V Vol. 22, No.
3 March 2000
CE Refereed Peer Review
FOCAL POINT
★ Surgical treatment of vertebral
injury can help decrease spinal
instability and realign spinal
structures.
KEY FACTS
■ Knowledge of normal vertebral
anatomy is important before
surgical repair of vertebral
fractures or luxations is
undertaken.
■ Cortical bone screws, pins, and
polymethylmethacrylate are often
useful as internal spinal fracture
apparatus.
■ Decompression is indicated if
myelography confirms spinal
cord compression from
intervertebral disk rupture
or hematoma.
■ Because spinal injury and surgery
are associated with considerable
postoperative pain, opiate
analgesics are commonly
administered.
■ Several simple but effective
methods of physical therapy can
be used for patients recovering
from spinal surgery.
Exogenous Spinal
Trauma: Surgical
Therapy and Aftercare*
Washington State University
Rodney S. Bagley, DVM Michael L. Harrington, DVM, MS
Gena M. Silver, DVM, MS Anthony J. Cambridge, BVMS
Rebecca L. Connors, LVT Michael P. Moore, DVM, MS
ABSTRACT: Surgical treatment should be considered in animals with spinal cord instability
and/or compression related to exogenous injury. This article reviews some techniques for
manual reduction, internal fixation, and stabilization of spinal injuries and discusses such af-
tercare issues as pain control, complications associated with prolonged recumbency, and
physical therapy.
S
pinal trauma is a common cause of spinal cord dysfunction in dogs and
cats. When the spine is subjected to exogenous injury, the impact often
causes vertebral fracture or luxation. Because each spinal injury is unique,
treatment guidelines need to be individualized. The indications for surgical
treatment of spinal trauma are numerous but controversial. Some authors sug-
gest that similar results are obtained with both surgical and nonsurgical treat-
ment of spinal fractures, regardless of the severity.1,2 Intuitively, however, surgical
stabilization of spinal instability seems reasonable when the chance of increasing
instability is likely. No prospective case-controlled studies definitively show the
best treatment for animals with spinal fracture or luxation. Surgical treatment,
however, should be considered for animals with spinal cord instability and/or
compression related to exogenous injury. Serial radiographs and cautious palpa-
tion may confirm instability. However, myelography or other advanced imaging
(e.g., computed tomography, magnetic resonance imaging) may be needed to es-
tablish spinal cord compression or damage.
Instability of a vertebral segment can be difficult to predict from a single ra-
diograph. Thus a scheme for predicting spinal instability based on the degree of
vertebral damage was devised for humans and adapted to dogs.3 In this model,
the vertebrae are divided into three compartments: ventral, middle, and dorsal.
The ventral (anterior) compartment is composed of the ventral vertebral body,
ventral ligament, and anulus. The middle compartment includes the dorsal anu-
*A companion article entitled “Exogenous Spinal Trauma: Clinical Assessment and Initial
Management” appeared in the December 1999 (Vol. 21, No. 12) issue of Compendium.
Compendium March 2000
lus, dorsal vertebral body, and dorsal longitudinal liga-
ment; and the dorsal compartment includes the articu-
lar facets and joint capsules, ligamentum flavum, dorsal
vertebral arch and pedicle, and dorsal spinous processes
and interspinous ligaments. Damage to two or more com-
ponents would indicate the need for surgical stabiliza-
tion because the chance of clinically significant spinal
instability is high.3
When instability is documented, external fixation
with splints and bandages may be helpful if they are ap-
plied correctly.4 Internal fixation and stabilization, how-
ever, are often necessary. Various techniques have been
reviewed in the literature5–17; each technique has advan-
tages and disadvantages.
SURGICAL THERAPY
Alignment and Reduction
To begin spinal stabilization, the skin over the affect-
ed area is incised and the paraspinal muscles are re-
moved from affected vertebrae. However, veterinarians
are advised to use caution when removing muscle be-
cause the animal’s normal anatomy may have been dis-
rupted by the trauma; removal of supporting muscle,
tendons, and ligaments during surgery could aggravate
existing vertebral instability. The vertebral segments
should be aligned either before or after placement of
screws or pins. More normal anatomic alignment can de-
crease compression of associated dura mater and nerve
roots. Excessive spinal manipulation, however, should
be avoided to minimize additional cord damage.
Manual reduction of vertebral fractures can be diffi-
cult. Surgical tools can provide counterbalancing forces
or torque to aid in realignment. Because most vertebral
fractures are associated with collapsed vertebral seg-
ments, lamina spreaders are useful. By slowly increasing
the degree of distraction of the vertebral segments, vet-
erinarians can avoid some of the paraspinal muscle
spasms and contracture that result in vertebral segment
collapse. Manipulations may also be aided by neuro-
muscular blockage during anesthesia. If achieving a sol-
id purchase point at the vertebrae on either side of the
fracture becomes difficult, the lamina spreader can be
positioned in previously placed screws or pins. The
jaws of the lamina spreader should be positioned as
close to the screw–bone interface as possible to mini-
mize the potential of screws becoming loose when dis-
traction force is applied. When the vertebral segments
are distracted, they are easier to realign manually or us-
ing surgical instruments.
Realignment is typically required for lumbosacral
fractures. Because the body of L-7 is generally displaced
in a dorsocaudal direction and the lumbosacral articular
facets are luxated, elevation of the sacrum or depression
MANUAL REDUCTION ■ LAMINA SPREADER ■ FIXATION DEVICES
Small Animal/Exotics
of L-7 is required to anatomically reduce the fracture.
Reduction can be accomplished using the L-shaped end
of a Senn retractor.18 The blade end of the retractor
should be positioned in a caudal direction in the verte-
bral canal. The retractor shaft should then be pushed
cranially and dorsally to elevate the sacrum and depress
L-7. Use of a lamina spreader to distract the vertebrae
after realignment with the Senn retractor may result in
better anatomic reduction.
Internal Fixation and Stabilization
After reasonable alignment of most vertebral seg-
ments is obtained and if at least one pair of articular
facets remains intact, a small Kirschner wire can be
driven across the facets to maintain alignment during
subsequent screw placement. The articular facets should
be positioned in as normal a configuration as possible to
avoid fixation of the vertebral segments in a collapsed to
excessively distracted position. Screws or pins should
then be inserted on either side of the vertebrae and in
vertebral bodies cranial and caudal to the fracture site.
At Washington State University, internal fixation in-
volves a combination of bone screws, Kirschner wires,
Steinmann pins, and polymethylmethacrylate (PMMA)
(Figures 1, 2, 3, and 4). The methods used to insert fix-
ation devices are modifications of previously described
techniques.19–23 Screws and pins can be used to anchor
the PMMA to bone. Similar fixation devices have been
shown to provide adequate protection against excessive
spinal rotation in canine cadaver spine preparations.3,7,8
In dogs, rigid spinal fixation can improve the likelihood
of the fracture healing.24 Whereas stiffer implants may
initially (i.e., 6 to 12 weeks after reduction) result in more
mineral loss, the ultimate bone mineral density equal-
izes 24 weeks after reduction.
The principles of vertebral screw placement have been
reviewed.25 Preventing disruption to as much normal
bone and joint space as possible and increasing the
amount of bone contact with the screws are important
considerations. In dogs and cats, screws can usually be
placed in the vertebral bodies because of the presence of
relatively larger amounts of bone volume. Screw holes
should be drilled from a dorsolateral to ventromedial di-
rection at an approximate 45° to 60° angle to the dorsal
sagittal plane into the vertebral body to increase the
amount of contact with bone. To avoid entering the
spinal canal, the screws should be placed no more dorsal
than are the accessory processes. In the lumbar area, a
screw can safely be placed in a ventral direction at the
level where the transverse process connects with the ver-
tebral body. In the thoracic area, ventral exposure may
be more difficult to achieve without entering the tho-
racic cavity. Thus screw holes are usually drilled into the
Small Animal/Exotics Compendium March 2000

transverse processes in a more nerves. Screw size depends on

dorsal to ventral rather than the amount of bone available
lateral to medial direction. for screw placement.
The bone at the articular and In the cervical area, screws
dorsal spinous processes of the can similarly be placed in the
vertebrae can be used for screw vertebral bodies using a ven-
placement. tral approach rather than dor-
To allow room for drilling, sal or lateral approach (Figure
muscles over the unstable ver- 4). The ventral convex surface
tebral segments should be bi- of the cervical vertebrae can
laterally retracted. However, re- provide an estimate of the po-
traction should be attempted sition of the underlying spinal
cautiously because excessive re- cord. Screw holes should ini-
moval of paraspinal ligament Figure 1A tially begin slightly lateral to
and bone may exacerbate midline and angled more lat-
spinal instability. The necessary erally to avoid iatrogenic pen-
orientation of the screw holes etration of the spinal cord.
often requires veterinarians to Because this angulation can
drill on a slanted part of the damage paraspinal vascular
vertebrae. Thus it may be help- structures (e.g., the vertebral
ful to make a small divot in the artery), brisk bleeding may
bone using a bone curette occur when the drill bit is re-
(House curette) that accom- moved. Bleeding can usually
modates an initial drill pur- be controlled by quickly tap-
chase. Because of the angle of ping and placing the screw
the drill, the bit can be placed into the drill hole. Bone wax
close to and possibly entwine placed at the interface of the
overlying musculature. Figure 1B bone and screw can also min-
To avoid tissue damage, an imize bleeding. For fractures
aluminum suture packet can involving C1-2, the wings of
be used to cover underlying C-1 can be used for screw
musculature during drilling. purchase (Figure 4).
Drilling screw holes with a Fixation using cortical
drill bit does not evidently bone screws and PMMA
decrease pullout strength or may fail more often than us-
cause weaker fixation.25 Tap- ing Steinmann pins and
ping screw holes before in- PMMA.26 According to one
serting the screws, however, study,26 cortical screws bent
may weaken the fixation be- at the screw–bone interface
cause of a substantial amount during experimental manip-
of associated cancellous bone ulations of isolated canine
in vertebrae.25 spinal cadaver preparations.
A screw hole should be Figure 1C We have, however, not en-
drilled through the vertebral Figure 1—(A) Preoperative lateral myelographic view of a dog countered this situation clin-
body to the ventral cortical with a subluxation at L1-2. (B) Postoperative lateral radio- ically when using cortical
level. The drill hole often ex- graphic view of the same area after surgical repair using corti- bone screws and PMMA to
tends ventrally through the cal bone screws and polymethylmethacrylate. (C) Schematic fix in vivo spinal fractures.
ventral cortical surface of the showing the approximate angle for placing a vertebral body Bending is most likely the
screw in the lumbar spinal area.
vertebral body. This cortical result of the associated para-
surface should be penetrated spinal ligament and muscu-
cautiously to avoid damage to underlying structures, lar support in the intact animal, additional apparatus
such as the aorta. Screws should be directed away from incorporated in the fixation, and decreased likelihood
the intervertebral disk area to avoid damage to exiting of intact spinal segments withstanding the excessive

ORIENTATION OF SCREW HOLES ■ SCREW PLACEMENT ■ SCREW–BONE INTERFACE

Compendium March 2000 Small Animal/Exotics

forces used experimentally. Re- be placed perpendicularly through

gardless, pins may be used as al- the dorsal spinous processes and
ternatives to screws for obtaining incorporated into the fixation (Fig-
purchase into the vertebrae. ure 2).
The advantages of using bone
screws over Steinmann pins for Decompression
spinal fixation include ease of Decompression is indicated if
placement and possibly more se- myelography confirms spinal cord
cure anchoring of vertebral bone compression from intervertebral
and PMMA. Increased resistance disk rupture or hematoma. With
to Steinmann pin placement is fractures and luxations, spinal com-
encountered at the vertebral end pression often results from bony in-
plate, which can cause the pins to stability, thus requiring realignment
wobble during placement, possi- and stabilization of the vertebrae.
bly contributing to pin loosening. Additional bone removed from the
Predrilling the pin path with a damaged area during laminectomy
smaller pin can prevent this prob- may increase the degree of instabili-
lem. ty and make internal fixation more
Bone screws can be incorporated difficult. Removal of the articular
with PMMA in either a donut- or facets and diskectomy have substan-
bilateral cigar-shaped configura- tially increased spinal rotation insta-
tion. Bone wax should be placed in- bility in canine cadaver spinal prep-
side the screw heads to prevent arations.3,8
them from being plugged with Figure 2A Of the decompressive proce-
PMMA. This becomes important if dures, hemilaminectomy is prefer-
the screws need to be removed later. able because it causes the least
The area should be lavaged with amount of instability.3,8 If no com-
saline while the PMMA is curing pression other than that occurring
because the heat that is generated from displaced vertebrae is evident,
could damage adjacent tissues. This we recommend realigning the ver-
step is most critical when a tebrae and not performing a lam-
laminectomy has been concurrently inectomy in order to preserve as
performed because of potential heat much bone integrity as possible.
damage to the spinal cord. The Durotomy and myelotomy may
PMMA should be formed to en- also be indicated in severely affect-
compass the metal apparatus with- ed animals to afford further de-
out damaging exiting peripheral compression and to assess the se-
nerves. If it is necessary to form the Figure 2B verity of spinal cord damage.28–30
PMMA close to the laminectomy Figure 2—(A) Postoperative ventrodorsal radio- Myelomalacia can be accurately
defect, the spinal cord can be cov- graphic view of a dog showing a repaired spinal assessed only after durotomy.
ered with an aluminum suture fracture/luxation using cortical bone screws,
packet. After the cement has cured, Kirschner wires, Steinmann pins, and polymethyl- AFTERCARE
the packet can be removed. methacrylate. (B) Schematic showing the place- Pain Control
If additional implant rigidity is ment of vertebral body screws and connecting Because spinal injury and sur-
required, Steinmann pins can be Steinmann pins on either side of a lumbar fracture. gery are associated with consider-
placed dorsally in a longitudinal able postoperative pain, opiate anal-
fashion along the dorsal spinous gesics are commonly administered.
processes (Figure 2). These pins can be bent to approxi- Although some veterinarians may prefer administering
mate the angle of the vertebral column and wired to the NSAIDs either alone or in conjunction with opiate
implanted screws to secure them in place. PMMA analgesics, NSAIDs and corticosteroids administered
should be put on the pins and screws as described pre- concurrently can increase the risk of gastrointestinal ul-
viously. Any wires should be totally encased with PMMA ceration. Fentanyl, a synthetic opioid, is available in a
to increase wire strength.27 Small Kirschner wires can also dermal patch that conveniently manages postoperative

BONE SCREWS ■ STEINMANN PINS ■ SPINAL COMPRESSION

Small Animal/Exotics Compendium March 2000

pain for up to 72 hours. Be- can effectively prevent limb

cause 12 to 24 hours may be edema and muscle atrophy
required to reach adequate and improve general circula-
blood levels of fentanyl, ini- tion to the limbs. Passive
tial pain management can be range-of-motion exercises
supplemented with inject- (e.g., extending and flexing
able agents (e.g., 0.3 mg/kg of each joint in the thoracic
intramuscular morphine ev- and pelvic limbs) can also
ery 4 hours for at least the thwart joint stiffness, edema,
first 12 hours). After shaving and muscle atrophy. It can
a 3-square-inch area, the Figure 3A also be helpful to mimic an
fentanyl patch should be ap- exaggerated walking motion
plied to the dorsal neck or by moving limbs in a circu-
rump area away from the lar fashion. These exercises
surgical site. should be done daily for 10
Because an elevated body to 20 minutes.
temperature may increase
the amount of drug admin- Support Devices
istered through the patch, During recovery, patients
patients should be checked should be encouraged to be-
daily for fevers. If a patient gin walking, preferably on a
develops dermatitis at the textured, nonslip surface such
patch site, the patch should as concrete or soil. Several
be removed and alternative techniques and support de-
pain therapy initiated. Figure 3B vices can be used for patients
Figure 3—(A) Preoperative lateral radiographic view of a dog with paraparesis. For exam-
Recumbency with a fracture of L-6. (B) Postoperative lateral radiographic ple, dogs can be grasped by
Complications view of the same area after surgical repair using cortical bone the base of the tail or sup-
To prevent complications screws, Kirschner wires, Steinmann pins, and polymethyl- ported by placing a towel un-
associated with prolonged re- methacrylate. der the abdomen. Commer-
cumbency, special attention cial support devices are also
should be given to patients following spinal trauma or available in a variety of sizes. These devices can be used
surgery.31,32 Recumbent patients should be turned every 1 on both thoracic and pelvic limbs to provide stability;
to 4 hours to prevent decubital ulcers from developing however, because they can bind the axial and groin areas,
on bony protuberances (e.g., the hips or shoulders).3 Ex- support devices should not be used for extended walking
tra padding of foam rubber or thick fleece and small exercises. For patients that are reluctant to walk or have
soft-sided waterbeds may also help prevent the develop- tetraparesis, a supportive sling, preferably on wheels, may
ment of bed sores. Frequent turning also prevents atelec- be required.
tasis, which can lead to pneumonia. Ideally, these pa- We do not encourage using specially manufactured
tients should remain in a sternal or sternal oblique carts that support the pelvic limbs and rump of animals
position to allow chest expansion. recovering from spinal trauma unless the prognosis for
Because recumbent animals are often unable to avoid return to function is hopeless. If an animal is confined
soiling their bedding, absorbent waterproof pads can be to a cart, it becomes less motivated to exercise the pel-
used to soak up urine and prevent urine or fecal satura- vic limbs. However, after sufficient recovery time has passed
tion of bedding material. Frequent bathing, preferably (at least 1 month), a custom-sized cart may benefit the
during hydrotherapy, may be needed to protect patients quality of life of animals that are unable to regain limb
from urine scald. function.

Physical Therapy Hydrotherapy

Massage and Passive Exercise Although not practical in all hospital settings, hy-
Several simple, effective methods of physical therapy drotherapy can be effective. Swimming provides a buoy-
that do not require expensive equipment can be used for ant environment that allows patients to move their limbs
postsurgical spinal patients.32,34 For example, massages without supporting their full weight. Warm water also

PAIN MANAGEMENT ■ PROLONGED RECUMBENCY ■ POSTSURGICAL EXERCISE

Compendium March 2000 Small Animal/Exotics

promotes adequate circula- urinating. Because retained

tion and muscle relaxation. urine can lead to cystitis,
A nonslip surface (e.g., a cage manual expression may be
mat) should be placed on the necessary every 6 hours if
bottom of the tub or deep the animal cannot urinate
sink. Although wound infec- on its own.
tions rarely occur if clean wa- The color and smell of
ter is used, sterile petrolatum urine should be evaluated at
ointment should be applied each voiding. Urinalysis using
over the surgical incision. The a urine dipstick and sediment
tub or sink should be suffi- evaluation should be done
ciently filled to support the daily to detect any infection
animal while it attempts to Figure 4A and appropriate cultures sub-
stand or swim. An animal mitted if pyuria, bacteriuria,
should never be left unattend- or hematuria is noted.
ed while it is in water. The If expression is difficult,
therapist should keep his or the bladder can be drained
her hands on the animal at all using a sterile urinary cathe-
times to prevent slipping or at- ter. Indwelling urinary cath-
tempts to jump out. eters are not recommended
Various flotation devices, because they increase the risk
ranging from simple inflat- of bladder infection.35 De-
able children’s toys available at pending on the nature of the
department stores to specially neurologic lesion and the
adapted canine life vests sold cause of abnormal bladder
at water ski or dive equip- function, several pharmaco-
ment stores, can help support Figure 4B logic agents that assist in blad-
animals in the water.32 Popu- der management are avail-
lar swim toys available from Figure 4—(A) Pre- and (B) postoperative lateral radiographs able. Phenoxybenzamine can
pool accessory outlets include of a dog with a C-2 fracture. The fracture has been stabilized reduce the tone of the inter-
using cortical bone screws, Steinmann pins, and polymethyl-
long, foam rubber tubes. nal urethral sphincter, where-
methacrylate.
These can be used to support as diazepam or dantrolene
the abdomen of swimming can increase the tone. Detru-
dogs and can be assembled into raftlike devices that sup- sor contractility can be enhanced with administration of
port heavy or tetraparetic animals. bethanechol. The actions of these agents, however, are
highly specific; and veterinarians should pay strict atten-
Bladder Management tion to labeled contraindications.
An animal’s ability to urinate after spinal trauma is Animals unable to voluntarily urinate often require
an important factor in determining the prognosis for continued hospitalization, although some owners are
recovery and quality of life. Because an incontinent dog comfortable with at-home bladder management while
sometimes presents overwhelming nursing care de- their pets are recovering from spinal surgery. Commu-
mands for owners, inability to control bladder function nication between veterinarians and clients on the post-
may affect an animal’s quality of life more than does operative care of animals with spinal trauma is critical
the return of limb function. Thus assessing an animal’s to a successful outcome.
bladder function both before and after spinal surgery is
crucial. The presence or absence of urine on the ani- Follow-Up
mal’s bedding or in the cage, voluntary or involuntary Appropriate wound management should be followed
urination, and the ease or difficulty with which the until the skin at the surgical site has healed. When clin-
bladder can be expressed are important determinants. ical improvement in limb function is noted, an exercise
The bladder should be gently palpated regularly (i.e., at scheme can be initiated. Radiographs should be taken
least every 6 hours and more frequently for animals at least 6 weeks after surgery to assess alignment, surgi-
with polyuria) to determine urine volume and establish cal implants, and fracture healing. Postoperative infec-
whether the animal is fully emptying its bladder when tion of implants can result in systemic illness or the de-

FLOTATION DEVICES ■ INCONTINENCE ■ MANUAL EXPRESSION

 Small Animal/Exotics Compendium March 2000

The Rapid
I I
velopment of draining tracts at or near the surgical site.
If localized infection develops, appropriate antibiotics
Publication should be administered until fracture healing is com-
plete.

Veterinary Research In humans, deep wound infections of the spine have

been treated with local debridement, intravenous and
oral antibiotics, and insertion of an antibiotic-contain-
Quarterly ing irrigation–suction system without removing the sur-
gical implants.36 If aggressive local and systemic treat-
Inaugura
l Issue
ment fail to resolve the infection, the fixation apparatus
2000

F: MS,
Volum
e 1, Nu
mber
1• Winter
can be removed after the fracture has healed and defini-
-IN-CHIE , DVM,

tive cultures of the surgical area have been taken. If

ary
EDITOR M. Dowling
Patrici
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M, DA
DACVI

Veterin utics
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BOARD
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EDITORI erson, DVM,

screws have been implanted, the PMMA cement can be

And
Mark ,
DACVS M, PhD
tges, DV
W. Bar
Joseph M, DA
CVN
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DACVI DVM, PhD
Bauer,

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John rn, PhD
Blagbu MS, PhD

Therap
Byron

removed from the screw heads by using a high-speed air

, BS, M,
Blecha , DV
Frank Boothe
Merton CVIM,
Dawn , DA
MS, PhD
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erinary drill with a burr and then the screws removed using a
PhD M, DA
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Dennis ism an, DV
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DeB DC
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be cleared with ease. Similarly, if pins have been used
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man, DVM,
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for fixation, pliers or a similar tool can be used to re-

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Frie M, MS ngi p,
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43
cleared from the pinheads. If healing occurs normally
PhD, S, PhD ica cy

and the apparatus does not become infected, it may re-

Eff eiler and tibodies ations
BVM
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About the Authors

a L. Voi
Victori DACPV the Editors
DA CVB
P. Wa
ges, DV
M,
, DVM,
MS, From
Dennis ldridge ent
M. Wa
Bryan Statem
DABVP ite, DV
M, Mission
D. Wh
Stephen
DACVD

Drs. Bagley, Harrington, Silver, Cambridge, and Moore and

Ms. Connors are associated with the Department of Clinical
Presenting applied medical Sciences, College of Veterinary Medicine, Washington
State University, Pullman, Washington. Drs. Bagley (Neu-
information across all species rology and Internal Medicine), Harrington (Neurology), and
and practice specialty lines Moore are Diplomates of the American College of Veteri-
nary Internal Medicine. Dr. Silver is a neurology and neuro-
■ Canine to food animal to exotics surgery resident. Dr. Cambridge is a resident in surgery.
Ms. Connors is the neurology veterinary technician.
■ Dermatology to internal medicine
to behavior

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Price is in US dollars and is subject to change.

POSTOPERATIVE INFECTION
Compendium March 2000
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