herniation, maintenance of sag-
ittal alignment, and high fusion rates. Concerns stem from
anterior fixation being biomechanically inferior to posterior,
8/26/11 10:06:19 PM

along with complications of dysphagia and hoarseness. In gen-
eral, DLC disruptions are best approached from the location of
maximal soft tissue injury. Neurologic injury often requires an
anterior approach, as this is the most direct approach for surgi-
cal decompression.1
As in the thoracolumbar spine, the STSG used the SLIC to
develop evidence-based treatment algorithms for common
injury patterns in the subaxial cervical spine. One such pattern
encountered with increasing frequency given our aging popu-
lation, is the hyperextension injury in a patient with cervical
spondylosis. Despite no morphologic injury and an intact DLC,
these patients have incomplete neurologic injury with cord
compression, and thus score a 4 overall. Although some would
advocate for nonoperative management if the neurologic
examination is stable or improving, most would agree that
operative intervention is warranted. The approach is then dic-
tated by the sagittal alignment as well number of levels involved.
If the cervical spine is lordotic, then laminectomy and fusion or
laminoplasty is indicated. However, when a kyphotic deformity
exists, a posterior approach is contraindicated, as this can lead
to progressive kyphosis. In this instance, anterior decompres-
sion and stabilization is appropriate. As with the thoracolumbar
spine, cervical burst fractures with neurologic compression
should be managed anteriorly, to facilitate direct decompres-
sion of the canal. If the posterior elements are intact, strut
grafting and anterior plating provide adequate stability.3
Distraction injuries are a result of either hyperextension or
hyperflexion injuries. In hyperextension injuries, the approach
is dictated by where the DLC is disrupted. Since the ALL and
disc are injured in hyperextension, these are best managed
with anterior discectomy and fusion. These injuries can also be
influenced by the presence of ankylosing spondylitis (AS) or
diffuse idiopathic skeletal hyperostosis (DISH), as these condi-
tions can lead to essentially circumferentially fused cervical
spines, causing the spine to behave more like a long bone when
fractured. Thus, even with minimal displacement, these inju-
ries are extremely unstable and often warrant both anterior
and posterior fixation.1,3 Distraction injuries resulting from
hyperflexion lead to failure of the posterior DLC, manifested
by unilateral facet subluxation or bilateral perched facets.
Again, the pattern of DLC disruption will dictate surgical
approach. If there is disc material displaced into the canal,
then anterior approach with direct decompression, followed by
reduction, interbody graft, and plate fixation is indicated.
When the disc is intact, then the surgeon may elect either ante-
rior or posterior fixation.
Translation or rotation injuries are the most severe mor-
phologic pattern and are usually associated with marked DLC
disruption. Therefore, these injuries score a 6 on the SLIC
before even considering neurologic injury, and should all be
managed operatively. These injuries are manifested by unilat-
eral or bilateral facet fracture dislocation or subluxation. In
the absence of vertebral body fracture, an anterior approach
is warranted if there is disc displaced into the canal. If there is
no disc in the canal, then the surgeon may elect anterior or
posterior fixation. Associated vertebral burst fractures indi-
cate a more significant injury pattern. These can often be
seen as a small or large fracture off the anterior lip of the ros-
tral vertebral body, referred to as a teardrop or quadrangular
fracture, respectively. These patterns are associated with
severe soft tissue injury, and often necessitate anterior and
posterior fixation.1,3
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Chapter 127 Trauma State of the Art 1379
The cervical spine does present some unique management
principles. There remains controversy regarding cervical trac-
tion for reduction of facet fracture or dislocation. The debate
surrounds whether to obtain an MRI prior to attempting reduc-
tion because of the potential risk of neurologic injury by push-
ing a disc herniation back into the spinal cord during a reduc-
tion maneuver. To date, there has been no report of permanent
spinal cord injury in an awake, cooperative, neurologically
intact patient who has undergone closed reduction with cervi-
cal traction. In general, closed reductions may be attempted
prior to MRI in awake, cooperative patients. Another contro-
versial subject in acute spinal cord injury, not exclusive to the
cervical spine, is the use of methylprednisolone. For more than
a decade, administration of high-dose methylprednisolone has
been given in acute spinal cord injury based on the National
Acute Spinal Cord Injury studies. Recently, there has been
much criticism regarding the methodology and conclusions
drawn by these studies, and its continued use in acute spinal
cord injuries has been called into question.3
Upper cervical spine injuries include injuries of the occiput
to C2. Occipitocervical injuries are relatively rare, as the majority
of patients do not survive the initial injury. These injuries are
extremely unstable and should be placed in a halo vest immedi-
ately, with care to avoid traction. Occipitocervical fusion is the
definitive management of these injuries. Techniques for poste-
rior upper cervical instrumentation include C1 lateral mass
screws, C2 pedicle, pars/isthmus, or laminar screws, and C1-2
transarticular screw placement.2,11,17 Transarticular screws, while
providing rigid fixation and high fusion rates, have largely fallen
out of favor due to technical difficulty and risk of vertebral artery
injury. In fact, an aberrant course of the vertebral artery occurs
in up to 23% of patients. C2 pedicle screws also risk injury to the
vertebral artery at the foramen transversarium. Pars/isthmus
screws may be safer, however there is still potential for vertebral
artery injury as these screws follow the same trajectory as transar-
ticular screws. In addition, pars screws are relatively short, and
thus do not provide the rigid fixation seen with transarticular
and pedicle screws. Intralaminar screws avoid the risk of verte-
bral artery injury and are a reasonable salvage option after failed
pedicle screw placement. Intralaminar screws are not without
potential risks. A ventral cortical breech would place the spinal
cord at risk. Given the space available for the spinal cord at this
level, this would be a rare, although potentially devastating com-
plication.4,5 Techniques for occipital instrumentation include six
bicortical screws in the thickest bone in the midline of the
occiput, as well as a C1-occiput transarticular fixation.2,11,17
The management of spinal trauma remains a controversial
subject, in large part due to a lack of consensus regarding injury
classification and appropriate management. Recent classifica-
tion systems, presented in this chapter, have attempted to sim-
plify and standardize injury classification and create treatment
algorithms. This will hopefully lead to better communication
and understanding of spinal trauma at all levels of medical
training and translate into better patient care.
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