CHAPTER
David G. Schwartz
134
Minimal Access Techniques
for Spine Trauma
INTRODUCTION
Initially, the concept of minimal access surgery in the face of
trauma scenarios may seem counterintuitive. After all, the
insult of the initial injury has done little to preserve the native
tissue and it may not seem that these techniques are warranted.
It is, however, in cases where there has been extensive disrup-
tion of bony, ligamentous, and other soft tissue structures that
minimal access techniques can excel. From a historical perspec-
tive, minimal access surgical (MIS) techniques have been
explored for decades, but only in the last several years have
they gained serious attention. The underlying drive has been
an attempt to achieve the functional and biomechanical goals
inherent to trauma care but through MIS techniques. These
include both the general trauma care principles of early mobi-
lization and pulmonary toilet, along with spine trauma princi-
ples of rigid stabilization, neural decompression, and anatomic
bone alignment. Utilizing MIS techniques that result in mini-
mal additional tissue trauma, these patients can often be accel-
erated along the pathway to recovery.
These concepts are in their relative infancy and there is very
little literature to support or deny their use. In this chapter we
describe some of these newer techniques and technologies that
can be used in trauma care. We will explore anterior, lateral,
and posterior procedures, and we will discuss relative indica-
tions for their use as well as the advantages and disadvantages
over standard open techniques. We conclude the chapter with
a brief discussion about the future of these technologies in spi-
nal trauma surgery.
ANTERIOR THORACIC AND
LUMBAR PROCEDURES
Approaching the anterior column of the spine in both the tho-
racic and lumbar regions can be a necessary but morbid proce-
dure during fracture care. The need to adequately decompress
the spinal canal anteriorly and also to restore the sagittal align-
ment of the spinal column requires multiple options for access.
Several different approaches have been described including:
endoscopic-assisted access to the thoracic spine and thora-
columbar junction using transdiaphragmatic approaches,
laparoscopic-assisted transperitoneal approaches to lower lum-
LWBK836_Ch134_p1449-1459.indd 1449
Joseph Riina
Jason E. Smith
Kathy J. Flint
bar segments including L4 and L5, endoscopic-assisted retro-
peritoneal approaches to lumbar segments L1-L5, mini-open
retroperitoneal approaches to the lumbar spine, and tradi-
tional oblique muscle-splitting retroperitoneal surgical
approaches. A review of the literature has produced several
articles not only describing each approach, but also retrospec-
tively and prospectively comparing the various techniques. Most
literature describing these various access techniques involves
deformity and degenerative disease processes. However, many
also describe anterior decompression techniques accompanied
with reconstruction of sagittal balanceboth of which have
applicability in trauma surgery. Although decompression of the
spinal canal after fracture can be accomplished both anteriorly
(corpectomy) and posteriorly (transpedicular), in this section
we will discuss various ways to access the spinal canal anteriorly
for both corpectomy and placement of instrumentation.
Minimally invasive approaches do not change the underly-
ing procedure. Instead, they offer an alternative surgical
approach to the spine. Decompression of the spinal canal is
typically indicated in the face of progressive or incomplete neu-
rological compromise. Approaching the anterior column may
also be necessary when there is extensive comminution of the
vertebral body and reconstruction efforts are needed to pro-
vide anterior column support along with posterior fixation to
prevent development of a posttraumatic kyphotic deformity.
Minimal access techniques serve to minimize the soft tissue
injury, thereby affording the patient improved pain control and
recovery time. The surgical technique for an endoscopically
assisted transdiaphragmatic approach is performed by placing
the patient in the lateral decubitus position and the approach
is usually done on the patients left side. A working portal is
placed directly cephalad to the fractured vertebrae and a sepa-
rate portal for the endoscope is placed directly over the spine
just cranial to the working portal (Fig. 134.1). Additional por-
tals for a retractor and suction can be used ventrally. One of the
key aspects of this surgical technique is the nature in which the
diaphragmatic attachment to the spine is taken down. It is rec-
ommended to make a semicircular incision parallel to the
attachment of the diaphragm onto the spine and ribs and after
completion of the procedure to close this incision to prevent
diaphragmatic hernia (Figs. 134.2A and B).
Once down onto the spine, the cephalad and caudad
intervertebral discs are removed and a partial corpectomy is
1449
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 1450 Section XII Trauma
Figure 134.1. Placement of trocars in relation to the thoracolum-
bar junction.
performed. The remainder of the decompression procedure is
performed in the same manner as in an open approach. Much
of the literature surrounding minimal access to the anterior
spine is directed toward the treatment of degenerative pro-
cesses and deformity. These primary modes of treatment of the
anterior lumbar spine involve several different types of fusion
techniques. While traumatic injuries to the lower lumbar spine
are less common than the thoracolumbar junction, several of
the approaches can be extrapolated for fractures throughout
B
LWBK836_Ch134_p1449-1459.indd 1450
the lumbar spine. Traditionally, endoscopic techniques have
been used in approaching the L5-S1 level between the bifurca-
tions of the great vessels; but endoscopic, transperitoneal
approaches to L4-5 have been fraught with problems. The inci-
dence of vascular injury has been considerable because it
requires ligation of the iliolumbar vein and mobilization of the
great vessels. In studies comparing laparoscopic versus mini-
open anterior lumbar interbody fusion (ALIF) approaches and
laparoscopic fusions at a variety of levels from L2-S1 there have
been reported complications of deep vein thrombosis, disc her-
niation, ureter injury, retrograde ejaculation, and vascular
injury.23,24 Again, these studies were focused on degenerative
processes but the same approach can be used for discectomy
and corpectomy in the face of anterior and middle column
injury secondary to trauma. There is, however, a very significant
learning curve with these approaches and a laparoscopic recon-
struction of L5 should be considered with caution.
Complications inherent to the transperitoneal endoscopic
approach including postoperative intra-abdominal adhesions,
retrograde ejaculation, and great vessel injury led to the devel-
opment of a minimally invasive laparoscopic, retroperitoneal
approach to the lumbar spine. This approach does not require
CO2 insufflation, entrance into the peritoneum, or anterior dis-
section near the great vessels, providing a safer exposure for
spinal surgery. In some patients inadequate surgical exposure
will allow for placement of only one interbody device.
Figure 134.2. (A) Intraoperative views of the diaphragm at the
thoracolumbar junction. 1. Psoas, 2. Vertebral body. 3. Disc. (B)
Additional view of diaphragm and rib cage endoscopically. Numbers
are placed to the right of the structure.
8/26/11 2:34:33 PM

Although endoscopically assisted techniques have been
gaining in popularity, the workhorse for trauma remains tradi-
tional open procedures. Some minimally invasive procedures
are mini-open procedures, which incorporate muscle-sparing
techniques to reduce morbidity, with faster surgical times and
safer mobilization of the vascular structures. In the mini-ALIF
approach the rectus fascia is exposed and incised transversely
medially to the confluence of the rectus fascia. The preperito-
neal space is entered bluntly, allowing exposure of the retro-
peritoneal space. The lumbar spine and the iliac vessels are
then easily identified. If L5-S1 is involved, one can work below
the bifurcation. If L4-5 or above is involved, the vessels will
need to be mobilized and retracted medially. One to two levels
can easily be exposed using this technique, making corpectomy
feasible using this method.
The choice of whether or not to approach the spine anteri-
orly in the face of significant trauma should be made based on
known criteria and classification systems.14 When a single verte-
bral segment is highly comminuted, anterior reconstruction of
the spinal column and anterior instrumentation is superior to
posterior fixation. When posterior instrumentation alone is
used to treat these particular fractures, pedicle screw fracture
or loss of sagittal alignment may occur due to lack of load shar-
ing across the fracture site unless a sufficient number of levels
have been included in the construct. In the face of progressive
neurologic compromise, the need to decompress the neural
elements is most often accomplished from an anterior approach
to the spine; however, posterior decompression techniques
have also been described. The potential advantages of the
described minimal access anterior approaches are a decrease in
soft tissue damage during exposure of the spine, which theo-
retically results in decreased patient morbidity, shortened hos-
pital stay, and thereby reduction in costs. Also, patients with
significant thoracolumbar fractures often have other injuries
and comorbidities. By limiting our surgical insult, these patients
can be mobilized and potential pulmonary, thrombotic, and
skin complications can be minimized. Although the described
procedures have a known learning curve and their own set of
intraoperative and perioperative complications and risks, there
are several series documenting safe and effective utilization of
these approaches and each of the approaches can be converted
to traditional open exposures, if necessary.1,12,13,23,24 Minimal
access approaches to the anterior spine are relatively new and
their use in trauma surgery is in its infancy. Although many of
the approaches are intriguing because of their proposed bene-
fits over traditional open approaches, their applicability in
trauma surgery needs to be explored further.
LATERAL THORACIC AND
LUMBAR PROCEDURES
The natural progression from anterior transperitoneal and ret-
roperitoneal minimally invasive approaches is a lateral psoas
splitting approach to the anterior spine, as in the direct lateral
interbody fusion (DLIF) and extreme lateral interbody fusion
(XLIF) techniques. This approach, which utilizes muscle spar-
ing at every level, has the advantage of negating retraction and
dissection of the muscles of the abdominal wall. The disadvan-
tage is that the roots of the lumbosacral plexus are at risk dur-
ing blunt dissection through the muscle itself. Therefore,
LWBK836_Ch134_p1449-1459.indd 1451
Chapter 134 Minimal Access Techniques for Spine Trauma 1451
Figure 134.3. Lateral decubitus positioning of patient.
neuromonitoring is a mandatory component of these
approaches. Patients are placed in the 90 lateral decubitus
position, and the table is slightly flexed to open the space
between the iliac crest and the ribcage (Fig. 134.3). A 5-cm
oblique incision is made directly over the disc space in line
with the fibers of the external oblique muscle. Blunt dissection
is then performed through the three abdominal muscle layers
until the retroperitoneal space is entered. The disc space is
accessed through strict blunt dissection through the psoas
muscle. Care is used not to deviate too far anteriorly where
injury to the major blood vessels and sympathetic chain are
possible. Also, it is important not to deviate too far posteriorly
as the exiting nerve roots are in danger. Although this approach
has several advantages, one significant disadvantage is the
inability to access L5-S1 without creating an osteotomy through
the iliac crest. Again, most traumatic fractures occur about
the thoracolumbar junction and L5 is less frequently involved,
but this limitation is still noteworthy. If, however, this is not an
issue, the lateral approach can afford excellent visualization of
not only adjacent disc spaces but also of fractured vertebral
bodies. Decompression of the spinal canal can also be accom-
plished with insertion of a strut graft and anterior lateral
instrumentation.
The benefits of this mini-open surgical technique were cor-
related in an article by Ozgur et al15 where they described an
XLIF technique to the lateral psoas splitting approach. This
technique is essentially the same as above except for the use of
a second incision to identify the retroperitoneal space. In this
approach a small incision is made just posterior to the spinal
level to be addressed. Using the surgeons finger the retroperi-
toneal space is developed allowing for the peritoneal contents
to fall anteriorly along with the ureter. Next a second incision is
made on the patients flank and a lateral psoas splitting
approach is performed. This described technique utilizes a par-
ticular retractor and neuromonitoring system developed by
NuVasive (San Diego, CA) (Fig. 134.4) to avoid complications
involving the lumbar plexus along with genitofemoral nerve
injury. Several variations on the retractor and monitoring sys-
tem have been developed.
Again, the advantages of this lateral psoas splitting approach
are identical to those of the mini-open technique. The anterior
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 1452 Section XII Trauma

tive study, an existing pedicle screw system was modified by

Figure 134.4. NeuroVision neuromonitoring system. 1. Retro-
peritoneal fat, 2. Psoas (numbers are placed to the left of the struc-
ture). (Reprinted with permission from NuVasive.)
longitudinal ligament and posterior longitudinal ligament are
not violated, which affords a significant biomechanical advan-
tage. Also, during preparation of the disc space, any violation of
the space itself with curettes, a high-speed burr, or other instru-
ment would enter the contralateral psoas muscle rather than
the spinal canal. Staying within the anterior one third of the
psoas muscle is necessary to avoid nerve root injury, and the
approach should only be attempted with appropriate neuro-
logical surveillance.
using extension sleeves over the screws. Further modifications
led to the Longitude system (Fig. 134.5). This system consists
of one screw extender that allows the screw to be guided by a
freehand technique through the extender/screw conduit. The
device allows the spine to be reduced to the rod and then
locked in place with set screws (Figs. 134.6 and 134.7). Several
varieties have now been developed that allow placement of
pedicle screws through a small portal. In relation to MIS trauma
treatment, several fixation approaches have been developed.
Each approach has advantages and specific applications, com-
bining a mini-open technique at the level of injury and percu-
taneous fixation at the adjacent levels. These hybrids should be
used after consideration of the trauma patients condition as
well as injury. Use of a classification system such as the
Thoracolumbar Injury Classification and Severity Scale19 can
assist clinicians in the approach decision-making process
(Fig. 134.8).
This concept can be extrapolated for treatment of nondis-
placed bony flexion/distraction injuries or Chance fractures.
Patients with bony Chance fractures who are neurologically
intact can often be treated in a hyperextension cast, but some
patients cannot tolerate bracing for 12 weeks or longer. This
led to the development of minimally invasive internal bracing
using percutaneous pedicle screws. Posterior internal stabiliza-
tion can involve pedicle screws two levels above and two levels
below the site of fracture or short-segment pedicle screw instru-
mentation. With recent advances in percutaneous pedicle screw
instrumentation, lumbar constructs can be created with
minimal tissue disruption. The thought process is that bluntly

POSTERIOR THORACIC AND

LUMBAR PROCEDURES
Posterior approaches to the thoracic and lumbar spine after
trauma are arguably the workhorse approaches. The ability to
achieve spinal stabilization using a variety of instrumentation
systems makes these approaches the most widely utilized. Often
placement of pedicle screws or other instrumentation requires
extensive paraspinal muscle stripping. This requires prolonged
surgical time with the patient in the prone position, and possi-
ble complications including the potential for infection, paraspi-
nal muscular denervation with associated postoperative muscle
inactivity, and weakness. Because of the previously mentioned
complications of prolonged posterior approaches to the spine,
minimally invasive techniques for stabilization have obvious
appeal. There have been a wide variety of techniques described
for the majority of fracture patterns from simple anterior com-
pression fractures to highly comminuted unstable burst frac-
tures. We will explore some of these techniques in the following
section.
The use of percutaneous pedicle screw systems has grown in
popularity over recent years as this technology has improved.
Foley and Gupta5 provided one of the first descriptions of this
technique in 2002 using the Sextant (Medtronic Sofamor
Danek, Memphis, TN) system. While the 12 patients in their
study underwent percutaneous pedicle screw fixation for Figure 134.5. Longitude system demonstrating instrumentation
mechanical back pain and spondylolisthesis, the technique for screw extenders. (Image provided by Medtronic Sofamor Danek USA,
fixation is no different in the face of trauma. In their descrip- Inc.)

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 Chapter 134 Minimal Access Techniques for Spine Trauma 1453

Figure 134.6. Fluoroscopic image confirming rod placement. Figure 134.7. Anteroposterior view of screw placement.

MIS Thoracolumbar
Trauma Algorithm

Distraction injury Compression Translation/

rotation

Ligamentous Limited open

Burst Failure of reduction and/or
conservative
fracture treatment in brace,
decompression at
fracture site
or need for faster followed by perc
mobilization pedicle
Posterior
percutaneous Bony instrumentation
instrumentation
with mini open
fusion
Lumbar Thoracic

Percutaneous Internal See vertebral

posterior brace with augmentation
instrumentation perc pedicle algorithm
NO fusion screws

PLC injury no Canal injury

canal requiring
decompression decompression
required

Posterior Posterior mini open Thorascopic

percutaneous decompression and or vertebrectomy with
pedicle screw reduction with additional either anterior fusion or
stabilization with percutaneous posterior perc
Figure 134.8. Minimal access surgi- mini open fusion instrumentation instrumentation
cal (MIS) Thoracolumbar Trauma Algo-
* Patient must be able to tolerate surgery and appropriate staff must be available
rithm for further guidance.

LWBK836_Ch134_p1449-1459.indd 1453 8/26/11 2:34:39 PM

 1454 Section XII Trauma
splitting the paraspinous muscles rather than dissecting and
dividing results in less muscle atrophy, blood loss, with preser-
vation of the normal surrounding anatomy and increased sta-
bility. Future studies are essential in directing fracture manage-
ment whereby the principles of spine trauma are seamlessly
blended with the principles of soft tissue management.
Much of the chapter has been spent discussing a variety of
anterior and lateral approaches used for spinal decompression
and fusion; however, there are described techniques for poste-
rior decompression through MIS portals. A posterior keyhole
corpectomy with percutaneous pedicle screw stabilization can
be used in the surgical management of lumbar burst fractures.
Indications for their technique included Denis classification
subtype B or Magerl subtype A.3.1 burst fractures. Both of these
particular subtypes represent fractures with failure and retro-
pulsion of the upper portion of the vertebral body. Advantages
of this approach include sparing the posterior elements and a
safe decompression provided by the use of a surgical micro-
scope and illumination of the operating field. Disadvantages
include the limitation in the type of burst fracture that can be
treated by this method, the fact that the approach is technically
demanding, and requires use of a special retractor system to
eliminate the cumbersome alternate insertion and reinsertion
of the standard microdiscectomy retractor.
A B
C 2. Disc, 3. Vertebral body. (B) Exposure for removal of disc. 1. Verte-
LWBK836_Ch134_p1449-1459.indd 1454
The described approach requires the patient to be in the
prone position and the surgical table has to be adjusted to gain
distraction and reduction of any kyphotic deformity. The skin
incisions are made 1.5 to 2 cm off the midline on either side
and they are centered above the projection of the lower edge of
the disc adjacent cranially to the fractured vertebrae. The pro-
cedure begins with decompression on the most compromised
side. The muscles are retracted subperiosteally in the same
fashion as in a standard microdiscectomy but are taken more
laterally over the facet joint. Under microscopic view, fenestra-
tion and medial facetectomy are performed to expose the nerve
root and the lateral aspect of the dura. Further resection of the
facets can then be accomplished if necessary. Extensive resec-
tion of the medial wall of the pedicle is then performed.
Resection of the facets and the pedicle exposes the posterolat-
eral aspect of the upper part of the affected vertebral body with
the adjacent disc. This creates a surgical corridor spacious
enough to remove the retropulsed fragment or upper part of
the vertebral body together with an adjacent intervertebral disc
(Fig. 134.9). The upper corpectomy can be extended as cau-
dally as the lower edge of the pedicle. Interbody fusion is then
accomplished in standard fashion with expandable interbody
devices and percutaneous pedicle screws are placed as described
above. While this technique appears very demanding and its
Figure 134.9. (A) Decompression of the vertebral body. 1. Curette,
bral bodies, 2. Disc. (C) View of completion of decompression.
8/26/11 2:34:39 PM

applicability is significantly limited to a small subset of fracture
patterns, the concept is interesting in that it shows how our
surgical approach to spinal pathology is changing (Fig. 134.8).
VERTEBRAL AUGMENTATION
Vertebral augmentation is a well-known minimally invasive tech-
nique utilized in the treatment of spinal fractures from the cervi-
cal spine through the sacrum. While many of the procedures
have bled over into the realm of interventional pain specialists,
these techniques are still widely used by spine surgeons as a rapid
and reliable way to mobilize patients and even provide some
deformity correction. There are more than 700,000 pathologic
vertebral body compression fractures reported annually with
thoracic and lumbar locations being the most common and
more than 25% of women older than 65 years sustain vertebral
compression fractures.16 Most of these fractures can be divided
into two distinct morphologic types. The first type is an acute
crush fracture, whereby the patient experiences sudden onset of
pain and muscle spasm after some sort of major or minor trauma.
The second type is a minimally symptomatic anterior wedge
compression fracture that occurs over multiple levels in time and
leads to a kyphotic deformity and loss of height. Traditionally,
surgery to restore height and alignment meant subjecting the
patient to the tremendous morbidity of a thoracotomy or abdom-
inal surgery in addition to the inherent difficulties with obtain-
ing fixation into osteoporotic bone. Several studies have shown
that with neglect or nonoperative therapies, disturbance of the
normal sagittal balance can lead to further back pain and have a
negative effect on the ability of the patient to participate in the
activities of daily living.2,8,16
Kyphoplasty is differentiated from vertebroplasty in that
kyphoplasty involves inserting an inflatable balloon in the ver-
tebral body to elevate the vertebral end plates and then insert-
ing polymethylmethacrylate (PMMA) into this cavity. The theo-
retic advantages of this procedure over vertebroplasty include
the potential for vertebral body height restoration and kyphosis
reduction while allowing for the more controlled deposition of
PMMA into the cavity. Theoretically this also decreases the risk
of cement extravasation. Both vertebroplasty and kyphoplasty
have been shown to reduce the back pain associated with verte-
bral compression fractures.7,11 It is important for physicians to
treat only symptomatic fractures and not to treat all fractures
seen on imaging studies, because most evidence suggests that
healed fractures are stable and do not cause pain. Indications
for vertebroplasty and kyphoplasty in the treatment of vertebral
compression fractures include acute, painful osteoporotic or
osteolytic fractures; isolated vertebrae with metastatic lesions
that are causing pain; and painful vertebral hemangioma. The
goals of the procedure are to restore stability, anatomic align-
ment, and function as soon as safely possible.4,17 Some contrain-
dications for these percutaneous procedures include fractures
associated with neurologic injury, fractures with a burst compo-
nent, a fracture with a cleft or fracture plane that extends into
the spinal canal, and healed chronic compression fractures. In
patients who have severe cardiac disease, percutaneous verte-
bral augmentation also poses an additional risk that is cumula-
tive for each added level because PMMA contains a vasodilator
agent that is rapidly absorbed systemically.
One of the most significant advantages of kyphoplasty over
vertebroplasty is that it has now been shown in multiple studies
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Chapter 134 Minimal Access Techniques for Spine Trauma 1455
Vertebral
Augmentation
Algorithm
Traumatic Pathologic or osteoporotic
compression compression fracture ++
fracture*
Biologic
vertebral
augmentation
or spinoplasty
Vertebroplasty*
++
Kyphoplasty*
++
*Consider use of calcium phosphate cement or
alternatives to methyl methacrylate in younger
patients to allow for bone healing.
++ PMMA
Figure 134.10. Vertebral Augmentation Algorithm. PMMA,
polymethylmethacrylate.
to result in greater height restoration thus decreasing kypho-
sis.9,16 One potential problem with these vertebral augmenta-
tion techniques is that biomechanical studies have found that
vertebral augmentation leads to increased stiffness in that ver-
tebral body and can lead to altered force distribution in the
adjacent levels, thus increasing the chance of additional osteo-
porotic compression fractures.10 Although data regarding
adjacent-level fractures after vertebroplasty or kyphoplasty are
limited, Grados et al6 reported a 52% incidence of remote or
adjacent-level vertebral compression fractures after kyphop-
lasty. Although each of these techniques has its supporters and
critics, both techniques have unique advantages and disadvan-
tages that afford them a vital role in the treatment of osteo-
porotic compression fractures.16 While vertebral augmentation
throughout the thoracic and lumbar spine has been studied for
years, recently there is an emerging trend to extend the
applicability to the sacrum and even the cervical spine
(Fig. 134.10).
ANTERIOR CERVICAL PROCEDURES
Most of the literature regarding minimally invasive approaches
to the anterior cervical spine is recent and revolves around
degenerative conditions such as radiculopathy secondary to
disc pathology and stenosis secondary to bony pathology. As in
the thoracic and lumbar spine, some of the approaches can be
extrapolated for applicability in certain trauma scenarios.
Traumatic disc herniation leading to spinal canal compromise
8/26/11 2:34:42 PM
 1456 Section XII Trauma

without bony fracture can be approached using some of these

newly described techniques.
Percutaneous endoscopic cervical discectomy has been
described as early as 1989 by Tajima et al18 and several authors
have advocated its use since that time. Minimally invasive
approaches to the anterior cervical spine including percutane-
ous endoscopic cervical discectomy are also being developed.
This procedure is indicated for soft disc compression causing
radiculopathy and can be useful for traumatic disc herniation.
It is, however, contraindicated in situations involving gross
instability; such as with associated fractures, thereby limiting its
use in trauma scenarios. The goal of the procedure is to decom-
press the spinal nerve root by percutaneously removing the
herniated nuclear material and shrinking the remaining
nuclear material. The benefits of this procedure over standard
anterior cervical discectomy and fusion include avoidance of
known complications such as dysphagia, epidural bleeding,
graft-related complications, and perineural fibrosis. It also
maintains the stability of the motion segment and does not pre-
clude any potential future open procedures.
Usually a right-sided approach perpendicular to the midline
is preferred for central disc herniation, whereas a paramedian
approach (2 to 5 mm from the anterior midline) is chosen for a
contralateral foraminal herniation. The larynx or trachea is gen- Figure 134.11. Postoperative computed tomography of odontoid
tly pushed toward the opposite side, and firm pressure is applied reduction.
in the space between the sternocleidomastoid muscle and
trachea. The anterior edge of the disc should be palpated. An
18-gauge spinal needle is applied in the space between the tra- Preoperatively, the ability to obtain a near-anatomic reduction
chea/esophagus and the carotid sheath. Once placement of the must be ensured under fluoroscopic imaging. Two fluoroscopy
needle in the disc is confirmed with fluoroscopy, the needle is units or computed tomography (CT)-guided navigation are used
advanced approximately 5 mm into the disc space. Discography and a radiolucent bite is placed in the patients mouth to facilitate
with 10 cm of radiopaque dye and methylene blue is then per- an open-mouth view. The lateral masses of C1, the body of C2,
formed to confirm the presence of a soft disc herniation and to and the odontoid process must all be well visualized in both the
stain the nucleus a contrasting color to the surrounding neural anteroposterior (AP) and lateral planes. The patients head is
tissue. A guide wire then replaces the needle and a 3- to 5-mm secured using GardnerWells tongs, and it is also held using sand-
incision is made to allow passage of serial dilators. Before the bags and tape. Just medial to the right sternocleidomastoid mus-
final working cannula is inserted, the anterior annulus is cut. cle, at approximately the level of the C4-5 disc space, an initial
The final working cannula is then inserted and its position con- 5-mm incision is made. A needle is then introduced into the area
firmed with fluoroscopy. First the medial aspect of the nucleus is between the carotid sheath and the trachea/esophagus. A K-wire
decompressed, followed by the lateral side, and finally by the is advanced through the needle. Under fluoroscopic guidance a
posterior aspect of the nucleus. Endoscopic vision helps confirm starting point is then made at the anterior inferior lip of C2 and
the adequacy of the decompression of the dural sac or exiting directly in the middle on the AP view. The K-wire is advanced into
nerve root. Potential applications of this technique in cases of the distal portion of the fracture fragment. A 3.5-mm self-tapping
traumatic facet dislocations in the presence of traumatic disc partially threaded cannulated screw is introduced over the guide
ruptures are feasible. The disc pathology could be addressed wire and is slowly advanced under imaging to ensure that the
prior to definitive stabilization of the posterior cervical spine. guide wire does not advance any further. The screw head should
The use of anterior screws to treat minimally displaced frac- be countersunk before insertion. The fracture should compress
tures of the odontoid is well known. Since its introduction by together through a standard lag technique (Fig. 134.11).
Bohler there have been several reports of this technique with While only a handful of the recently described anterior cer-
fusion rates from 81% to 100%. More recently, descriptions of vical spine techniques can potentially be useful in trauma situa-
minimally invasive percutaneous techniques for screw insertion tions, our knowledge of these procedures helps to facilitate
have gained in popularity. Again, the benefits of these tech- further investigations, which could potentially offer some ben-
niques include the avoidance of soft tissue injury during surgi- efit in trauma scenarios. These few procedures are encouraging
cal exposure and all of the potential complications associated and open doors for other innovative technicians to find appli-
with anterior cervical surgeries. Chi et al3 out of China in 2007 cability in the trauma arena where soft tissue preservation is
published their work with 10 patients who had undergone per- essential for long-term outcomes.
cutaneous anterior odontoid screw fixation. Six of the cases
were type II and four were type III fractures according to the
Anderson and DAlonzo classification system. All were second- POSTERIOR CERVICAL PROCEDURES
ary to trauma, and all were treated successfully without compli-
cation. Nine out of the ten went on to bony union and the one Much like the anterior cervical spine, minimally invasive proce-
who did not was asymptomatic. dures for the posterior cervical spine are relatively new and

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often revolve around degenerative conditions. However, some
described approaches can be beneficial in certain cervical
trauma scenarios. Open posterior approaches to the cervical
spine require extensive subperiosteal stripping of the paraspi-
nal musculature, which often results in postoperative pain,
muscle spasm, and dysfunction that can be permanently dis-
abling in 18% to 60% of patients.20 The advent of muscle-
splitting tubular retractor systems, their instruments, and
improvements in endoscopic technology have allowed mini-
mally invasive techniques to be used for posterior cervical
decompressive procedures as well as stabilization procedures.
Cervical microendoscopic foraminotomy or discectomy can
be used to treat nerve root compression from bony or soft tis-
sue pathology. Reports of this procedure have shown equal effi-
cacy to traditional open procedures but with a marked reduc-
tion in the blood loss, length of stay, and postoperative pain
medication use. In this procedure, the patient is placed in a
semisitting position so that the head is flexed but not rotated
and the long axis of the cervical spine is perpendicular to the
floor. This position allows for decreased blood accumulation
within the operative field, reduced operative times, and
improved lateral fluoroscopic images (Fig. 134.12). An 18-mm
longitudinal incision is marked out approximately 1.5 cm off
the midline. For a two-level procedure, the incision should be
placed midway between the levels of interest.
After an initial stab incision, through the cervical fascia allow-
ing muscle dilation to be performed in a safe and controlled
fashion. After dilation is complete, a final 16- or 18-mm tubular
retractor is placed and mounted to the bed (Fig. 134.13). Small-
angled curettes are then used to detach the ligamentum flavum
from the undersurface of the inferior edge of the lamina, and
the laminotomy is begun using Kerrison punches. After the
laminotomy, the flavum can be removed medially until the lat-
eral edge of the dural sac and proximal portion of the nerve
root are identified. A partial medial facetectomy should be per-
formed to decompress the nerve root fully, however, preserve at
least 50% of the facet for stability. Soft disc material can be
removed from under the root using a small nerve hook to com-
plete the decompression (Fig. 134.14). Complication rates for
Figure 134.12. Intraoperative positioning of patient.
LWBK836_Ch134_p1449-1459.indd 1457
Chapter 134 Minimal Access Techniques for Spine Trauma 1457
Figure 134.13. Cervical retractor.
this procedure are small and include dural tears, infection, and
air embolus from the seated position.
For stabilization of the posterior column, lateral mass fixa-
tion is the mainstay in the subaxial cervical spine. This fixation
restores the dorsal tension band and also provides highly effec-
tive long-term stabilization for many traumatic injuries. The
fixation is sturdy and the open insertion of these screws is not
technically demanding. However, the extensive soft tissue strip-
ping that occurs to place lateral mass screws can lead to signifi-
cant posterior neck pain, infection, and other known complica-
tions. Recently, authors have described minimally invasive
techniques for the insertion of lateral mass screws, which can
have significant applicability in cervical spine trauma associated
with fractures. Wang et al21,22 had two studies published describ-
ing this technique as well as some long-term follow-up of some
of their patients.
A similar approach is used as above. The skin entry point is
typically chosen so that the tube trajectory is parallel to the
facet joint in the sagittal plane and also directed laterally so as
to dock on the posterolateral elements. The surface of the lat-
eral mass is exposed using bovie and pituitary rongeurs. The
synovium of the facet joint to be fused is removed with curette
Figure 134.14. Microscopic view of anatomy of the nerve root
space. 1. Lamina, 2. Dura, 3. Nerve root. Numbers are to the right of
the structure.
8/26/11 2:34:43 PM
 1458 Section XII Trauma

Cervical Trauma
Algorithm

Disc herniation Fracture

Incomplete Multiple
Multiple spinal cord levels or
levels injury gross
instability

Open procedure

Complete
Single level
SCI, No
Single posterior
SCI or
Figure 134.15. View down the dilator demonstrating dorsal level fracture or
combined
jumped facet
instrumentation with polyaxial screws and rod. injury

and packed with bone graft. A cancellous drill is used to create

a 14-mm pilot hole and then after the hole is tapped, a 14 or
16 mm 3.5 mm polyaxial head lateral mass screw is placed.
Additional screws are placed with only minor adjustments to
the tube placement. Rods are fed down the tube and inserted
in standard fashion (Fig. 134.15). In cases where the preopera-
tive reduction of jumped facets is not accomplished, intraop-
erative drilling of the perched superior facet can be performed
before instrumentation. In Wang et als study21 of 18 patients
treated with this method, 10 had anterior and posterior surgery
at the same setting, 4 had posterior-only surgery, and 4 had pos-
terior surgery after a failed anterior surgery. For the vast major-
ity, the indication was trauma. Successful fusion was obtained in
all cases without any hardware failures at 2-year follow-up.
There was one report of superficial wound infection and one of
iliac crest donor site pain. Two of the cases were converted to
open because of inability to visualize the lower cervical spine
on fluoroscopic imaging.
There are some limitations to this procedure; however, the
use of a minimally invasive approach in performing posterior
fusion has several advantages. In general, the open technique
requires a fairly lengthy skin incision and muscle dissection,
because one must detach the muscles at not only the affected
level but also at inferior levels to obtain the appropriate drill
trajectory. The limited incision in the above technique pre-
serves the ligamentous attachments of the neck muscles to the
laminae and spinous processes. Several of these muscles
(including the semispinalis, cervicis, and multifidus) function
as dynamic stabilizers. By eliminating the need to detach these
muscles for surgical exposure, the integrity of this posterior
dynamic tension band is ensured (Fig. 134.16).
FUTURE DIRECTIONS
Many of these procedures are only now being developed and
refined. We are in a dawning of a new era in spinal surgery with
more attention being paid to the preservation of normal ana-
tomic structures and elimination of significant surgical morbid-
ity. As we move forward, these techniques will be honed and
expounded upon by other pioneers in the field of spinal trauma
Percutaneous Posterior MIS
discectomy reduction with
without instrumentation and
instability fusion
Keys:
Patient must be able to tolerate surgery
1) Medically stable
a. Hemoglobin/Hematocrit
b. Lactate levels
c. ICP
2) Appropriate staff available and familiar with MIS techniques
Figure 134.16. Cervical Trauma Algorithm. ICP, intracranial pres-
sure; MIS, minimal access surgical; SCI, spinal cord injury.
surgery and minimally invasive surgery. Also, with the advent of
newer fields such as biologics, genetic engineering, and gene
therapy many of our traditional surgical answers will be sup-
planted with newer and less invasive methods of addressing
pathology. New advances and therapies in spinal cord injury
associated with trauma may lead to newer algorithms in how we
address certain fractures. Proper training, including extensive
open treatment experience and the careful adaptation of mini-
mal access techniques will guide clinicians in the future treat-
ment of spine trauma.
Although the future of spinal trauma surgery is unclear,
there are many exciting advances occurring throughout the
world today, which must be evaluated. With the principles of
fracture management as the foundation and the goal of pre-
serving the soft tissue envelope at the forefront, these mini-
mally invasive techniques will only continue to grow in number
and our ability to utilize them in a variety of situations will
mature as well.
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