c



 
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 c



Traumati c injuri es to the spi nal column are common events, with
more than 50,000 fractures to the spinal column occurri ng
annually in the United States (1). Spi nal injury remains a
heterogeneous group of injuri es and therefore vari ous strategi es
are empl oyed in thei r treatment. Mul ti ple clinical vari ables must
be addressed, incl uding the degree of ligamentous and bony
injury, the presence of neurol ogi c defi cits, perceived pati ent
compliance, and overall health status; these factors are used to
determine how the i njuri es are treated. Treatment can range from
simpl e limi tati on i n activity to external orthosi s to open reducti on
and internal fi xati on wi th spinal i nstrumentati on. The goal of
treati ng these i njuries is to utilize the least invasive surgi cal
technique to stabili ze the injured segment while limiti ng the
potenti al for subsequent catastrophi c neurol ogi c injury,
progressi on of a deformi ty, and chroni c pai n condi ti ons. These
surgi cal goal s are al so tempered by other medical management
i ssues that focus on minimi zi ng hospitali zati on and immobilizati on
and maxi mizi ng the benefits of early and aggressive rehabilitati on.




 
  c



 

Treatment of traumatic spinal i njuries was fi rst recorded by
Hi ppocrates (460-370 BCE) who used tracti on devi ces to obtain
spinal reducti on and advocated external stabili zati on and
immobilizati on. Surgery was not consi dered a viabl e opti on at thi s
ti me because of the hi gh mortality of surgi cal techni ques, and the
presence of neurol ogi c defi cits in the setting of spi nal trauma was
deemed universally fatal. Surgi cal decompressi on for the
treatment of traumatic spinal cord injury was initi ally popul ari zed
by Paulus of Aegina (625-690 CE) but was not universally
accepted because of very poor surgi cal outcomes at the time. In
1646, Fabri ci us Hildanus performed the fi rst documented open
reducti on of a spi nal fracture (2, 3, 4, 5, 6 and 7).
It was not until the advent of spi nal instrumentation i n the 1950s
that a more aggressi ve surgi cal approach was favored in the
treatment of spinal col umn injuries. Before the devel opment of
spinal instrumentati on, there was a bi as toward conservative
treatment, whi ch often invol ved
P.40

l ong peri ods of i mmobili zati on (4 to 8 weeks commonly) typi cally

with tracti on to restore the spinal alignment and all ow the
fractures ti me to heal (8). These long peri ods of immobilizati on
were associ ated with si gnifi cant medi cal complicati ons includi ng
pneumonia, deep vei n thrombosi s, and decubitus ulcers. The use
of spi nal instrumentati on provi ded surgeons the ability to restore
immediate stability to the spinal col umn, thus allowi ng for earlier
mobilizati on and fewer complicati ons from prol onged
immobilizati on. In addi ti on, spi nal instrumentati on theoreti cally
improved fusi on rates by provi di ng a stable envi ronment of bone
healing, thus reducing the ri sks of l ate neurol ogi c deteri orati on
due to spi nal instability, progressive spinal deformity, and
associ ated axial back pain syndromes. Even with i mprovements in
instrumentati on, i t was realized that all instrumentati on will fail
eventually unl ess a bony fusi on i s achi eved and, therefore,
arthrodesi s remains a cri tical part of all spi nal stabili zati on
surgeries (4,6).

V 
 

  

 
 
 

The treatment of spi nal trauma consi sts of an assessment of the
traumatic injury through a detailed neurol ogi c examinati on,
physi cal examinati on, and then a radi ographi c evaluation.
Radi ographi c eval uati on often begins with pl ain radi ographs
followed by supplemental imagi ng of questi onabl e areas of injury.
Although modern i maging techni ques have greatl y ai ded i n the
di agnosi s of fractures, determination of ligamentous instability
with i maging al one i s still unproven even with techni ques designed
to evaluate the soft ti ssues such as magneti c resonance imagi ng
(MRI) (9).

V
 
 

Any trauma pati ent shoul d immediatel y be placed in cervi cal spine
immobilizati on when assessed by emergency medi cal servi ces
(EMS) in the fi el d. Any nonintoxi cated patient without neck pai n,
neurol ogi c defi cits, and di stracti ng i njuries (i njuri es to other
porti ons of the body that coul d potenti ally mask the pai n
associ ated with spi nal injury) can be cl eared of cervi cal spi ne
injury wi th a normal clini cal examinati on al one (i .e., showing no
neck pai n over a full range of motion of the cervi cal spine) (10).
[eurol ogi cally i ntact pati ents wi th neck pai n or tenderness are
usually assessed with three vi ew (anteroposteri or [AP], lateral ,
and open-mouth odontoi d views) pl ain radi ographs as ini tial
assessment (11). If these plai n radi ographs are normal , these
pati ents are often kept i n cervical coll ar i mmobili zati on for 1 to 2
weeks and then shoul d have delayed passi ve cervical flexi on and
extensi on i maging to assess for potential occul t li gamentous
injury. Although the prevalence of occult ligamentous injury in the
setting of normal radi ographs i s small , the del ay in the follow-up
fl exi on/extensi on imagi ng can minimi ze fal se negati ve resul ts by
all owing muscle spasm to subsi de. In the neurol ogi cally i ntact
pati ent with á
 neck pai n and normal pl ain radi ographs,
computed tomography (CT), and possi bly MRI should be
consi dered to rul e out an occul t fracture or herni ated di sc not
seen on the plai n radi ographs (11).
In comatose, obtunded, or i ntoxi cated/sedated patients, where an
adequate neurol ogi c examinati on cannot be obtained, pl ain
radi ographs or CT scan are standard i n most trauma protocol s.
Wi th the i ncrease in speed and resol uti on of multi detector heli cal
CT scanni ng, this modali ty i s becomi ng more popul ar for
eval uating mul titrauma patients in a time-effi cient manner. If
these patients remain comatose, dynamic fl exi on/extensi on
studi es wi th fluoroscopi c guidance or a normal cervi cal spine MRI
within 48 hours of i njury is sometimes performed for cervi cal
spine clearance, al though the inherent val ue of either method for
the exclusi on of occul t soft ti ssue injury is questi onable (9,11).
Pati ents with neurol ogi c defi cits that are clinically attri butabl e to a
spinal cord injury deserve rapi d radi ographi c assessment possi bl y
incl uding plai n films, CT scanning, and MRI. In the setti ng of an
obvi ous cervical spi ne deformity with neurol ogi c defi cits, some
surgeons may immedi ately i nsti tute reducti on measures such as
cervi cal tracti on. Other surgeons may insi st upon further
eval uati on with CT and MRI before ini tiating any reducti on
measures. The extent of radi ographi c workup in the setti ng of
spinal cord injury will depend on the preferences of the indi vidual
surgeon, the uni que characteri stics of the fracture being
eval uated, and the character of neurol ogi c exami nati on. Pati ents
with i ncompl ete spinal cord i njuries, where there i s some
neurol ogi c functi on bel ow the level of the spi nal cord injury, may
warrant an emergent MRI exami nati on to assess integri ty of the
spinal canal and rul e out herniated di scs as an expl anati on for the
neurol ogi c defi cits. The pati ent wi th a progressi ve, incompl ete
neurol ogi c defi cit requi res immedi ate assessment and treatment
as these patients have the greatest potenti al to permanently l ose
functi on wi th treatment del ay.

V 


 
 

Awake, neurol ogi cally intact pati ents can have thoraci c and
lumbar spine precauti ons di scontinued if they do not have any
pain suggestive of spinal injury and do not have distracti ng
injuri es. [eurol ogi cally intact patients that compl ain of pain
l ocali zing to the spi ne or who harbor a di stracting injury shoul d be
eval uated radi ographi cally with a mi nimum of AP and l ateral plai n
radi ographs.
P.41

Depending upon the severi ty of thei r symptoms, CT or MRI

imagi ng may be warranted. Comatose, obtunded, or
sedated/intoxicated pati ents should al ways be evaluated with pl ai n
films or CT scanni ng. Mul tisystem trauma pati ents often requi re
routine CT imaging of the chest, abdomen, and pelvis. It has been
suggested that limited resoluti on imagi ng of the thoraci c and
lumbar spine can be extracted from these data sets and used as a
substi tute for radi ographs of these areas (12).
In patients with neurol ogi c defici ts where there i s a hi gh suspici on
for spi nal injury, CT scans with coronal and sagi ttal
reconstructi ons are often the initi al imagi ng modality to improve
the sensitivi ty for di agnosi s of spinal injury and also provi de
better anatomic details about the specifi c fracture. A pati ent with
a persi stent neurol ogi c defici t and a ³normal ´ CT scan warrants
performance of an emergent MRI both to vi suali ze the spinal cord
and cauda equina and to rul e out soft tissue eti ol ogies of spinal
col umn compromi se such as herni ated di scs or epi dural hematoma
that may be not vi suali zed with CT scanning. Some surgeons may
wi sh to obtain emergent MRI i n pati ents with obvi ous fractures
di agnosed with CT, since the MRI can hel p l ocate the l evel of the
conus medullari s, assess the integri ty of the intervertebral di scs,
and better appreci ate the extent of li gamentous injury. All of
these factors may impact the treatment of the patient by
provi ding the surgeon wi th a better appreci ati on of the anatomy of
the spinal injury.

V




 

 




[umerous external orthosi s (spinal braces) opti ons are availabl e
for the treatment of spinal injuries. The pri nci ple of braci ng i s to
reduce moti on at the i njured spinal area in order to i mprove the
likelihood of healing and reduce the potenti al for neurol ogi c injury
as a result of spinal i nstability. In general it is felt that maxi mal
reducti on i n moti on will result in better healing of the i njured
spinal segment, but literature i s lacki ng i n regard to how much
moti on is ³too much´ when consi deri ng braci ng. Indi cati ons for
external orthosi s foll owi ng spi nal injury can vary si gnifi cantly
among indi vidual surgeons si nce there are limited gui delines in
the surgi cal literature for thi s type of treatment. Some fractures
may not requi re any braci ng as they are deemed to be very l ow
ri sk for spinal i nstability and other fractures may be stabilized
surgi cally, thus elimi nating the need for external orthosi s.
For the cervi cal spine, opti ons ranging from l east to most
restri cti ve are soft and hard cervical coll ars (Philadel phia, Aspen,
Mi ami J), cervi cal braci ng with the addi ti on of a thoraci c vest
(SOMI and Minerva braces), and hal o-vest immobili zati on (Fig. 3-
1). A cervi cal coll ar is the l east cumbersome of the cervi cal spi ne
orthosi s opti ons; however, thi s comes at the cost of i t offeri ng the
least support in terms of limiti ng range of moti on. Studi es have
shown that cervi cal hard coll ars allow for over 30 degrees of
fl exi on-extensi on moti on in the cervi cal spi ne and provi de mini mal
support at the l ower cervi cal spi ne (13). Braces that add a
thoraci c vest immobili ze the cervi cal spi ne and cervicothoraci c
juncti on better but still all ow for signi fi cant moti on at the
crani ocervi cal juncti on (Fi g. 3-1B) (14,15). Hal o-vest
immobilizati on (Fig. 3-1C) accompli shes the most ri gi d
immobilizati on by fixating a hal o-ring around the head (pins into
the skull) and securing the hal o-ring to a thoraci c vest by rods.
Although hal o i mmobili zati on provides the most support and may
improve fusi on rates, i t may be associ ated with compli cati ons
ranging from pin l oosening, pin site i nfecti ons, to swall owing
dysfuncti on, reduced i mmobili zation, and cerebral abscesses
attri butable to intracrani al penetrati on of fixation pins. Hal o
immobilizati on al so tends to limit moti on of the upper cervi cal
spine with greater effi ciency than the mi ddl e and lower cervi cal
spine. Even with hal o immobili zation, studies have shown that 2 to
10 degrees of moti on can take pl ace at the crani ocervi cal juncti on,
and the l ower cervical spine and cervi cothoraci c juncti on may not
be adequately mobilized (14). In addi ti on, immobilizati on in a hal o
can cause limited moti on at the ends of the spine (crani ocervi cal
and cervicothoraci c) wi th exaggerated moti on in the subaxi al
spine, referred to as snaking (14).
In the thoraci c spine, the ri b cage provi des some natural support
for thoraci c spine fractures. The upper thoraci c regi on (T5 and
above) i s a very di ffi cul t regi on to immobilize with external
orthosi s, unless the patient i s i mmobili zed with a hal o orthosi s
with a l ong thoraci c vest. Spinal fractures from T6 to L2 are
typi cally braced with a custom molded, hard-shell orthosi s
(thoracol umbar-sacral orthosi s [TLSO]) or wi th more versatile,
adjustabl e-fi t braces (e.g., Jewi tt, Aspen) (Fi g. 3-2A) or cl amshell
brace (Fi g. 3-2B). Bel ow L3, a lumbosacral orthosi s i s used for
support. In additi on, to increase the i mmobili zati on at the
lumbosacral juncti on, a leg extension can be fi tted to the orthosi s
to assi st i n limiti ng moti on across the pel vis. Casti ng (Fig. 3-2C)
i s another opti on for lumbar and thoracol umbar fractures and can
provi de better support and eliminate concerns of noncompliance.


 

V
  



 
Controversy persi sts in the surgi cal community regardi ng the
optimal treatment of many traumati c spinal i njuri es, especi ally
regardi ng timi ng of surgi cal i nterventi on and type of surgi cal
approach. Surgi cal intervention is often
P.42

advocated to (a) decompress the neural elements in cases of

neurol ogi c defi cit; (b) prevent possi ble late neurol ogi c injury in
unstable fractures; (c) correct and prevent deformity that coul d
resul t i n chroni c axial (back) pai n or neurol ogi c l oss; and (d)
provi de for early mobili zati on, thus avoi ding the compli cati ons of
prol onged bed rest.
@ A wi de variety of spinal orthoses are avail able to
treat cervi cal spi ne injuri es incl uding: 
cervi cal coll ars (Aspen
cervi cal coll ar shown), 
cervi cal brace with thoraci c vest
(Mi nerva brace shown), and V
hal o-vest immobili zati on (Bremer
Hal o Crown and Ai rFl o vest by DePuy Spine, A Johnson & Johnson
Company).

Anteri or (ventral ), posteri or (dorsal), and combined anteri or and

posteri or approaches can be used to treat traumati c spinal
instability. The surgi cal approach sel ected may depend on the
fracture pattern, the neurol ogi c status of the patient, and the
indi vidual preference of the surgeon. Anteri or approaches may be
favored in situati ons
P.43

where a herni ated di sc or bone fragment i s causing ventral

compressi on on the spinal cord. In addi ti on, fracture patterns
where the i ntegri ty of the anteri or col umn of the spi ne is
si gni ficantl y compromi sed (unstable spi ne) may be best addressed
by an anteri or approach to restore the structural stability of the
anteri or spinal column. In either case, the surgi cal approach also
incl udes some form of iná nion. Spin iná nion is a
method of strai ghtening and stabilizing the spine after spinal
fusi on, by surgi cally attaching hooks, rods, and wi re to the spine
in a way that redistri butes the stresses on the bones and keeps
them in proper ali gnment.
@! Thoracol umbar fractures can be braced wi th 

adjustabl e-fi t thoracolumbar sacral orthosi s (Aspen TLSO shown),

custom-fit hard-shell braces (cl am shell), and V
casting.
Posteri or surgi cal approaches and instrumentati on typically allow
for better reducti on when deformities are present and may benefit
in restoring the poá io  náion bnd in di stracti on-type injuri es
where there i s disrupti on of the posteri or li gamentous structures.
The posteri or li gamentous structures (ligamentum fl avum,
interspinous ligaments, supraspi nous li gaments, and so forth)
serve to hol d the spine in normal alignment and si nce
P.44

they are under tensi on in most parts of the spine they are
referred to collectively as the poá io  náion bnd. Injury to
these li gamentous structures can all ow the spine to deform into a
more kyphoti c posture. With posteri or instrumentati on, there i s
restorati on of the bi omechani cal forces needed to hol d the spi ne
in normal alignment. In terms of restorati on of alignment,
posteri or instrumentati on (lateral mass screws) typi cally provi des
better fixati on and mechani cal advantage that can be used i n
spinal reducti on maneuvers to better restore spinal alignment.
In translati on injuri es (fracture-di sl ocati ons), when there i s
severe, ci rcumferenti al di srupti on of the spinal col umn, combined
anteri or-posteri or instrumentati on procedures may be used to
maximi ze stability of the spinal column and increase the fusi on
rates. Ci rcumferenti al spinal i nstrumentati on (anteri or and
posteri or combined operati ons) i s more commonly utilized i n areas
of hi gh bi omechani cal stress, such as the cervicothoraci c juncti on
and thoracol umbar juncti on, where the bi omechanical forces on
the spine are greater and make these areas more prone to failure
of stabilizati on procedures.
There is no si ngle preferred approach to many types of spinal
fractures; frequently the preferences of the indi vidual surgeon
take precedence. Despi te the maturati on of surgi cal techni ques
and devel opment of sophi sti cated spinal instrumentati on devi ces,
there is a l ack of good gui delines for the treatment of many
fractures. In general , posteri or approaches to the thoraci c and
lumbar spine are often favored because of the ease and familiari ty
of approach. Anteri or approaches to the thoraci c and lumbar spi ne
tend to be more technically challenging (mobili zing the l ung,
vi scera, and great vessel s) and may requi re the assistance of a
general or thoraci c surgeon to ai d with the approach to the spine.



 
 V
c 
 
  V
" @
 

Occi ptial condyl e fracture is an uncommon injury occurri ng in l ess
than 3% of pati ents with blunt crani overtebral trauma (16,17). CT
i s requi red to di agnose thi s i njury as there i s l ess than 3%
di agnosti c sensiti vity with pl ain radi ographs (18). These fractures
were fi rst cl assified by Anderson and Montesano (19) i nto (a) Type
I²commi nuted due to axi al compressi on, (b) Type II²extensi on of
a basil ar skull fracture through the occi pital condyle, and (c) Type
III²an avul si on of the occi pital condyl e likely due to a rotati onal
force that avul ses a porti on of the occi pital condyl e with the al ar
ligament (Fi g. 3-3). There i s a l ack of adequate studies to
determine the optimum treatment strategy for these fractures.
Most surgeons consider type I and II fractures stable injuri es and
will recommend cervi cal coll ar immobili zati on al one as an opti on
to reduce pai n associ ated wi th thi s i njury.
Type III occi pi tal condyl e fractures are consi dered to be
mechani cally unstabl e and have been associ ated with devel opment
of l ower cranial nerve defi cits if untreated. Transl ati on ” 1 mm
between the occi pi tal condyles and l ateral masses of C1 at the
occi pital -C1 joi nt is consi dered abnormal . Most unil ateral type III
fractures are treated with cervical coll ar i mmobili zati on, but some
surgeons advocate hal o immobili zati on for fractures that have
features of i nstability such as marked fracture displ acement or
abnormal crani ocervi cal ali gnment. There are no specifi c
gui delines or measurements that predi ct whi ch unil ateral type III
fractures are at ri sk for l ong-term instability. After a peri od of
immobilizati on, unilateral fractures can be eval uated in foll ow-up
with CT scanning to assess for the extent of bone uni on across the
fractured segment, and flexion/extensi on radi ographs can be
useful to assess for stability at the occi pitocervi cal juncti on. Gross
instability at the occi pi tocervical juncti on i s presumed for the rare
bilateral type III occi pi tal condyle fractures, and atlanto-occi pi tal
di sl ocati on (AOD) can be a component of thi s i njury. When the
features of AOD are present, an occi pital cervi cal fusi on i s the
preferred method of treatment or in any patient that continues to
have i nstability despite conservative therapy with external
immobilizati on. (20,21).

' 
  # 

AOD has a si gni ficantly hi gh fatality rate as a result of the
si gni ficant forces requi red to create this injury. AOD is commonl y
associ ated with si gnifi cant i ntracrani al i njury as well as vertebral
artery injuri es as a result of thi s distracti on injury across the
crani ocervi cal juncti on. With i mprovements i n the earl y
recogniti on and stabili zati on of spinal injuri es by EMS, more
pati ents are surviving thi s injury. As a result of the tremendous
di stracti ve forces associ ated with the AOD, the tectori al
membrane, posteri or li gamentous structures, and facet capsules
between the atl as and occi pital condyl es are injured, yet
surpri singl y these i njuri es can be difficult to detect on radi ography
and a hi gh degree of vi gil ance i s requi red. Several diagnosti c
cri teri a exi st to hel p di agnose thi s injury on lateral radi ographs
incl uding (a) the Powers rati o (22), (b) basi on-dens di stances,
(such as Harri s's rul e of 12) (23, 24 and 25), (c) di stances from
posteri or mandi ble to anteri or arch of C1 or dens (Dublin method)
(26), and (d) Lee's X-line method (27) (Table 3-1). Of these
di agnosti c opti ons, Harri s's rule of 12 appears to be the most
sensi tive means of di agnosi ng thi s injury on pl ain films or sagi ttal
reformatted CT images (Fig. 3-4A). MRI potenti ally can al so be
P.45

very benefi ci al by showing the li gamentous di srupti on at the

crani ocervi cal juncti on.
@ Cl assifi cati on of occipital condyl e fractures
accordi ng to Anderson and Montesano (1).  Type I fractures may
occur wi th axial l oadi ng. (Anderson PA, Montesano PX. Morphol ogy
and treatment of occi pital condyl e fractures. Spin .
1988;13(7):731-736.)  Type II fractures are extensi ons of a
basilar crani al fracture. V Type III fractures may resul t from an
avul si on of the condyl e duri ng rotati on, l ateral bending, or a
combinati on of mechani sms. (From Jackson RS, Banit DM, Rhyne
AL III, et al . Upper cervi cal spi ne injuri es. R A Acd Oop S .
2002;10(4):271-280, wi th permissi on.)
AOD i s considered hi ghly unstabl e because of the extent of
ligamentous i njury and requi res surgi cal stabilizati on with
occi pitocervi cal fusi on procedures that i nstrument bri dge across
the occi put and upper cervical spi ne via a posteri or approach (Fig.
3-4B).

R 

@
 

Bil ateral fractures through the ri ng of C1 (classi c Jefferson
fracture) (Fig. 3-5A) and other fractures of C1 can typically be
treated with conservative measures (coll ar or hal o immobilizati on)
because of the hi gh rate of spontaneous fusi on and limited
ligamentous i nstability. Integri ty of the transverse ligament is
used as a determinant of stability and the need for possi bl e
surgi cal stabilization. The most common means of evaluating the
integrity of the transverse ligament i s wi th an open-mouth
odontoi d vi ew radi ograph to assess the alignment of the l ateral
masses of C1 and C2 usi ng the rule of Spence (28). Greater than
7 mm of combi ned l ateral overhang of the lateral masses of C1 on
C2 constitutes vi ol ati on of the rul e of Spence and suggests likel y
transverse li gament rupture (Fi g. 3-5B). The transverse ligament
may also be evaluated on MRI, but the appli cati on of MRI in
detecting transverse li gament rupture i s unproven (29). Flexi on-
extensi on pl ain films can al so be used to assess for possi ble C1-2
instability. In the presence of C1-2 i nstability from transverse
ligament rupture, C1-2 arthrodesi s i s recommended via wi ring
techniques, transarti cul ar screws, or other C1 and C2 screw
techniques (Fig. 3-6). Vari ous rods, pl ates, and wire l oop (Fi g. 3-
6A) constructs are availabl e to stabilize the crani ocervical
juncti on. These systems generally provi de screw fixati on into the
posteri or occi put at the cephal ad end. For fixati on at the caudal
end, a vari ety of devi ces can be used, i ncluding atlantoaxi al
transarti cular screws (screws pl aced through the C2 pars
interarti cul ari s, across the C1-2 lateral mass articul ation, and into
the lateral mass of C1) (Fig. 3-6B), C2 pars interarti cul ari s or
P.46

pedi cle screws, and C2 laminar screws (Fi g. 3-6C). Extensi on of

the construct to the subaxi al spi ne wi th l ateral mass screws can
provi de i mproved fixati on in some cases where bone quality or
poor screw purchase is a concern.

  !"#V


$ 
  


"
 
  
%

 


1. Powers Rati o

ŀ Rati o of the di stances from basi on to the anteri or wall of the

posteri or arch of C1 divi ded by the di stance from the opi sthi on
(posteri or li p of the foramen magnum) to the posteri or wall of
the anteri or arch of C1.

ŀ [ormal ”0.9, Indeterminate 0.9±1.0, Abnormal >1.0

ŀ Only sensi tive for diagnosi ng anteri orl y di rected di sl ocati ons.

2. Harri s Rule of 12s

ŀ Two distances are measured: (a) di stance from the base of
the dens to the clivus and (b) distance from a line draw from
the posteri or wall of the dens to the clivus.

ŀ It i s considered abnormal if the clivus i s >12 mm above the

ti p of the dens or 12 mm anteri or to the posteri or dens line;
therefore, the basi s for rule of 12s. If the clivus i s >4 mm
posteri orl y di spl aced behi nd the posteri or dens line, thi s i s
al so consi der abnormal and likely represents a posteri orly
di rected di sl ocati on.

ŀ Consi dered the most sensiti ve rule to di agnose all di recti ons
of di sl ocati on.

3. Dubli n method

ŀ Measures the distance from the posteri or ramus of the

mandi ble to the ventral aspect of the anteri or ring of C1 and
the ventral aspect of the base of the dens.

ŀ A di stance from the posteri or ramus of the mandi ble to the

anteri or arch of C1 >9 mm and >17 mm from the mandible to
the base of the dens are both abnormal and concerning for
AOD.

ŀ Care must be taken to take radi ographs wi th the mouth in

cl osed posi ti on because opening the mandi bl e shortens these
di stances and can provi de fal se-negati ve results.
 4. X-line method

ŀ Utili zes two lines drawn from the foramen magnum to C2

vertebral landmarks.

ŀ The fi rst line is drawn from the basi on to the inferi or aspect
of the axi s spinol aminar juncti on. If any porti on of this line
intersects with porti ons of C2 body or dens, then thi s i s
consi dered abnormal .

ŀ The second line i s drawn from the opi sthi on to the posteri or
inferi or corner of the body of C2. If any porti on of this line
intersects C1, then this is abnormal and a concern for AOD.


@
 

Odontoi d fractures have been cl assifi ed i nto three types by
Anderson and D'Al onzo (30) based on the anatomi c l evel of the
fracture. Type I fractures, avul si on fractures of the tip of the
odontoi d at the attachment of the api cal ligament, are exceedingl y
rare. The most common odontoi d fracture, type II fractures, occur
through the base of the dens at the i ntersecti on with the body of
C2 but do not extend into the facets. Type III fractures invol ve
the body of C2. Most odontoi d fractures, parti cul arly type III, can
be treated nonoperatively through immobilizati on. Type III
fractures have a hi gh spontaneous fusi on rate wi th hal o
immobilizati on attri butable to the large surface area of type III
fractures and good bl ood supply to the bone i n the area of the
fracture. In contrast, type II fractures have the lowest fusi on rate
because of the small fusi on area and poor vascul arity of thi s
regi on. Certain groups of patients with type II fractures have been
shown to have an even higher ri sk for nonuni on, including those in
pati ents ol der than 40 to 60 years ol d, posteri orly di splaced
fractures, and fractures displ aced greater than 4 to 6 mm (31, 32,
33 and 34).
There are two surgi cal approaches for the treatment of type II
odontoi d fractures (Fig. 3-7): odontoi d screw fixati on
(osteosynthesis), or a posteri or C1-2 fusi on techni que. Odontoi d
screw fixati on involves placement of a l ag screw across the
fracture in the pl ane of the dens. A l ag screw i s a smooth shaft
screw that i s threaded only at a short porti on at the tip of the
screw. Thi s techni que wi th a l ag screw pá the fractured dens
fragment back into posi ti on with the body of C2 to promote bone
healing through compressi on and stabili zati on. Ini tially when thi s
technique was devel oped, some surgeons recommended pl acing
two screws into the odontoi d; however, thi s two-screw techni que
has not proven to be superi or to one-screw techni ques in
bi omechanical and clinical studies (35,36). The di rect odontoi d
screw i s typi cally limited to recent fractures << 6 months ol d
because fractures ol der than 6 months show a l ower rate of
fusi on. The theoreti cal benefit of odontoi d screw fixati on i s
preservati on of moti on at the C1-2 arti culati on; however, this
benefit is debated because there can be a si gni ficant l oss in range
of moti on attri butable to the traumati c injury of the C1-2
arti cul ations at the time of the i niti al event. Another benefi t of
odontoi d screw fixati on i s that the anteri or approach i s usually
very well tol erated with minimal pain in compari son with posteri or
approaches to the cervi cal spine; however, severe dysphagi a has
been known to occur commonly i n ol der pati ents and can l ast for
months after surgery (37,38).
P.47
@$ Atl anto-occi pi tal di slocati on (AOD).  Sagi ttal
reformatted CT image showing l oss of normal ori entati on of the
skull base to the upper cervi cal spine from an acute AOD with
increased distance between the basi on and ti p of the odontoi d
process. The di stance between the basi on and the tip of the dens
i s the basi on-dental i nterval (BDI; dob ow). The di stance
between the basi on and the posteri or spinal line extensi on from
C2 i s the basi on-axial interval (BAI; do d in ). Distances ” 12
mm are consi dered abnormal .  Occi pital-cervi cal
instrumentati on used to treat a 32-year-ol d male with atl anto-
occi pital disl ocati on (AOD). Occi pital-cervi cal l oop construct
attached to the occi put with three screws centered on the mi dline
occi pital keel and attached to C2 with C1-2 transarti cular screws.

Posteri or approaches to immobili ze the C1-2 joints can be

performed using C1-2 transarticul ar screws (Fig. 3-6), a C1-2
screw and rod instrumentati on techni que, or posterior wi ring
stand-al one techni ques (Gallie, Brooks, and Sonntag techniques).
These posteri or fusi on techni ques address the C1-2 instability
caused by an odontoi d fracture but at the expense of moti on at
C1-2. The C1-2 articul ati on accounts for approximately 50% of
rotati on in the cervi cal spine, whi ch will be l ost with a successful
posteri or fusi on procedure, but patients with an intact subaxi al
spine typi cally are able to compensate for this l oss of rotati on at
C1-2 and functi on without si gni ficant lifestyle changes.
The earli est method for posteri or C1-2 fusi on, which used a l oop
of wi re to transfix the posteri or arches of C1 and C2, was fi rst
introduced by Cone and Turner (39) in 1937, and improved by
Gallie (40) i n 1939. Subsequent modi ficati ons were made to
Gallie's techni que by Brooks and then Sonntag (Fig. 6A) (41,42).
All of these techni ques had adequate fusi on rates (~ 80%) but
requi red external orthosi s, usually in the form of halo
immobilizati on, for 6 months. In 1976, Grob and Magerl (43)
introduced C1-2 transarticul ar screws, whi ch provi de immediate
stability to the C1-2 arti cul ati on and i n most cases eliminate the
need for ri gi d external orthosi s. The use of C1-2 transarti cular
screws i nvol ves pl acing a screw (or bilateral screws) through the
pars interarticul ari s of C2, across the C1-2 l ateral mass
arti cul ation, and into the l ateral mass of C1 (Fi g. 3-6B). Thi s i s a
technically challenging procedure because of the small si ze of the
C2 pars interarti cul ari s and due to the close proximi ty of the
vertebral artery to the trajectory of the screws. In up to 10% of
cases, an aberrant vertebral artery encroaches i nto the pars
interarti cul ari s of C2 and does not provi de suffi cient space to pass
a transarti cul ar screw safel y. Wi th the limitati ons of transarti cular
screws, a newer techni que was devel oped where screws are
inserted di rectly into the C1 l ateral masses and addi ti onal screws
into C2 pars interarti cul ari s or C2 pedi cle wi th stabilizati on
accomplished by attachi ng a rod between these two screws (Fi g.
3-6C) (44). Thi s procedure si gni ficantly reduces the risk of
vertebral artery injury and can be safely used in a l arger
percentage of cases than transarticul ar screws. In additi on, this
technique all ows the fracture to be di rectly mani pul ated and
reduced intraoperati vel y. Both of these screw techniques have
increased fusi on rates to almost 95% and have reduced the need
for external orthosi s.

i

@
 

Bil ateral fractures through the pars i nterarti culari s of C2, the so-
called hangman fracture, can be successfully treated wi th
immobilizati on i n over 90% of cases. Two cl assifi cati on schemes,
the Franci s and Effendi classi fications, use fracture di spl acement
(” 3.5 mm) and angul ati on (” 11
P.48

degrees ventral angulati on) to help predi ct whi ch fractures may

requi re surgi cal stabili zati on (45,46). Fractures without si gnifi cant
angul ati on (<< 11 degrees) or subluxati on (<< 3.5 mm) can be
treated with just cervical coll ar and cl ose observation. Fractures
with si gnifi cant subluxation or angul ati on that can be reduced are
typi cally treated with hal o immobili zati on. Surgi cal stabili zati on is
usually reserved for nonreduci bl e fractures or fractures with
recurrent subl uxati on despite immobili zati on. Surgi cal stabili zati on
can be accompli shed by either C2-3 anteri or cervi cal di scectomy
and fusi on (ACDF), C1-2 transarticul ar screws, C1 lateral mass
and C2 screws, or C2 pars screws to reapproximate the fracture
(47).

@%  Axial CT and 
open-mouth odontoi d view of a

30-year-ol d male wi th a Jefferson fracture of C1. The axi al CT
shows bil ateral fractures through the anteri or and posteri or ri ngs
of C1 (arrows). The open-mouth odontoi d view shows the l ateral
masses of C1 overhangi ng l aterall y on the l ateral masses of C2 by
” 7 mm (11 mm total overhang in thi s pati ent) indi cating likel y
transverse li gament rupture (arrows).

V
 


 
Anteri or col umn (spi nal el ements that are ventral to posteri or
l ongitudinal li gament) fractures, i sol ated posteri or element
injuri es, and fracture-di sl ocati ons are all rel atively common
traumatic subaxi al cervical spi ne injuri es. Isol ated injury to the
anteri or spinal column may be treated with conservati ve measures
(collar, cervi cothoraci c orthosi s, or hal o) but occasi onally these
injuri es will requi re surgi cal stabilizati on. Al though there are no
establi shed guidelines for surgi cal interventi on of i sol ated anteri or
col umn i njury, in general , neurol ogi c defici ts with ventral spinal
cord compressi on, ” 50% l oss of vertebral body hei ght, kyphosi s
” 11 degrees, sagittal pl ane translati on ” 3.5 mm, and persi stent
neck pai n i n the presence of deformi ty are all indicati ons for
surgi cal stabilization (Tabl e 3-2) (48,49). Once a kyphoti c
deformi ty i s present, it typi cally will progress because the wei ght-
bearing axis of the spine i s shifted to a positi on ventral to the
vertebral body, promoti ng further kyphotic progressi on (50). For
thi s reason, kyphotic deformi ties in the cervi cal spine that are
treated with conservative measures deserve cl ose observati on to
prevent l oss of stability.

  !"&' 


 
c



 
 
 
 


V  
 
 

 c (V
c 

ŀ [eurol ogi c defi cits with ventral spinal cord compressi on

ŀ Vertebral body hei ght l oss >50%

ŀ Kyphosi s >11 degrees

ŀ Sagi ttal plane translati on of 3.5 mm or greater between

adjacent vertebral bodies

ŀ Persi stent neck pain in the presence of deformity

Isol ated anteri or-col umn i njuri es to the cervi cal spine that need
surgi cal stabilization are most commonl y approached anteri orl y to
perform corpectomy (removal of vertebral body) and pl ace strut
bone graft (usually iliac crest o 
 or o 
). Ao 
 i s
obtaini ng by harvesting a small pi ece of the patient's iliac crest
and o 
 has been harvested from a cadaveri c donor. Titanium
mesh cages are an al ternative to structural grafts to restore
structural stability to the anteri or col umn (Fig. 3-8A). These cages
can be filled wi th mi xtures of autograft, all ograft, and other
osteoconductive and -inductive agents (e.g., bone morphogeni c
protein). Anteri or pl ati ng (Fig. 3-8B,C) i s often used to provi de
addi ti onal structural support, which improves fusi on rates,
decreases postoperative pain, and all ows for an earlier return to
more normal activi ties (51). [ewer anteri or cervi cal pl ati ng
systems, termed ³dynamic pl ates´ (Fi g. 3-8C), provide for settling
to take pl ace between the adjacent vertebrae, keeping the
interbody bone grafts under compressi on and, in theory,
improvi ng bone formati on (52). Stati c pl ates (Fi g. 3-8B), which do
not all ow for settling, are cri tici zed for carryi ng all of the
P.49

axi al l oad through the pl ate and screws, thus ³stress shiel ding´
the interbody graft and possi bl y l eading to pseudoarthrosi s
formati on. In the setti ng of trauma, stati c pl ates are favored by
many surgeons as they may provi de more structural stability than
dynamic pl ates, but thi s remains controversi al . The i nherent
mechani sms of dynami c plates may permit more moti on and less
stability than stati c cervi cal pl ates, and thi s i s hypothesi zed to be
more pronounced in the setting of traumatic instability.
@& Posteri or i nstrumentati on used to treat C1-2
instability.  Posteri or wi ring and bone graft techni que (Sonntag
fusi on) where cables are pl aced around the C1 posteri or ring and
spinous process of C2 with custom fit bone grafts pl aced between
C1 and C2 to improve stability and promote arthrodesi s. (From
Weinstein SL. Ä diic Spin S . 2nd ed. Phil adelphi a:
Li ppi ncott Williams & Wilki ns; 2001:143, with permi ssi on.)  CT
scan sagi ttal reconstruction showi ng C1-2 transarticul ar screws
pl aced through the pars i nterarti cul ari s of C2, across the C1-2
l ateral mass articul ati on, and into the lateral mass of C1. V
Lateral radi ograph showi ng C1-2 screw and rod construct, whi ch
involves placi ng bil ateral screws into the l ateral mass of C1 and
pedi cle or pars of C2. Bil ateral rods are pl aced within C1 and C2
screws to stabilize the moti on segment. Both transarti cul ar screws
and C1-2 screw with rod constructs are usually suppl emented with
posteri or bone grafting and wi ring to promote arthrodesi s.

P.50
@' Odontoi d fractures can be surgi cally stabili zed by
anteri or (odontoi d screw fixati on) or posteri or (C1-2 arthrodesi s
procedures). Odontoi d screw fixation i s performed by pl acing a l ag
(smooth shaft screw threaded only at end) screw through the
inferi or porti on of the C2 body in a trajectory parallel to the
odontoi d to pull the fractured dens i nto normal ali gnment to
promote bone healing.  Thi s procedure if performed with the ai d
of bi pl ane fl uoroscopy to determine screw trajectory. In theory,
di rect odontoi d screw fixati on preserves moti on at the C1-2
arti cul ation.  The posteri or l ateral radi ograph shows an odontoi d
screw pl aced to treat a type 2 odontoi d fracture. V Posteri or
procedures, such as the transarti cul ar screws shown, that were
pl aced after odontoi d nonuni on and odontoi d screw fracture,
stabili ze the C1-2 arti culati on and are usually supplemented wi th
posteri or bone graft and wi ri ng to promote fusi on.

In more severe injuri es, such as fracture-di sl ocations, the amount

of li gamentous and intravertebral di sc i njury is often greater than
the bony invol vement. When posttraumatic deformi ty i s present,
such as cases of unilateral or bil ateral jumped facets, these
injuri es are often ini tially treated with tracti on in an attempt to
achi eve reducti on to normal anatomi c alignment (Fi g. 3-9). The
val ue of obtai ning of a prereducti on MRI i n an awake and
cooperati ve patient is frequently debated by the spine surgeons.
Some surgeons argue that there is potential for cord i njury from a
herni ated di sc impi nging on the spinal cord during reducti on; and
a pri ori knowledge of thi s fact i s relevant before attempti ng a
cl osed reducti on. However, most surgeons agree that prereducti on
MRI i s not needed in an awake patient, in whi ch seri al neurol ogi c
exams can be performed during the cl osed reducti on. Moreover, in
pati ents with compl ete or near-compl ete spinal cord injuri es, the
mi sali gned spine shoul d be reduced as soon as possi bl e wi thout
the inherent delay in performing MRI because the potential
benefits of early reducti on far outwei gh the ri sks of neurol ogi c
decline. Comatose, anestheti zed, or noncooperati ve
P.51

pati ents with minimal to no neurologi c defi cits shoul d have an MRI
before reducti on (53).
@( Subaxi al spine i njuries can be addressed by
anteri or, posteri or, or combi ned anteri or-posteri or approaches. 
Lateral radi ograph of a C5 burst fracture that was treated wi th C5
corpectomy, interposi ti onal ti tanium cage, and anteri or cervi cal
fusi on.  Stati c anteri or cervi cal pl ate (CSLP pl ate, Synthes
Corp). V Dynamic anteri or cervical pl ate (ABC pl ate, Aesculap)
all ows for l oad sharing and settling of the i nterbody graft by
all owing for the fixati on screws to slide within the sl ots on the
pl ate.

Once a disl ocati on has been reduced, the injury must be stabilized
with either an anteri or or posteri or fusi on procedure, but often
repai r will necessitate a combination (i .e., both an anteri or and
posteri or) of procedures (Fi g. 3-10) to restore the integri ty of the
anteri or spinal column and the posteri or tensi on band. Posteri or
instrumentati on in the subaxial spine i s most commonly
accomplished using lateral mass screws (Fi g. 3-11A) i n C3, C4,
and C5. Dependi ng on the anatomy and experi ence of the surgeon,
C6 screw fixati on can be accompli shed with l ateral mass screws or
pedi cle screws (Fi g. 3-11B,C). To counteract the increase
bi omechanical stress at the cervi cal-thoraci c juncti on,
instrumentati on failure i s reduced by the use of pedi cle screws at
the lower limb of the metallic construct instead of l ateral mass
screws, whi ch provi des more secure anchoring.


%  
c 
 

V 
  
V 



V

Mul ti ple classi ficati on schemes (Tabl e 3-3) have been proposed to
hel p define thoracol umbar spi nal injuri es and improve consi stency
of communi cati on between
P.52

physi ci ans. There is still no general consensus on whi ch schema to

use. In 1968, Hol dsworth (54) was one of the fi rst to classi fy
traumatic thoracolumbar fractures. He proposed a two-column
model (Fi g. 3-12), divi ding the spine into anteri or and posteri or
col umns, and placed emphasis on the integrity of the posteri or
l ongitudinal li gament (PLL) and posteri or el ements for predi cting
stability. In Hol dsworth's two-col umn model all the elements
ventral to the PLL are considered the anteri or column and the
el ements posteri or to the PLL are the posteri or column.
P.53

Mechani sti cally, Hol dsworth's classifi cati on divi ded fractures into
fl exi on, fl exi on and rotati on, extensi on, and compressi on injuries.
Whitesi des (55) further expanded on the two-col umn model of
Hol dsworth by cl assifyi ng these fractures based upon thei r
inherent stability (i.e., stable or unstabl e), and al so emphasi zed
the importance of the posteri or ligamentous complex i n
determini ng stability. Accordi ng to Whi tesides, stabl e fractures
incl uded simpl e compressi on fractures and burst fractures wi th
intact posteri or elements. Unstabl e fractures incl uded sli ce
fractures,
P.54
burst fractures with posteri or element disrupti on, flexi on-
di stracti on i njuries, and extensi on injuri es.

@) Cervi cal tracti on i s often used to reduce spinal

fractures pri or to surgi cal stabilizati on.  Garder-Well s tongs are
fi xated into the skull and wei ghts are appli ed to these tongs to
provi de tracti on. V A 35-year-ol d male who was i nvol ved in a
motor vehicl e acci dent and suffered a spi nal cord injury as a
resul t of subl uxati on with C5-6 bilateral jumped facets. B: The
ini tial l ateral radi ograph shows greater than 50% subluxati on of
C6 on C7 and bilateral jumped facets at thi s level . C: The patient
was pl aced in 35 pounds of cervical tracti on and the C5-6
interspace i s wi dening. D: At 50 pounds of cervi cal tracti on, the
facets and the subluxati on were reduced.

@* Severe C5-6 traumati c di sl ocati on i n a 21-year-ol d

female.  Initi al CT sagi ttal reconstructi on shows ” 100 %
anteri or subluxati on of C5 on C6.  Foll owing cl osed reducti on to
re-establi sh alignment, thi s i njury was treated with anteri or
(pl ating at C5 to C6) and posteri or i nstrumentati on from C4 to C6
(l ateral mass screws) due to the extensive instability of thi s
injury.

  !"!
V
 
c  $ 

V


) 

   






[  @
 

V 


Hol dsworth Fl exi on, Flexi on

and Rotati on,
Extensi on, and
Compressi on
injuri es

Whitesi des Stable

ŀ Compressi on
 and burst
fractures wi th
intact posteri or
el ements
Unstable
ŀ Burst wi th
posteri or
el ement i njury,
slice fractures,
fl exi on-
di stracti on
injuri es,
extensi on
injuri es

Denis Compressi on,

Burst, Seat
belt-type, and
Fracture
Di sl ocati on

McAfee Wedge-
Compressi on,
Stable Burst,
Unstable Burst,
Chance
fractures,
 Fl exi on±
Di stracti on
Injuri es, and
Transl ati onal
Injuri es

Gai nes Subclassi fied

burst fractures
based on the
amount of
commi nuti on,
apposi ti on of
fragments, and
the amount of
preoperative
kyphosi s to
predi ct which
fractures woul d
fail short-
segment
posteri or
fi xati on.

AO Fractures are
(Magerl) cl assified into 3
basi c
categories:
Type A:
compressi on,
Type B:
di stracti on,
Type C:
mul tidi recti onal
with
transl ati on.
There is
increased ri sk
of i nstability
and neurol ogi c
insult as
injuri es
progress from
Type A to Type
C fractures,
and each type
of fracture i s
further
subdi vi ded
based on the
severi ty.
@ Posteri or screw fixati on in the subaxi al spi ne i s
usually accompli shed with l ateral mass screws at C3, C4, and C5.
The posteri or el ements of C6 can accommodate either l ateral
mass screws or pedicl es screws. A pedi cle screw will typically
provi de stronger pullout strength but at C6 there is ri sk of
vertebral artery injury with pedi cle screw pl acement. At C7,
pedi cle screws are used for posterior fi xation.  Axial CT
showi ng bilateral l ateral mass screws i nto C5.  Sagi ttal CT
reconstructed images showing C7 and T1 pedi cle screws and an
V
axi al CT i mage showing C7 pedi cle screws.

In 1983, Denis (56) proposed the three-col umn model (Fig. 3-12)
for thoracol umbar fractures based on axi al CT scan images and
cl assified these fractures into four categories: cop ááion, bá,
á b  p , and
c diáocion. In contrast to previ ous
authors who emphasi zed the importance of the posteri or col umn in
predi cting stability, Deni s's three-col umn model underscores the
importance of the mi ddle column. The mi ddl e col umn consi sts of
the posteri or porti on of the vertebral body, the posteri or annul us
fi brosus, and the posteri or l ongi tudinal ligament. Deni s believed
that i nvol vement of two of the three col umns resul ted in unstable
fractures (56). McAfee et al . (57) agreed wi th the three-col umn
model of Deni s, but suggested that Deni s's cl assificati on scheme
was too compl ex. They proposed a new cl assifi cati on scheme with
more emphasi s on the mechani sm of i njury and categori zed
fractures into the foll owi ng groups: w d cop ááion, áb
bá, náb bá, Cnc
c á,
 iondiácion
inji á, and náion inji á. Stabl e and unstabl e burst
fractures were differentiated by the competence of the posteri or
el ements.
In 1994 McCormack et al . (58) proposed a cl assifi cati on for burst
fractures to hel p predi ct whi ch patients woul d fail with short-
segment (i.e., fewer adjacent l evels)
P.55
posteri or pedi cle screw instrumentati on al one. Thi s cl assifi cati on
characteri zes burst fractures wi th a point scal e (3 to 9) based on
the amount of comminuti on, appositi on of fragments, and the
amount of preoperative kyphosi s. Burst fractures with seven or
more points on thi s scal e appear to be more prone to
instrumentati on failure with short-segment posteri or fi xati on
al one. Thi s is generally attri buted to failure of the anteri or col umn
to provi de structural support and, thus, this scale may be useful
in determining in whi ch instances an addi ti onal anteri or procedure
may be warranted.

@! Two- and three-column model s have been used to

characteri ze spinal i njuri es and help gauge instability wi th the
respecti ve col umns shown in thi s illustrati on. In the two-col umn
model (left of red verti cal line), all structures l ocated ventral to
the posteri or l ongitudinal ligament (dá d in ) are part of the
anteri or col umn. In the three-column model of Denis (ri ght of red
verti cal line), the anteri or column structures are divi ded i nto an
anteri or and mi ddle column roughly divi ded by the mi ddle of the
vertebral body.

The Modifi ed Comprehensive Classifi cati on (Arbeitsgemei nschaft

für Osteosynthesefragen/Associ ation for the Study of Internal
Fi xati on [AO/ASIF]), ori ginally descri bed by Magerl et al . (59) and
then modifi ed by Gertzbein (60), is currently the most commonl y
used cl assifi cati on system for thoraco-lumbar fractures. Thi s
cl assifi cati on system di vides fractures i nto three mai n types: A,
cop ááion; B, diácion; and C, idi cion wi
náion (Fi g. 3-13). The utility of this system i s the orderl y
manner i n which i t ranks fractures based on severi ty. There i s
increased ri sk of instability and neurol ogi c i nsul t as injuries
progress from type A to type C fractures, and each type of
fracture is further subdivi ded based on the severity. Despite the
orderl y cl assifi cati on of fractures within thi s system, di ffi cul ties
can ari se wi th the AO/ASIF classi ficati on system because of the
complexity of its 27 subtypes. Many surgeons use thi s
cl assifi cati on system, but few use all 27 subtypes within thi s
cl assifi cati on system.
@ Modi fied Comprehensi ve Cl assifi cati on System
(AO/ASIF). Type A: Compressi on injury to the anterior and middl e
col umns, Type B: Di stracti on i njuries i nvol ving posteri or col umn,
Type C: Transl ati on (fracture-di sl ocati on) i njuri es.



  
  


'
 
 V 
 

The fracture l ocati on within the thoraci c and lumbar spine can
have a si gnifi cant influence on the surgi cal approach taken.
Traumati c injuri es to the upper thoraci c spi ne
P.56

(T1-5) can be very difficult to treat. In addi ti on to the diffi cul ty

with braci ng thi s area of the spi ne, surgi cal stabilizati on of the
upper thoraci c spi ne i s challenging because of the limited
intraoperative vi sualizati on of thi s area. Anteri or surgi cal
approaches i n the upper thoraci c spine can be especially difficult,
often requi ring measures like sternotomy to gai n adequate
exposure of the ventral spine. There i s also a lack of
instrumentati on desi gned specifically to address thi s area of the
spine. In additi on, posteri or i nstrumentati on constructs that cross
the cervi cothoraci c juncti on are limi ted. Posteri or approaches with
pedi cle screw fixati on are most commonly used to treat traumati c
instability in thi s area; however, the pedicl es i n the upper thoraci c
spine can be very small , especi ally the T4, T5, and T6 pedicl es,
making pedi cle screw fixati on techni cally more challengi ng to
perform. Laminar hooks and transverse process hooks can be used
for additi onal stability when the anatomy does not favor use of
pedi cle screw fixati on.
Mi ddle thoraci c spine injuries (T6 to T10) can accommodate
immobilizati on better than upper thoraci c i njuri es and, with the
added support of the ri b cage, they can be managed more
conservatively than other thoracolumbar fractures. Both anteri or
and posteri or instrumentati on approaches are avail able to treat
fractures in this area. Anteri or approaches have the benefit of
all owing for reconstructi on of the anteri or spinal column, but a
thoracotomy is requi red and therefore thi s approach incurs the
addi ti onal potenti al compli cati ons of operati ng wi thin the thoraci c
cavi ty. Anteri or i nstrumentati on for use in this area has evolved to
l ower profil e systems that mi nimi ze the ri sk of injury to the
thoraci c viscera. [ewer endoscopi c approaches are now being
performed that not only have a l ower morbi di ty of an open
procedure but have the added benefi t for qui cker recovery from
surgery. Early anteri or thoraci c and l umbar i nstrumentati on, like
the Kaneda devi ce (Fi g. 3-14A), used anteri or screws pl aced into
the vertebral bodi es from a l ateral trajectory and rods connecting
the screws for stabili zati on. [ewer pl ating systems (Fi g. 3-14B),
whi ch have a l ower profile (i .e., no protrusi on of screw heads
above the level of the plates), al so use screw fi xati on i nto the
vertebral bodies. Expandabl e cages (Fi g. 3-14C) can be used in
the thoraci c and lumbar spine to provi de immedi ate structural
stability to the anteri or column after a corpectomy or
vertebrectomy. These devices produce suffici ent anteri or
di stracti on and deformi ty correcti on.
Posteri or instrumentati on in the thoraci c and lumbar spine has
evol ved from earl y rod and wi ri ng, such as Harrington rods and
hook-and-rod constructs, to pedi cle screws (Fi g. 3-15) that
produce stronger three-column spinal fi xati on. Posteri or pedi cle
screw pl acement creates immediate stabilizati on through the
posteri or, middl e, and anteri or columns, whi ch allows greater
forces to be used for fracture or deformi ty reduction and
correcti on.
Traumati c injuri es at the thoracolumbar junction (T11-L2) are
among the more common spinal injuries because of the unique
bi omechanics of thi s area. The transi ti on between the ri gid
thoraci c spinal column and the relati vely mobile lumbar spine
creates a fulcrum at the thoracolumbar junction. There i s a
transfer of energy up the l ordoti c lumbar spine and down the
kyphotic thoraci c spine, creati ng maxi mum stress at the
thoracolumbar juncti on. As a result, up to 75% of fractures in the
thoraci c and l umbar spine occur at the thoracolumbar juncti on,
and i t i s the second most common site for spi nal fractures after
the cervi cal spine. Management of these fractures can be compl ex
and many of the strategies remai n controversi al , with some
physi ci ans favori ng more aggressive surgi cal treatment because of
the hi gh bi omechanical forces exerted on this area of the spi ne
and the sensiti vity of the conus medull ari s to compressi on. Like
other areas of the thoraci c and lumbar spi ne, there may be a bi as
toward posteri or instrumentati on because of the ease and
familiari ty of the approach. Transthoraci c and thoracoscopi c
approaches, wi th possi bl e splitting of the di aphragm, may be used
to access the ventral vertebral column down to L2.
There is a general tendency to treat the remai nder of the lumbar
spine (L3 and bel ow) more conservati vely than thoracolumbar
juncti on fractures because the bi omechani cal stresses are not as
substantial as in other areas and the cauda equi na i s more
tolerant to compressi on than the spinal cord. When surgery i s
contempl ated, the posteri or approaches are often favored, as
general surgery assistance may be needed by some spi nal
surgeons for anteri or approaches to thi s area of the spine vi a
retroperi toneal or transperi toneal approaches.


V
 
 
V 

@
 
+


Most thoracol umbar (compressi on/wedge/burst fractures) can be
treated conservatively wi th bracing; i n general , only severe burst
fractures in this cl ass of i njuri es requi re surgi cal stabili zati on.
[eurol ogi c defi cits i n the setting of canal compromi se are one
surgi cal indi cati on for decompression and stabili zati on. Another
general indi cati on for surgi cal stabilizati on of burst fractures
incl udes l oss or di srupti on of the posteri or ligamentous compl ex,
whi ch can be inferred from ” 25 degrees of kyphosi s on
radi ographs or di rect visualizati on of di srupti on of the posteri or
ligamentous compl ex on fat-suppressed sagi ttal T2-wei ghted MRI.
There has been a trend over the past decade toward short-
segment fi xati on at the thoracol umbar juncti on in an effort to
preserve motion at adjacent level s. The McCormack et al . (58)
cl assifi cati on may be used to determi ne which burst fractures will
fail short-segment instrumentati on and requi re further anteri or
col umn reconstructi on.
Di stracti on injuri es, seat belt-type i njuries, and Chance fractures,
where there i s l oss of i ntegri ty of the posteri or
P.57
col umn, may be managed conservati vely but often requi re
posteri or instrumentati on to restore the posteri or tensi on band.
Transl ati on injuri es or rotati onal fractures are the most unstable
fractures and have the hi ghest ri sk for neurol ogi c injury; they
therefore al most al ways requi re surgi cal stabilizati on. Severe
transl ati on injuri es often requi re a combi ned anteri or-posteri or
approach to restore stability to the spi nal col umn.

@$ Anteri or instrumentati on has become more popul ar

in the thoraci c and lumbar spi ne.  AP radi ograph showing
Kaneda devi ce (Depuy Spine) stabili zing a corpectomy.  MACS-
TL (Aescul ap) i s a new, l ower profile system in whi ch the screw
heads are flush wi th the fixati on plate can be pl aced
thoracoscopi cally. V Expandabl e cages (Synex cage, Synthes
Corp) have been designed for the thoraci c and lumbar spi ne to
restore i ntegri ty of the anteri or column and provi de di stracti on to
hel p correct deformiti es.

$  

 

 
Intraoperati ve imagi ng i s often used by surgeons to confi rm the
appropri ate level for surgery and improve the accuracy of spinal
instrumentati on pl acement. Fluoroscopy and plai n films can each
be used to confi rm the level of surgery, but fluoroscopy has the
added fl exi bility of real-time i mages for gui dance. Lateral
fl uoroscopy i s used most commonly, but AP, obli que, and bi pl anar
(one AP and one l ateral ) (Fig. 3-7A) fluoroscopy each have rol es
dependi ng on the surgi cal need. Careful attenti on shoul d be made
to obtai n ³true´ l ateral or AP i mages by adjusting the fluoroscope
to eliminate obli quity, which can lead to errors i n percepti on. In
the cervi cal spine, aligning the facet joi nts so they are
superi mposed on each other serves as a good guide for obtai ning
the true l ateral vi ew. In the thoraci c and l umbar spi ne, the
vertebral body endpl ates can serve this same function for
obtaini ng perfect lateral ali gnment on the fluoroscope. In the AP
pl ane, the pedi cles and spinous processes serve as good
l andmarks for adjusti ng the fl uoroscope to eliminate obli qui ty.
P.58
@% Posteri or thoraci c and l umbar instrumentati on.
Pedi cle screws are the most commonly used instrumentati on in the
thoraci c and l umbar spine and can usually be pl aced throughout
the thoraci c and lumbar spine dependi ng on the i ndivi dual s
anatomy and si ze of pedi cles (T4-6 typi cally have smallest
pedi cles).  The axi al CT scan shows a pedi cle screw pl aced
through the pedi cle into the vertebral body.  Lateral pl ai n
radi ograph showing rods connected to pedi cle screws.
The cervi cothoraci c juncti on i s typically the most diffi cult area to
vi sualize with intraoperative fl uoroscopy. Maneuvers to pull the
shoul ders toward the feet (taping or tracti on) can hel p maxi mize
vi sualizati on at the l ower cervical spine. Collimating the
fl uoroscopi c beam to the si te of i nterest can al so improve
vi sualizati on and reduce radi ati on exposure. In obese pati ents,
fl uoroscopi c vi suali zati on may be marginal throughout the spi ne
but can be i mproved with these same maneuvers.
Counting vertebral l evel s to l ocalize the appropri ate surgi cal l evel
can be very diffi cul t in the thoraci c regi on. It i s often best to
count up from a known l evel in the l umbar regi on rather than
counting down from the cervicothoraci c junction, whi ch i s often
poorl y vi sualized. If l ocalizati on i s a concern, a skin marker or
subcutaneously impl anted marker can hel p si gnifi cantly with
l ocali zati on when correl ated with preoperative studies. More
complex stereotactic navi gati on systems using preoperative CT
scans or sophi sticated i ntraoperative fl uoroscopy are also
avail able to help with i ntraoperati ve l ocali zati on and hardware
pl acement, but image quality and accuracy are often subopti mal
with current technol ogy.

c 

Although the surgi cal techni ques and i nstrumentati on for repai r of
spinal fractures have progressed substantially, there i s a rel ati ve
l ack of uniformi ty in the surgi cal management of spinal trauma
because of a lack of good cl ass I evi dence and gui delines for a
majori ty of spinal injuries. The surgi cal indi cati ons and
approaches taken to manage spinal trauma vary greatl y among
spine surgeons. Instrumentati on conti nues to have a si gni ficant
rol e in the stabilizati on of some unstabl e fractures. Continued
evol ution of instrumentati on that more faithfully reproduces the
bi omechanics of the normal ti ssues i s expected, and new
mi nimally invasi ve surgi cal techni ques that will mi nimi ze
peri operative morbi di ty and length of hospitali zati on overall are
being devel oped.
P.59

 
 
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?

c


 
 c



 


 c



Traumati c injuri es to the spi nal column are common events, with
more than 50,000 fractures to the spinal column occurri ng
annually in the United States (1). Spi nal injury remains a
heterogeneous group of injuri es and therefore vari ous strategi es
are empl oyed in thei r treatment. Mul ti ple clinical vari ables must
be addressed, incl uding the degree of ligamentous and bony
injury, the presence of neurol ogi c defi cits, perceived pati ent
compliance, and overall health status; these factors are used to
determine how the i njuri es are treated. Treatment can range from
simpl e limi tati on i n activity to external orthosi s to open reducti on
and internal fi xati on wi th spinal i nstrumentati on. The goal of
treati ng these i njuries is to utilize the least invasive surgi cal
technique to stabili ze the injured segment while limiti ng the
potenti al for subsequent catastrophi c neurol ogi c injury,
progressi on of a deformi ty, and chroni c pai n condi ti ons. These
surgi cal goal s are al so tempered by other medical management
i ssues that focus on minimi zi ng hospitali zati on and immobilizati on
and maxi mizi ng the benefits of early and aggressive rehabilitati on.




 
  c



 

Treatment of traumatic spinal i njuries was fi rst recorded by
Hi ppocrates (460-370 BCE) who used tracti on devi ces to obtain
spinal reducti on and advocated external stabili zati on and
immobilizati on. Surgery was not consi dered a viabl e opti on at thi s
ti me because of the hi gh mortality of surgi cal techni ques, and the
presence of neurol ogi c defi cits in the setting of spi nal trauma was
deemed universally fatal. Surgi cal decompressi on for the
treatment of traumatic spinal cord injury was initi ally popul ari zed
by Paulus of Aegina (625-690 CE) but was not universally
accepted because of very poor surgi cal outcomes at the time. In
1646, Fabri ci us Hildanus performed the fi rst documented open
reducti on of a spi nal fracture (2, 3, 4, 5, 6 and 7).
It was not until the advent of spi nal instrumentation i n the 1950s
that a more aggressi ve surgi cal approach was favored in the
treatment of spinal col umn injuries. Before the devel opment of
spinal instrumentati on, there was a bi as toward conservative
treatment, whi ch often invol ved
P.40

l ong peri ods of i mmobili zati on (4 to 8 weeks commonly) typi cally

with tracti on to restore the spinal alignment and all ow the
fractures ti me to heal (8). These long peri ods of immobilizati on
were associ ated with si gnifi cant medi cal complicati ons includi ng
pneumonia, deep vei n thrombosi s, and decubitus ulcers. The use
of spi nal instrumentati on provi ded surgeons the ability to restore
immediate stability to the spinal col umn, thus allowi ng for earlier
mobilizati on and fewer complicati ons from prol onged
immobilizati on. In addi ti on, spi nal instrumentati on theoreti cally
improved fusi on rates by provi di ng a stable envi ronment of bone
healing, thus reducing the ri sks of l ate neurol ogi c deteri orati on
due to spi nal instability, progressive spinal deformity, and
associ ated axial back pain syndromes. Even with i mprovements in
instrumentati on, i t was realized that all instrumentati on will fail
eventually unl ess a bony fusi on i s achi eved and, therefore,
arthrodesi s remains a cri tical part of all spi nal stabili zati on
surgeries (4,6).

V 
 

  

 
 
 

The treatment of spi nal trauma consi sts of an assessment of the
traumatic injury through a detailed neurol ogi c examinati on,
physi cal examinati on, and then a radi ographi c evaluation.
Radi ographi c eval uati on often begins with pl ain radi ographs
followed by supplemental imagi ng of questi onabl e areas of injury.
Although modern i maging techni ques have greatl y ai ded i n the
di agnosi s of fractures, determination of ligamentous instability
with i maging al one i s still unproven even with techni ques designed
to evaluate the soft ti ssues such as magneti c resonance imagi ng
(MRI) (9).

V
 
 

Any trauma pati ent shoul d immediatel y be placed in cervi cal spine
immobilizati on when assessed by emergency medi cal servi ces
(EMS) in the fi el d. Any nonintoxi cated patient without neck pai n,
neurol ogi c defi cits, and di stracti ng i njuries (i njuri es to other
porti ons of the body that coul d potenti ally mask the pai n
associ ated with spi nal injury) can be cl eared of cervi cal spi ne
injury wi th a normal clini cal examinati on al one (i .e., showing no
neck pai n over a full range of motion of the cervi cal spine) (10).
[eurol ogi cally i ntact pati ents wi th neck pai n or tenderness are
usually assessed with three vi ew (anteroposteri or [AP], lateral ,
and open-mouth odontoi d views) pl ain radi ographs as ini tial
assessment (11). If these plai n radi ographs are normal , these
pati ents are often kept i n cervical coll ar i mmobili zati on for 1 to 2
weeks and then shoul d have delayed passi ve cervical flexi on and
extensi on i maging to assess for potential occul t li gamentous
injury. Although the prevalence of occult ligamentous injury in the
setting of normal radi ographs i s small , the del ay in the follow-up
fl exi on/extensi on imagi ng can minimi ze fal se negati ve resul ts by
all owing muscle spasm to subsi de. In the neurol ogi cally i ntact
pati ent with á
 neck pai n and normal pl ain radi ographs,
computed tomography (CT), and possi bly MRI should be
consi dered to rul e out an occul t fracture or herni ated di sc not
seen on the plai n radi ographs (11).
In comatose, obtunded, or i ntoxi cated/sedated patients, where an
adequate neurol ogi c examinati on cannot be obtained, pl ain
radi ographs or CT scan are standard i n most trauma protocol s.
Wi th the i ncrease in speed and resol uti on of multi detector heli cal
CT scanni ng, this modali ty i s becomi ng more popul ar for
eval uating mul titrauma patients in a time-effi cient manner. If
these patients remain comatose, dynamic fl exi on/extensi on
studi es wi th fluoroscopi c guidance or a normal cervi cal spine MRI
within 48 hours of i njury is sometimes performed for cervi cal
spine clearance, al though the inherent val ue of either method for
the exclusi on of occul t soft ti ssue injury is questi onable (9,11).
Pati ents with neurol ogi c defi cits that are clinically attri butabl e to a
spinal cord injury deserve rapi d radi ographi c assessment possi bl y
incl uding plai n films, CT scanning, and MRI. In the setti ng of an
obvi ous cervical spi ne deformity with neurol ogi c defi cits, some
surgeons may immedi ately i nsti tute reducti on measures such as
cervi cal tracti on. Other surgeons may insi st upon further
eval uati on with CT and MRI before ini tiating any reducti on
measures. The extent of radi ographi c workup in the setti ng of
spinal cord injury will depend on the preferences of the indi vidual
surgeon, the uni que characteri stics of the fracture being
eval uated, and the character of neurol ogi c exami nati on. Pati ents
with i ncompl ete spinal cord i njuries, where there i s some
neurol ogi c functi on bel ow the level of the spi nal cord injury, may
warrant an emergent MRI exami nati on to assess integri ty of the
spinal canal and rul e out herniated di scs as an expl anati on for the
neurol ogi c defi cits. The pati ent wi th a progressi ve, incompl ete
neurol ogi c defi cit requi res immedi ate assessment and treatment
as these patients have the greatest potenti al to permanently l ose
functi on wi th treatment del ay.

V 


 
 

Awake, neurol ogi cally intact pati ents can have thoraci c and
lumbar spine precauti ons di scontinued if they do not have any
pain suggestive of spinal injury and do not have distracti ng
injuri es. [eurol ogi cally intact patients that compl ain of pain
l ocali zing to the spi ne or who harbor a di stracting injury shoul d be
eval uated radi ographi cally with a mi nimum of AP and l ateral plai n
radi ographs.
P.41

Depending upon the severi ty of thei r symptoms, CT or MRI

imagi ng may be warranted. Comatose, obtunded, or
sedated/intoxicated pati ents should al ways be evaluated with pl ai n
films or CT scanni ng. Mul tisystem trauma pati ents often requi re
routine CT imaging of the chest, abdomen, and pelvis. It has been
suggested that limited resoluti on imagi ng of the thoraci c and
lumbar spine can be extracted from these data sets and used as a
substi tute for radi ographs of these areas (12).
In patients with neurol ogi c defici ts where there i s a hi gh suspici on
for spi nal injury, CT scans with coronal and sagi ttal
reconstructi ons are often the initi al imagi ng modality to improve
the sensitivi ty for di agnosi s of spinal injury and also provi de
better anatomic details about the specifi c fracture. A pati ent with
a persi stent neurol ogi c defici t and a ³normal ´ CT scan warrants
performance of an emergent MRI both to vi suali ze the spinal cord
and cauda equina and to rul e out soft tissue eti ol ogies of spinal
col umn compromi se such as herni ated di scs or epi dural hematoma
that may be not vi suali zed with CT scanning. Some surgeons may
wi sh to obtain emergent MRI i n pati ents with obvi ous fractures
di agnosed with CT, since the MRI can hel p l ocate the l evel of the
conus medullari s, assess the integri ty of the intervertebral di scs,
and better appreci ate the extent of li gamentous injury. All of
these factors may impact the treatment of the patient by
provi ding the surgeon wi th a better appreci ati on of the anatomy of
the spinal injury.

V




 

 




[umerous external orthosi s (spinal braces) opti ons are availabl e
for the treatment of spinal injuries. The pri nci ple of braci ng i s to
reduce moti on at the i njured spinal area in order to i mprove the
likelihood of healing and reduce the potenti al for neurol ogi c injury
as a result of spinal i nstability. In general it is felt that maxi mal
reducti on i n moti on will result in better healing of the i njured
spinal segment, but literature i s lacki ng i n regard to how much
moti on is ³too much´ when consi deri ng braci ng. Indi cati ons for
external orthosi s foll owi ng spi nal injury can vary si gnifi cantly
among indi vidual surgeons si nce there are limited gui delines in
the surgi cal literature for thi s type of treatment. Some fractures
may not requi re any braci ng as they are deemed to be very l ow
ri sk for spinal i nstability and other fractures may be stabilized
surgi cally, thus elimi nating the need for external orthosi s.
For the cervi cal spine, opti ons ranging from l east to most
restri cti ve are soft and hard cervical coll ars (Philadel phia, Aspen,
Mi ami J), cervi cal braci ng with the addi ti on of a thoraci c vest
(SOMI and Minerva braces), and hal o-vest immobili zati on (Fig. 3-
1). A cervi cal coll ar is the l east cumbersome of the cervi cal spi ne
orthosi s opti ons; however, thi s comes at the cost of i t offeri ng the
least support in terms of limiti ng range of moti on. Studi es have
shown that cervi cal hard coll ars allow for over 30 degrees of
fl exi on-extensi on moti on in the cervi cal spi ne and provi de mini mal
support at the l ower cervi cal spi ne (13). Braces that add a
thoraci c vest immobili ze the cervi cal spi ne and cervicothoraci c
juncti on better but still all ow for signi fi cant moti on at the
crani ocervi cal juncti on (Fi g. 3-1B) (14,15). Hal o-vest
immobilizati on (Fig. 3-1C) accompli shes the most ri gi d
immobilizati on by fixating a hal o-ring around the head (pins into
the skull) and securing the hal o-ring to a thoraci c vest by rods.
Although hal o i mmobili zati on provides the most support and may
improve fusi on rates, i t may be associ ated with compli cati ons
ranging from pin l oosening, pin site i nfecti ons, to swall owing
dysfuncti on, reduced i mmobili zation, and cerebral abscesses
attri butable to intracrani al penetrati on of fixation pins. Hal o
immobilizati on al so tends to limit moti on of the upper cervi cal
spine with greater effi ciency than the mi ddl e and lower cervi cal
spine. Even with hal o immobili zation, studies have shown that 2 to
10 degrees of moti on can take pl ace at the crani ocervi cal juncti on,
and the l ower cervical spine and cervi cothoraci c juncti on may not
be adequately mobilized (14). In addi ti on, immobilizati on in a hal o
can cause limited moti on at the ends of the spine (crani ocervi cal
and cervicothoraci c) wi th exaggerated moti on in the subaxi al
spine, referred to as snaking (14).
In the thoraci c spine, the ri b cage provi des some natural support
for thoraci c spine fractures. The upper thoraci c regi on (T5 and
above) i s a very di ffi cul t regi on to immobilize with external
orthosi s, unless the patient i s i mmobili zed with a hal o orthosi s
with a l ong thoraci c vest. Spinal fractures from T6 to L2 are
typi cally braced with a custom molded, hard-shell orthosi s
(thoracol umbar-sacral orthosi s [TLSO]) or wi th more versatile,
adjustabl e-fi t braces (e.g., Jewi tt, Aspen) (Fi g. 3-2A) or cl amshell
brace (Fi g. 3-2B). Bel ow L3, a lumbosacral orthosi s i s used for
support. In additi on, to increase the i mmobili zati on at the
lumbosacral juncti on, a leg extension can be fi tted to the orthosi s
to assi st i n limiti ng moti on across the pel vis. Casti ng (Fig. 3-2C)
i s another opti on for lumbar and thoracol umbar fractures and can
provi de better support and eliminate concerns of noncompliance.


 

V
  



 
Controversy persi sts in the surgi cal community regardi ng the
optimal treatment of many traumati c spinal i njuri es, especi ally
regardi ng timi ng of surgi cal i nterventi on and type of surgi cal
approach. Surgi cal intervention is often
P.42

advocated to (a) decompress the neural elements in cases of

neurol ogi c defi cit; (b) prevent possi ble late neurol ogi c injury in
unstable fractures; (c) correct and prevent deformity that coul d
resul t i n chroni c axial (back) pai n or neurol ogi c l oss; and (d)
provi de for early mobili zati on, thus avoi ding the compli cati ons of
prol onged bed rest.
@ A wi de variety of spinal orthoses are avail able to
treat cervi cal spi ne injuri es incl uding: 
cervi cal coll ars (Aspen
cervi cal coll ar shown), 
cervi cal brace with thoraci c vest
(Mi nerva brace shown), and V
hal o-vest immobili zati on (Bremer
Hal o Crown and Ai rFl o vest by DePuy Spine, A Johnson & Johnson
Company).

Anteri or (ventral ), posteri or (dorsal), and combined anteri or and

posteri or approaches can be used to treat traumati c spinal
instability. The surgi cal approach sel ected may depend on the
fracture pattern, the neurol ogi c status of the patient, and the
indi vidual preference of the surgeon. Anteri or approaches may be
favored in situati ons
P.43

where a herni ated di sc or bone fragment i s causing ventral

compressi on on the spinal cord. In addi ti on, fracture patterns
where the i ntegri ty of the anteri or col umn of the spi ne is
si gni ficantl y compromi sed (unstable spi ne) may be best addressed
by an anteri or approach to restore the structural stability of the
anteri or spinal column. In either case, the surgi cal approach also
incl udes some form of iná nion. Spin iná nion is a
method of strai ghtening and stabilizing the spine after spinal
fusi on, by surgi cally attaching hooks, rods, and wi re to the spine
in a way that redistri butes the stresses on the bones and keeps
them in proper ali gnment.
@! Thoracol umbar fractures can be braced wi th 

adjustabl e-fi t thoracolumbar sacral orthosi s (Aspen TLSO shown),

custom-fit hard-shell braces (cl am shell), and V
casting.
Posteri or surgi cal approaches and instrumentati on typically allow
for better reducti on when deformities are present and may benefit
in restoring the poá io  náion bnd in di stracti on-type injuri es
where there i s disrupti on of the posteri or li gamentous structures.
The posteri or li gamentous structures (ligamentum fl avum,
interspinous ligaments, supraspi nous li gaments, and so forth)
serve to hol d the spine in normal alignment and si nce
P.44

they are under tensi on in most parts of the spine they are
referred to collectively as the poá io  náion bnd. Injury to
these li gamentous structures can all ow the spine to deform into a
more kyphoti c posture. With posteri or instrumentati on, there i s
restorati on of the bi omechani cal forces needed to hol d the spi ne
in normal alignment. In terms of restorati on of alignment,
posteri or instrumentati on (lateral mass screws) typi cally provi des
better fixati on and mechani cal advantage that can be used i n
spinal reducti on maneuvers to better restore spinal alignment.
In translati on injuri es (fracture-di sl ocati ons), when there i s
severe, ci rcumferenti al di srupti on of the spinal col umn, combined
anteri or-posteri or instrumentati on procedures may be used to
maximi ze stability of the spinal column and increase the fusi on
rates. Ci rcumferenti al spinal i nstrumentati on (anteri or and
posteri or combined operati ons) i s more commonly utilized i n areas
of hi gh bi omechani cal stress, such as the cervicothoraci c juncti on
and thoracol umbar juncti on, where the bi omechanical forces on
the spine are greater and make these areas more prone to failure
of stabilizati on procedures.
There is no si ngle preferred approach to many types of spinal
fractures; frequently the preferences of the indi vidual surgeon
take precedence. Despi te the maturati on of surgi cal techni ques
and devel opment of sophi sti cated spinal instrumentati on devi ces,
there is a l ack of good gui delines for the treatment of many
fractures. In general , posteri or approaches to the thoraci c and
lumbar spine are often favored because of the ease and familiari ty
of approach. Anteri or approaches to the thoraci c and lumbar spi ne
tend to be more technically challenging (mobili zing the l ung,
vi scera, and great vessel s) and may requi re the assistance of a
general or thoraci c surgeon to ai d with the approach to the spine.



 
 V
c 
 
  V
" @
 

Occi ptial condyl e fracture is an uncommon injury occurri ng in l ess
than 3% of pati ents with blunt crani overtebral trauma (16,17). CT
i s requi red to di agnose thi s i njury as there i s l ess than 3%
di agnosti c sensiti vity with pl ain radi ographs (18). These fractures
were fi rst cl assified by Anderson and Montesano (19) i nto (a) Type
I²commi nuted due to axi al compressi on, (b) Type II²extensi on of
a basil ar skull fracture through the occi pital condyle, and (c) Type
III²an avul si on of the occi pital condyl e likely due to a rotati onal
force that avul ses a porti on of the occi pital condyl e with the al ar
ligament (Fi g. 3-3). There i s a l ack of adequate studies to
determine the optimum treatment strategy for these fractures.
Most surgeons consider type I and II fractures stable injuri es and
will recommend cervi cal coll ar immobili zati on al one as an opti on
to reduce pai n associ ated wi th thi s i njury.
Type III occi pi tal condyl e fractures are consi dered to be
mechani cally unstabl e and have been associ ated with devel opment
of l ower cranial nerve defi cits if untreated. Transl ati on ” 1 mm
between the occi pi tal condyles and l ateral masses of C1 at the
occi pital -C1 joi nt is consi dered abnormal . Most unil ateral type III
fractures are treated with cervical coll ar i mmobili zati on, but some
surgeons advocate hal o immobili zati on for fractures that have
features of i nstability such as marked fracture displ acement or
abnormal crani ocervi cal ali gnment. There are no specifi c
gui delines or measurements that predi ct whi ch unil ateral type III
fractures are at ri sk for l ong-term instability. After a peri od of
immobilizati on, unilateral fractures can be eval uated in foll ow-up
with CT scanning to assess for the extent of bone uni on across the
fractured segment, and flexion/extensi on radi ographs can be
useful to assess for stability at the occi pitocervi cal juncti on. Gross
instability at the occi pi tocervical juncti on i s presumed for the rare
bilateral type III occi pi tal condyle fractures, and atlanto-occi pi tal
di sl ocati on (AOD) can be a component of thi s i njury. When the
features of AOD are present, an occi pital cervi cal fusi on i s the
preferred method of treatment or in any patient that continues to
have i nstability despite conservative therapy with external
immobilizati on. (20,21).

' 
  # 

AOD has a si gni ficantly hi gh fatality rate as a result of the
si gni ficant forces requi red to create this injury. AOD is commonl y
associ ated with si gnifi cant i ntracrani al i njury as well as vertebral
artery injuri es as a result of thi s distracti on injury across the
crani ocervi cal juncti on. With i mprovements i n the earl y
recogniti on and stabili zati on of spinal injuri es by EMS, more
pati ents are surviving thi s injury. As a result of the tremendous
di stracti ve forces associ ated with the AOD, the tectori al
membrane, posteri or li gamentous structures, and facet capsules
between the atl as and occi pital condyl es are injured, yet
surpri singl y these i njuri es can be difficult to detect on radi ography
and a hi gh degree of vi gil ance i s requi red. Several diagnosti c
cri teri a exi st to hel p di agnose thi s injury on lateral radi ographs
incl uding (a) the Powers rati o (22), (b) basi on-dens di stances,
(such as Harri s's rul e of 12) (23, 24 and 25), (c) di stances from
posteri or mandi ble to anteri or arch of C1 or dens (Dublin method)
(26), and (d) Lee's X-line method (27) (Table 3-1). Of these
di agnosti c opti ons, Harri s's rule of 12 appears to be the most
sensi tive means of di agnosi ng thi s injury on pl ain films or sagi ttal
reformatted CT images (Fig. 3-4A). MRI potenti ally can al so be
P.45

very benefi ci al by showing the li gamentous di srupti on at the

crani ocervi cal juncti on.
@ Cl assifi cati on of occipital condyl e fractures
accordi ng to Anderson and Montesano (1).  Type I fractures may
occur wi th axial l oadi ng. (Anderson PA, Montesano PX. Morphol ogy
and treatment of occi pital condyl e fractures. Spin .
1988;13(7):731-736.)  Type II fractures are extensi ons of a
basilar crani al fracture. V Type III fractures may resul t from an
avul si on of the condyl e duri ng rotati on, l ateral bending, or a
combinati on of mechani sms. (From Jackson RS, Banit DM, Rhyne
AL III, et al . Upper cervi cal spi ne injuri es. R A Acd Oop S .
2002;10(4):271-280, wi th permissi on.)
AOD i s considered hi ghly unstabl e because of the extent of
ligamentous i njury and requi res surgi cal stabilizati on with
occi pitocervi cal fusi on procedures that i nstrument bri dge across
the occi put and upper cervical spi ne via a posteri or approach (Fig.
3-4B).

R 

@
 

Bil ateral fractures through the ri ng of C1 (classi c Jefferson
fracture) (Fig. 3-5A) and other fractures of C1 can typically be
treated with conservative measures (coll ar or hal o immobilizati on)
because of the hi gh rate of spontaneous fusi on and limited
ligamentous i nstability. Integri ty of the transverse ligament is
used as a determinant of stability and the need for possi bl e
surgi cal stabilization. The most common means of evaluating the
integrity of the transverse ligament i s wi th an open-mouth
odontoi d vi ew radi ograph to assess the alignment of the l ateral
masses of C1 and C2 usi ng the rule of Spence (28). Greater than
7 mm of combi ned l ateral overhang of the lateral masses of C1 on
C2 constitutes vi ol ati on of the rul e of Spence and suggests likel y
transverse li gament rupture (Fi g. 3-5B). The transverse ligament
may also be evaluated on MRI, but the appli cati on of MRI in
detecting transverse li gament rupture i s unproven (29). Flexi on-
extensi on pl ain films can al so be used to assess for possi ble C1-2
instability. In the presence of C1-2 i nstability from transverse
ligament rupture, C1-2 arthrodesi s i s recommended via wi ring
techniques, transarti cul ar screws, or other C1 and C2 screw
techniques (Fig. 3-6). Vari ous rods, pl ates, and wire l oop (Fi g. 3-
6A) constructs are availabl e to stabilize the crani ocervical
juncti on. These systems generally provi de screw fixati on into the
posteri or occi put at the cephal ad end. For fixati on at the caudal
end, a vari ety of devi ces can be used, i ncluding atlantoaxi al
transarti cular screws (screws pl aced through the C2 pars
interarti cul ari s, across the C1-2 lateral mass articul ation, and into
the lateral mass of C1) (Fig. 3-6B), C2 pars interarti cul ari s or
P.46

pedi cle screws, and C2 laminar screws (Fi g. 3-6C). Extensi on of

the construct to the subaxi al spi ne wi th l ateral mass screws can
provi de i mproved fixati on in some cases where bone quality or
poor screw purchase is a concern.

  !"#V


$ 
  


"
 
  
%

 


1. Powers Rati o

ŀ Rati o of the di stances from basi on to the anteri or wall of the

posteri or arch of C1 divi ded by the di stance from the opi sthi on
(posteri or li p of the foramen magnum) to the posteri or wall of
the anteri or arch of C1.

ŀ [ormal ”0.9, Indeterminate 0.9±1.0, Abnormal >1.0

ŀ Only sensi tive for diagnosi ng anteri orl y di rected di sl ocati ons.

2. Harri s Rule of 12s

ŀ Two distances are measured: (a) di stance from the base of
the dens to the clivus and (b) distance from a line draw from
the posteri or wall of the dens to the clivus.

ŀ It i s considered abnormal if the clivus i s >12 mm above the

ti p of the dens or 12 mm anteri or to the posteri or dens line;
therefore, the basi s for rule of 12s. If the clivus i s >4 mm
posteri orl y di spl aced behi nd the posteri or dens line, thi s i s
al so consi der abnormal and likely represents a posteri orly
di rected di sl ocati on.

ŀ Consi dered the most sensiti ve rule to di agnose all di recti ons
of di sl ocati on.

3. Dubli n method

ŀ Measures the distance from the posteri or ramus of the

mandi ble to the ventral aspect of the anteri or ring of C1 and
the ventral aspect of the base of the dens.

ŀ A di stance from the posteri or ramus of the mandi ble to the

anteri or arch of C1 >9 mm and >17 mm from the mandible to
the base of the dens are both abnormal and concerning for
AOD.

ŀ Care must be taken to take radi ographs wi th the mouth in

cl osed posi ti on because opening the mandi bl e shortens these
di stances and can provi de fal se-negati ve results.
 4. X-line method

ŀ Utili zes two lines drawn from the foramen magnum to C2

vertebral landmarks.

ŀ The fi rst line is drawn from the basi on to the inferi or aspect
of the axi s spinol aminar juncti on. If any porti on of this line
intersects with porti ons of C2 body or dens, then thi s i s
consi dered abnormal .

ŀ The second line i s drawn from the opi sthi on to the posteri or
inferi or corner of the body of C2. If any porti on of this line
intersects C1, then this is abnormal and a concern for AOD.


@
 

Odontoi d fractures have been cl assifi ed i nto three types by
Anderson and D'Al onzo (30) based on the anatomi c l evel of the
fracture. Type I fractures, avul si on fractures of the tip of the
odontoi d at the attachment of the api cal ligament, are exceedingl y
rare. The most common odontoi d fracture, type II fractures, occur
through the base of the dens at the i ntersecti on with the body of
C2 but do not extend into the facets. Type III fractures invol ve
the body of C2. Most odontoi d fractures, parti cul arly type III, can
be treated nonoperatively through immobilizati on. Type III
fractures have a hi gh spontaneous fusi on rate wi th hal o
immobilizati on attri butable to the large surface area of type III
fractures and good bl ood supply to the bone i n the area of the
fracture. In contrast, type II fractures have the lowest fusi on rate
because of the small fusi on area and poor vascul arity of thi s
regi on. Certain groups of patients with type II fractures have been
shown to have an even higher ri sk for nonuni on, including those in
pati ents ol der than 40 to 60 years ol d, posteri orly di splaced
fractures, and fractures displ aced greater than 4 to 6 mm (31, 32,
33 and 34).
There are two surgi cal approaches for the treatment of type II
odontoi d fractures (Fig. 3-7): odontoi d screw fixati on
(osteosynthesis), or a posteri or C1-2 fusi on techni que. Odontoi d
screw fixati on involves placement of a l ag screw across the
fracture in the pl ane of the dens. A l ag screw i s a smooth shaft
screw that i s threaded only at a short porti on at the tip of the
screw. Thi s techni que wi th a l ag screw pá the fractured dens
fragment back into posi ti on with the body of C2 to promote bone
healing through compressi on and stabili zati on. Ini tially when thi s
technique was devel oped, some surgeons recommended pl acing
two screws into the odontoi d; however, thi s two-screw techni que
has not proven to be superi or to one-screw techni ques in
bi omechanical and clinical studies (35,36). The di rect odontoi d
screw i s typi cally limited to recent fractures << 6 months ol d
because fractures ol der than 6 months show a l ower rate of
fusi on. The theoreti cal benefit of odontoi d screw fixati on i s
preservati on of moti on at the C1-2 arti culati on; however, this
benefit is debated because there can be a si gni ficant l oss in range
of moti on attri butable to the traumati c injury of the C1-2
arti cul ations at the time of the i niti al event. Another benefi t of
odontoi d screw fixati on i s that the anteri or approach i s usually
very well tol erated with minimal pain in compari son with posteri or
approaches to the cervi cal spine; however, severe dysphagi a has
been known to occur commonly i n ol der pati ents and can l ast for
months after surgery (37,38).
P.47
@$ Atl anto-occi pi tal di slocati on (AOD).  Sagi ttal
reformatted CT image showing l oss of normal ori entati on of the
skull base to the upper cervi cal spine from an acute AOD with
increased distance between the basi on and ti p of the odontoi d
process. The di stance between the basi on and the tip of the dens
i s the basi on-dental i nterval (BDI; dob ow). The di stance
between the basi on and the posteri or spinal line extensi on from
C2 i s the basi on-axial interval (BAI; do d in ). Distances ” 12
mm are consi dered abnormal .  Occi pital-cervi cal
instrumentati on used to treat a 32-year-ol d male with atl anto-
occi pital disl ocati on (AOD). Occi pital-cervi cal l oop construct
attached to the occi put with three screws centered on the mi dline
occi pital keel and attached to C2 with C1-2 transarti cular screws.

Posteri or approaches to immobili ze the C1-2 joints can be

performed using C1-2 transarticul ar screws (Fig. 3-6), a C1-2
screw and rod instrumentati on techni que, or posterior wi ring
stand-al one techni ques (Gallie, Brooks, and Sonntag techniques).
These posteri or fusi on techni ques address the C1-2 instability
caused by an odontoi d fracture but at the expense of moti on at
C1-2. The C1-2 articul ati on accounts for approximately 50% of
rotati on in the cervi cal spine, whi ch will be l ost with a successful
posteri or fusi on procedure, but patients with an intact subaxi al
spine typi cally are able to compensate for this l oss of rotati on at
C1-2 and functi on without si gni ficant lifestyle changes.
The earli est method for posteri or C1-2 fusi on, which used a l oop
of wi re to transfix the posteri or arches of C1 and C2, was fi rst
introduced by Cone and Turner (39) in 1937, and improved by
Gallie (40) i n 1939. Subsequent modi ficati ons were made to
Gallie's techni que by Brooks and then Sonntag (Fig. 6A) (41,42).
All of these techni ques had adequate fusi on rates (~ 80%) but
requi red external orthosi s, usually in the form of halo
immobilizati on, for 6 months. In 1976, Grob and Magerl (43)
introduced C1-2 transarticul ar screws, whi ch provi de immediate
stability to the C1-2 arti cul ati on and i n most cases eliminate the
need for ri gi d external orthosi s. The use of C1-2 transarti cular
screws i nvol ves pl acing a screw (or bilateral screws) through the
pars interarticul ari s of C2, across the C1-2 l ateral mass
arti cul ation, and into the l ateral mass of C1 (Fi g. 3-6B). Thi s i s a
technically challenging procedure because of the small si ze of the
C2 pars interarti cul ari s and due to the close proximi ty of the
vertebral artery to the trajectory of the screws. In up to 10% of
cases, an aberrant vertebral artery encroaches i nto the pars
interarti cul ari s of C2 and does not provi de suffi cient space to pass
a transarti cul ar screw safel y. Wi th the limitati ons of transarti cular
screws, a newer techni que was devel oped where screws are
inserted di rectly into the C1 l ateral masses and addi ti onal screws
into C2 pars interarti cul ari s or C2 pedi cle wi th stabilizati on
accomplished by attachi ng a rod between these two screws (Fi g.
3-6C) (44). Thi s procedure si gni ficantly reduces the risk of
vertebral artery injury and can be safely used in a l arger
percentage of cases than transarticul ar screws. In additi on, this
technique all ows the fracture to be di rectly mani pul ated and
reduced intraoperati vel y. Both of these screw techniques have
increased fusi on rates to almost 95% and have reduced the need
for external orthosi s.

i

@
 

Bil ateral fractures through the pars i nterarti culari s of C2, the so-
called hangman fracture, can be successfully treated wi th
immobilizati on i n over 90% of cases. Two cl assifi cati on schemes,
the Franci s and Effendi classi fications, use fracture di spl acement
(” 3.5 mm) and angul ati on (” 11
P.48

degrees ventral angulati on) to help predi ct whi ch fractures may

requi re surgi cal stabili zati on (45,46). Fractures without si gnifi cant
angul ati on (<< 11 degrees) or subluxati on (<< 3.5 mm) can be
treated with just cervical coll ar and cl ose observation. Fractures
with si gnifi cant subluxation or angul ati on that can be reduced are
typi cally treated with hal o immobili zati on. Surgi cal stabili zati on is
usually reserved for nonreduci bl e fractures or fractures with
recurrent subl uxati on despite immobili zati on. Surgi cal stabili zati on
can be accompli shed by either C2-3 anteri or cervi cal di scectomy
and fusi on (ACDF), C1-2 transarticul ar screws, C1 lateral mass
and C2 screws, or C2 pars screws to reapproximate the fracture
(47).

@%  Axial CT and 
open-mouth odontoi d view of a

30-year-ol d male wi th a Jefferson fracture of C1. The axi al CT
shows bil ateral fractures through the anteri or and posteri or ri ngs
of C1 (arrows). The open-mouth odontoi d view shows the l ateral
masses of C1 overhangi ng l aterall y on the l ateral masses of C2 by
” 7 mm (11 mm total overhang in thi s pati ent) indi cating likel y
transverse li gament rupture (arrows).

V
 


 
Anteri or col umn (spi nal el ements that are ventral to posteri or
l ongitudinal li gament) fractures, i sol ated posteri or element
injuri es, and fracture-di sl ocati ons are all rel atively common
traumatic subaxi al cervical spi ne injuri es. Isol ated injury to the
anteri or spinal column may be treated with conservati ve measures
(collar, cervi cothoraci c orthosi s, or hal o) but occasi onally these
injuri es will requi re surgi cal stabilizati on. Al though there are no
establi shed guidelines for surgi cal interventi on of i sol ated anteri or
col umn i njury, in general , neurol ogi c defici ts with ventral spinal
cord compressi on, ” 50% l oss of vertebral body hei ght, kyphosi s
” 11 degrees, sagittal pl ane translati on ” 3.5 mm, and persi stent
neck pai n i n the presence of deformi ty are all indicati ons for
surgi cal stabilization (Tabl e 3-2) (48,49). Once a kyphoti c
deformi ty i s present, it typi cally will progress because the wei ght-
bearing axis of the spine i s shifted to a positi on ventral to the
vertebral body, promoti ng further kyphotic progressi on (50). For
thi s reason, kyphotic deformi ties in the cervi cal spine that are
treated with conservative measures deserve cl ose observati on to
prevent l oss of stability.

  !"&' 


 
c



 
 
 
 


V  
 
 

 c (V
c 

ŀ [eurol ogi c defi cits with ventral spinal cord compressi on

ŀ Vertebral body hei ght l oss >50%

ŀ Kyphosi s >11 degrees

ŀ Sagi ttal plane translati on of 3.5 mm or greater between

adjacent vertebral bodies

ŀ Persi stent neck pain in the presence of deformity

Isol ated anteri or-col umn i njuri es to the cervi cal spine that need
surgi cal stabilization are most commonl y approached anteri orl y to
perform corpectomy (removal of vertebral body) and pl ace strut
bone graft (usually iliac crest o 
 or o 
). Ao 
 i s
obtaini ng by harvesting a small pi ece of the patient's iliac crest
and o 
 has been harvested from a cadaveri c donor. Titanium
mesh cages are an al ternative to structural grafts to restore
structural stability to the anteri or col umn (Fig. 3-8A). These cages
can be filled wi th mi xtures of autograft, all ograft, and other
osteoconductive and -inductive agents (e.g., bone morphogeni c
protein). Anteri or pl ati ng (Fig. 3-8B,C) i s often used to provi de
addi ti onal structural support, which improves fusi on rates,
decreases postoperative pain, and all ows for an earlier return to
more normal activi ties (51). [ewer anteri or cervi cal pl ati ng
systems, termed ³dynamic pl ates´ (Fi g. 3-8C), provide for settling
to take pl ace between the adjacent vertebrae, keeping the
interbody bone grafts under compressi on and, in theory,
improvi ng bone formati on (52). Stati c pl ates (Fi g. 3-8B), which do
not all ow for settling, are cri tici zed for carryi ng all of the
P.49

axi al l oad through the pl ate and screws, thus ³stress shiel ding´
the interbody graft and possi bl y l eading to pseudoarthrosi s
formati on. In the setti ng of trauma, stati c pl ates are favored by
many surgeons as they may provi de more structural stability than
dynamic pl ates, but thi s remains controversi al . The i nherent
mechani sms of dynami c plates may permit more moti on and less
stability than stati c cervi cal pl ates, and thi s i s hypothesi zed to be
more pronounced in the setting of traumatic instability.
@& Posteri or i nstrumentati on used to treat C1-2
instability.  Posteri or wi ring and bone graft techni que (Sonntag
fusi on) where cables are pl aced around the C1 posteri or ring and
spinous process of C2 with custom fit bone grafts pl aced between
C1 and C2 to improve stability and promote arthrodesi s. (From
Weinstein SL. Ä diic Spin S . 2nd ed. Phil adelphi a:
Li ppi ncott Williams & Wilki ns; 2001:143, with permi ssi on.)  CT
scan sagi ttal reconstruction showi ng C1-2 transarticul ar screws
pl aced through the pars i nterarti cul ari s of C2, across the C1-2
l ateral mass articul ati on, and into the lateral mass of C1. V
Lateral radi ograph showi ng C1-2 screw and rod construct, whi ch
involves placi ng bil ateral screws into the l ateral mass of C1 and
pedi cle or pars of C2. Bil ateral rods are pl aced within C1 and C2
screws to stabilize the moti on segment. Both transarti cul ar screws
and C1-2 screw with rod constructs are usually suppl emented with
posteri or bone grafting and wi ring to promote arthrodesi s.

P.50
@' Odontoi d fractures can be surgi cally stabili zed by
anteri or (odontoi d screw fixati on) or posteri or (C1-2 arthrodesi s
procedures). Odontoi d screw fixation i s performed by pl acing a l ag
(smooth shaft screw threaded only at end) screw through the
inferi or porti on of the C2 body in a trajectory parallel to the
odontoi d to pull the fractured dens i nto normal ali gnment to
promote bone healing.  Thi s procedure if performed with the ai d
of bi pl ane fl uoroscopy to determine screw trajectory. In theory,
di rect odontoi d screw fixati on preserves moti on at the C1-2
arti cul ation.  The posteri or l ateral radi ograph shows an odontoi d
screw pl aced to treat a type 2 odontoi d fracture. V Posteri or
procedures, such as the transarti cul ar screws shown, that were
pl aced after odontoi d nonuni on and odontoi d screw fracture,
stabili ze the C1-2 arti culati on and are usually supplemented wi th
posteri or bone graft and wi ri ng to promote fusi on.

In more severe injuri es, such as fracture-di sl ocations, the amount

of li gamentous and intravertebral di sc i njury is often greater than
the bony invol vement. When posttraumatic deformi ty i s present,
such as cases of unilateral or bil ateral jumped facets, these
injuri es are often ini tially treated with tracti on in an attempt to
achi eve reducti on to normal anatomi c alignment (Fi g. 3-9). The
val ue of obtai ning of a prereducti on MRI i n an awake and
cooperati ve patient is frequently debated by the spine surgeons.
Some surgeons argue that there is potential for cord i njury from a
herni ated di sc impi nging on the spinal cord during reducti on; and
a pri ori knowledge of thi s fact i s relevant before attempti ng a
cl osed reducti on. However, most surgeons agree that prereducti on
MRI i s not needed in an awake patient, in whi ch seri al neurol ogi c
exams can be performed during the cl osed reducti on. Moreover, in
pati ents with compl ete or near-compl ete spinal cord injuri es, the
mi sali gned spine shoul d be reduced as soon as possi bl e wi thout
the inherent delay in performing MRI because the potential
benefits of early reducti on far outwei gh the ri sks of neurol ogi c
decline. Comatose, anestheti zed, or noncooperati ve
P.51

pati ents with minimal to no neurologi c defi cits shoul d have an MRI
before reducti on (53).
@( Subaxi al spine i njuries can be addressed by
anteri or, posteri or, or combi ned anteri or-posteri or approaches. 
Lateral radi ograph of a C5 burst fracture that was treated wi th C5
corpectomy, interposi ti onal ti tanium cage, and anteri or cervi cal
fusi on.  Stati c anteri or cervi cal pl ate (CSLP pl ate, Synthes
Corp). V Dynamic anteri or cervical pl ate (ABC pl ate, Aesculap)
all ows for l oad sharing and settling of the i nterbody graft by
all owing for the fixati on screws to slide within the sl ots on the
pl ate.

Once a disl ocati on has been reduced, the injury must be stabilized
with either an anteri or or posteri or fusi on procedure, but often
repai r will necessitate a combination (i .e., both an anteri or and
posteri or) of procedures (Fi g. 3-10) to restore the integri ty of the
anteri or spinal column and the posteri or tensi on band. Posteri or
instrumentati on in the subaxial spine i s most commonly
accomplished using lateral mass screws (Fi g. 3-11A) i n C3, C4,
and C5. Dependi ng on the anatomy and experi ence of the surgeon,
C6 screw fixati on can be accompli shed with l ateral mass screws or
pedi cle screws (Fi g. 3-11B,C). To counteract the increase
bi omechanical stress at the cervi cal-thoraci c juncti on,
instrumentati on failure i s reduced by the use of pedi cle screws at
the lower limb of the metallic construct instead of l ateral mass
screws, whi ch provi des more secure anchoring.


%  
c 
 

V 
  
V 



V

Mul ti ple classi ficati on schemes (Tabl e 3-3) have been proposed to
hel p define thoracol umbar spi nal injuri es and improve consi stency
of communi cati on between
P.52

physi ci ans. There is still no general consensus on whi ch schema to

use. In 1968, Hol dsworth (54) was one of the fi rst to classi fy
traumatic thoracolumbar fractures. He proposed a two-column
model (Fi g. 3-12), divi ding the spine into anteri or and posteri or
col umns, and placed emphasis on the integrity of the posteri or
l ongitudinal li gament (PLL) and posteri or el ements for predi cting
stability. In Hol dsworth's two-col umn model all the elements
ventral to the PLL are considered the anteri or column and the
el ements posteri or to the PLL are the posteri or column.
P.53

Mechani sti cally, Hol dsworth's classifi cati on divi ded fractures into
fl exi on, fl exi on and rotati on, extensi on, and compressi on injuries.
Whitesi des (55) further expanded on the two-col umn model of
Hol dsworth by cl assifyi ng these fractures based upon thei r
inherent stability (i.e., stable or unstabl e), and al so emphasi zed
the importance of the posteri or ligamentous complex i n
determini ng stability. Accordi ng to Whi tesides, stabl e fractures
incl uded simpl e compressi on fractures and burst fractures wi th
intact posteri or elements. Unstabl e fractures incl uded sli ce
fractures,
P.54
burst fractures with posteri or element disrupti on, flexi on-
di stracti on i njuries, and extensi on injuri es.

@) Cervi cal tracti on i s often used to reduce spinal

fractures pri or to surgi cal stabilizati on.  Garder-Well s tongs are
fi xated into the skull and wei ghts are appli ed to these tongs to
provi de tracti on. V A 35-year-ol d male who was i nvol ved in a
motor vehicl e acci dent and suffered a spi nal cord injury as a
resul t of subl uxati on with C5-6 bilateral jumped facets. B: The
ini tial l ateral radi ograph shows greater than 50% subluxati on of
C6 on C7 and bilateral jumped facets at thi s level . C: The patient
was pl aced in 35 pounds of cervical tracti on and the C5-6
interspace i s wi dening. D: At 50 pounds of cervi cal tracti on, the
facets and the subluxati on were reduced.

@* Severe C5-6 traumati c di sl ocati on i n a 21-year-ol d

female.  Initi al CT sagi ttal reconstructi on shows ” 100 %
anteri or subluxati on of C5 on C6.  Foll owing cl osed reducti on to
re-establi sh alignment, thi s i njury was treated with anteri or
(pl ating at C5 to C6) and posteri or i nstrumentati on from C4 to C6
(l ateral mass screws) due to the extensive instability of thi s
injury.

  !"!
V
 
c  $ 

V


) 

   






[  @
 

V 


Hol dsworth Fl exi on, Flexi on

and Rotati on,
Extensi on, and
Compressi on
injuri es

Whitesi des Stable

ŀ Compressi on
 and burst
fractures wi th
intact posteri or
el ements
Unstable
ŀ Burst wi th
posteri or
el ement i njury,
slice fractures,
fl exi on-
di stracti on
injuri es,
extensi on
injuri es

Denis Compressi on,

Burst, Seat
belt-type, and
Fracture
Di sl ocati on

McAfee Wedge-
Compressi on,
Stable Burst,
Unstable Burst,
Chance
fractures,
 Fl exi on±
Di stracti on
Injuri es, and
Transl ati onal
Injuri es

Gai nes Subclassi fied

burst fractures
based on the
amount of
commi nuti on,
apposi ti on of
fragments, and
the amount of
preoperative
kyphosi s to
predi ct which
fractures woul d
fail short-
segment
posteri or
fi xati on.

AO Fractures are
(Magerl) cl assified into 3
basi c
categories:
Type A:
compressi on,
Type B:
di stracti on,
Type C:
mul tidi recti onal
with
transl ati on.
There is
increased ri sk
of i nstability
and neurol ogi c
insult as
injuri es
progress from
Type A to Type
C fractures,
and each type
of fracture i s
further
subdi vi ded
based on the
severi ty.
@ Posteri or screw fixati on in the subaxi al spi ne i s
usually accompli shed with l ateral mass screws at C3, C4, and C5.
The posteri or el ements of C6 can accommodate either l ateral
mass screws or pedicl es screws. A pedi cle screw will typically
provi de stronger pullout strength but at C6 there is ri sk of
vertebral artery injury with pedi cle screw pl acement. At C7,
pedi cle screws are used for posterior fi xation.  Axial CT
showi ng bilateral l ateral mass screws i nto C5.  Sagi ttal CT
reconstructed images showing C7 and T1 pedi cle screws and an
V
axi al CT i mage showing C7 pedi cle screws.

In 1983, Denis (56) proposed the three-col umn model (Fig. 3-12)
for thoracol umbar fractures based on axi al CT scan images and
cl assified these fractures into four categories: cop ááion, bá,
á b  p , and
c diáocion. In contrast to previ ous
authors who emphasi zed the importance of the posteri or col umn in
predi cting stability, Deni s's three-col umn model underscores the
importance of the mi ddle column. The mi ddl e col umn consi sts of
the posteri or porti on of the vertebral body, the posteri or annul us
fi brosus, and the posteri or l ongi tudinal ligament. Deni s believed
that i nvol vement of two of the three col umns resul ted in unstable
fractures (56). McAfee et al . (57) agreed wi th the three-col umn
model of Deni s, but suggested that Deni s's cl assificati on scheme
was too compl ex. They proposed a new cl assifi cati on scheme with
more emphasi s on the mechani sm of i njury and categori zed
fractures into the foll owi ng groups: w d cop ááion, áb
bá, náb bá, Cnc
c á,
 iondiácion
inji á, and náion inji á. Stabl e and unstabl e burst
fractures were differentiated by the competence of the posteri or
el ements.
In 1994 McCormack et al . (58) proposed a cl assifi cati on for burst
fractures to hel p predi ct whi ch patients woul d fail with short-
segment (i.e., fewer adjacent l evels)
P.55
posteri or pedi cle screw instrumentati on al one. Thi s cl assifi cati on
characteri zes burst fractures wi th a point scal e (3 to 9) based on
the amount of comminuti on, appositi on of fragments, and the
amount of preoperative kyphosi s. Burst fractures with seven or
more points on thi s scal e appear to be more prone to
instrumentati on failure with short-segment posteri or fi xati on
al one. Thi s is generally attri buted to failure of the anteri or col umn
to provi de structural support and, thus, this scale may be useful
in determining in whi ch instances an addi ti onal anteri or procedure
may be warranted.

@! Two- and three-column model s have been used to

characteri ze spinal i njuri es and help gauge instability wi th the
respecti ve col umns shown in thi s illustrati on. In the two-col umn
model (left of red verti cal line), all structures l ocated ventral to
the posteri or l ongitudinal ligament (dá d in ) are part of the
anteri or col umn. In the three-column model of Denis (ri ght of red
verti cal line), the anteri or column structures are divi ded i nto an
anteri or and mi ddle column roughly divi ded by the mi ddle of the
vertebral body.

The Modifi ed Comprehensive Classifi cati on (Arbeitsgemei nschaft

für Osteosynthesefragen/Associ ation for the Study of Internal
Fi xati on [AO/ASIF]), ori ginally descri bed by Magerl et al . (59) and
then modifi ed by Gertzbein (60), is currently the most commonl y
used cl assifi cati on system for thoraco-lumbar fractures. Thi s
cl assifi cati on system di vides fractures i nto three mai n types: A,
cop ááion; B, diácion; and C, idi cion wi
náion (Fi g. 3-13). The utility of this system i s the orderl y
manner i n which i t ranks fractures based on severi ty. There i s
increased ri sk of instability and neurol ogi c i nsul t as injuries
progress from type A to type C fractures, and each type of
fracture is further subdivi ded based on the severity. Despite the
orderl y cl assifi cati on of fractures within thi s system, di ffi cul ties
can ari se wi th the AO/ASIF classi ficati on system because of the
complexity of its 27 subtypes. Many surgeons use thi s
cl assifi cati on system, but few use all 27 subtypes within thi s
cl assifi cati on system.
@ Modi fied Comprehensi ve Cl assifi cati on System
(AO/ASIF). Type A: Compressi on injury to the anterior and middl e
col umns, Type B: Di stracti on i njuries i nvol ving posteri or col umn,
Type C: Transl ati on (fracture-di sl ocati on) i njuri es.



  
  


'
 
 V 
 

The fracture l ocati on within the thoraci c and lumbar spine can
have a si gnifi cant influence on the surgi cal approach taken.
Traumati c injuri es to the upper thoraci c spi ne
P.56

(T1-5) can be very difficult to treat. In addi ti on to the diffi cul ty

with braci ng thi s area of the spi ne, surgi cal stabilizati on of the
upper thoraci c spi ne i s challenging because of the limited
intraoperative vi sualizati on of thi s area. Anteri or surgi cal
approaches i n the upper thoraci c spine can be especially difficult,
often requi ring measures like sternotomy to gai n adequate
exposure of the ventral spine. There i s also a lack of
instrumentati on desi gned specifically to address thi s area of the
spine. In additi on, posteri or i nstrumentati on constructs that cross
the cervi cothoraci c juncti on are limi ted. Posteri or approaches with
pedi cle screw fixati on are most commonly used to treat traumati c
instability in thi s area; however, the pedicl es i n the upper thoraci c
spine can be very small , especi ally the T4, T5, and T6 pedicl es,
making pedi cle screw fixati on techni cally more challengi ng to
perform. Laminar hooks and transverse process hooks can be used
for additi onal stability when the anatomy does not favor use of
pedi cle screw fixati on.
Mi ddle thoraci c spine injuries (T6 to T10) can accommodate
immobilizati on better than upper thoraci c i njuri es and, with the
added support of the ri b cage, they can be managed more
conservatively than other thoracolumbar fractures. Both anteri or
and posteri or instrumentati on approaches are avail able to treat
fractures in this area. Anteri or approaches have the benefit of
all owing for reconstructi on of the anteri or spinal column, but a
thoracotomy is requi red and therefore thi s approach incurs the
addi ti onal potenti al compli cati ons of operati ng wi thin the thoraci c
cavi ty. Anteri or i nstrumentati on for use in this area has evolved to
l ower profil e systems that mi nimi ze the ri sk of injury to the
thoraci c viscera. [ewer endoscopi c approaches are now being
performed that not only have a l ower morbi di ty of an open
procedure but have the added benefi t for qui cker recovery from
surgery. Early anteri or thoraci c and l umbar i nstrumentati on, like
the Kaneda devi ce (Fi g. 3-14A), used anteri or screws pl aced into
the vertebral bodi es from a l ateral trajectory and rods connecting
the screws for stabili zati on. [ewer pl ating systems (Fi g. 3-14B),
whi ch have a l ower profile (i .e., no protrusi on of screw heads
above the level of the plates), al so use screw fi xati on i nto the
vertebral bodies. Expandabl e cages (Fi g. 3-14C) can be used in
the thoraci c and lumbar spine to provi de immedi ate structural
stability to the anteri or column after a corpectomy or
vertebrectomy. These devices produce suffici ent anteri or
di stracti on and deformi ty correcti on.
Posteri or instrumentati on in the thoraci c and lumbar spine has
evol ved from earl y rod and wi ri ng, such as Harrington rods and
hook-and-rod constructs, to pedi cle screws (Fi g. 3-15) that
produce stronger three-column spinal fi xati on. Posteri or pedi cle
screw pl acement creates immediate stabilizati on through the
posteri or, middl e, and anteri or columns, whi ch allows greater
forces to be used for fracture or deformi ty reduction and
correcti on.
Traumati c injuri es at the thoracolumbar junction (T11-L2) are
among the more common spinal injuries because of the unique
bi omechanics of thi s area. The transi ti on between the ri gid
thoraci c spinal column and the relati vely mobile lumbar spine
creates a fulcrum at the thoracolumbar junction. There i s a
transfer of energy up the l ordoti c lumbar spine and down the
kyphotic thoraci c spine, creati ng maxi mum stress at the
thoracolumbar juncti on. As a result, up to 75% of fractures in the
thoraci c and l umbar spine occur at the thoracolumbar juncti on,
and i t i s the second most common site for spi nal fractures after
the cervi cal spine. Management of these fractures can be compl ex
and many of the strategies remai n controversi al , with some
physi ci ans favori ng more aggressive surgi cal treatment because of
the hi gh bi omechanical forces exerted on this area of the spi ne
and the sensiti vity of the conus medull ari s to compressi on. Like
other areas of the thoraci c and lumbar spi ne, there may be a bi as
toward posteri or instrumentati on because of the ease and
familiari ty of the approach. Transthoraci c and thoracoscopi c
approaches, wi th possi bl e splitting of the di aphragm, may be used
to access the ventral vertebral column down to L2.
There is a general tendency to treat the remai nder of the lumbar
spine (L3 and bel ow) more conservati vely than thoracolumbar
juncti on fractures because the bi omechani cal stresses are not as
substantial as in other areas and the cauda equi na i s more
tolerant to compressi on than the spinal cord. When surgery i s
contempl ated, the posteri or approaches are often favored, as
general surgery assistance may be needed by some spi nal
surgeons for anteri or approaches to thi s area of the spine vi a
retroperi toneal or transperi toneal approaches.


V
 
 
V 

@
 
+


Most thoracol umbar (compressi on/wedge/burst fractures) can be
treated conservatively wi th bracing; i n general , only severe burst
fractures in this cl ass of i njuri es requi re surgi cal stabili zati on.
[eurol ogi c defi cits i n the setting of canal compromi se are one
surgi cal indi cati on for decompression and stabili zati on. Another
general indi cati on for surgi cal stabilizati on of burst fractures
incl udes l oss or di srupti on of the posteri or ligamentous compl ex,
whi ch can be inferred from ” 25 degrees of kyphosi s on
radi ographs or di rect visualizati on of di srupti on of the posteri or
ligamentous compl ex on fat-suppressed sagi ttal T2-wei ghted MRI.
There has been a trend over the past decade toward short-
segment fi xati on at the thoracol umbar juncti on in an effort to
preserve motion at adjacent level s. The McCormack et al . (58)
cl assifi cati on may be used to determi ne which burst fractures will
fail short-segment instrumentati on and requi re further anteri or
col umn reconstructi on.
Di stracti on injuri es, seat belt-type i njuries, and Chance fractures,
where there i s l oss of i ntegri ty of the posteri or
P.57
col umn, may be managed conservati vely but often requi re
posteri or instrumentati on to restore the posteri or tensi on band.
Transl ati on injuri es or rotati onal fractures are the most unstable
fractures and have the hi ghest ri sk for neurol ogi c injury; they
therefore al most al ways requi re surgi cal stabilizati on. Severe
transl ati on injuri es often requi re a combi ned anteri or-posteri or
approach to restore stability to the spi nal col umn.

@$ Anteri or instrumentati on has become more popul ar

in the thoraci c and lumbar spi ne.  AP radi ograph showing
Kaneda devi ce (Depuy Spine) stabili zing a corpectomy.  MACS-
TL (Aescul ap) i s a new, l ower profile system in whi ch the screw
heads are flush wi th the fixati on plate can be pl aced
thoracoscopi cally. V Expandabl e cages (Synex cage, Synthes
Corp) have been designed for the thoraci c and lumbar spi ne to
restore i ntegri ty of the anteri or column and provi de di stracti on to
hel p correct deformiti es.

$  

 

 
Intraoperati ve imagi ng i s often used by surgeons to confi rm the
appropri ate level for surgery and improve the accuracy of spinal
instrumentati on pl acement. Fluoroscopy and plai n films can each
be used to confi rm the level of surgery, but fluoroscopy has the
added fl exi bility of real-time i mages for gui dance. Lateral
fl uoroscopy i s used most commonly, but AP, obli que, and bi pl anar
(one AP and one l ateral ) (Fig. 3-7A) fluoroscopy each have rol es
dependi ng on the surgi cal need. Careful attenti on shoul d be made
to obtai n ³true´ l ateral or AP i mages by adjusting the fluoroscope
to eliminate obli quity, which can lead to errors i n percepti on. In
the cervi cal spine, aligning the facet joi nts so they are
superi mposed on each other serves as a good guide for obtai ning
the true l ateral vi ew. In the thoraci c and l umbar spi ne, the
vertebral body endpl ates can serve this same function for
obtaini ng perfect lateral ali gnment on the fluoroscope. In the AP
pl ane, the pedi cles and spinous processes serve as good
l andmarks for adjusti ng the fl uoroscope to eliminate obli qui ty.
P.58
@% Posteri or thoraci c and l umbar instrumentati on.
Pedi cle screws are the most commonly used instrumentati on in the
thoraci c and l umbar spine and can usually be pl aced throughout
the thoraci c and lumbar spine dependi ng on the i ndivi dual s
anatomy and si ze of pedi cles (T4-6 typi cally have smallest
pedi cles).  The axi al CT scan shows a pedi cle screw pl aced
through the pedi cle into the vertebral body.  Lateral pl ai n
radi ograph showing rods connected to pedi cle screws.
The cervi cothoraci c juncti on i s typically the most diffi cult area to
vi sualize with intraoperative fl uoroscopy. Maneuvers to pull the
shoul ders toward the feet (taping or tracti on) can hel p maxi mize
vi sualizati on at the l ower cervical spine. Collimating the
fl uoroscopi c beam to the si te of i nterest can al so improve
vi sualizati on and reduce radi ati on exposure. In obese pati ents,
fl uoroscopi c vi suali zati on may be marginal throughout the spi ne
but can be i mproved with these same maneuvers.
Counting vertebral l evel s to l ocalize the appropri ate surgi cal l evel
can be very diffi cul t in the thoraci c regi on. It i s often best to
count up from a known l evel in the l umbar regi on rather than
counting down from the cervicothoraci c junction, whi ch i s often
poorl y vi sualized. If l ocalizati on i s a concern, a skin marker or
subcutaneously impl anted marker can hel p si gnifi cantly with
l ocali zati on when correl ated with preoperative studies. More
complex stereotactic navi gati on systems using preoperative CT
scans or sophi sticated i ntraoperative fl uoroscopy are also
avail able to help with i ntraoperati ve l ocali zati on and hardware
pl acement, but image quality and accuracy are often subopti mal
with current technol ogy.

c 

Although the surgi cal techni ques and i nstrumentati on for repai r of
spinal fractures have progressed substantially, there i s a rel ati ve
l ack of uniformi ty in the surgi cal management of spinal trauma
because of a lack of good cl ass I evi dence and gui delines for a
majori ty of spinal injuries. The surgi cal indi cati ons and
approaches taken to manage spinal trauma vary greatl y among
spine surgeons. Instrumentati on conti nues to have a si gni ficant
rol e in the stabilizati on of some unstabl e fractures. Continued
evol ution of instrumentati on that more faithfully reproduces the
bi omechanics of the normal ti ssues i s expected, and new
mi nimally invasi ve surgi cal techni ques that will mi nimi ze
peri operative morbi di ty and length of hospitali zati on overall are
being devel oped.
P.59

 
 
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