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Thoracic and Upper Lumbar Spine Injuries
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Mark A. Prevost, M.D. Robert A. McGuire, M.D. Steven R. Garn, M.D. Frank J. Eismont, M.D.
The primary goals in providing care for patients who have sustained thoracolumbar spinal trauma must include preservation of life and protection of neurologic function, in addition to restoration and maintenance of alignment and stability of the spine. Upholding these goals while managing thoracolumbar fractures is both challenging and controversial to the spinal surgeon. Many times the bottom line is whether the spine can function as a load-bearing column. If it can, is an orthosis necessary? If not, can stability and alignment be restored with surgical intervention? Each of these objectives is best accomplished when the treating physician understands the anatomy of the spinal column, appreciates the biomechanics of the injury and instability, and has an awareness of the expanding treatment options available for the care of a spine-injured patient.104, 105
paralysis of the lower extremities and urinary incontinence. He also expanded on Hippocrates concept of manual extension for reduction of spinal deformities.35 In the 16th century, Ambroise Pare readdressed the problem of spinal injury.25, 118 He accurately described the symptoms of cord compression as follows: Amongst the symptoms are the stupidity, or numbness or palsy of the arms, legs, fundament and bladder, which take away their sense and motion, so that their urine and excrements come from them against their wills and knowledge, or else are wholly suppressed. Which when they happen saith Hippocrates, you may foretell that death is at hand, by reason that the spinal marrow is hurt. . . . Having made such a prognostication, you may make an incision so to take forth the splinters of the broken vertebrae, which driven in press the spinal marrow in the nerves thereof. Modern management of vertebral column trauma arrived with the development of anesthesia and radiography. In the 1920s, based heavily on principles advocated by Guttman, emphasis in the treatment of vertebral trauma was placed on closed reduction of fractures.117 Davis proposed a method of reduction in which the patient was anesthetized and placed in the prone position. An overhead pulley suspension raised the lower limbs and produced marked hyperextension. The physician then made a manual thrust over the fractured vertebra in an attempt to realign the fracture. When reduction was achieved, the patient was immobilized in a plaster jacket. In 1931, Watson-Jones modied this technique by using tables of different height to hyperextend the spine and obtain reduction.269 Internal xation of thoracic and lumbar spinal fractures began after the Second World War with the development of spinous process plating for unstable fractures.133, 135
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HISTORICAL BACKGROUND
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz For physicians taking care of patients with spinal injuries, it is helpful to gain perspective regarding diagnosis and treatment of these injuries as they have evolved through time. The earliest written record of spinal cord injury is found in the Edwin Smith Papyrus (3000 BC).35 Later, Egyptian physicians noted that patients with vertebral trauma often had paralysis of the arms and legs and urinary incontinence, thus suggesting an association among vertebral injuries, spinal cord damage, and loss of function. Celsus made the next important contribution to the description of spinal cord trauma when he distinguished cervical from thoracolumbar spinal cord injuries. He reported that fractures of the cervical spine produced respiratory embarrassment and vomiting whereas trauma to the lower portion of the spinal column produced
Copyright 2003 Elsevier Science (USA). All rights reserved.
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Later, Harrington revolutionized spinal care and rehabilitation with the introduction of his posterior spinal instrumentation devices.66 Since then, surgical techniques and instruments have proliferated and have continued to improve the ability to anatomically reduce and internally stabilize the injured spinal column.* Neurologic recovery, however, has remained unchanged or only slightly improved over the results obtained with postural reduction and nonoperative care.18, 32, 49, 66, 95, 139, 151, 192 At this time, the major predictable benets of internal xation of spinal fractures are decreased hospital stay, early rehabilitation, and prevention of deformity.49 However, root function and, in properly selected patients, spinal cord function can be dramatically altered and improved with appropriate surgery and stabilization.
ANATOMY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The thoracolumbar spine is characterized by a dynamic and complex interaction between the bony vertebral elements, discs, and interconnecting ligaments. It would be impossible to make sound diagnostic and therapeutic decisions regarding thoracolumbar trauma without a solid understanding of this anatomy. The human spine has 12 thoracic and 5 lumbar vertebrae with interspaced intervertebral discs. Stagnara and associates studied spinal alignment in healthy persons aged 20 to 29 years without back complaints.259 Wide variation was noted in this healthy population, the range of thoracic kyphosis being 7 to 63, with 91% between 18 and 51 (Fig. 301A). In the thoracic spine, this conguration is maintained by the wedge-shaped vertebral bodies and discs, which are larger posteriorly than anteriorly. Across the thoracolumbar junction (T10L2), where most injuries occur, the normal range is reported to be 0 to 10 kyphosis. In the lumbar spine, the average lordosis in this same group of normal people was 50, with a range of 32 to 84; 92% of these individuals had between 42 and 74 of lordosis259 (see Fig. 321B). In the lumbar spine, the discs have an increased height anteriorly, which helps create this lordosis. White and Panjabi investigated the types of motion present throughout the spine273 (Fig. 302). The thoracic spine has signicantly less exion-extension motion than the cervical or lumbar spines. In the cervical spine from the occiput to C7, the average motion between exion and extension is 13 per level, with a range of 8 to 17. At C7T1 this motion decreases to 9, and in the thoracic spine from T1 to T6, each level has only 4 of total exion-extension motion. From the T6T7 to the T12L1 levels, exion-extension motion gradually increases from 5 to 12, in contrast to the average 15 exion-extension motion at each lumbar level (range of 12 to 20). The thoracic spine is less capable of bending laterally than the cervical spine. Lateral bending in the cervical spine from occiput to C7 averages 8 per level, whereas it
*See references 8, 22, 23, 27, 51, 63, 64, 76, 80, 87, 93, 107, 131, 140, 149, 160, 181183, 185, 186, 197, 207, 212, 243245, 262, 264, 276, 284.
is only about 6 per level from T1 to T10. At the area of the T10L1 thoracolumbar junction, lateral bending increases to an average of 8 per level. In the lumbar spine, this motion decreases to about 6 per level. Much of the thoracic-level rigidity is related to the presence of the rib cage and the costovertebral articulations.216 Axial rotation in the thoracic spine averages 8 from T1 to T8 but decreases to approximately 2 per level below T10. Axial rotation is greater in the thoracic spine than in the lumbar spine because the facets are aligned in the coronal plane, as opposed to the more sagittal alignment that occurs in the lumbar spine (Fig. 303). The transition region for facet orientation is the area from T10 to T12. Because of this alteration in facet orientation, the motion characteristics of the lower thoracic spine more closely resemble those of the lumbar spine. In the lumbar spine, the facet joints gradually attain an almost true sagittal orientation at the L4L5 level. Such alignment provides signicant restriction to rotation and side bending. The thoracolumbar junction is more susceptible to injury than are other adjacent portions of the spine. Approximately 50% of all vertebral body fractures and 40% of all spinal cord injuries occur from T11 to L2. This greater susceptibility to injury can be explained by the decrease in rib restraint, changes in stiffness for exionextension and rotation, and changes in disc size and shape, which occur relatively acutely in the transitional area between the upper thoracic and the midlumbar spine. The conus medullaris usually begins at T11 and, in most males, ends at the L1L2 disc space. The conus in females frequently stops slightly more proximally. The conus medullaris can occasionally extend much lower into the lumbar spine and is often associated with a hypertrophic lum terminale. The neural elements of the lumbar spine below the L1L2 disc are usually purely spinal nerve rootlets (cauda equina). In addition, an extensive collateral circulation is located distal to the nerve roots and proximal to the spinal cord, thus making this region less prone to vascular compromise and more likely to recover from a spinal cord injury.218 The thoracic spinal cord has relatively poor vascularity and limited collateral circulation when compared with the cervical spinal cord and the conus medullaris. Adamkiewicz in 1882 described the blood supply of the spinal cord, including a relatively constant medullary artery known as the great medullary artery or the artery of Adamkiewicz. This artery may be injured as a result of trauma or thoracic disc herniation or from one of the lateral or posterolateral extracavitary approaches. Injury to this artery may cause serious ischemic insult to the cord and lead to paralysis. In most people, the artery of Adamkiewicz originates from the intercostal artery on the left side between T10 and T12, where it joins the nerve root sleeve and becomes intradural. The artery then crosses one to three disc spaces, at which point it anastomoses with the anterior spinal artery. Knowledge of this artery and its course is important during certain approaches and may explain certain neurologic decits that may not recover despite adequate anterior decompression.184 The spinal canal in the midthoracic region is considerably narrower than in the cervical or lumbar region.86, 237 At the T6 level, the spinal canal has a circular congura-
CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries
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FIGURE 301. A, Distribution of thoracic kyphosis in 100 French people, 43 women and 57 men. B, Distribution of lumbar lordosis in the same group of 100 French people. (A, B, Data from Stagnara, P.; et al. Spine 7:335342, 1982.)
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tion with a 16-mm diameter. In the middle to lower cervical spine, the canal is 23 14 mm, and in the lumbosacral region, it is 26 17 mm.183 The small size of the thoracic spinal canal must be appreciated for two reasons. First, because less space is available, even minor spinal column displacement may produce signicant spinal cord compression. Second, when considering reconstruction of the spine, many systems use sublaminar xation within this already narrowed region of the spinal canal. Therefore, the patients specic injuries, the availability of xation devices, and spinal anatomy must be
taken into account when selecting instrument shape and size. As Dommisse and others have shown, in the thoracic spine the free space between the spinal cord and the borders of the spinal canal is relatively minimal.69 Although the thoracic cord tends to be smaller than the cervical and lumbar enlargements, the free space also narrows. In addition and of signicance with regard to spinal trauma, the blood supply in the middle and lower thoracic spine is less abundant than elsewhere in the spinal cord. Adding to the variability is the location of the conus
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FLEXIONEXTENSION OcC1 CERVICAL C23 C45 C67 C7T1 T12 T34 THORACIC Print Graphic T56 T78 T910 T1112 T12L1 L12 LUMBAR L34 L5S1 0 5 10 15 20
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FIGURE 302. The motion present at each level of the spine. (Data from multiple reviews and from the experimental work of White, A.; Panjabi, M. Spine 3:1220, 1978.)
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FIGURE 303. Rotation in the midthoracic spine and at the thoracolumbar junction. A, The rotation at T5T6 is represented by the arrow between the spinous processes. The inset shows how the lamina of T5 glides over the posterior elements of T6 with no resistance to rotation. B, After facetectomy, the motion present between T5 and T6 (arrow) is unchanged from A. C, The rotation present between T12 and L1 is represented by the arrow between the spinous processes. Because of the sagittal orientation of the facets (inset), rotation is markedly restricted. D, After bilateral facetectomy, motion between T12 and L1 (arrow) is markedly increased. The restriction from the sagittally oriented facets has been eliminated.
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T12-L1
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medullaris, with terminations in the general population following almost a bell-shaped curve from the T12 to the L3 level.69 The cord is usually wider in the lateral plane than in the anterior-to-posterior direction. Elliott demonstrated that the largest diameter of the cervical enlargement, which is at approximately C5C6, was 13.2 mm in the lateral plane and 7.7 mm from anterior to posterior. In the thoracic region, the smallest measurements were 8 mm laterally and 6.5 mm from anterior to posterior, and the lumbosacral enlargement was 9.6 and 8.0 mm, respectively.86 These dimensions can be correlated with the space available within the spinal canal. Aebi and Thalgott demonstrated that the largest area (i.e., the space available in the cervical canal) was 24.5 mm laterally and 14.7 mm from anterior to posterior in the thoracic region, thus correlating with the small size of the spinal cord at this location.4 The largest space available was 17.2 mm in the lateral plane and 16.8 mm anterior to posterior. At the level of the lumbar enlargement, it was 23.4 mm laterally and 17.4 mm from anterior to posterior. In general, the cord occupies approximately half the space available in each direction. In the thoracic spine, according to Dommisse, the anterior-toposterior diameter of the spinal canal changes minimally; it averages approximately 13 mm throughout but increases to 15 mm in the lower thoracic spine.69 His measurements of interpedicular distance (lateral measurement) averaged about 15 mm at the smallest point (approximately T6) and increased to 17 mm at T10T11. The morphometry of the pedicles of the thoracic and lumbar spines varies considerably from level to level, as well as from patient to patient.24, 166, 246, 267, 285 Zindrick and colleagues,286 in an evaluation of 2900 pedicles, determined pedicle isthmus widths and pedicle angles in the sagittal and transverse planes. In general, pedicle isthmus widths were signicantly smaller in the thoracic spine than in the lumbar spine (Fig. 304A and B). The pedicle angles in the transverse plane varied from 27 medial inclination (in a posterior-to-anterior direction) in the proximal thoracic spine to approximately 1 at T11 and 4 at T12. At L1, the angle again inclines medially at 11 and gradually increases to approximately 30 at L5 (see Fig. 324C). In an anatomic study investigating the internal architecture of thoracic pedicles, Kothe and associates showed that the medial wall is two to three times thicker than the lateral wall. This difference in thickness could explain the fact that most pedicle fractures related to pedicle screw insertion occur laterally.162 An understanding of these dimensions and angles is important when considering the use of pedicle screw xation systems to stabilize thoracic and thoracolumbar spinal injuries. The exion axis of the normal thoracic spine and the thoracolumbar junction occurs at the middle to posterior third junction of the vertebral body.235, 275 This location of the axis results in an anterior compressive force moment arm that is approximately one fourth the length of the posterior tensile force.257 Brown and colleagues in 1957 demonstrated that posterior elements fail under tension at approximately 400 lb.37 This amount of posterior force corresponds to a resultant anterior compressive force of approximately 1200 to 1600 lb. Comprehension of this biomechanical principle is essential to gain an
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FIGURE 304. Analysis of the morphometric characteristics of the thoracic and lumbar pedicles. A, The transverse width of the pedicle at each level of the thoracic and lumbar spine is shown. The average pedicle width of the lumbar spine ranges from 9 to 18 mm. In the thoracic spine, all pedicles are smaller than 9 mm. B, The longitudinal pedicle width of each level in the thoracic and lumbar spine is represented. It peaks at 17 mm at the T11 vertebra and decreases to 10 mm at T1 and to 14 mm at L5. C, The transverse angle of the pedicles for each level of the thoracic and lumbar spine is shown. The angle is 4 at the T12 vertebra and increases to 30 at L5 and to 27 at T1. (AC, Redrawn from Zindrick, M.R.; et al. Spine 12:160166, 1987.)
understanding of spinal stability (described later). In the thoracic spine, the human bodys center of gravity is anterior to the spine. As a result, the resting condition in the thoracic spine and at the thoracolumbar junction is one
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of vertebral body compression and posterior ligamentous complex tension. In the thoracic spine, the ribs anterior to the spinal column and the thick ligaments posteriorly, acting in tension, restrict any further forward exion in the normal situation.234 In the lumbar spine, particularly in the more lordotic lower lumbar spine, the center of gravity is located more posteriorly, and the posterior elements provide approximately 30% of the weight-bearing support. These considerations are important for realignment or for maintenance of alignment after spinal injury.216, 252, 273 One of the important components of thoracolumbar spinal anatomy is the soft tissue that interconnects the bony elements. The complex interaction of ligaments, disc, and musculature allows for both controlled motion and stability of the spine. Trauma to the soft tissues of the thoracolumbar spine can have profound effects on function and stability. The anterior longitudinal ligament is a strong, broadbased ligament that runs on the anterior aspect of the vertebral body from the atlas to the sacrum. It is rmly attached to both the ventral aspect of the disc and the periosteum of the vertebral body. It is a major contributor to spinal stability and limits hyperextension of the vertebral column. The posterior longitudinal ligament also runs the length of the spinal column, but it is narrower and weaker than its anterior counterpart. Its primary function is to limit hyperexion. The intervertebral disc is composed of the anulus brosus and the nucleus pulposus. The anulus is formed by concentric bands of brocartilage that run obliquely from one vertebral body to another. This arrangement allows for some motion, yet is one of the strongest connections between vertebral segments. The nucleus, which is encased in the anulus, acts as a shock absorber for axial forces. Of importance in thoracolumbar trauma is that the disc is essentially an avascular structure that relies on passive diffusion through the end-plates and peripheral aspect of the anulus for nutrition. When this structure is disrupted, the potential for healing is limited. Posteriorly, the lamina are joined by the ligamentum avum, a broad band of elastic ber. The spinous processes are joined by a weak interspinous ligament and a strong supraspinous ligament. The intrinsic muscles of the back include the erector spinae group of muscles (spinalis, longissimus, iliocostalis) and the transversospinalis group (rotatores, multidus, semispinalis). The intrinsic muscles maintain posture and provide movement of the vertebral column. Any deformity resulting from trauma can alter the function of these muscles. In addition, it is important to have an understanding of these muscle groups when considering the various anatomic approaches to the spine described later in this chapter.
compression, exion-rotation, shear, exion-distraction, and extension. Each is discussed from a mechanical viewpoint, and their effect on the bone-disc-ligament complex of the spine is described.
Axial Compression
Because of the normal thoracic kyphosis, axial loading in this area usually results in an anterior exion load on the vertebral body. The resultant spine injuries are discussed under Flexion. An axial load in the straight thoracolumbar region (Fig. 305) often results in pure compressive loading of the vertebral body.156 As described by Roaf, this mechanism
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MECHANISMS OF INJURY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Frequently, many complex forces occur at the time of injury, each of which has the potential to produce structural damage to the spine.119 Most often, however, one or two forces account for most of the bone or ligamentous injuries encountered. The forces most commonly associated with thoracic, thoracolumbar, and lumbar spine injuries are axial compression, exion, lateral
FIGURE 305. Axial compression across the straight thoracolumbar region results in pure compressive loading of the vertebral body and most often causes a thoracolumbar burst fracture.
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FIGURE 306. A 21-year-old man involved in a motor vehicle accident sustained a burst fracture of L1 and L3. The patient had an incomplete spinal cord injury. A, A preoperative lateral view shows loss of height predominately at L1. B, A sagittal-cut magnetic resonance image shows compression at both L1 and L3. C, An axial-cut computed tomographic (CT) scan at L3 shows a retropulsed fragment lling half the canal. D, An axial CT scan at L1 shows a fracture of the lamina and retropulsion of a fragment into canal. E, This injury was stabilized with ISOLA instrumentation combining both pedicle screws and laminar hooks. Sagittal alignment was maintained. Note the use of a lamina hook at L4 to protect the pedicle screw at that level. F, Postoperative anteroposterior radiograph showing a cross-connection added for additional stability.
produces end-plate failure, followed by vertebral body compression.235 With sufcient force, vertical fractures develop through the vertebral body and produce a burst fracture21, 62, 157, 209 (Fig. 306). Frederickson and coworkers observed that this fracture then propagates through the midportion of the posterior cortex of the vertebral body through the vascular foramina.99 With further loading, centripetal displacement of the bone occurs, frequently with disc fragmentation and posterior disruption. This centripetal force can produce fractures at the pedicle-body junction and result in widening of the interpedicular distance and, particularly if a exion component is present, a greenstick fracture of the lamina (see Fig. 306). With severe compression, signicant disruption of the posterior element may occur. Heggeness and Doherty studied the trabecular anatomy of the thoracolumbar vertebrae and documented a trabecular framework that originates from the medial corner of the base of the pedicle and extends in a radial fashion throughout the vertebral body, with thinning of the vertebral cortex near the base of the pedicle at the site of
origin of this trabecular array. Such anatomy may produce a site of stress concentration and may explain the trapezoidal shape of the bony fragments that are frequently retropulsed into the spinal canal in burst-type fractures caused by an axial load130 (Fig. 307).
Flexion
Flexion forces (Fig. 308) cause compression anteriorly along the vertebral bodies and discs, with tensile forces developed posteriorly. The posterior ligaments may not tear, particularly with rapid loading rates, but posterior avulsion fractures may develop.235 Anteriorly, as the bone fractures and angulation increase, the force is dissipated. With intact posterior ligaments, a stable fracture pattern most often results. Frequently, the middle column remains intact with no subluxation or retropulsion of bone or disc fragments (Fig. 309). However, with disrupted posterior ligaments and facet capsules, instability may occur.58, 133, 150, 195, 196, 211 If the anterior wedging exceeds 40% to 50%, posterior ligamentous and facet joint failure
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can be assumed, and late instability with progressive deformity may occur.271 Flexion-compression injuries with concomitant middle element failure have a higher potential for causing mechanical instability, progressive deformity, and neurologic decit.146
Flexion-Rotation
A exion-rotation injury pattern includes a combination of exion and rotation forces (Fig. 3012). As described previously for pure exion, the predominant injury pattern may be anterior bone disruption. However, as rotational forces increase, the ligaments127, 128, 215 and facet capsules tend to fail, with subsequent disruption of both the anterior and posterior columns. A highly unstable injury pattern frequently develops, with the posterior ligaments and joint capsules ruptured and the anterior disc and vertebral body disrupted obliquely. This mechanism can result in the classic slice fracture originally described by Holdsworth.133 In contrast to the cervical spine, pure dislocations are uncommon in the thoracic or lumbar spine174 because of the size and orientation of the facets, which require
Lateral Compression
Lateral compression forces produce an injury similar to the anterior wedge compression injuries previously described, except that the force is applied laterally (Fig. 3010). Lesions may be limited to vertebral body fractures, or associated posterior ligamentous injury may occur92, 93 (Fig. 3011). The former are usually stable injuries, whereas the latter may be chronically unstable and lead to progressive pain and deformity.
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FIGURE 307. A, Line drawing of a coronal and sagittal section from a vertebral body illustrating the trabecular array. B, Computed tomographic image of a burst injury with a typical trapezoidal-shaped fragment taking origin from the point in the posterior cortex where it thins abruptly. Also note that the trapezoidal shape of the fragment roughly parallels the direction of the trabecular arrays. (Line drawing from Heggeness, M.H.; Doherty, B.J. J Anat 191:309312, 1997.)
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axis of exion is moved anteriorly (usually toward the anterior abdominal wall), and the entire vertebral column is subjected to large tensile forces. The bony vertebral elements, discs, and ligaments are torn or avulsed, not crushed as typically occurs in most spinal injuries. These forces can produce a pure osseous lesion, a mixed osteoligamentous lesion, or a pure soft tissue (ligamentous or disc) injury.118 The pure osseous lesion, described by Chance, involves a horizontal fracture beginning in the spinous process, progressing through the lamina, transverse processes, and pedicles, and extending into the vertebral body (Fig. 3015). This pure osseous lesion usually occurs in the region of L1L3, and even though it is acutely unstable, it has excellent potential for healing with good long-term stability if alignment can be obtained. Combined osteoligamentous or pure soft tissue injuries most commonly occur from T12 to L2 and should be considered unstable with low spontaneous healing potential (Figs. 3016 and 3017). Flexion-distraction can cause a bilateral facet dislocation in the thoracic or thoracolumbar spine173 (see Fig. 3017). The ligaments, capsules, and disc are disrupted, but the anterior longitudinal ligament usually remains intact; however, it is sometimes stripped off the anterior aspect of the caudal vertebra. If the axis of exion is far enough anterior and the energy is sufcient, rupture of the anterior longitudinal ligament may occur and result in a severely unstable injury.150, 256 Generally, this injury is a pure distraction rather than a exion-distraction injury. If the axis of rotation is at the anterior border of the vertebral bodies, compression may occur. The locus of the axis of rotation changes the nature of the injury.
Shear
A pure shear force (Fig. 3018) was found by Roaf to produce severe ligamentous disruption, similar to the combination of exion and rotation described previously.235 This force can result in anterior, posterior, or lateral spondylolisthesis of the superior vertebral segments on those inferior. Traumatic anterior spondylolisthesis is most common and usually results in a complete spinal cord injury. Occasionally, concomitant fractures through the pars interarticularis may occur and result in an autolaminectomy with neural sparing.128 Shear is frequently combined with other mechanisms to cause complex injuries.
FIGURE 308. Flexion forces are causing anterior compression of the vertebral bodies and discs and tension in the posterior elements. This mechanism of injury usually results in a stable compression fracture of the vertebral body anteriorly, but as the force continues, posterior ligamentous disruption may occur.
distraction in addition to exion and rotation for dislocation to occur. With only a exion-rotation mechanism of injury, fracture of the facets or other posterior elements will occur more commonly and allow the spine to dislocate139, 177, 261 (Fig. 3013).
Extension
Extension forces (Fig. 3019) are created when the head or upper part of the trunk is thrust posteriorly; these forces produce an injury pattern that is the reverse of that seen with pure exion. Tension is applied anteriorly to the strong anterior longitudinal ligaments and the anterior portion of the anulus brosus, whereas compression forces are transmitted to the posterior elements (Fig. 3020). This mechanism may result in facet, lamina, and spinous process fractures.96 Avulsion fractures of the anteroinferior portion of the vertebral bodies may occur, but they are not
Flexion-Distraction
Flexion-distraction lesions were rst demonstrated radiographically by Chance in 1948,44 but the mechanism of this so-called seat belt injury was not fully elucidated until later.136, 150, 229, 239 In this injury pattern (Fig. 3014), the
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pathognomonic of extension injuries, as previously thought. Most of these injuries are stable unless signicant retrolisthesis of the upper vertebral body on the lower vertebral body has occurred or they are combined with shear forces.38, 273 Denis and Burkus reported on a hyperextension injury pattern that they termed a lumberjack fracture-dislocation.60 The mechanism of this injury is a falling mass, often timber, striking the midportion of the patients back. The injury involves complete disruption of the anterior ligaments and is an extremely unstable injury pattern.
SPINAL STABILITY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The concept of thoracic, thoracolumbar, and lumbar stability after trauma continues to evolve.161 Work by Nicoll211 and Holdsworth133 suggested that the posterior ligamentous complex was the major determinant of spinal stability. They considered fracture-dislocations and severe shear injuries with complete disruption of the posterior ligamentous complex to be highly unstable injuries and most other injuries to be stable. Roaf biomechanically conrmed that gross instability was produced by exionrotation forces and shear stress.235 Bedbrook disagreed with the importance given to the posterior ligamentous complex and believed that the anterior disc and vertebral body were the prime determinants of stability.18 He cited the lack of instability after laminectomy as an example of the relative importance of the anterior spinal elements, as opposed to the posterior structures, in providing stability. These two concepts gradually merged into a twocolumn concept of spinal stability: an anterior weightbearing column of vertebral bodies and discs and a posterior column of neural arches and ligaments resisting tension.153 It was believed that destruction of either of
these columns was enough to produce instability. This model helped explain the chronic instability often seen after spinal injuries, especially those that result in a kyphotic deformity. However, it was unable to fully explain all cases of acute instability. Experiments had shown that complete section of the posterior elements alone does not result in acute instability with exion, extension, rotation, or shear.216, 225, 230, 236 It was necessary to also section the posterior portion of the anterior column to produce acute instability, at least in exion. Further progress was made when Denis proposed his three-column model of the spine (Fig. 3021) to better reconcile these clinical and biomechanical observations.58 In his classication system, the posterior column is composed of the posterior bony arch (including the spinous process, the lamina, the facets, and the pedicles) and the interconnecting posterior ligamentous structures (including the supraspinous ligament, interspinous ligament, ligamentum avum, and facet joint capsules). The middle column is composed of the posterior aspects of the vertebral body, the posterior portion of the anulus brosus, and the posterior longitudinal ligament. The anterior column includes the anterior longitudinal ligament, the anterior portion of the anulus brosus, and the anterior vertebral body. Though useful in helping dene vertebral column instability, this basic anatomic description of the support columns of the spine does not include the spinal cord and spinal nerves. The neural elements, although they do not directly contribute to spinal stability, cannot be forgotten or ignored in stability considerations.138, 139 Denis reviewed his fracture classication system and proposed four categories based on the presence and type of instability.58 These categories were stable injuries, mechanical instability, neurologic instability, and mechanical and neurologic instability. Stable injuries include minimal and moderate compression fractures with an intact posterior column, which prevents abnormal forward exion. By denition, the
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FIGURE 309. Radiographs and computed tomographic (CT) scans of a compression fracture in a 48-year-old woman involved in a motor vehicle accident. A, An anteroposterior radiograph of the thoracolumbar junction shows a slight irregularity of the superior end-plate of the body of L1 with minimal interspinous widening between T12 and L1. B, A lateral radiograph shows loss of height anteriorly and preservation posteriorly at L1. C, A CT scan through the body of L1 shows disruption of the cortex anteriorly (black dots) with an intact posterior cortex.
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FIGURE 3010. Lateral compression forces may produce stable lateral wedge compression injuries. They are most often not associated with posterior ligamentous injury.
middle column is intact; it prevents any extrusion of bone or disc into the spinal canal and protects against signicant subluxation. A compression fracture without posterior column involvement is an example of a stable injury.154 Mechanical instability includes injuries in which two of the three columns are injured, thereby allowing abnormal motion. An example is a severe compression fracture with disruption of the anterior and posterior columns, which allows abnormal exion across an intact middle column. This instability is often associated with pain, but not necessarily with a neurologic decit. It is important to
closely evaluate the status of the posterior elements when evaluating this type of injury. The position of these elements in relation to each other in the horizontal and vertical planes can give clues regarding exion and rotatory deformity and possible instability. A second example is a exion-distraction injury with disruption of the posterior and middle columns; this mechanism causes abnormal exion with a fulcrum at the intact anterior column, which functions as a hinge. Chronic instability and pain may result, but again, the injury does not necessarily jeopardize neurologic function. Panjabi and colleagues performed a biomechanical study on a highspeed trauma model and measured multidirectional exibility. The results of this study supported the three-column theory of Denis and also showed that the middle column appears to be the primary determinant of mechanical stability in the thoracolumbar spine.217 Neurologic instability refers specically to a burst fracture. Denis believed that most of these lesions heal and that they often become mechanically stable. However, he found that a neurologic decit developed in 20% of his patients with a burst fracture after mobilization as a result of middle column failure and protrusion of bone into the spinal canal. Neurologic compromise is a strong indication for surgical stabilization and decompression. The decompression may be accomplished either directly or indirectly by reduction of deformity and rigid internal immobilization of the segment. It is generally assumed that injuries severe enough to cause neurologic decits are unstable. Ones index of suspicion should remain high when evaluating these patients. The typical example of mechanical and neurologic instability is a fracture-dislocation with disruption of all three columns and either a neurologic decit or impending neurologic deterioration with the neural elements either being compressed or threatened.58 As with the use of any classication system, treatment failure may result from rigid adherence to denitions without individualizing treatment for each patient.70 To keep the use of these denitions in proper perspective, White and Panjabi dened generic clinical instability as the loss of the ability of the spine under physiologic conditions to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve root and, in addition, there is no development of incapacitating deformity or pain from structural changes.273 White and Panjabi273 dened physiologic loads as loads incurred during normal activity, incapacitating deformity as gross deformity unacceptable to the patient, and incapacitating pain as discomfort uncontrolled by non-narcotic analgesics. This denition addresses both the acute and the late stages of vertebral column trauma. It also draws attention to the neural elements as a major structure of the spinal column and requires the physician to consider these structures, in addition to bones, ligaments, discs, and other soft tissues, as determinants of stability.232 Though less specic than Denis classication, it requires a basic understanding of spinal anatomy, the mechanism of injury, and modes of failure when undertaking treatment. The preceding discussion should be supplemented with a reminder that instability does not always require surgical
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treatment. In some cases, prolonged bedrest may be able to achieve the same long-term degree of spinal stability as surgery, and it may be appropriate for the particular circumstances of an individual patient.
Denis Classication of Spinal Injuries

Many classication systems have been designed to describe thoracic and thoracolumbar injuries. They may be based on the mechanism of injury, radiologic/descriptive characteristics, or stability. Denis three-column concept is frequently used because it includes each of the injury patterns most commonly seen and relates them to a specic mechanism of injury.58 Denis developed his classication system after a review of 412 patients with thoracic and lumbar spinal injuries. He divided them into minor and major injuries. Minor injuries included isolated articular process fractures (0.7%), transverse process fractures (13.6%), spinous process fractures (1.7%), and pars interarticularis fractures (1.0%). The four major injury types were compression fractures (47.8%), burst fractures (14.3%), exiondistraction (seat belt) injuries (4.6%), and fracturedislocations (16.3%). Each of these major injuries was further subdivided, depending on the specic radiographic ndings. COMPRESSION FRACTURES By denition, compression fracture injuries are associated with fracture of the anterior portion of the vertebral body, but the middle column of the spine is intact (Fig. 3022). In some cases, the posterior column may be disrupted in tension as the upper segments hinge forward on the intact middle column. The mechanism of the injury is either anterior or lateral exion.
Compression fractures may be anterior or lateral, with the former accounting for 89% of this group (see Figs. 309 and 3011). Fractures may involve both end-plates (type A, 16%), the superior end-plate only (type B, 63%), the inferior end-plate only (type C, 6%), or a buckling of the anterior cortex but with both end-plates intact (type D, 15%). None of the 197 patients with compression fractures reported by Denis had a neurologic decit related to the spinal fracture. Compression fractures with less than 40% to 50% compression and without posterior ligamentous disruption tend to be stable, low-energy injuries. However, it is still important to assess the patient for noncontiguous spinal fractures.7 A 40% to 50% anterior body compression fracture with the posterior body intact in a physiologically young individual (with no osteoporosis) strongly suggests that the posterior ligaments were disrupted. BURST FRACTURES Burst fractures are characterized by disruption of the posterior wall of the vertebral body (middle column of the spine), which differentiates them from compression fractures (Figs. 3023 through 3028). Spreading of the posterior elements may occur and can be seen as a widening of the interpedicular distance on a plain anteroposterior (AP) radiograph of the spine.12 Lamina fractures may also occur (see Fig. 306). Cammisa and associates40 found that lamina fractures were present on computed tomographic (CT) scans in 50% of patients with severe burst fractures, especially in the lower lumbar spine. In this surgical series, 11 of 30 patients with burst fractures and lamina fractures also had posterior dural tears located at the site of the posterior lamina fracture (Fig. 3029). The incidence was almost 70% in those with burst fractures, retropulsed bone in the canal, and neurologic injury. The possibility of a dural tear
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FIGURE 3011. Example of a lateral compression fracture. A, An anteroposterior radiograph demonstrates lateral compression with asymmetric loss of height. No interspinous process widening is present. B, A lateral radiograph conrms a wedge compression injury with maintenance of height of the posterior portion of the vertebral body. C, A computed tomographic scan through the injured vertebra shows that the injury is limited to the right anterolateral aspect (arrows), with the remaining cortex intact.
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FIGURE 3012. Flexion-rotation forces are much more likely to produce serious spinal injuries than is exion alone. The combination frequently disrupts the posterior ligaments and joint capsules and obliquely disrupts the anterior disc and vertebral body.
with a burst fracture, which are accompanied by horizontal fractures not only in the posterior but also in the middle column. This fracture pattern seems to be more unstable than burst fractures with no horizontal splitting and may require surgical stabilization to prevent progression of kyphosis.2 The mechanism of injury for burst fractures is primarily axial loading. Axial loading is combined with other forces such as exion (either anterior or lateral) or rotation to account for the different fracture patterns seen. Denis noted that burst injuries can be divided into ve frequently observed subgroups (Fig. 3030). One involves fractures of both end-plates (type A, 24%) and is usually seen in the lower lumbar spine. Another involves fracture of only the superior end-plate (type B, 49%) and usually occurs at the thoracolumbar junction. Fracture of only the inferior end-plate is much less common (type C, 7%). A fourth pattern is diagnosed by the presence of a burst fracture of the middle column in combination with a rotational injury leading to some degree of lateral subluxation or tilt (type D, 15%); this pattern is best seen on a plain AP radiograph. The nal subgroup is a burst fracture of the middle column associated with asymmetric compression of the anterior column, as seen in a lateral compression fracture (type E, 5%). Willen and co-workers veried these injury types anatomically in autopsy specimens.278 Neurologic decits were seen in 47% of the 59 patients studied with burst fractures. There did not appear to be a simple, direct relationship between the extent of spinal canal compromise and the severity of neurologic decit. Willen and colleagues found increased neurologic damage with type D fractures, whereas Gertzbein111 found only a weak correlation between canal compromise and neurologic decit in a study of more than 1000 patients with thoracolumbar spine injuries. Gertzbein thought that most trauma to the neural elements probably occurred at the instant of injury. A relationship was, however, found between the location of injury and subsequent neurologic decit, with the incidence of complete neurologic injury being signicantly lower below the thoracolumbar junction (T12L1). Burst fractures may be unstable because they represent at least a minimum of a two-column injury,154 but additionally, they may also be accompanied by extensive disc injury at the levels directly adjacent to the fracture. This possibility has to be considered when deciding on treatment options.99, 278 FLEXION-DISTRACTION INJURIES The exion and distraction mechanism of injury, which most commonly occurs in a motor vehicle accident when the passenger is using a lap seat belt with no shoulder harness, results in failure of the posterior and middle columns in tension with the anterior column serving as the fulcrum (see Figs. 3015 to 3017). Denis divided these injuries into one-level and twolevel lesions (Fig. 3031). A one-level lesion can occur through bone, as described by Chance (type A, 47%), or it may be primarily ligamentous (type B, 11%). Two-level injuries involve the middle column by disruption through
should be taken into consideration if posterior decompression and stabilization procedures are planned. It should not, however, mandate treatment to routinely repair the dural laceration. Some burst fractures are accompanied by horizontal fractures of the posterior column. In a retrospective study by Abe and colleagues, nine patients with a thoracolumbar burst fracture and an associated horizontal fracture of the posterior column were studied. They found that this type of fracture pattern is not rare; it represented 21% of the burst fractures treated by them over an 8-year period. It is best visualized on plain radiographs because it is not easily seen on CT axial cuts. This type of burst fracture differs from exion-distraction injuries combined
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bone (type C, 26%) or through the ligaments and disc with no middle column fractures (type D, 16%). One weakness of this classication system is that it does not include a category for patients who have distraction failure of the posterior column with axial load failure of the middle and anterior columns resulting in a compression or burst fracture. This shortcoming has been noted by several authors, who have added additional categories for seat belt injury.112, 120 In none of the 19 patients with a seat belt injury in Denis series did a neurologic decit related to the spinal fracture develop. In other series, the incidence is also low, usually less than 10%.111 Injuries with ligamentous
involvement should be considered acutely and chronically unstable, whereas those with signicant bone involvement are acutely unstable but may heal well. FRACTURE-DISLOCATIONS (SHEAR) Fracture-dislocations are caused by failure of all three columns of the spine as a result of compression, tension, rotation, or shear forces (Figs. 3032 through 3034). Three different mechanisms (i.e., three types of fracture-dislocation) can occur (see Fig. 3034). One pattern (type A) is a exion-rotation injury, which was originally described by Holdsworth in victims of mining
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FIGURE 3013. This patient sustained a bilateral facet dislocation at T12L1 as a result of a exion-distraction/rotation mechanism. A, A lateral radiograph shows signicant translation of T12 over L1 with maintenance of the integrity (height) of the posterior wall of L1 but some slight comminution of the anterosuperior portion of the body. B, This relationship is well demonstrated on a midsagittal reconstruction of the computed tomographic (CT) scan. C, The characteristic ndings on axial images of the CT scan are the double-body image and the empty facet sign (arrows).
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failure of either the anterior intervertebral disc or the anterior vertebral body. The anterior longitudinal ligament is usually stripped off the inferior vertebral body, thereby allowing signicant subluxation to occur. Denis described 67 patients with fracture-dislocations. Of these patients, 56 had exion-rotation injuries, 7 had shear injuries, and 4 had bilateral facet dislocations resulting from exion-distraction injuries. All these injuries involve signicant destruction of each of the three columns. This group of injuries was associated with the highest incidence of neurologic decit. Of the patients with exion-rotation injuries, only 25% were neurologically normal, and 39% had complete spinal cord injuries. All seven patients with shear injuries had complete neurologic decits. Of the four patients with exiondistraction injuries, three had incomplete neurologic decits, and one was neurologically normal. Other investigators have also reported a signicantly higher incidence of neurologic decit in patients with fracture-dislocations than in those with other injury patterns.111 These injuries are acutely highly unstable.
Comprehensive Classication
Various attempts have been made to develop a universal classication of spinal injuries. In reality, to be effective, such a classication must include structural injury to both bone and soft tissue, as well as consideration of the patients neurologic status. Gertzbein and colleagues103, 110 formulated a classication system dealing with the structural components of spinal injury, similar to the AO fracture classication used for the extremities. The lesions are differentiated on the basis of not only the mechanism and radiographic appearance of the injury but also the associated soft tissue disruption. The classication consists of well-dened categories based on common morphologic characteristics, as well as common primary forces producing the particular injury pattern (Fig. 3036). Three main injury types are recognized. Type A injuries are vertebral body compression fractures (Fig. 3037). They are caused by axial loading with or without additional exion forces and are associated with loss of vertebral height. Type B injuries involve both the anterior and the posterior elements and are caused by distractive forces (Fig. 3038). The hallmark of these injuries is elongation of the distance between portions of the adjacent vertebrae. In type C injuries, anterior and posterior disruption is present along with associated evidence of rotational instability, such as offset vertebral bodies, unilateral facet fracture-dislocations, or fractured transverse processes (Fig. 3039). The three major patterns and their associated subtypes represent a continuum of injury severity, from type A lesions, which are axially unstable, to type B lesions, which have additional sagittal-plane instability, to type C, with instability in all three planes. Because the classication progresses according to the severity of bony and soft tissue disruption, as well as stability, it may be used as a guide for treatment, with injuries more advanced on the classication being more likely to benet from surgical treatment. However, it has not been validated as a reproducible
FIGURE 3014. Flexion-distraction forces across the thoracolumbar spine frequently produce the typical seat belt injury. The axis of rotation is anterior to the spine, with all the elements of the spine in tension. If this axis of rotation is moved posteriorly into the vertebral body, it is possible to have compressive forces across the anterior vertebral body and distraction forces across the posterior elements and middle column of the spine.
accidents.133 This type may also occur after ejection from a motor vehicle or a fall from a height (Fig. 3035A). A shear fracture-dislocation (type B) can be caused by a violent force directed across the long axis of the trunk. One such example, as described by Denis and Burkus, occurs when a lumberjack is struck across the midportion of his back by a falling tree (see Fig. 3035B).60 Denis third type (type C) is a bilateral facet dislocation (see Fig. 3035C) caused by a exion-distraction injury. It resembles the seat belt injury previously described, but with failure of the anterior column. This injury most commonly occurs with
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FIGURE 3015. Example of a exion-distraction injury with disruption through bone. A, An anteroposterior radiograph demonstrates interspinous widening (arrow) with a fracture line through the lamina of L1 (arrowheads). B, A lateral radiograph conrms the pure osseous lesion, with the fracture line coursing posteriorly through the upper portion of the lamina anteriorly into the vertebral body. C, The injury is better seen on this lateral tomogram, with the fracture line extending through the pedicle. D, The patient was treated operatively with Edwards compression rods from T12 to L2. In this instance, the L1 lamina could not be used for anchoring hooks because of the injury to the lamina at this level. E, A lateral radiograph shows reduction of the fracture and restoration of anterior height.
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FIGURE 3016. Example of a combined osseoligamentous exion-distraction injury at T12. A, A lateral radiograph demonstrates the fracture line coursing through the pedicle and traversing the posteroinferior aspect of the body to the T12L1 disc space. B, A lateral tomogram highlights the path of the fracture (arrowheads). C, An anteroposterior (AP) tomogram clearly demonstrates the fracture through the pars interarticularis. Note the distinctive interspinous widening with this injury. D, A computed tomographic scan through the upper portion of T12 demonstrates absent inferior T11 facets as a result of the distraction component. E, This injury was corrected with Edwards compression rodding from T11 to L1, with reduction of the fracture and realignment of the spine. F, A postoperative AP radiograph conrms reduction of the interspinous widening.
classication and is unlikely to be validated because of its extreme complexity. Other useful classication systems are those described by Ferguson and Allen92 and by McAfee and coworkers.191, 195, 196 These classication systems focus primarily on the mechanical forces involved and describe the type of bone or ligamentous injuries associated with these forces. The American Spinal Injury Association (ASIA) classication system for neurologic injury is the most commonly used objective system currently available. Because the primary goal of this chapter is to provide clinical guidelines for diagnosing and treating specic injuries, the more pragmatic classication system of Denis is preferred. For purposes of consistency in this book, a nomenclature and classication system consisting of a
combination of mechanistic and descriptive features is used; it is the same for thoracic, thoracolumbar, and lumbar injuries. The rst group of injuries consists of minor injuries, such as avulsion and minor fractures. The second group includes compression fractures, or injuries generated by a combination of exion and bending that can be either stable or unstable, depending on the degree of anterior compression and ligamentous disruption. The third major group represents burst fractures caused by a combination of exion and axial loading in varying proportion, and they are easily subdivided by Denis classication. The fourth group is exion-distraction injuries, which are subdivided according to the injured tissues: the pure bony form is a Chance fracture, the purely ligamentous form is a bilateral facet dislocation, and the
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combination form is either an anterior bony injury with posterior ligamentous disruption or a posterior bony injury with anterior discal disruption. The fth group of injuries results from an extension force. The nal type is caused by shear. Clearly, no comprehensive or truly universal system exists because the optimal classication system would have to combine the fracture pattern with instability and neural status.
OPERATIVE VERSUS NONOPERATIVE TREATMENT
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Nonoperative treatment of thoracic and thoracolumbar spine injuries can be extremely effective. The data presented by Frankel and associates in 1969 remain the standard against which most treatments and nal outcomes are measured.98 Similar excellent results were published by Davies and colleagues.56, 139 Postural reduction, as described by Frankel, is still used in some European centers, reportedly with good results.34, 268 A comparison of the results of surgical and nonsurgical treatment in the literature is difcult because of the variations in injury type and differences in severity in the two groups, with the surgically treated groups often containing patients with more severe injuries.111 Some series show a slight trend toward better neurologic improvement with surgical treatment, but the statistical signicance is
not high.159 Most investigators describing better neurologic improvement with surgery have directed their attention at neural decompression through either an anterior or a posterior approach.3, 4, 73, 111, 113, 135, 160, 233, 284 Edwards and Levine described better neurologic recovery than would be expected with nonoperative treatment by using the Edwards instrumentation system posteriorly while depending on indirect decompression based on improved fracture reduction.80, 81 Gertzbein, in a study of 1019 spine fractures, found no signicant improvement in neurologic function with operative treatment.111 In addition, Bravo and co-workers did not nd a signicant difference in neurologic improvement in patients treated with surgery versus those treated by postural reduction and immobilization.34 Neurologic deterioration can occur during nonoperative treatment and was documented in 6 of 33 patients with burst fractures of the thoracic or thoracolumbar spine.59 Denis and co-workers concluded that surgical treatment was a safer treatment option for this specic injury.59 However, Frankel and associates,98 in their review of 371 patients with thoracic or thoracolumbar fractures, found that only 0.5% had neurologic deterioration when treated by postural reduction and recumbency. Mumford and co-workers reported a 2.4% incidence of neurologic deterioration in patients with burst fractures treated nonoperatively.206 If patients do experience neurologic deterioration during nonoperative treatment, surgical treatment, including decompression by an anterior ap-
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FIGURE 3017. Flexion-distraction injury at T12L1 predominantly disrupting ligamentous structures. A, An anteroposterior radiograph shows interspinous widening between T12 and L1. B, A lateral radiograph demonstrates the predominantly ligamentous involvement, with the anterior bodies remaining intact. Note the subluxation of T12 on L1 as a result of the dislocated facets. C, A three-dimensional computed tomographic reconstruction of the injured level shows the dislocated, locked facets. Note the fractured transverse process at L1. D, This patient was operatively managed with an AO internal xator from T12 to L1. E, A postoperative lateral radiograph demonstrates reduction and realignment of the injured level.
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that kyphosis of more than 30 was associated with a signicantly increased amount of back pain at 2-year follow-up.111 Edwards and Levines data also suggest that anatomic restoration is important in obtaining good long-term results.7981, 83 Some authors believe that chronic back pain is diminished in operatively treated patients when compared with those treated nonoperatively.111 This improvement in relief of pain may be a result of better correction and maintenance of alignment with operative treatment. In addition, operative treatment includes fusion of motion segments with signicantly damaged soft tissue elements. These injured tissues often have poor healing potential,
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FIGURE 3018. Shearing requires forces from opposing directions to pass through the spine at slightly different levels. This mechanism tends to produce extremely unstable injuries with disruption of all columns of the spine and may produce severe spondylolisthesis with the cephalic spine positioned anteriorly, posteriorly, or laterally in relation to the caudal portion of the spine.
proach, is recommended.111 Finally, whether surgical treatment or nonoperative treatment is safer depends to some degree on the experience and preference of the treating physician and the medical team. Deformity can be corrected with surgery, but it is unclear whether it is clinically relevant.34, 56, 215 Nicoll211 noted no correlation between deformity and symptoms, whereas Soreff and colleagues258 found a signicant correlation. McAfee and associates,193 in their review of late anterior decompression and fusion for thoracolumbar and lumbar injuries, found that residual kyphosis did not inhibit neural improvement. Gertzbein, however, reported
FIGURE 3019. Extension forces occur when the upper part of the trunk is thrust posteriorly, with the application of anterior tension and posterior compression. Most of these injuries are stable unless retrolisthesis of the upper on the lower vertebral body has occurred.
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ysis.49, 66, 95, 139, 233 Mobilization and rehabilitation can be facilitated by rigid surgical stabilization, which decreases the associated morbidity of prolonged immobilization. However, Gertzbein, in a multicenter spinal fracture study, found the complication rate in surgical patients to be more than 25%, whereas patients treated nonoperatively had a complication rate of only 1%.111 The patients treated surgically tended to have more severe injuries and a higher incidence of neurologic decit, both of which increase the likelihood of complications regardless of treatment type. Place and colleagues compared operative and nonoperative treatment of patients who sustained spinal fractures with resultant complete spinal cord injuries. The length of inpatient hospital and rehabilitation stay was 19% less for the surgically treated group, even though their rate of complications was almost twice as high as that in the nonoperative group.223 At this time, early mobilization remains the primary predictable advantage of instrumentation.
TREATMENT OF SPECIFIC INJURIES

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Minor Fractures
Fractures of the transverse processes usually occur either from direct trauma or as a result of violent muscular contraction (avulsion injuries) in response to injury. Isolated fractures of the spinous processes may result from a direct blow over the posterior aspect of the spine. Similarly, fracture of the articular process may occur as a result of direct trauma. In each of these cases, even though the injury may appear benign, further evaluation is necessary to be certain that no other associated spinal injuries are present. Such evaluation is most easily accomplished by obtaining a CT scan through the vertebra in question and the adjacent vertebrae. If the CT scan is negative (no other injuries detected), lateral exion and extension radiographs should be considered if dynamic instability is a concern. Once other major injuries to the spine have been excluded, these patients can be mobilized with no special brace or activity restrictions, except as needed for painful symptoms. Transverse process fractures are painful, and orthotics may be helpful. Another minor injury is an isolated fracture of the pars interarticularis at one level, either unilaterally or bilaterally. In Denis series, four individuals had this type of fracture,58 with all four being the result of a sports injury. If the patient has this injury along with a negative previous history of local spine pain (particularly in a young adult or teenager), it can be assumed that this fracture is an acute injury that is best treated with immobilization. In the thoracolumbar and upper lumbar regions of the spine, a total-contact thoracolumbosacral orthosis (TLSO) is appropriate. At the L5 level of the spine, it may be necessary to include one thigh to provide adequate immobilization. Fractures of the pars interarticularis in the thoracolumbar or upper lumbar spine in combination with a history of more severe trauma suggest a major spine injury (e.g., seat belt injury). This injury can be discerned on thin-cut CT scans with reconstructions of the spine and may also be well visualized on exion-extension radiographs if the
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FIGURE 3020. This 26-year-old man was involved in a motor vehicle accident and sustained an extension injury to the lower part of the spine. A, An anteroposterior radiograph shows a fracture line coursing through the lamina of L4 (arrows). Arrowheads point to transverse process fractures. B, A lateral radiograph was unremarkable. C, Computed tomographic scan through the injured body of L4 with multiple fracture lines noted in the posterior column (arrowheads).
and the patient is left with an abnormal motion segment even after adequate healing of bone. Most authors agree that hospitalization time can be shortened by surgical stabilization in patients with paral-
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FIGURE 3021. Denis three-column model of the spine. The middle column is made up of the posterior longitudinal ligament, the posterior portion of the anulus brosus, and the posterior aspect of the vertebral body and disc.
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Anterior
Middle
Posterior
A
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FIGURE 3022. Denis classication of compression fractures. These fractures may involve both end-plates (A, type A), the superior end-plate only (B, type B), the inferior end-plate only (C, type C), or a buckling of the anterior cortex with both end-plates intact (D, type D).
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FIGURE 3023. A 43-year-old man sustained a T12 and L1 burst fracture when a mobile home roof fell on him during a storm. The patient was neurologically intact. A, A preoperative anteroposterior (AP) radiograph shows approximately 50% loss of height at T12 and L1. B, A preoperative lateral view shows local kyphosis measuring 27. C, An axial computed tomographic scan shows a minimal burst component at L1. D, This injury was stabilized with Synthes USS instrumentation. A pedicle screw was placed in the burst-fractured vertebra of T12 (the pedicles were intact) to act as a fulcrum in the reduction of his 27 of kyphosis. E, Postoperative AP radiograph showing two cross-connectors used for additional stability.
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FIGURE 3024. Example of a stable burst fracture (Denis type B) in a 52-year-old man who was neurologically intact. The fracture was treated nonoperatively. A, An anteroposterior radiograph demonstrates loss of height of the body of T12, with minimal interpedicular widening and no interspinous separation noted. B, A lateral radiograph conrms involvement of the anterior and middle columns with loss of height at both sites. C, A computed tomographic scan through T12 demonstrates disruption of the posterior vertebral cortex (arrow) but only minimal displacement of the fragment. The posterior ring remains intact.
patient can tolerate the motion. A CT scan, unless the cuts are ne, may not be helpful in determining whether the pars fracture is isolated or a component of a seat belt injury because the fracture lines often lie in the transverse plane of the spine and are difcult to visualize with standard CT scanning.33
Compression Fractures
By denition, compression fractures include disruption of the anterior column with an intact middle column. Differentiation between a compression fracture and a minimally displaced burst fracture with associated middle column involvement may be subtle. McGrory and colleagues200 described the use of the posterior vertebral body angle (PVBA) measured on a lateral plain radiograph. The PVBA is the angle formed by either the superior or the inferior end-plate and the posterior vertebral body wall. An angle greater than 100 for either the superior or the inferior PVBA is considered diagnostic of a burst fracture. A slight decrease in height of the posterior wall in comparison to the vertebra above and below and loss of the biconcave contour may also suggest the presence of a burst rather than a compression fracture. Even with careful scrutiny, 20% or more of subtle burst fractures can be misdiagnosed on plain radiographs. Therefore, the routine use of CT scanning for patients with probable compression fractures is a better method to evaluate the middle column.17 Treatment of these injuries depends on the status of the posterior elements, which may or may not be disrupted. If the anterior column is compressed 40% or more or if the kyphosis exceeds 25 to 30, it can be inferred that the ligaments of the posterior column have been attenuated to the point that they can no longer function normally. Magnetic resonance imaging (MRI) has been shown to be a useful adjunct for identifying the
presence of posterior ligament injury.155 In addition, MRI may be useful in helping differentiate benign from pathologic compression fractures.9 Nonoperative treatment is adequate in most compression fractures with less than 40% anterior compression and less than 25 to 30 kyphosis. These patients can usually be managed in a restrictive orthosis, such as a total-contact TLSO or, occasionally, a Jewett brace. They can be allowed to participate in most of their normal activities while wearing the brace (see Fig. 309). These patients should be encouraged to lie in the prone position, which tends to minimize the deformity. They should be discouraged from lying supine on a soft mattress with multiple pillows because this position can accentuate the deformity. Hazel and associates reviewed the long-term outcome of neurologically intact patients with compression fractures treated nonoperatively. Of the 25 patients monitored, 8 had no symptoms, 11 had occasional back pain, 5 needed treatment or modication of activity because of frequent pain, and only 1 patient had chronic disabling back pain.129 The brace should be worn for 3 months or longer. Standing lateral exion and extension radiographs out of the brace should then be obtained. If no abnormal motion is seen through the fractured vertebra or the disc above and if signicant progression of the deformity has not occurred, use of the orthosis can be discontinued. Muscle weakness may be signicant, and gradual cessation of bracing over a few weeks may be benecial, along with a muscle-strengthening program to help support the spine. In those with abnormal motion at the level of injury, continued pain, or progression of deformity to a degree unacceptable to the patient, surgery may be indicated. Some authors believe that stable fractures in the upper and middle thoracic spine do not require brace treatment at all because of the inherent stability of the rib cage. Most authors tend to be more cautious and usually recommend
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external immobilization at the thoracolumbar junction or in the lumbar spine. Schlickewei and associates249 compared a group of patients with stable thoracolumbar injuries treated by early mobilization with or without a brace. After an average of 2.5-years follow-up, they found good or excellent results in both groups, without clinically signicant differences in progression of deformity between groups. Initial surgical treatment should be recommended if the anterior column is compressed more than 40% or if the kyphosis exceeds 25 to 30. For those with borderline indications, surgery could be considered as an option in a young patient with a high-energy injury, but it would
probably not be recommended in an elderly patient with marked osteoporosis and low-energy trauma. In the former case, the posterior ligaments are much more likely to be disrupted than in the latter. Because the posterior elements are disrupted, a posterior surgical approach is indicated, and any dual-rod technique would be adequate. A distraction system can be used with three-point xation (e.g., hook-rod system or segmental xation systems). If the middle column is denitely intact, a compression system can be used (e.g., a segmental xation system with hooks or screws). The surgeon should be aware that a compression system may cause posterior protrusion of an already disrupted disc at
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FIGURE 3025. This 19-year-old man was involved in a fall from an all-terrain vehicle and sustained a burst injury at T12 that resulted in a complete spinal cord injury. A, An anteroposterior (AP) radiograph demonstrates signicant loss of height at T12 with interpedicular widening, classically seen with burst fractures. A compression fracture of the superior corner of L2 is also noted (arrow). B, A lateral radiograph shows signicant loss of height of both the anterior and middle columns of T12. Small compression injuries at L1 and L2 (arrows) are also seen. C, A computed tomographic scan through T12 conrms the presence of a burst fracture with a large retropulsed fragment compromising 80% of the canal and resulting in injury to the conus. D, A postoperative AP radiograph shows placement of Cotrel-Dubousset instrumentation. A laminar claw conguration was used above and below T12. Two Texas Scottish Rite Hospital cross-links were used to reinforce the construction. The patient was postoperatively mobilized without a brace. E, Lateral postoperative radiograph. It would have been better had the upper claw been placed around the T10 lamina to increase the superior lever arm and minimize metal stenosis at the site of the retropulsed bone fragment.
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FIGURE 3026. This 30-year-old man was an unrestrained passenger involved in a motor vehicle accident and was ejected from his car. He sustained an L1 burst fracture with an incomplete spinal cord injury. A, An axial computed tomographic scan through the body of L1 shows a large retropulsed fragment occupying most of the spinal canal. B, The patient was treated by anterior corpectomy and decompression at L1. Stability was achieved with the Kaneda system. C, A 2-year postoperative lateral view shows continued restoration of height and reestablishment of sagittal alignment.
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FIGURE 3027. This 38-year-old man was involved in a motor vehicle accident and sustained a burst fracture of T12. The patient had decreased motor function in both lower extremities as well as bladder dysfunction. A, An anteroposterior (AP) radiograph shows collapse of the body and interpedicular widening. B, A lateral radiograph shows loss of height and segmental kyphosis measuring 28. C, An axial-cut computed tomographic scan through T12 shows a large retropulsed fragment compromising most of the canal. D, A postoperative AP radiograph shows stabilization after corpectomy with a tibia allograft strut and instrumentation consisting of the University Plate (Acromed). E, A lateral postoperative radiograph shows restoration of height and sagittal alignment with 3 of kyphosis.
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the level of injury and that this protrusion may be large enough to cause neurologic deterioration. If a compression construct is being considered, the use of intraoperative evoked potentials is important because it may provide early documentation of protrusion and allow the surgeon to change the technique or perform a posterolateral decompression to remove the disc fragment. The use of anterior surgery is not required for neural decompression with these fractures because the middle
column remains intact. However, supplemental anterior surgery may occasionally be necessary for patients with marked anterior destruction to restore bone stock. This situation is usually seen in patients with severe osteopenia who are involved in high-energy injuries. These same patients may also undergo late collapse with progressive kyphosis and subsequent neurologic decit. They are best treated by an anterior approach, although the use of vertebroplasty has obviated this approach in most cases.146
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FIGURE 3028. Example of a exion-distraction injury at T12L1 with an associated burst component of the L1 vertebral body. This patient had an incomplete cord injury. A, Anteroposterior radiograph showing interpedicular widening and increased distance between the posterior spinous processes at T12L1. B, A lateral radiograph shows the local kyphosis and burst injury at L1. C, A preoperative computed tomographic (CT) scan shows severe canal encroachment from the burst component. D, The patient was treated with ISOLA instrumentation and Edwards sleeves. E, A postoperative lateral radiograph shows good sagittal alignment and reduction of the vertebral body height. F, A postoperative axial CT scan shows partial restoration of the canal.
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FIGURE 3029. Illustration of the proposed mechanism of injury in patients with burst fractures along with associated laminar fractures and posterior dural tears. A, With axial loading and spreading of the pedicles, a laminar fracture is produced and bone is retropulsed from the vertebral body into the spinal canal. This mechanism of injury may result in protrusion of the dura between the laminar fracture fragments. B, As the axial load is dissipated, the laminar fracture fragments recoil and may entrap the dura and nerve rootlets. C, If approached posteriorly, the laminar fracture is difcult to visualize, and if not carefully sought, the dura and nerve rootlets may be further injured. (A C, Redrawn from Eismont, F Green, .J.; B.A. J Bone Joint Surg Am 71:1044 1052, 1989.)
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Burst Fractures
By denition, every burst fracture includes disruption of the anterior and middle columns, with or without disruption of the posterior column. The type of treatment depends on the severity of the injury.150 The three most important factors to be considered are the percentage of spinal canal compromise, the degree of angulation present at the site of injury, and the presence or absence of a neurologic decit. No strong clinical basis is available to develop a consensus regarding the best treatment of patients with burst fractures. James and co-workers,141 using a human cadaver L1 burst fracture model, showed that the condition of the posterior column was the most important factor in determining the acute stability of a burst fracture and, therefore, the suitability for nonoperative treatment. They went on to review a series of patients with intact posterior columns, but varying degrees of anterior and middle column disruption, and noted that they healed without deformity. Willen and colleagues277 reported on 54 patients with thoracolumbar burst fractures treated nonoperatively, including patients with neurologic decit. Most of the deformity occurred on initial mobilization, with little progression of deformity noted at follow-up. Patients with more than 50% loss of height or more than 50% canal compromise were found to have signicantly increased complaints of pain at follow-up. Cantor and
co-workers41 also recommended operative treatment for patients with evidence of posterior column disruption. Treatment of burst fractures can be logically dened with regard to the goals of surgery. Three parameters determine these goals: neurologic status, instability, and deformity. In patients with neurologic compromise accompanied by instability, cord compression, marked deformity, or any combination of these conditions, surgical intervention is the most appropriate treatment. Nonoperative treatment of a patient with a neural decit can be considered in the rare instance of a stable burst fracture without deformity or residual cord compression. If the patient is neurologically intact and has less than 50% canal compromise and less than 30 kyphosis (see Fig. 3024), nonoperative treatment is indicated. Patients with minimal angulation and a two-column or stable burst pattern should be placed in a total-contact orthosis with early ambulation as tolerated.41 If the canal compromise is greater than 40% or a three-column injury is present, recumbency for several weeks should be considered if surgery is not performed; ambulation can then begin in a total-contact TLSO. Surgery is the preferred treatment in patients with more than 50% canal compromise or more than 30 kyphosis at the level of injury, even if they do not have any neurologic decit. It should be emphasized that a neurologic decit includes not only lower extremity motor and sensory dysfunction but also perineal sensory loss and bowel or
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bladder dysfunction. A rectal examination should be performed to determine whether anal tone is normal with voluntary contracture. Postvoid residual urine should also be checked to be certain that the volume of retained urine is less than 50 mL. Any abnormality in bowel or bladder function should be considered a neurologic decit. Controversies in the nonoperative treatment of burst fractures include the appropriateness of bedrest and the duration and types of orthosis. However, the duration of using a total-contact orthosis should be at least 3 months. During that time, once ambulation is initiated and no change in alignment is observed on standing lateral radiographs, an increase in activities can be allowed. Some progressive loss of height of the involved disc space is to be expected; however, if posterior spinous process widening is noted or angulation increases to more than 30, surgical treatment is recommended.141 Mumford and co-workers206 studied 41 patients with thoracolumbar fractures and no neurologic decit who were treated nonoperatively. The average collapse at follow-up was only
8%, with signicant resorption of protruding bone and diminution in canal compromise (22%). Almost 90% of patients had satisfactory work status at last follow-up. The authors were unable to correlate residual deformity with symptoms. Cantor and associates41 reported their results on 18 neurologically intact patients with burst fractures treated nonoperatively. They found no prolonged hospital stay, no signicantly increased kyphosis, and little or no restriction of function at follow-up. If nonoperative treatment is used, prolonged riding in automobiles and participation in impact activities should be discouraged for 3 to 6 months. The patient should also be instructed to avoid marked exion at the level of injury while lying in bed and to avoid lying supine with multiple pillows because this position could increase the deformity. Patients should be encouraged to sleep in the prone position. If they are unable to understand or follow these instructions, either a cast or surgery should be considered. Patients should be instructed to notify the physician immediately if any paresthesias, cramping in their lower
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FIGURE 3030. Denis classication of burst fractures. A C, Types A, B, and C represent fractures of both end-plates, the superior end-plate, and the inferior end-plate, respectively. D, Type D is a combination of a type A burst fracture with rotation, which is best appreciated on an anteroposterior (AP) radiograph. E, A type E burst fracture is caused by a laterally directed force and hence appears asymmetric on an AP radiograph. The superior or inferior end-plate, or both, may be involved in this fracture.
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FIGURE 3031. Denis classication of exion-distraction injuries. These injuries may occur at one level through bone (A), at one level through the ligaments and disc (B), at two levels with the middle column injured through bone (C), or at two levels with the middle column injured through ligament and disc (D).
extremities, weakness in their legs, or a change in bowel or bladder control develops. Patients should be evaluated frequently (1 week, 1 month, 2 months, and 3 months after injury) with standing lateral radiographs to be certain that the angulation at the level of injury has not increased. After healing appears to be adequate, exion-extension radiographs are taken with the patient out of the brace to make sure that no excessive motion has occurred at the fracture level. If nonoperative treatment fails and either progressive deformity or a neurologic decit develops, surgical intervention should be initiated. The type of surgery is dependent on the method of failure of nonoperative treatment. If a neurologic decit develops, anterior decompression should be considered because posterior instrumentation performed more than 2 to 3 weeks after injury will not adequately reduce the canal compromise. Similarly, posterolateral decompression may be difcult as the fragment begins to heal into position. However, if the patient fails nonoperative treatment because of persistent pain or increasing deformity, poster-
ior surgery is usually adequate. If the deformity is partially corrected on exion-extension views, satisfactory reduction of kyphosis can be achieved with posterior instrumentation and fusion. Burst fractures that require operative treatment can be appropriately reduced and stabilized with any system that allows distraction and three- or four-point xation. By means of force vectors placed by posterior instrumentation, the ligaments of the middle column can be tightened, thereby reducing the intracanal fragment. Indirect reduction was originally thought to be caused by tensing of the posterior longitudinal ligament, but more recent studies point to the annular attachments as being responsible for indirect reduction.39, 99, 127 The most commonly used posterior systems are currently those that allow segmental xation with varying combinations of hooks and screws. Such systems allow variation in the length of the construct, as well as in methods of attachment to the vertebra, depending on the location of the fracture within the spine and the fracture pattern.
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Zou and colleagues287 studied the use of various posterior xation devices for the treatment of burst fractures in a cadaver model. They noted that devices capable of providing distraction and restoration of sagittal alignment resulted in signicantly better canal decompression than did systems that used only distraction. Mann and associates188 compared the Syracuse I-Plate (applied anteriorly) with the AO Fixateur Interne pedicle screw system for the treatment of burst fractures. They found that both systems provided adequate stability in patients without posterior column disruption. In the presence of posterior disruption, posterior instrumentation provided signicantly increased stability. Gurwitz and colleagues122 compared the use of the Kaneda device for anterior xation with pedicle screws and a variable spinal plate (VSP) posteriorly for xation of a corpectomy model used to simulate a burst fracture. They found that shortsegment posterior instrumentation did not adequately restore spinal stability. Farcey and co-workers91 reported that posterior xation does not adequately prevent late collapse if signicant anterior destruction with concomitant kyphosis has occurred. They recommended the addition of an anterior strut graft for mechanical reasons, in addition to posterior instrumentation. With posterior distraction systems, intraoperative evoked potentials, posterolateral decompression, and spinal sonography may all be used to document and treat any residual neural compression that remains after alignment and stabilization of the fracture. An alternative is to obtain postoperative CT scans to determine the extent of residual
neural compression and decide whether additional anterior decompression and fusion may be necessary (see Fig. 3047). This decision should be predicated on the patients postoperative neurologic status with a plateau at a less desired or expected level of function. Surgeons who perform posterior stabilization procedures should be aware that patients who have burst fractures with concomitant lamina fractures and a neurologic decit have a 50% to 70% chance that a posterior dural laceration secondary to the injury is also present.40 Should this complication be encountered, the surgical team should be prepared to make appropriate repairs. Burst fractures that require surgery should not be treated with a compression construct, which may increase the extent of bone retropulsion into the spinal canal. This injury should also not be treated with Luque rods because the spine is not protected from axial loading with this type of xation and increased retropulsion of bone into the spinal canal is possible. A neutralization system such as one using plates and screws may be adequate for the treatment of midlumbar and lower lumbar injuries, if realignment (distraction lordosis) can be obtained. If reduction is achievable, pedicle screw systems allow the surgeon to minimize the length of the fusion and still provide stability. Although these systems have also been advocated for thoracolumbar junction injuries, they fail more often in such applications, with resultant recurrent deformity and neural compression, particularly if the normal spinal contour is not achieved. If a pedicle screwbased construct with
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FIGURE 3032. A T4T5 fracture-dislocation resulted in a complete spinal cord injury in a 30-year-old man. A, A computed tomographic scan through the injured level demonstrates marked displacement and comminution at T4T5, with multiple bone fragments within the canal. B, A postoperative anteroposterior radiograph shows stabilization with a Luque rectangle and sublaminar wires. This instrumentation provided rigid xation and allowed early mobilization with minimal external support. The strength of xation could have been improved with the use of double wires around the lamina bilaterally. C, Postoperative lateral radiograph.
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FIGURE 3033. This 32-year-old man was involved in a motor vehicle accident and sustained a fracture-dislocation of the thoracic spine and a complete spinal cord injury. A, An anteroposterior radiograph demonstrates loss of height at T9, with a minimal rotatory component. B, A lateral radiograph conrms fracture of the body of T9 with forward subluxation of the body of T8 on T9. Involvement of the posterior wall of T9 appears minimal. C, A computed tomographic scan through the injured level reveals the offset of the T8 vertebra in comparison to T9. The canal compromise is predominantly related to the malalignment. D, The patient was treated operatively, with instrumentation applied by using the Harrington-Luque technique. Segmental sublaminar wires are used to enhance xation and allow mobilization with minimal external support. E, A lateral radiograph demonstrates restoration of height and realignment at the injury level.
only two-point xation extending one level above and one level below the injury is used at the thoracolumbar junction, it may be necessary to combine this procedure with anterior fusion to provide axial support through the injured vertebra. Such fusion is often not necessary in the lower and midlumbar spine, in which more weight is carried through the posterior elements. Insertion of screws into the fractured vertebra (if the pedicles are intact) to create three-point xation and re-create the normal lordosis may obviate the need for concurrent anterior stabilization. Anterior decompression and fusion (with instrumenta-
tion) may be performed to treat burst injuries. This procedure is best for patients with signicant neural compression and neurologic decit, particularly those with minimal kyphotic deformity. Anterior decompression and fusion should be routinely considered if the injury occurred 3 or more weeks previously. The use of this approach best ensures adequate neural decompression, and although more residual deformity may remain than with most posterior instrumentation systems, it is tolerated by the patient if the anterior fusion is solid. With the use of anterior instrumentation it is possible to obtain adequate correction of deformity, as well as decompression
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and rigid stabilization in the thoracolumbar, midlumbar, and low lumbar spine. Laminectomy by itself is never indicated for the treatment of burst fractures. It cannot relieve the anterior neural compression, further destabilizes the spine, and is often associated with an increase in neurologic decit.16, 28, 30
Flexion-Distraction Injuries
Flexion-distraction injuries are characterized by disruption of the posterior and middle columns of the spine in tension, whereas the anterior column usually remains intact and acts as a hinge. The decision to perform nonoperative rather than operative treatment depends primarily on whether this injury is through bone, as originally described by Chance44 (Denis type A), or whether it also involves signicant ligamentous injuries, as seen in atypical Chance fractures (Denis types B, C, and D). A Chance fracture extending only through bone has an excellent prognosis for healing, although it may be unstable early and difcult to hold in anatomic reduction without surgery. Injuries with signicant ligamentous disruption tend to heal in a less predictable fashion and should be considered unstable both acutely and chronically. Nonoperative care of a patient with a seat belt injury through bone may consist of bedrest for 2 weeks or longer, followed by mobilization in a total-contact TLSO molded in hyperextension. This orthosis is best molded with the patient in the prone position or supine on an extension frame. The patient should be instructed to wear the TLSO and participate in activities as tolerated while wearing the brace. Frequent evaluation with radiographs taken in the standing position should be made to ensure that the
deformity has not progressed. After 3 to 4 months, the level of injury should be assessed for excess motion with exion-extension radiographs obtained out of the brace. If nonoperative treatment has failed to produce a stable spine with minimal deformity, surgical treatment consisting of posterior fusion with a compression system is indicated. Even if treatment is performed late after the injury, the chance of obtaining successful fusion and satisfactory alignment of the spine is good. Alternatively, early xation with compression instrumentation can be considered if fracture-ligament stability or patient compliance is a concern. If a seat belt injury is to be treated operatively, a posterior compression system is generally used. The system often needs to extend only one level above and one level below the disruption if the laminae are intact. Hook-and-rod or pedicle screw systems can be used. Positioning the patient in the prone position with support under the chest and pelvis can often anatomically reduce the fracture. The Luque rod system with segmental wires is not indicated because it is less able to resist forward exion unless many levels above and below the injury are included in the construct. Anterior decompression is not usually appropriate or necessary (unless a large disc herniation is present at the level) because it removes the last intact column and further destabilizes the spine.
Fracture-Dislocations
In fracture-dislocations, all three columns of the spine are disrupted. These injuries have the highest incidence of neurologic decit, and most patients should be treated surgically. If a fracture-dislocation is present and the patient is neurologically normal, surgery is performed to
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FIGURE 3034. This 24-year-old man was a victim of a fall from a height that resulted in a fracture-dislocation at L1L2 and a complete spinal cord injury. A, An anteroposterior radiograph highlights the malalignment at L1L2 with a signicant rotatory component and lateral slip at this level. B, A lateral radiograph conrms the displacement with forward subluxation and overlap at L1L2. C, A computed tomographic scan through L1L2 highlights the displacement and malalignment resulting in signicant canal compromise and spinal cord injury.
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A a
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FIGURE 3035. Denis classication of fracture-dislocation of the spine. A, Type A is a exion-rotation injury occurring either through bone or through the disc. All three columns of the spine are completely disrupted, usually with the anterior longitudinal ligament being the only intact structure. Commonly, this ligament is stripped off the anterior portion of the vertebral body below. These injuries are usually associated with fractures of the superior facet of the more caudal vertebra. B, Type B is a shear injury. The type that produces anterior spondylolisthesis of the more cephalad vertebra usually fractures a facet, and that causing posterior spondylolisthesis of the more cephalad vertebra normally does not cause a fracture of the facet joint. C, Type C is bilateral facet dislocation. This injury is a exion-distraction injury but with disruption of the anterior column in addition to the posterior and middle columns. This disruption through the anterior column may occur through either the anterior intervertebral disc or the anterior vertebral body.
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FIGURE 3036. Comprehensive classication of spine injuries. Type A (A) is vertebral body compression. Type B (B) is anterior and posterior element injury with distraction. Type C (C) is anterior and posterior element injury with rotation. (Redrawn by permission from Gertzbein, S.D. In: Gertzbein, S.D., ed. Fractures of the Thoracic and Lumbar Spine. Baltimore, Williams & Wilkins, 1992.)
FIGURE 3037. Comprehensive classication of type A spinal injuries. The three categories of type A fractures include impaction injuries (A1), of which wedge fractures are most commonly seen; split fractures (A2), of which a pincer fracture is the typical injury; and burst fractures (A3). (Redrawn by permission from Gertzbein, S.D. In: Gertzbein, S.D., ed. Fractures of the Thoracic and Lumbar Spine. Baltimore, Williams & Wilkins, 1992.)
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A3
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B1
B2
B3
FIGURE 3038. Comprehensive classication of type B spinal injuries. Flexion-distraction injuries can result in disruption of soft tissues posteriorly through the capsule of the facet joints (B1) or through the bony arch (B2). If distraction and extension occur, anterior disruption through the disc may often be seen (B3), with or without associated fractures or soft tissue injuries of the posterior elements. (Redrawn by permission from Gertzbein, S.D. In: Gertzbein, S.D., ed. Fractures of the Thoracic and Lumbar Spine. Baltimore, Williams & Wilkins, 1992.)
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stabilize the spine and prevent the occurrence of a neurologic decit while allowing the patient to be mobilized. If a fracture-dislocation is present and the patient has an incomplete neurologic decit, surgery should be performed to stabilize the spine and decompress the neural elements. If a fracture-dislocation is present and the patient has a complete neurologic decit, surgery should be performed to stabilize the spine, shorten the hospital stay, minimize the need for rigid external immobilization, and maximize the patients potential for rehabilitation. The surgical management of fracture-dislocations varies according to the type of injury. If the patient is neurologically normal or has an incomplete neurologic decit, it is best to intubate and turn the patient to the prone position while still awake. The patients muscle tone helps stabilize the spine during turning, and the patient can be quickly monitored after turning to make certain that neurologic function is unchanged. Most patients do not nd this maneuver particularly distressful, provided that they are informed of it in advance. It makes the turning and positioning maneuvers safer than logrolling an anesthetized patient with a spinal column injury and no inherent ability to protect the cord. After positioning has been completed and neurologic assessment has been performed, the patient may be anesthetized. In both exion-rotation and exion-distraction injuries, the anterior longitudinal ligament most often remains intact. These injuries can be reduced with the use of any of the previously described distraction systems. If overdistraction occurs, a shorter central compression system acting as a tension band can be used between the two distraction rods, with the system spanning one level above to one level below the fracture-dislocation. In many cases, a double-looped 1.20-mm wire passed around the spinous processes can prevent overdistraction. In the case of exion-rotation injury, a compression system by itself cannot usually provide anatomic realignment. However, with a exion-distraction injury, it allows excellent xation and stabilization of the injury. Conversely, in exionrotation or exion-distraction injuries with jumped facets, distraction may be applied to reduce the dislocation. After reduction has been achieved with the distraction system, a neutralization system with a plate and screws can be used
to hold the reduction while the distraction component is removed. The Luque instrumentation system is secure enough to maintain reduction in a exion-rotation injury, but it may be difcult to achieve anatomic reduction with this technique because the system does not allow application or maintenance of distraction. The use of rigid segmental xation systems allows better stabilization in this type of injury. Shear injuries are the most unstable of the injuries because all three columns are disrupted and all supporting ligaments are completely torn.60 Overdistraction is a common occurrence. The combination of long distraction with short compression should be considered. An alternative is to reduce these injuries with long distraction and short local compression, followed by xation with a plate-and-screw system extending two levels above and two levels below the injury. The distraction and compression instrumentation can then be removed. A segmental claw with transverse xation devices or pedicle screws is also useful. Another possibility is to achieve reduction, again with distraction and compression systems, and then x the reduction in situ with Luque rods and segmental wires. All these approaches provide excellent stability and allow postoperative mobilization of the patient, usually with a TLSO. Primary acute anterior decompression rarely has a role in fracture-dislocations because the main problem in these injuries is usually stability and malalignment. Realignment by itself frequently decompresses the compromised neural elements. Anterior decompression may be used in conjunction with posterior instrumentation if adequate decompression cannot be achieved. This option is particularly important in a patient with a partial neurologic decit.253
Soft Tissue Injuries

Soft tissue injuries (grades 1 and 2 sprains) involving the thoracic and lumbar spine without complete ligamentous disruption are diagnosed by exclusion after obtaining a detailed history, performing a thorough physical examination, and ordering appropriate tests. Treatment is symptomatic, as for soft tissue injuries that occur elsewhere in
FIGURE 3039. Comprehensive classication of type C spinal injuries. The common feature of these injuries is rotation associated with compression (C1), distraction (C2), or rotational shear (C3). (Redrawn by permission from Gertzbein, S.D. In: Gertzbein, S.D. ed. Fractures of the Thoracic and Lumbar Spine. Baltimore, Williams & Wilkins, 1992.)
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C1
C2
C3
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the body. Standard physical therapy measures coupled with short-term bedrest may prove helpful, if necessary, to relieve symptoms. Provided that structural integrity is present, gradual mobilization of the patient should be encouraged. The use of analgesics is appropriate, and the use of nonsteroidal anti-inammatory drugs may also shorten the course of disability and decrease symptoms. Two treatment options to be avoided are prolonged rigid immobilization and chronic use of narcotic analgesics. If symptoms of the soft tissue injury persist, the patient should be reevaluated with the use of plain radiographs with exion and extension lateral views. If results are negative, a bone scan or MRI may be performed to rule out an occult spinal fracture or ligamentous injury. If any area is abnormal in the bone scan or MRI, a thin-section CT scan with reconstructions should be obtained. Additionally, if the symptoms warrant, MRI can be performed to rule out disc herniation or other soft tissue injury.
Disc Injuries
High-energy injuries of the intervertebral discs in the thoracic and thoracolumbar spine are uncommon, but they can be a signicant source of morbidity and cause pain or even paralysis. Disc herniations down to the T12L1 and sometimes the L1L2 interspaces can involve spinal cord compression, whereas in disc herniations below these levels, compression is limited to the cauda equina. As stated previously, the spinal cord is more susceptible to injury and less likely to recover once injured. This discussion is limited to disc herniations in the thoracic and thoracolumbar regions. The classication of disc herniations in the thoracic spine is the same as for herniations in the low lumbar spine. Disc abnormalities are dened as bulging, protruded, extruded, or sequestered. A bulging or protruded disc is dened as an injury in which the nucleus pulposus migrates posteriorly but remains conned within the anulus brosus. With an extruded disc, the nucleus pulposus ruptures through the anulus brosus but is still conned anterior to the posterior longitudinal ligament. When a disc is sequestered, the nucleus pulposus has ruptured through the anulus brosus, as well as the posterior longitudinal ligament, and lies within the spinal canal. The thoracic and thoracolumbar regions of the spine are less tolerant than the lumbar spine of any of these disc abnormalities. Even a protruded intervertebral disc may be symptomatic because the spinal canal is narrower than in the cervical and low lumbar regions and the thoracic cord is more susceptible to pressure because of the limited vascular supply and small space. Though signicantly less common, limbus fractures of the lumbar vertebrae must be considered in the differential diagnosis of any adolescent or young adult thought to have a traumatic herniated nucleus pulposus. Fracture of the lumbar vertebral limbus consists of a fracture of the peripheral apophyseal ring from either the posterosuperior or the posteroinferior aspect of the vertebra, and the symptoms are similar to those seen with a herniated nucleus pulposus. Although they were originally thought to occur exclusively in the pediatric population, a number
of studies have shown the existence of fragmented, unfused apophyseal rings in adults. Epstein and Epstein88 reported on 27 patients who sustained limbus vertebral fractures at an average age of 32 years and a range extending to 44 years of age. Treatment of these lesions is by surgical excision. Symptoms of thoracic and thoracolumbar disc herniation include pain, paresthesias, and neurologic decits. The pain may be local and axial at the level of injury, or it may be radicular in nature, with radiation to the ank, along a rib, or down toward the groin if the disc herniation is at the thoracolumbar junction. Less commonly, pain may involve all areas distal to the spinal cord compression. When this type of dysesthetic pain occurs, signicant neural compression and weakness are usually present. Neurologic ndings can include a wide-based, ataxic gait. Sensation may be decreased either in a radicular distribution or in a distribution involving all regions distal to the level of spinal cord compression. Weakness may be present and may follow any of the patterns of spinal cord syndromes, from a central cord or Brown-Sequard syn drome to an anterior cord syndrome. On occasion, complete paralysis may also be associated with thoracic or thoracolumbar disc herniation. In addition, abnormal ndings related to rectal tone, perineal sensation, and bladder function may be observed. Subtle changes may be detected with cystometric evaluation. The reexes may range from normal in patients with minimal spinal cord compression to marked hyperreexia with a positive Babinski sign in patients with signicant spinal cord compression. Thoracic disc herniation can be detected by MRI (see Fig. 3052), myelography, or myelography followed by CT scanning (which has the added advantage of demonstrating spinal cord deformity at the level of the disc herniation). A CT scan alone is not usually adequate to demonstrate thoracic disc herniation or accurately assess the extent of spinal cord compression. Plain radiographs are seldom diagnostic. Plain lms can, however, be helpful if the patient has Scheuermanns disease because thoracic disc herniation is more likely to develop in these patients. Appropriate treatment of thoracic and thoracolumbar disc herniation is surgical, provided that the herniation is associated with incapacitating pain or abnormal neurologic ndings. Surgical approaches to treatment of disc herniation in this region include anterior transthoracic discectomy (see Fig. 3052) with or without fusion, posterolateral decompression from a transpedicular approach, and a costotransversectomy approach. Standard laminectomy should not be used to remove a thoracic or thoracolumbar herniated disc. Because spinal cord manipulation is required to remove a disc through a standard posterior laminectomy, worsening of the neurologic condition can occur and has been reported in up to 45% of patients treated with this approach. The results reported for the anterior transthoracic, costotransversectomy, and posterolateral transpedicle approaches all show that 80% to 90% of patients improve after surgery, with the remainder being without change or deterioration.83, 170, 187, 216, 219 Because the condition is traumatically induced, internal xation and fusion should be considered, concurrent with the discectomy.
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Bohlman and Zdelblick31 reviewed 19 patients treated surgically for thoracic disc herniation; 8 were treated with a transthoracic approach, and the remaining 11 were treated with a costotransversectomy approach. They concluded that the transthoracic approach was preferable because it greatly improved visualization of the pertinent anatomic structures, including the disc and the neural elements. All seven patients with paralysis improved after anterior transthoracic decompression. Thoracoscopy has been used as a diagnostic tool for many years. It has been successfully used in complex surgical procedures, including thoracic discectomy. The potential benets of video-assisted thoracoscopic surgery include reduced postoperative pain, improved early shoulder girdle function, and a shorter hospital stay.171 Regan and associates reported on video-assisted thoracoscopic surgery performed on 12 thoracic spinal patients, including 5 discectomies.227 Postoperative CT scans showed adequate spinal cord decompression, and pain was relieved in all patients. Huntington and associates undertook a randomized comparison of 30 thoracoscopic and 30 open thoracic discectomies for anterior spinal fusion in a live sheep model.137 Their data showed no signicant difference in the amount of disc end-plate resected between the two techniques.
OPERATIVE TREATMENT
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Selection of the instrumentation and type of construct is not random, nor should it be based entirely on the preference of the surgeon. All systems have relative strengths and weaknesses that can be used to advantage. The optimal system and construct for a given fracture should counteract the deforming forces and maximally diminish the degree of instability. For example, burst fractures are caused by exion and axial loading forces, so correction of deformity and restoration of stability are best achieved by a system that can impart extension and distraction. Therefore, neither a Harrington rod nor Luque segmental instrumentation is optimal for these fractures; the use of segmental xation with multiple hook or screw xation is preferable.
posteriorly at the hook sites cephalad and caudad to the injury while constantly pushing anteriorly toward the fractured vertebra through the lamina and pedicles, either at or above and below the level of injury. These vectors are achieved at the expense of increased force at the hooklaminar junction with the use of square-ended Moe rods.61 This three- or four-point xation translates to vector forces that reduce the vertebral body fracture deformity anteriorly and close the disruption posteriorly. The distraction rod can be used successfully to stabilize and reduce burst fractures, fracture-dislocations, and compression fractures with associated posterior element disruption. They may also be appropriate in exion-distraction injuries that have a burst component associated with the vertebral body injury. In the latter case, placement of a tension band (spinous process wires or laminar compression rod) may be necessary posteriorly before application of the distraction force.96 Compression rods xed to hooks around the lamina have been shown to provide a stronger construct than possible with distraction systems when tested against exion loading,263 although some authors disagree.222, 242 Rod-hook distraction systems tend to fail by dislodgment at the rod-hook junction, at the hook-lamina junction, or at the ratchet-rod junction. Compression rods, perhaps because they better resist exion and rotation forces, contribute to failure by fracturing the lamina to which the hooks are attached.82, 170 Many varied recommendations have been made regarding the number of spinal segments to instrument, the number of spinal segments to fuse,45 and whether the instrumentation should be removed after the spinal injury has healed. Early recommendations were to apply instrumentation from three levels above the injury to two levels below the injury, fuse all the intervening segments, and not remove the instrumentation unless specic problems occur.66 The optimal length should be determined by the length of the lever arm necessary to achieve the reduction.14
Rod Sleeve Distraction Instrumentation

The Edwards instrumentation system, which was initially designed for treating spinal trauma, used ratcheted universal rods with an outer diameter similar to that of the Harrington distraction rods but with a large core diameter; the system could be used for either distraction or compression. It is combined with polyethylene rod sleeves and an improved anatomic hook in three sizes rather than the standard curved Harrington hooks.7981, 83, 176 Most burst fractures result from varying degrees of axial compression and exion, and the two components of the Edwards system allowed individual adjustment of distraction and extension forces to correct the deformity. The rod provided distraction across the fracture site, which in most cases restored vertebral and disc height. The rod sleeves (in three sizes) were used to generate the central, anteriorly directed force vector to allow for sagittal plane reduction (Fig. 3040). Sagittal-plane correction was better than with other posterior instrumentation systems because the rod sleeves allowed some continued postoperative increase in reduction by gradual accommodation to the spines
Hook-Rod Systems
The Harrington rod system was one of the rst rod-hook systems to treat fractures in the thoracic and the lumbar segments of the spine.1, 28, 95, 127, 177, 225, 279 Although it has allowed fracture reduction and spine stabilization, as well as early rehabilitation, it has little intrinsic stability and is mentioned here primarily for historical purposes.* Reduction of anterior vertebral body fractures is dependent on both distraction and extension (lordotic) forces created by the rods and hooks (see Figs. 3022 and 3032). With contouring, the rods must achieve three- or four-point xation to provide force vectors that pull
*See references 1, 51, 67, 71, 72, 96, 101, 142, 143, 145, 152, 200, 225, 231, 242, 251, 263.
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FIGURE 3040. This 53-year-old man was involved in a motor vehicle accident and sustained an unstable fracture of his spine. A, A lateral radiograph shows compression of the T10 vertebral body. B, A sagittal computed tomographic (CT) reconstruction shows propagation of the fracture through the posterior elements at T9. C, A CT scan through T10 reveals a comminuted fracture through the body and posterior elements. The patient was neurologically intact, possibly as a result of disruption of the posterior ring, which provided decompression of the canal. CT views above and below T10 revealed laminar fractures at T8 and T9 superiorly and at T11 inferiorly. D, A postoperative anteroposterior radiograph shows stabilization with an Edwards distraction system. Bridging sleeves are positioned superior and inferior to the rst intact laminar levels to avoid the fractured posterior elements. E, A lateral postoperative lm conrms proper positioning of the sleeves over the superior facet points, with realignment and restoration of height at T10. Because of the long instrumentation, transverse loading devices were used to link the rods and help solidify the construction.
normal viscoelastic creep and by constant tensioning of the anterior longitudinal ligament through interoperative bowing of the rods within their elastic range.47 In addition, the sleeves produced increased rotational stability by securely wedging between the spinous process and the facet joints. Such wedging improved the overall rotational rigidity of the system in comparison to other rod-hook systems. The results of use of the Edwards system for fracture management in 135 patients treated at a single center were reported by Edwards and Levine.81 Postoperative follow-up results at 1 to 4 years and at 6 to 10 years were reported in 122 of these patients. After partial reduction with the use of transverse rolls on a Stryker frame, preoperative deformity averaged 14 of kyphosis, 8 mm of displacement, and 68% loss of vertebral body and disc height. The initial study included 61 patients with incomplete paralysis, 41 with complete paralysis, and 33 who were neurologically normal. The immediate postoperative kyphosis was reduced from 14 to 1 (4). At late follow-up, the kyphosis had increased to 0.5 (5).
Vertebral height was restored from 68% preoperatively to 96% in the immediate postoperative period and was 90% (8%) at late follow-up. Translation was similarly reduced from 8 mm preoperatively to 0.8 mm (1.5 mm) immediately after surgery and at late follow-up. For the last 32 cases in this series, preoperative and postoperative CT scans of the spinal canal area were performed at the level of injury, and ndings were compared with those for the adjacent normal levels. For injuries treated within 2 days, rod sleeve reduction increased the canal area from 55% to 87% of normal. If surgery was performed between 3 and 14 days after injury, the canal area was increased from 53% to 76% of normal.81
Segmental Instrumentation Systems

The use of segmental xation instrumentation systems has improved the treatment of spinal deformities such as kyphosis and scoliosis.51 The primary advantage of these
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systems is that multiple hooks and pedicle screws can be used in both distraction and compression modes, thereby allowing correction of complex deformities and providing stability while maintaining normal sagittal contours. This system is further strengthened with the use of transverse traction devices to convert the system to a rigid rectangle46 (see Figs. 3025, 3044, and 3047). With these systems, increased stability is obtained without the apparent increased risk of neurologic damage reported with the Luque sublaminar wiring technique. The role of segmental xation in the treatment of spinal trauma continues to evolve. One disadvantage is that the surgical time required to insert the instrumentation may be slightly greater than with distraction rod systems, especially early in the surgeons experience. A second disadvantage is that a moderate amount of manipulation is required when connecting multiple hooks to rods while simultaneously reducing the unstable spinal injury. One advantage of segmental xation is that under certain circumstances postoperative bracing may be eliminated (especially in the thoracic spine) without jeopardizing the stability and eventual healing of the fusion. Another potential advantage is that these techniques may allow shorter instrumentation length, thus immobilizing fewer segments.222, 272, 280283 The pattern of hook placement varies from author to author, but a few general principles for the constructs may be used in most cases (Fig. 3041). Cephalad, a claw conguration either at a single level or at adjacent levels is the mainstay of most constructs (Fig. 3042). Many different recommendations have been made regarding the length of instrumentation and conguration of the hooks and pedicle screws. Shufebarger (personal communication) recommended that the lever arms be of equal length above and below the fracture and stressed the use of a double lamina claw at both the rostral and caudal extremes of instrumentation. Although in the thoracic spine he would not hesitate to extend xation to three levels above and two levels below the injury, at the thoracolumbar junction, he recommended instrumentation two levels above and one level below the fracture. However, a short construct should not be used unless the comminution of the anterior column is minimal or anterior stability is restored with a strut graft. A minimum of three hooks must be used on each rod proximal to the fracture, whether in the thoracic area or at the thoracolumbar junction. The construct may consist of at least one single-level claw plus an additional pedicle hook below it (augmented claw) or two single-level claws spaced one segment apart. A bilaminar claw must be placed distal to the fracture because distal single-level claws fail 20% of the time as a result of laminar fractures caused by the huge force placed on that single level.203 If a single-level distal claw is used, it must be augmented with an anterior strut. The claw provides signicantly increased holding power over a single upgoing hook, thereby allowing greater potential for correction of deformity while decreasing the rate of instrumentation failure. Another advantage of segmental xation over single hook-rod systems is the ability to provide both distractive and compressive forces over the same construct and thus allow maintenance of
normal sagittal contours. In general, compression maintains lumbar lordosis, and distraction is used to maintain thoracic kyphosis.197 Pedicle screws placed either above or below a vertebral body fracture can be used like the rod sleeves of the Edwards system to generate a central, anteriorly directed force vector to assist in maintaining or creating sagittalplane reduction (Fig. 3043). In fractures at the thoracolumbar junction, where the pedicles are relatively large, a construct of all pedicle screws may be considered. In fractures occurring in the lower thoracic spine, a combination of hooks cephalad to the fracture and pedicle screws below the fracture may be used. In fractures occurring in the middle and upper thoracic spine, hook constructs are most commonly used. Pedicle screws used in this manner, with adequate xation above and below with either a claw conguration or additional pedicle screws, can improve the overall rigidity of the system and maintain the reduction until fusion occurs. When treating signicant burst fractures with posterior instrumentation, it is important to look at the biomechanical implications. In a mechanical study by Dufeld and colleagues, it was concluded that single-level posterior instrumentation adjacent to a comminuted segment will have a nite fatigue life and that anterior column support equivalent to a healthy motion segment can reduce the internal bending moments within an implant to levels that have a low probability of causing fatigue of the implant. They also showed that instrumentation of two levels adjacent to a comminuted vertebra as opposed to a single level will reduce the exion bending moment in the implant. These results illustrate the clinical need to create load sharing when possible and to select implants capable of maintaining reduction and supporting the spine until fusion has occurred.72 Other studies have shown the importance of transxing these constructs with cross-connectors. In a mechanical study of transpedicular spine instrumentation, Carson and associates showed that transxing bilevel constructs stabilizes them to all modes of loading and will reduce the excessive increase in internal components of force and moment associated with linkage instability.43 Akbarnia and colleagues5 reviewed 67 patients with thoracic and lumbar spine injuries treated at two different centers; the range of follow-up was 3 to 26 months. Thirty-nine of these patients had injuries between T11 and L2. Most had instrumentation extending over ve to eight vertebral levels, with an average of 10 hooks or screws per patient. The degree of preoperative and postoperative kyphosis and canal compromise was not detailed in this report. The authors stated that alignment was maintained in 65 patients throughout the duration of follow-up. Fusion was denitely achieved in 31 patients, and two pseudarthroses were performed. It was too early to assess fusion status in the remaining 34 patients. No patient was neurologically worse after surgery. Complications included two deep wound infections. Hook dislodgment or screw pull-out occurred in ve patients, although all ve had fusion at follow-up. In the thoracic spine, these authors recommended instrumentation three levels above and three levels below the injured segment, with claws at the extremes of instrumentation and segmental xation at the
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TP/PL T4 T6 T10
TP/L
T5 P T6 P T7 L T8
T7 L TP T8 P T9 L T10
T11 P T12 P L1 L L2
T9
T11 P
L3 P
A
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L3
L3 L/PS
PS
FIGURE 3041. Hook and screw placement patterns used with rigid segmental instrumentation systems for the treatment of thoracic and thoracolumbar spine injuries. A, T7 fracture. The instrumentation used is a claw conguration above and below the injury. For a very unstable injury pattern, pedicle hooks may be added one level above the injury. B, T9 fracture. An alternative hook pattern can be used in low thoracic fractures. A unilaminar claw is formed with hooks over the top of the transverse process and a pedicle hook at the same level to create a single-level claw, which is then reinforced with a single upgoing hook at the adjacent level to place the upper portion of the construct in two levels rather than three. C, L1 burst fracture. A construct similar to that in A may be used. Note that below T10, pedicle hooks are replaced by cephalad-facing lamina hooks. D, In the lumbar spine, where the pedicles are large enough, screws may be substituted for hooks, with the addition of cephalad lamina hooks placed at the distal end of the construct for additional stability in highly unstable injury patterns. E, Another construct consisting of pedicle screws two levels above and below the fracture to provide stability in all planes. Abbreviations: L, lamina hook; P, pedicle hook; PS, pedicle screw; TP, transverse process hook.
intervening levels. In the thoracolumbar spine they recommended that fusion extend three levels above and two levels below the fracture. In the lumbar spine they suggested extending the xation two levels above and one level below the injured segment. For both thoracolumbar
and lumbar hook arrangements they recommended that double claws be used superiorly but had varied recommendations for the caudal spinal xation. Stambough260 reported on 55 patients treated with Cotrel-Dubousset instrumentation by a single surgeon,
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B C
FIGURE 3042. Claw congurations used for proximal and distal xation in rigid segmental instrumentation systems. All these constructs may be used at single levels or two adjacent levels. A, Transverse process hook with a pedicle hook claw. B, Superior lamina hook with a pedicle hook claw. C, Supralaminar and infralaminar hook claw, useful below T10 where application of pedicle hooks is not recommended. D, Pedicle screw with an infralaminar hook; this is useful in the lumbar spine, where pedicles are large enough to accept pedicle screws. (A D, Redrawn from Bridwell, K.H.; DeWald, R.L., eds. The Textbook of Spinal Surgery. Philadelphia, J.B. Lippincott, 1991.)
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FIGURE 3043. This 30-year-old woman was involved in a motor vehicle accident and sustained a T12 burst fracture without neurologic decit. A, An anteroposterior radiograph shows minimal loss of height with widening of the pedicles. B, A lateral radiograph shows approximately 30% loss of height and local kyphosis of 8. The patient was treated initially with bedrest and a thoracolumbosacral orthosis. C, Two weeks after the injury, a repeat lateral radiograph shows greater than 50% loss of height and local kyphosis of 25. Illustration continued on following page
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FIGURE 3043. Continued. D, The patient was treated operatively with posterior segmental instrumentation with a claw at T9 and pedicle screws at T11 and at L1 and L2. E, A lateral radiograph shows restoration of height and sagittal alignment at the injury level.
with an average of 48 months follow-up. No instances of failure of instrumentation or pseudarthrosis formation were reported in his series. At nal follow-up, deterioration in alignment was minimal in comparison to the immediate postoperative period. Argenson and co-workers reported their results in 65 patients treated for thoracic or lumbar spine fractures with a follow-up of 6 months or longer.13 They recommended that instrumentation extend three levels above and two levels below the injured segment in the thoracic spine and the use of pedicular or double laminar hooks (claws) at the extremes of instrumentation with varied intermediate connections. Forty-nine patients had fractures from T11 to L2. Argenson and co-workers initially extended the instrumentation two levels above and two levels below the fracture with the use of hooks only and obtained satisfactory early results. With shortening of the instrumentation, they noted considerable problems (e.g., loss of xation in two patients and loss of reduction in four others). Their current recommendations are to use pedicle screws one level above and one level below the level of fracture, accompanied by pedicle or laminar hooks two levels cephalad to the fractured vertebra and at the same
level as the caudal pedicle screws. In 12 patients treated in this fashion, 1 had considerable loss of reduction as a result of sepsis, whereas the others averaged only 4.3 loss of reduction at follow-up. The earlier results of this group with the use of only hooks or only screws resulted in an average loss of reduction of 8.6. Graziano118 reported his results in 14 patients for whom he used lumbar pedicle screws and thoracic pedicletransverse process hook claws in a hybrid CotrelDubousset construct. The pedicle screw xation was used one level below the injured segment. Graziano reported breakage of only one screw, and increased kyphosis developed in one patient after surgery. This construct offers the advantages of short-segment xation in the lumbar spine, where motion preservation is important, while providing a longer xation span above the level of injury, which helps add rigidity to the construct. In the lumbar spine, Argenson and co-workers13 recommended the use of short instrumentation and pedicle screw fusion one level above and one level below the injury, combined with a sublaminar hook at the inferior extent of the instrumentation. Twenty patients were treated in this fashion, and the average loss of
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correction in the rst 15 patients was 9. Even though this loss of reduction seems signicant, the nal lordosis at the level of injury was 4, which is very close to normal physiologic alignment. Complications in this series included partial xation loosening in three, broken screws in four, and postoperative infection in eight patients. The authors attributed this high infection rate to the increased duration of surgery associated with the learning curve of the surgeon. Suk and associates265 reviewed their treatment of 18 lumbar fractures, including 5 fractures of L1, 2 fractures of L2, and 1 fracture of L3. They used pedicle screws for xation, and their average instrumentation extended over two segments. This technique contrasts with their previous experience of using segmental wiring in combination with Harrington distraction rods that spanned almost six segments. They found a postoperative kyphosis angle of 3.2 with the use of Cotrel-Dubousset instrumentation as compared with 4.3 for segmentally wired Harrington rods. Because the follow-up period was longer than 4 months in only 11 patients, these results must be categorized as preliminary. McBride recommended that when instrumentation is to be extended to L5, the fusion should be stopped short (at L4) and the hardware removed 9 to 12 months later, as with the rod long, fuse short technique with Harrington rods.197 The appropriate length of instrumentation was addressed by McKinley and colleagues202 in a review of only seven patients monitored for more than 24 months after Cotrel-Dubousset pedicle instrumentation with screws one level above and one level below the fractured vertebra. They observed an average loss of 18 of correction (range of 8 to 26) and a signicant incidence of screw breakage requiring reoperation. They concluded that patients with signicant injury to the anterior and middle columns of the spine require anterior corpectomy and fusion to prevent this type of late deterioration if short-segment Cotrel-Dubousset instrumentation with screw xation is used posteriorly. However, the data supporting this conclusion were limited, but a similar conclusion was also reached by Gereesan.109 Fabris and co-workers reported their results with Cotrel-Dubousset instrumentation on nine cases of seat belttype injuries of the thoracolumbar spine.90 They used a short compression construct spanning only a single motion segment and reported excellent maintenance of correction of deformity and no instrumentation failure. Benzel also described the use of short-segment compression instrumentation for the treatment of burst fractures after rst reconstructing the vertebral body with a strut graft.23 The construct consisted of a claw above and a claw below the injured segment. It spanned signicantly fewer motion segments than typical of traditional constructs while still maintaining excellent correction of deformity (<2 loss of correction at last follow-up). They noted that short constructs functioned best in compression and warned that short distraction constructs tended to fail over time. In these studies, the recommendations concerning postoperative use of a TLSO are variable. Akbarnia and colleagues6 recommended the use of a brace if the patient had osteoporotic bone or at surgery received less than a
double laminar claw, or its equivalent, both proximally and distally. Thirty-six of their patients had no immobilization, and 31 used a TLSO or other brace for an average of 4 months. Argenson and co-workers13 did not recommend the use of a postoperative brace for any of their patients, whereas Suk and associates265 treated all their patients with a postoperative TLSO. In general, the shorter the xation and the less secure the spine-implant interface, the more likely the authors were to recommend postoperative TLSO immobilization. SURGICAL TECHNIQUE With the patient in the prone position, a midline incision is made and extended one level further both proximally and distally than the expected length of instrumentation. The most frequently recommended scheme for instrumentation includes xation two levels above and one level below the injury. Shorter instrumentation is desirable in the lumbar spine if possible, but it is not as physiologically important to limit the levels of instrumentation in the thoracic spine. The construct described is based on a claw conguration on the lamina two levels above and one below the level of injury (see Figs. 3041 and 3043). For the hooks facing caudad, a laminotomy is performed just cephalad to the lamina so that the hooks may be placed around the lamina under direct vision. For the hooks directed cephalad, a ligamentum avum stripper should be inserted beneath the lamina to prepare the site for hook placement. In the thoracic spine, thoracic hooks should be used, and in the lumbar spine, lumbar hooks should be used to obtain maximal purchase on the lamina without increasing the chance of neural compression by canal intrusion. The superior portion of the rod should be bent appropriately to conform to the slanting of the lamina in the sagittal plane and thereby minimize the chance of fracture of the lamina and failure of the system. The same attention should be paid to contouring of the rod at the caudal lamina. Additional xation can be obtained with the use of a hook facing cephalad under the lamina one level above the level of injury (see Fig. 3042A). An alternative to this system would be the use of instrumentation extending three levels above and two levels below the injury, along with cephalic and caudal claws. Hooks are directed cephalad two levels above the level of injury and caudad one level below the injury. This construct is relatively safe and extremely rigid. To improve xation in the thoracic area, the hooks directed cephalad may be pedicle hooks rather than standard lamina hooks (Fig. 3044). Additionally, the top hook may be placed on the transverse process, provided that it is of adequate size. Two transverse traction devices should be applied to connect the rods if space allows. No medial or lateral force should be applied to the rods at the time of insertion of the transverse traction device. The fusion technique should include decortication of the transverse processes, laminae, and spinous processes within the instrumentation, with care taken to not weaken any laminae that are directly supporting hooks.
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Sequential application of segmental instrumentation can also be used for reduction of dislocations, as well as denitive stabilization (Fig. 3045). A single-rod construct is placed in distraction, and distractive forces are applied until reduction of the dislocation occurs. After the reduction is achieved, the appropriate construct is placed on the contralateral side to stabilize the spine. Finally, the distraction rod is removed and replaced with a symmetric construct on the opposite side. Others have described the use of rotational maneuvers, similar to those used for correction of scoliosis, to reduce fracturedislocations.87 For patients treated with instrumentation three levels above and two levels below the injury, a circumferential rigid postoperative brace is necessary. Similarly, when instrumentation two levels above and one level below the injury is used in the lower lumbar spine, where more of the weight-bearing forces are carried through the posterior elements, use of the brace can be eliminated or reduced. The use of a TSLO for mobilization of patients instrumented two levels above and one level below an injury at the level of the thoracolumbar junction is advised. In patients with severe anterior comminution and short posterior instrumentation, anterior corpectomy and strut fusion will decrease the chance of instrumentation failure.23, 121, 191, 193
Segmental Sublaminar Wires

The Luque technique was originally used to treat patients with scoliosis, with the presumed advantage of not requiring postoperative bracing. It entailed the use of two smooth, L-shaped stainless steel rods (either 14 or 316 inch in diameter) combined with segmental wires. The wires were made of 16-gauge malleable stainless steel, passed sublaminarly, and twisted around the rods at each level to provide segmental xation (see Fig. 3032). As originally described, no hooks or pedicle screws were used. This system had two major disadvantages. Many surgeons noted an increased incidence of neurologic decits after passage of the sublaminar wires. The frequency of new neurologic decits decreased as each surgeon became more familiar with the technique (the learning curve).21, 144 This incidence of neurologic decit also varied greatly from series to series, from 0% in some to as high as 10% in others.144 Because this increase was associated with segmental wiring at the level of the fracture in both cases, these authors recommended against insertion of segmental wires in the immediate area of the fracture. The risk of dural impingement may be even greater during wire removal.116, 210 In 27% of cases, Nicastro and associates210 demonstrated more than 25% canal narrowing with removal of a single wire.
6 mm
4 mm
3 mm Print Graphic 4 mm 7 mm
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B A
C
FIGURE 3044. Placement of thoracic pedicle hooks. A, Appropriate landmarks to remove a piece of inferior articular facet to permit adequate positioning of a pedicle hook. B, A pedicle elevator is inserted into the facet joint, and after engaging the pedicle, placement is checked by moving the vertebra laterally by lateral translation of the elevator tip. C, The distance between the inferior part of the pedicle and the inferior part of the remaining inferior articular facet must be equal to the depth of the hook plate from its base to the notch. (A C, Redrawn from Bridwell, K.H.; DeWald, R.L., eds. The Textbook of Spinal Surgery. Philadelphia, J.B. Lippincott, 1991.)
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T9
T10
shortening than did Harrington distraction rods (1.5 versus 0.5 cm). To combine the advantages of both systems, a hybrid system consisting of segmentally wired Harrington distraction rods was developed.100 This system offered the obvious advantage of increased control of translation and rotation and maintained an axial distractive force while minimizing the effect of ligament relaxation and resultant hook cutout (see Fig. 3032).
T11
Pedicle Screw Fixation Systems

T12 Print Graphic
L1 Presentation L2
L3
FIGURE 3045. Use of a unilateral distraction rod for reduction of a T12L1 fracture-dislocation. Note the placement of the hooks for denitive rigid segmental instrumentation on the opposite side of the distraction instrumentation before application of the distraction. Once distraction is achieved, a rod is placed on the opposite side and secured, and then the distraction instrumentation is removed and replaced with rigid segmental instrumentation. If the injury involves disruption of the anterior longitudinal ligament, consideration should be given to placement of spinous process wiring at the level of injury before reduction to prevent overdistraction. (Redrawn from Garn, S.; Northrup, B.E., eds. Surgery for Spinal Cord Injuries. New York, Raven, 1993.)
The second major problem with this system was that it was not able to provide signicant axial support to the spine. As originally designed, the L-shaped rods had no means to resist sliding axially. Modications included use of the Harrington outrigger to achieve intraoperative distraction and, later, modied rods to resist axial collapse by xation to the lamina and the spinous processes.8, 71, 92, 93 However, collapse still remains one of the major weaknesses of this system because the spinous processes are the weakest part of the posterior elements. After their prospective study, Ferguson and Allen recommended that this system not be used for treating any injury in which the middle column is disrupted, such as a thoracolumbar burst injury, because of the danger of spinal canal narrowing with axial collapse.92, 93 This inability to provide axial support has been veried in laboratory testing. Nasca and co-workers208 instrumented thoracolumbar swine spines and then subjected them to cyclical axial compression loading. The segmentally wired L rods allowed three times greater axial
Each of the various pedicle screw xation systems currently in use has different types and sizes of screws, different mechanisms for linking the screws, and different options concerning the ability to compress, distract, or stabilize in situ.* One of the major advantages of these systems is that shorter xation is often possible, frequently with instrumentation only one level above and one level below the injured segment (see Fig. 3018). As discussed previously, the advantages of this short xation are greatest in the lumbar spine. Fortunately, the larger pedicles allow for safer placement of pedicle screws in the lower lumbar spine than possible at more proximal levels. Conversely, the benets of short-segment xation in the thoracic spine are minimal; one additional level of motion does not affect the long-term functional results. Proper screw placement in the pedicle is more difcult in the thoracic spine and upper lumbar spine because pedicle size decreases from caudad to cephalad.166, 266, 286 In addition, the risk of serious neurologic deterioration from errant screws is greater in the thoracic and thoracolumbar spine because of the presence of the spinal cord rather than only nerve roots and rootlets. Vaccaro and co-workers studied 90 screws placed in the pedicles of cadaver spines from T4 to T12 by ve experienced spine surgeons.266, 267 They found a 41% incidence of cortical perforation of the pedicle, with 23% of the screws entering the spinal canal. In view of these potential risks and benets, we believe pedicle screw systems to be most appropriate in the lumbar spine, although they can be used successfully in the thoracic spine when appropriate and when good operative technique is used (Fig. 3046). Laboratory data are available for several of these systems. Gurr and colleagues121 used a calf spine corpectomy model to evaluate different posterior instrumentation systems in combination with an anterior bone graft. Of the systems tested, they found that the Cotrel-Dubousset pedicle screw system and the VSP system of Steffee could be applied one level above and one level below the defect with restoration of the spine to original strength in terms of axial loading, forward exion, and rotation. These systems were signicantly superior to the Harrington distraction system and the Luque segmentally wired L-rod system. The limitations of this research, as stated by the authors, are that the animals were young with uniformly
*See references 3, 4, 6, 22, 52, 54, 55, 57, 64, 65, 67, 79, 108, 109, 148, 157, 166, 180, 187, 215, 244, 245, 249, 252, 265, 275, 277, 287, 289.
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FIGURE 3046. This 50-year-old man fell at work from a height of approximately 16 ft and sustained a T4 burst fracture and multiple posterior element fractures from C7 to T5. He was neurologically intact. A, A lateral radiograph shows greater than 50% loss of height and local kyphosis. B, A preoperative computed tomographic (CT) scan shows approximately 30% canal compromise and disruption of the posterior elements. C, The patient was treated operatively with segmental instrumentation involving pedicle screws from T2 to T6. D, A lateral radiograph shows restoration of height and sagittal alignment.
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FIGURE 3046. Continued. E, A postoperative CT scan shows partial restoration of the canal by ligamentotaxis and correct placement of the pedicle screws (F).
good-quality bone and the tests were performed immediately after instrumentation, thus allowing no chance to show the effect of time on loosening or fatigue failure. In addition, an anterior bone graft was implanted in each animal to provide anterior axial support. The effect of the rigidity of this instrumentation was also investigated in an in vivo animal model.121, 193 The spine beneath the instrumentation became signicantly osteoporotic, and this effect increased with time. However, the rate and quality of the fusion increased with increased rigidity of the instrumentation. The proper length of screw penetration was investigated by Krag and co-workers.164 Although most of the resistance to pull-out is achieved within the pedicle, increasing the penetration into the vertebral body from 80% to 100% (up to the anterior vertebral cortex) increased resistance to exion by 54% and to torsion by 24%. However, this increased penetration markedly increases the risk of injury to the vessels immediately adjacent to the vertebral bodies. Pull-out strength also varies signicantly with screw design.165, 286 In general, the larger the outer diameter of the screw body, the greater the resistance to bending, and larger thread depth results in greater pull-out strength. The pitch of the thread was less signicant. Crowe and Gertzbein53 evaluated the AO Fixateur Interne in a prospective study involving pedicle xation one level above and one level below the injury. They analyzed the ability of this system to reduce burst fractures of the thoracic and lumbar segments of the spine. The average spinal canal cross-sectional area in 25 patients, which had been compromised 54% preoperatively, improved to 40% compromise after surgery. This benet was most marked in patients who initially had moderate spinal canal encroachment (34% to 64%); canal compromise in this group improved on average from 54% to 31%. The improvement was less marked in patients with mild or severe spinal canal compromise and in those treated more
than 4 days after injury. In view of this modest change of 14% over all their patients, it must be questioned whether this improvement is signicant. It was the authors conclusion that when canal clearance is essential, anterior decompression is the treatment of choice. However, Doerr and co-workers68 noted that the Fixateur Interne provided canal decompression equal to that achieved with Harrington rod systems. Esses and colleagues conducted a prospective, multicenter study on the effectiveness of the Fixateur Interne for the treatment of thoracolumbar spine trauma.89 They reported a mean improvement of 30% in canal compromise and a mean correction of 14 in kyphotic deformity. Complications included screw misplacement in seven cases and three cases of broken hardware noted incidentally on follow-up radiographs. In no patient did a pseudarthrosis develop. Akbarnia and associates reviewed 61 cases of thoracolumbar and lumbar spine fractures treated with the VSP system.6 Most of their patients were instrumented one level above and one level below the injury. Ninety percent maintained their reduction, but pseudarthrosis developed in 15%, and 15% had screw breakage or dislodgment. Follow-up was short, averaging only 1 year with a range of 2 to 36 months. Liu and colleagues treated 42 patients by short segmental posterior xation with the AO Fixateur Interne. After an average follow-up of 66.1 months, they showed an average postoperative improvement of 14.2 in their kyphotic angle with an average loss of 3.3 of correction at follow-up. Complications were seen in seven patients. Implant failure occurred in six, but no complaints were noted from these patients. One patient experienced a nonunion with screw breakage, which was revised by repairing the posterior fusion and replacing the instrumentation.180 Sasso and Cotler compared Harrington instrumenta-
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tion, Luque sublaminar wire instrumentation, and pedicle screw instrumentation in 70 patients with thoracolumbar spine fractures.247 The mean number of levels instrumented was 6.0, 6.3, and 3.3, respectively. No patient sustained postoperative neurologic injury or deterioration, and complication rates were similar in all three groups. At last follow-up, the pedicle screw group had the best maintenance of sagittal contours. Markel and Graziano, in comparing Cotrel-Dubousset instrumentation with pedicle screw instrumentation, found a signicantly fewer number of levels fused in patients treated with the latter systems.189 In another study, Cresswell and colleagues compared the stability of the AO internal xation system with the Hartshill rectangle and sublaminar wiring in the treatment of thoracolumbar burst fractures. They reported that both systems allowed good initial restoration of anterior and posterior vertebral body height. However, at a 2-year follow-up, loss of body height occurred in the Hartshill group, whereas body height was signicantly better maintained in the AO group. They thought that transpedicle body grafting, which was performed as part of the treatment with the AO system, contributed in some measure to their success with this system.52 Although most studies have shown excellent initial reduction of deformity with pedicle screw instrumentation, the ability of this instrumentation to maintain that correction has been questioned.107, 248 However, loss of correction is not necessarily associated with a poor clinical result or late neurologic deterioration. For example, Carl and co-workers42 reported an average correction of deformity of 7.4 with pedicle screws, and at last follow-up the average loss of correction was 6, which left a nal correction of just over 1. Nevertheless, 97% of their patients were satised with their result, and 85% of them went back to work. Although instrumentation failure would appear to be the most likely reason for late collapse, such is not usually the case. Rather, damage to the discs adjacent to the level of injury and to supporting soft tissues may be responsible. Because the pedicle screw instrumentation spans fewer segments than the traditional (Harrington, Luque, or Cotrel-Dubousset) systems do, it may fail to include all the damaged motion segments in the fusion, thus allowing for the occurrence of late deformity. The initial series describing the use of short-segment pedicle screw systems had an unacceptable high early failure rate. McLain and associates203 reported on 19 patients in whom thoracolumbar fractures were managed with short-segment pedicle screw instrumentation. Although no neurologic or vascular complications occurred in this small group, the rate of early xation failure was disturbingly high (10 of 19 patients), with resultant progressive deformity and pain. They noted three main modes of screw failure: bending, breaking, and pull-out. A signicant number of screw failures were associated with in situ rod bending, which possibly weakened the screws by prestressing them. Others have reported similarly high rates of early failure of short-segment pedicle screw instrumentation. However, such failure does not appear to be a problem when pedicle screw systems are used for degenerative conditions, possibly because the anterior and
middle columns are intact and, therefore, the instrumentation is load sharing. With signicant disruption of the anterior and middle columns (i.e., in traumatic injury), most of the load must be borne by the instrumentation, a situation that can lead to failure. Kostuik and colleagues161 performed a biomechanical study on shortsegment pedicle screw instrumentation systems and noted that the bending moment of the screws increased 300% after disruption of the anterior and middle columns. McCormack and associates198 were able to clinically predict patients who were at higher risk for instrumentation failure by classifying the amount of anterior and middle column disruption. A number of alternatives can be used for the prevention of such failures, including reconstruction of the anterior and middle columns by strut grafting. Ebelke and co-workers76 performed a survivorship analysis of pedicle screw instrumentation in patients with burst fractures treated with or without additional anterior decompression and strut grafting. Patients treated by anterior reconstruction had a 100% implant survivorship rate at 22 months, whereas those treated with posterior pedicle screws alone had an implant survival rate of 68% at 9 months, which dropped to 50% at 19 months. Other suggestions include the use of a hybrid hook-claw construct two to three segments above the level of injury with pedicle screws below.42 This construct is particularly useful at the thoracolumbar junction, where fusion of an increased number of motion segments does not result in increased morbidity from loss of motion. In a prospective study treating thoracolumbar injuries with Cotrel-Dubousset segmental transpedicular xation two levels above and one level below, Katonis and colleagues showed decreased instrument failure and sagittal collapse.149 Mermelstein and associates performed a biomechanical study to analyze the stability of burst fractures when reinforced with hydroxyapatite cement through a transpedicular approach and stabilized with short-segment pedicle screw instrumentation. Their results showed that reconstruction with hydroxyapatite cement reduced pedicle screw bending moments by 59% in exion and 38% in extension. They concluded that this technique may improve outcomes in burst fracture patients without the need for an anterior approach.204 Finally, the addition of supplemental hooks at the same levels as the pedicle screws, either cephalad, caudad, or both, may signicantly decrease failure rates.46, 132 Also, the addition of pedicle screws at the level of the fracture gives three-point xation and may prevent collapse, as with the Edwards hook-rod-sleeve construct. If this technique is used, the screws need to be angled away from the fractured end-plates. It should also be remembered that most screw-plate systems cannot easily provide distraction or anteriorly directed forces to achieve maximal reduction and preserve anatomic sagittal alignment. Systems that use hooks or screws (or both) attached to rods are better able to achieve these goals.288 SURGICAL TECHNIQUE Because many different pedicle screw xation devices are currently available and more are in the process of
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FIGURE 3047. Proper positioning of pedicle screw instrumentation. A, The central portion of the pedicle can be identied by the intersection of two lines. The transverse line bisects the transverse process of each level, and the longitudinal line runs in a cephalad-to-caudal direction and bisects the facet joints. B, A transverse section shows the ideal location for the pedicle screws. It also indicates the proximity of the neural elements to these screws, both within and outside the spinal canal. The medial-to-lateral inclination of each of these pedicles and screws will vary, depending on the level of the spine (as outlined in the section of this chapter on anatomy). (A Redrawn from Leona Allison.)
development, this surgical description is general, with emphasis on proper positioning of the pedicle screws. As stated in the previous section, xation of one pedicle above and one pedicle below the level of injury may be adequate, provided that the anterior fragmentation is minimal. If the anterior comminution is more signicant, the alternatives are to extend the instrumentation to two levels above and two levels below the injury or plan to perform anterior corpectomy and fusion of the fractured vertebra at a later date to provide anterior axial support. The patient is placed in the prone position, and a midline incision is made to expose the spinous processes, laminae, facet joints, and transverse processes of each level to be instrumented. The orientation of the pedicles is approximately 4 from sagittal at T12 and 11 from sagittal at L1, slowly increasing to 30 from sagittal at the L5 level.285 Pedicle diameter similarly varies and is approximately 8 mm at T12, L1, L2, and L3. It increases to approximately 1 cm at L4 and almost 1.3 cm at L5. A helpful way to assess angulation from the sagittal plane is to measure it on the patients CT scan. Pedicle diameter can also be determined from the CT scan. The central portion of the pedicle in a cranial-to-caudal direction can be approximated by passing a line through the center of the transverse processes of the vertebral body bilaterally. This line bisects the midpoint of the pedicles. The midportion crosses the transverse process line in a medial-to-lateral direction at a point dened by a line
drawn through the facet joints244 (Fig. 3047A). In the lumbar spine, the mammillary process, just lateral to the facets, is useful to guide entry into the pedicle. Once the soft tissues have been completely removed and the bone in the area exposed, a high-speed bur can be used to remove the outer cortex over the chosen entry point. An awl or 000 curette can then be used to penetrate the pedicle and the vertebral body while maintaining the appropriate inclination from the sagittal plane. Craniocaudal tilt is best discerned from a lateral scout radiograph. Intraoperative radiography or uoroscopy can be used to assess the position. If insertion of these screws is based only on anatomic landmarks and the experience of the spinal surgeon, the chance of having a screw outside the desired boundaries of the pedicle may be as high as 30%.270 The use of intraoperative radiographs and uoroscopy helps decrease this risk. Each hole can be probed with an angled instrument, such as a nerve hook or depth gauge, in all four quadrants from its anterior to its posterior extent to be certain that the pedicle has been entered and the cortex has not been violated. The hole can be tapped, if necessary, for the instrumentation to be used. The pedicle screws are then inserted. Regardless of the type of instrumentation, care should be taken to insert the screws with only two to three ngertips on the wrench or screwdriver to avoid stripping the threads within the pedicle and vertebral body. Because of the high risk of vascular and visceral injury, the anterior
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cortex of the vertebra should not be violated from the midthoracic region to L5, unless it is essential to increase xation strength, as in an osteoporotic spine. Over the sacrum, it is often necessary to advance one or two threads through the anterior cortex because xation strength increases with bicortical purchase.164 An additional consideration during placement of these screws is whether the plate, rod, or pedicle screw itself will violate an adjacent normal joint. The potential for this complication is determined by the basic design of the pedicle screw xation device and cannot usually be altered by the surgeon, so it must be considered when initially selecting the pedicle screw instrumentation system. As with all other instrumentation systems used to treat spinal fractures, achievement of reduction and normal sagittal alignment is one of the primary goals of surgical treatment. Both lordosis forces and distracting forces can be applied through short-segment pedicle screw constructs to achieve these desired outcomes (Fig. 3048). Radiographs in both the AP and the lateral planes should be obtained with the nal instrumentation system in place to be certain that the fracture is adequately reduced, sagittal spinal alignment is satisfactory, and each of the pedicle screws is in the desired position (see Fig. 3047B). A useful method for re-creating lordosis is placement of a screw at the level of injury. When used in conjunction with contouring of the rod, excellent three-point xation may be achieved. Another method of restoring lordosis is to leave the caudal aspect of the rod angled at approximately 15 up from the cephalad screw (best performed with screw heads that allow angulation), with the cephalad aspect xed to the spine. The rod is then forced down to engage the caudal screws. This technique provides distraction and lordosis of the proximal segments. As with all other instrumentation systems, solid fusion is one of the primary goals of surgery. Adequate care should be taken to decorticate the transverse processes and the lateral aspects of the superior facets to increase the
chance of achieving fusion. If the pedicle screw xation system uses plates, it is important that the bone graft be inserted before application of the plates because the procedure becomes more difcult after the plates have been secured in position. Finally, a number of newer instrumentation systems are made of titanium, which allows for better postoperative imaging, particularly MRI.77
Posterolateral Decompression
Surgical decompression frequently equates to surgical reduction when discussing treatment of thoracic and thoracolumbar spine injuries. If complete reduction can be achieved, no other decompression is needed. Edwards and Levine showed that surgical reduction performed within 2 days of injury restores the spinal canal area by an additional 32% whereas surgery performed between 3 and 14 days after injury restores only 23%.80, 83 They also found that little or no improvement occurs when posterior instrumentation is delayed for more than 2 weeks. Crutcher and co-workers54 reported similar results with the use of a simple Harrington construct and achieved an approximately 50% reduction in canal clearance. The fracture pattern inuences the adequacy of decompression, with Denis type A fractures having signicantly better canal clearance by indirect means than Denis type B fractures. Therefore, with early surgery and better surgical reduction, the chance of needing any formal neural decompression is lessened. The adequacy of reduction cannot be easily assessed by plain radiography. A postoperative myelo-CT scan is an effective way to assess for residual neural compression.33, 105 If a signicant abnormality is found, anterior decompression can be performed at a later date. In addition, if anatomic realignment has been achieved, some resorption of bone from within the spinal canal will occur over the course of the next year, thereby lessening the extent of neural compression.53 Krompinger and colleagues168 reviewed 29 patients with injuries of the thoracic or lumbar spine treated nonoperatively; 14 had canal compromise greater than 25% on initial evaluation. Bone remodeling of the compromised canal was noted in 11 of these 14 patients, and canal compromise of less than 25% resolved completely in 4 of 8 cases. Similar results during nonoperative treatment of burst fractures have been reported by others.41 Edwards and associates82 noted comparable canal fragment resorption in patients treated with rod sleeve reduction and fusion, and Sjostrom and colleagues256 noted resorption of intracanal fragments after the application of pedicle screw constructs and fusion. Willen and co-workers,279 however, reported that patients with more than 50% canal compromise rarely had signicant resorption. With these factors kept in mind, some patients in whom signicant neural compression remains and is not improved by posterior instrumentation and reduction may still require late operative treatment of fractures of the thoracic or thoracolumbar spine. Posterolateral decompression has also been used at the time of posterior instrumentation. The advantage of the posterolateral technique is that it allows stabilization of severe spine injuries, including
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FIGURE 3048. Application of both distraction and lordosis forces through short pedicle screw constructs is necessary to achieve normal sagittal alignment. (Redrawn from Muller, M.E.; Allgower, M., eds. Manual of Internal Fixation, 2nd ed. Heidelberg, Springer-Verlag, 1991.)
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fracture-dislocations, and at the same time allows some degree of neural decompression without requiring a second surgical procedure.74 One disadvantage of this technique is that it necessarily requires removal of posterior and posterolateral bone and may thus further jeopardize spinal stability and eventual fusion.16 The second major disadvantage is that it is a relatively blind procedure because the dura and neural elements lie between the surgeon and the anterior compressive tissue. The posterolateral technique has been evaluated by Garn and colleagues.106 In that series, nine patients with burst fractures of the thoracic or lumbar spine were treated by posterolateral decompression and evaluated with postoperative CT scans. Postoperative CT scanning showed only one patient with bone remaining in the canal. Hardaker and co-workers126 reported the use of bilateral transpedicular decompression with posterior instrumentation and fusion for severe burst fractures with an average canal compromise of more than 65%. Although anterior decompression would normally be required for such extreme amounts of canal compromise, only one patient in the study underwent an additional anterior procedure. Seventy-seven percent of the patients with a neurologic decit had signicant improvement, and signicant kyphotic deformity had not developed in any patient at follow-up. Hu and associates135 compared anterior decompression with transpedicular decompression in patients with incomplete neurologic decits and found no additional benet for anterior vertebrectomy over simple transpedicular decompression. Both treatments resulted in signicant neurologic improvement when compared with a similar group of patients treated by indirect reduction maneuvers alone. Others have reported comparable results with the use of transpedicular decompression.268 In contrast, Lemons and colleagues172 compared direct decompression by a posterolateral route with indirect reduction and found no signicant differences in improvement in canal clearance or neurologic function. They concluded that the posterolateral transpedicular approach is of questionable value for the treatment of burst fractures. SURGICAL TECHNIQUE Posterolateral decompression is performed as part of a posterior stabilizing operation in patients with thoracic, thoracolumbar, or lumbar spine injuries. Before the instrumentation system is applied and before any posterolateral decompression, the CT transverse sections at the level of the injury should be studied to determine which side of the spinal canal has the more severe neural compression. The instrumentation should be inserted rst on the side with the smaller amount of neural compression and corrective forces then applied to reduce the spine injury. In most cases, these forces include a combination of distraction and lordosis with three- or four-point xation and the force vector directed anteriorly at the level of injury. Attention is then directed to the side of the spine that is free of instrumentation (Fig. 3049A). A laminotomy is performed at the level of maximal neural compression, which is most commonly the area between the pedicles of the fractured vertebra. At this level, the adjacent spinous
processes are each trimmed and the intervening ligamentum avum is excised. Five millimeters of adjacent bone is removed, including portions of the cephalic and caudal laminae, as well as the medial portion of the facet joint at that level. The posterior edge of the fracture (anterior to the dura) can be palpated with an angled dural elevator (e.g., Frazier elevator) to assess the degree of residual canal compromise. The laminotomy should be extended distally at least to the inferior edge of the pedicle. Once the medial border of the pedicle is identied, a power bur is used to drill into the central portion of the pedicle with all cortices left intact (see Fig. 3049B). A thin rongeur or curette is then used to remove the medial cortex of the pedicle, with care taken to preserve the nerve root exiting below it (see Fig. 3049C). A trough is cut 1 cm into the vertebral body anterior to the medial portion of the pedicle that has been thinned. Reverse-angle curettes can be inserted through this opening, and any bone fragments compressing the anterior neural elements can be impacted into the vertebral body or brought out through the lateral trough previously made (see Fig. 3045D). Mimatsu and co-workers205 have designed a variety of impactors specically for use in the transpedicular approach. It is possible to extend this decompression slightly past midline through this unilateral exposure (see Fig. 3049E). If the decompression is adequate on both sides of the canal, no further decompression is needed. If further decompression is needed on the side that has already been instrumented, a second rod is inserted on the side already decompressed, the instrumentation is removed, transpedicular decompression is performed on the rst side, and the instrumentation is reinserted.
Anterior Transthoracic Decompression and Fusion

Anterior transthoracic decompression and fusion may be used for the treatment of thoracic and thoracolumbar spine fractures (T2 to L1), either as a single operative procedure or in conjunction with a posterior stabilization procedure. It is most indicated in patients with maximal anterior neural compression, patients with an incomplete spinal cord injury, and those with minimal instability, as well as for the delayed treatment of injuries, including late post-traumatic deformities123125, 131 (see Fig. 3026). This transthoracic approach for trauma was rst described by Paul and colleagues,220 and detailed techniques along with long-term results of this treatment have been published by Bohlman and associates.29, 30 In a review of acute injuries of the upper thoracic spine with paralysis, eight patients were treated by anterior decompression and fusion for residual neural compression. All had reached a plateau in terms of neurologic recovery at the time of anterior decompression. Postoperatively, ve patients were able to walk without aid, two recovered partially and were able to walk with crutches and braces, and one patient improved but remained unable to ambulate. No patient lost neurologic function as a result of this procedure, and solid fusion developed in all patients, even though three had previously undergone laminectomy.
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Presentation
E
FIGURE 3049. Technique of posterolateral decompression of the spinal canal. A, A posterior view of the spine shows the region of exposure and the amount of pedicle resection required to achieve posterolateral decompression. Care should be taken to not cut inferolaterally across the pars interarticularis. B, The ligamentum avum has been resected at the level of injury, and the dura has been exposed. Bone is resected laterally up to the medial extent of the pedicle and caudally to the inferior extent of the pedicle. A bur is used to make a hole in the central portion of the pedicle, with the hole proceeding anteriorly toward the vertebral body. A circumferential rim of cortical bone is left in place. The nerve root is shown medial to the pedicle and exiting below the pedicle. Care should be taken to not injure this nerve root. C, The medial wall of the pedicle is removed with a rongeur such as a pituitary rongeur. D, A transverse section shows the hole burred down through the pedicle and into the vertebral body. A reverse-angle curette is used to tap bone out of the spinal canal and into the trough that has been drilled out of the vertebral body. Large bone fragments may also be pulled out through this lateral trough. Care must be taken to not hook the anterior aspect of the dura. E, A transverse section shows the nal result after decompression. By performing unilateral posterolateral transpedicle decompression, it is usually possible to adequately decompress slightly past the midline.
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None was augmented with any type of instrumentation either anteriorly or posteriorly. No data were given concerning residual angulation at the site of injury.30 Most published series of transthoracic decompression for treatment of spinal trauma review either patients with minimal to moderate levels of instability or those who are no longer in the acute stage after their injury. In the latter group, some healing with partial stabilization may already have occurred. Gurr and colleagues121 showed in an animal corpectomy model that the strength of the spine is markedly reduced after corpectomy in comparison to the strength of an intact spine. This reduction in strength is true for axial loading, exion loading, and rotation testing. The addition of an iliac graft still allows three times the displacement with axial compression, as well as displacement with exion testing, and torsional stiffness is less than one third that of an intact spine. In trauma patients with signicant posterior disruption and an anterior corpectomy, additional instability is probably present. For this reason, uninstrumented anterior transthoracic decompression plus fusion is rarely indicated and should be reserved for patients with signicant neural compression and minimal instability. As the degree of instability increases, it becomes necessary to supplement the anterior decompression and fusion with either anterior instrumentation or posterior stabilization. In severe injuries associated with three-column disruption, some authors recommend supplementation of anterior instrumentation with posterior instrumentation and spinal fusion.19, 20 Almost all patients should have postoperative immobilization in a TLSO, except perhaps for those stabilized with rigid posterior segmental xation devices. Beginning in the late 1980s, the development of more sophisticated anterior plate systems has improved the quality of anterior xation in the thoracic and thoracolumbar spine.15, 158, 167 However, anterior plate xation to L4, L5, and S1 remains problematic. Most of the current systems are based on the principle of two screws per level, with one screw placed posteriorly, parallel to the posterior cortical wall of the vertebral body, and the second angled obliquely from anterior in the body to posterior. This triangular arrangement improves pull-out strength. In addition, in most systems an element of compression or distraction can be applied between the upper and the lower segments of xation before xing the bolt or screw to the plate. This technique may improve incorporation of the graft anteriorly, as well as the stability of the construct. Kaneda and associates reported their results in treating 150 consecutive patients with thoracolumbar burst fractures by anterior decompression and stabilization with the Kaneda device (see Fig. 3026). After a mean follow-up of 8 years, radiographs showed a successful fusion rate of 93%. Ten patients with a pseudoarthrosis were successfully managed by posterior spinal instrumentation and fusion. They believe that all their pseudoarthroses occurred in patients who had poor placement of the anterior strut graft. Kaneda thought that the success of his device relied directly on load transmission through a strong tricortical iliac crest graft, with placement of the tricortical portion beyond the contralateral pedicle. The mean percent canal obstruction preoperatively was 47% and, postoperatively, 2%. Neurologic function improved by at
least one grade in 95% of patients. Breakage of the implant occurred in nine patients, with no iatrogenically induced neurologic decits. Of the patients who were employed before the injury, 96% returned to work. The average kyphosis was 19 preoperatively, 7 immediately postoperatively, and 8 at follow-up.147 In a separate report,146 Kaneda and co-workers used the Kaneda device after anterior decompression in patients with neurologic decits caused by post-traumatic kyphosis. All patients reported excellent results. Gardner and associates102 used the contoured anterior spinal plate (CASP) system for a variety of conditions, including acute burst fractures, and had a fusion rate of 100%. McGuire reported 14 unstable three-column injuries treated by anterior decompression and stabilization with the University Plate (Acromed Corp.). Radiographically, vertebral height was maintained, and no measurable graft subsidence or kyphosis developed. He reported no hardware failures and one nonunion treated successfully with a posterior compression construct.201 Okuyama and associates reviewed 45 patients with unstable burst fractures treated by anterior decompression and stabilization. They reported 84% with no or minimal pain, a 74% return-to-work rate, and minimal loss of the kyphotic angle until fusion.213 Other recently published studies have also shown similar results with anterior decompression and stabilization for thoracolumbar burst fractures.115, 190 Most recent studies reporting the results of anterior decompression and stabilization have used rib or iliac crest bone grafts (or both) for their fusions. Finkelstein and associates reported the results of a prospective cohort study to evaluate the use of cortical allograft bone for anterior spine reconstruction in thoracolumbar fractures. They packed the medullary canal of tibial allografts with autogenous bone from the corpectomy. Twenty-two patients underwent anterior surgery alone, and 14 patients had both anterior and posterior surgery. In the latter group, posterior instrumentation was combined with autogenous bone grafting. They reported an overall fusion rate of 81%, with a trend suggesting that patients undergoing anterior surgery alone had a higher rate of nonunion, 5 of 22, than did those undergoing anterior and posterior instrumentation, 2 of 14. In addition, of eight patients who had loss of correction or loss of stability after anterior xation alone, three required revision surgery with the addition of posterior instrumentation.94 Other authors have noted high complication rates with anterior xation (30%), as well as signicant loss of the initial deformity correction over time (50%).121 Yuan and co-workers,284 reporting on their results with the Syracuse I-Plate, cautioned that osteoporosis and signicant posterior column disruption are relative contraindications to anterior xation.15 SURGICAL TECHNIQUE The patient should be intubated with a double-lumen tube for approaches above T10 so that the left and right main stem bronchi may be ventilated separately; this tube allows for later collapse of one lung to provide adequate exposure of the spine. From T10 distally, a single-lumen tube is adequate. For exposure of T10 and above, the patient is
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usually turned to the left lateral decubitus position. The right side of the chest is chosen as the side for surgery, assuming that the patient does not have any contraindications or exposure-related considerations. This position avoids any encroachment on the heart and great vessels, as would be encountered in a left-sided approach, especially in the middle and upper thoracic spine regions. A leftsided approach can be chosen if necessary, but prominent internal xation should not be used from this side. Special care should be taken to place a pad just distal to the patients downside axilla to prevent a stretch palsy of the brachial plexus. Also, an arm support should be used to hold the upper part of the arm in a neutral position: 90 forward exion at the shoulder, neutral abduction adduction, and almost straight at the elbow. Both arms should be adequately protected and padded, especially in the region of the radial nerve in the posterior aspect of the upper part of the arm and near the ulnar nerve at the elbow. Forward exion of more than 90 at the shoulder should be avoided to minimize the risk of brachial plexus palsy. Tape can be securely placed across the patient, both at the level of the greater trochanter and across the shoulder, and then afxed to the table. A beanbag placed under the patient is also useful to help maintain this position. The patients entire right ank, anterior part of the chest, and posterior portion of the torso should be prepared from just inferior to the level of the axilla to inferior to the lateral aspect of the iliac crest. Care should be taken to prepare the skin to the midline anteriorly and beyond the midline posteriorly. Such preparation minimizes the chance of disorientation during the operation and also makes it possible to perform anterior transthoracic decompression and fusion and posterior instrumentation and fusion simultaneously, if necessary. From T6 through T10, the incision should be made directly over the rib of the same number as the fractured vertebra (Fig. 3050A) or one level proximal to it. It is technically easier to work distally than proximally. Removal of a rib one level higher works well, especially if the corpectomy involves more than one level. For fractures above T6, the skin incision should extend over the T6 rib anteriorly and laterally. Posteriorly, it should extend to the inferior tip of the scapula and then curve gently more cephalad, halfway between the medial border of the scapula and the midline spinous processes (see Fig. 3050B). For exposure of T11, T12, or L1, the incision should be made over the T10 rib to simplify wound closure. The incision should be made through skin and subcutaneous tissue down to the deep fascia. From T6 through T10, the deep fascia and underlying muscles are incised in line with the skin incision down to the rib, which is stripped subperiosteally on both its outer and inner surfaces. The surgeon should be cautious in the use of electrocautery near the neurovascular bundle. A rib cutter is used to cut the rib at the costovertebral angle posteriorly and at the costochondral junction anteriorly. The remaining inner periosteum is then incised over the length of the rib bed. For T2T5, it is important to note that the long thoracic nerve courses in the midaxillary line from the region of the axilla to its innervation of the serratus anterior muscle. Rather than cut this nerve and lose innervation to the more caudal portion of the muscle, it is preferable to detach the serratus anterior muscle from
the anterior chest wall and reect it cephalad. This technique can be performed to provide exposure up to the T3 rib, with additional exposure achieved by mobilization of the scapula. Division of the dorsal scapular muscles, rhomboids, and trapezius allows the scapula to be elevated and displaced laterally from the midline. This maneuver offers a simple method of gaining a more extensive thoracotomy through the bed of the third rib. After the chest has been opened, the surgeon should place a hand in the chest in the midlateral line and count the cephalic and caudal ribs because that is more accurate than counting the ribs outside the chest wall. The surgeon should make certain that the rib removed is the rib that was planned for removal. It should also be veried that the total number of ribs corresponds to that seen on a good-quality AP radiograph of the thoracic spine. A self-retaining thoracotomy retractor is then inserted over moistened sponges in such a manner that the neurovascular bundle of the cephalic rib and the neurovascular bundle from the removed rib are not compressed by the retractor. The chest retractor is opened slowly to minimize the chance of fracture of adjacent ribs. At this point, the lung can be deated on the ipsilateral side to provide adequate exposure to the spine. The spine can be seen and palpated within the chest cavity. It is covered by the relatively thin and translucent parietal pleura. The rib base of the previously resected rib is traced down to its costovertebral junction, and with the knowledge that each rib inserts at the cephalic quarter of its own vertebra, the levels of each of the vertebral bodies and discs can be determined. At this point, a spinal needle should be placed in a disc and a radiograph obtained to denitively identify the levels. The parietal pleura is incised halfway between the vertebral neural foramina posteriorly and the anteriorly located azygos vein and inferior vena cava. After division of the parietal pleura one level above and one level below the vertebral body of interest, the segmental vessels are identied in the midportion of the vertebral body at each of these three levels. These segmental vessels should be isolated and either tied or ligated with vascular clips. The vessels should be cut over the anterior third of the vertebral bodies so that they do not interfere with any collateral ow to the spinal cord, which enters the segmental vessels near the neuroforamen. With a small sponge on a clamp or a periosteal elevator, the segmental vessels and parietal pleura can be swept anteriorly and posteriorly to expose the vertebral bodies and discs in an extraperiosteal fashion. Blunt dissection can then be carried out in this same plane, with a sponge on the surgeons nger used to expose the opposite side of the vertebral body at the site of primary interest. At this time, a malleable or cobra retractor can be inserted between the exposed spine and the parietal pleura that has been dissected anteriorly (see Fig. 3050C). The retractor protects the esophagus and great vessels during excision of the vertebral body. Because the rib extends anteriorly over the lateral aspect of the vertebral body, it is necessary to cut it just anterior to the neural foramina. The discs above and below the vertebra to be resected can be removed with a scalpel and rongeurs (see Fig. 3050D). The vertebral body may then be removed with a rongeur, as well as
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gouges, osteotomes, and power burs (see Fig. 3050E). Loupe magnication and a headlamp should be used for this procedure. In the case of an acute fracture with many loose pieces of bone, a large curette can be used to remove the bulk of the vertebral body. As the posterior margin of the vertebral body is approached, red cancellous bone begins to be replaced by white cortical bone, which represents the posterior cortex of the vertebral body. A high-speed bur may then be used to perforate the posterior cortex at the point of minimal neural compression (see Fig. 3050F). Another technique to gain access to the spinal canal is to use a small Kerrison rongeur to enter through the adjacent disc space. Alternatively, one can begin by removing the pedicle and following the nerve root to the spinal cord. Once a point of entry into the spinal canal has been made, the remainder of the
posterior cortex of the vertebral body can be removed with appropriately shaped rongeurs and curettes (see Fig. 3050G and H). Removal is often facilitated with the use of ne-angled curettes to allow the surgeon to push or pull the posterior cortex away from the spinal canal. This decompression should be performed from pedicle to pedicle to ensure that no spinal cord compression remains (see Fig. 3050I). If the bone has been removed and the posterior longitudinal ligament does not bulge anteriorly, the ligament should be removed while at the same time looking for other disc or bone fragments that may be causing continued compression of the dura. At the end of the decompression, the ligament or dura, or both, should be bulging anteriorly. A trough can be cut into the vertebral bodies through the end-plates above and below the area of decompression
A
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FIGURE 3050. Technique of anterior transthoracic corpectomy and fusion. A, The patient is placed in a straight decubitus position with the shoulders extended forward 90, neutral in terms of abduction and adduction, and with the elbows straight. Care is taken to protect the downside brachial plexus by using a pad just distal to the axilla. The dotted line over the rib represents the incision placed one level above that of the spinal fracture. B, If the incision is used to expose the region above the T6 rib, the posterior limb of the incision is extended cephalad halfway between the medial border of the scapula and the spinous processes. All the intervening muscles down to the chest wall are divided and tagged for later repair. Illustration continued on following page
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FIGURE 3050. Continued. C, After the thoracic cavity has been entered, a self-retaining chest retractor is inserted. The parietal pleura is incised halfway between the anterior great vessels and the posterior neural foramina, and the segmental vessels are ligated at this same level. The vertebra to be excised, as well as one vertebra above and one vertebra below, is exposed. Extraperiosteal dissection provides the best plane. A malleable retractor is placed on the opposite side of the spine and connected to the self-retaining chest retractor with a clamp. This malleable retractor serves to protect the great vessels during the vertebral corpectomy. D, A scalpel and rongeur are used to remove the discs above and below the level of the vertebral fracture.
E
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FIGURE 3050. Continued. E, An osteotome, chisel, or gouge is used to excise the vertebral body back to its posterior cortex. Special care is taken to originally position the patient exactly in the straight decubitus position. During resection of the vertebral body with these instruments, each of the cuts is made perpendicular to the oor. These instruments can be used as long as red cancellous bone is encountered. As soon as white cortical bone is observed, these instruments should no longer be used. F, A high-speed bur can be used to perforate the posterior vertebral body cortex and gain access to the spinal canal. When the neural compression is signicant, a diamond-tipped bur can be used to minimize the chance of dural or neural injury. G, Downbiting 90 Kerrison rongeurs are used to remove bone on the most supercial portion of the vertebral body. H, The bone from the spinal canal on the far side of the vertebral body is carefully impacted with reverse-angle curettes. Illustration continued on following page
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K
FIGURE 3050. Continued. I, The bone resection at the end of the decompression should extend from the pedicle on one side to the pedicle on the opposite side. It is easy to underestimate the extent of bone removal necessary to achieve this goal. At the end of the neural decompression, the dura should bulge anteriorly in a uniform fashion from the end-plate of the vertebra above to the end-plate of the vertebra below and from pedicle to pedicle. If the dura does not bulge out concentrically, the surgeon should check for residual neural compression. J, After the corpectomy and resection of the disc above and below the level of fracture have been accomplished, a trough is cut into the vertebral body above and below the corpectomy. If any degree of osteoporosis is present, the trough should be cut through the cancellous bone up to the next intact end-plate at the superior end of the cephalad vertebra and the inferior aspect of the caudal vertebra. A ridge of bone should be preserved at the posterior aspect of these adjacent vertebrae to prevent migration of the bone graft into the spinal canal. K, At the end of the neural decompression and fusion, the space between the bone graft and the dura and neural elements should be adequate to minimize the chance of producing any iatrogenic neural compression. This illustration shows three strips of rib being used as bone graft, but a single, large piece of iliac crest can also be used and may actually provide a stronger anterior strut.
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FIGURE 3050. Continued. A transverse section at the vertebrae above (L) and below (M) the level of the corpectomy should reveal an adequate posterior rim of cortical bone to prevent migration of the bone graft into the spinal canal and an anterior cortical and cancellous rim of bone to prevent dislodgment of the bone graft.
(see Fig. 3050J), but creation of a trough can weaken stabilization with the graft and is not routinely recommended. Alternatively, all the cartilage can be removed from the end-plates, but care must be taken to maintain cortical integrity of the end-plates. Appropriate bone graft is then obtained for insertion across this level of decompression. The patients own iliac crest may be harvested; a tricortical bone graft provides maximal support. Another option, particularly if the injury is associated with minimal instability and the patients rib is of adequate strength, is to impact three tiers of rib graft into this trough while an assistant pushes on the patients gibbus to minimize the deformity (see Fig. 3050K). Alternatively, fresh frozen corticocancellous allograft (iliac crest or distal end of the femur) can be used with good fusion success anteriorly; the use of metal or composite cages lled with autograft is also another good option. At the end of the decompression and bone grafting, adequate space should be left between the neural elements and the bone graft (see Fig. 3050K), and a posterior ridge should be present on the vertebra both cephalad and caudad to the decompression to prevent migration of the bone graft toward the neural elements (see Fig. 3050L and M). After the corpectomy is completed, an appropriately sized plate is selected to center the two screws at the level above and below the corpectomy as closely as possible on the adjacent bodies. A template (if supplied) is used to place the drill holes parallel to the posterior cortex of the vertebral body so that they accept screws or bolts in that location; the screws or bolts are commonly used to provide compression or distraction. Care must be taken to precisely understand the orientation of the patient on the operating table and the resulting direction of drilling. A bicortical hole is drilled. It is then depth-gauged to accept the proper length screw or bolt. The bolts are screwed tightly into position and may then be used to apply
distraction to the interspace, thereby achieving restoration of body height at the injured level. An appropriately sized tricortical iliac bone graft can be fashioned to t into the interspace. Placement of the graft should be slightly biased anteriorly in the corpectomy defect. The distraction can then be released and a plate of proper size selected so that it does not impinge on the open disc spaces above and below the stabilized levels. The plate is placed over the bolts and the nuts provisionally placed on the bolts. Slight compressive force is applied across the reconstructed level, and the nuts are tightened down to maintain position. Finally, the two anterior screw holes are drilled and the screws placed into position to complete the construct. The malleable retractor is removed, and hemostasis is obtained before closure. The parietal pleura is reapproximated with the use of absorbable suture material. One or two large chest tubes are inserted. The thoracotomy is closed with sutures placed above the cephalic rib and below the caudal rib, with care taken to avoid the neurovascular bundle immediately beneath the caudal rib. A rib approximator is used to close the chest wall defect, and the pericostal sutures are tied. All the muscles are sutured back to their original positions, including the serratus anterior if it was detached from the chest wall. If the spine injury was relatively stable and is at a level of the spine that can be adequately braced with an orthosis, the patient may be mobilized while wearing the brace. The brace is worn until solid union is demonstrated radiographically. If the spinal fracture was judged to be moderately or severely unstable, the anterior procedure should be combined with posterior instrumentation (usually in compression) and fusion to allow early mobilization. As an alternative, anterior instrumentation can be used to supplement the anterior decompression and fusion, provided that the instability is only moderate (Fig. 3051).
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E
FIGURE 3051. Technique for anterior spinal instrumentation after corpectomy. A, After using a depth gauge on the exposed vertebral body, appropriately sized screw lengths are selected to engage the opposite cortex of the vertebral body. The bolts are placed parallel to the adjacent end-plate to avoid intrusion into the disc space above or below the corpectomy site. B, Distraction is applied against the bolts to allow easy insertion of the strut graft into the corpectomy site. C, Determination of the proper length of plate with a template is important to avoid impingement of the superior or inferior disc space. Locking nuts are applied and provisionally tightened. D, Compressive force is applied and the locking nuts tightened down rmly. E, Finally, two anterior screws are placed and the nuts are crimped down to prevent possible backing out or loosening. (A E, Redrawn with permission from Zdeblick, T.A. Z-PlateATL Anterior Fixation System: Surgical Technique. Sofamor Danek Group, Inc. All rights reserved.)
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zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz With the correct application of currently available spinal instrumentation, it is possible to stabilize and anatomically correct most disrupted spinal columns. However, these procedures are not risk free and may be associated with major complications. This section does not address all complications related to spinal surgery, but focuses on those associated with the treatments described in this chapter. Certain complications such as death, deep vein thrombosis, and pulmonary embolism, though intimately related to surgery, are not peculiar to spine surgery and are therefore not discussed here. Other complications such as iliac crest bone graft donor site morbidity are common to all spinal surgeries.134, 169 It cannot be emphasized strongly enough that many potential intraoperative complications may be avoided, or their severity reduced, by careful preoperative planning. Accurate identication of the mechanism of injury and selection of the appropriate instrumentation and levels constitute the rst critical step. However, despite detailed planning, surgical complications may still occur.
Neurologic Deterioration
Neurologic deterioration can occur before initiation of denitive treatment. Gertzbein111 reported a 3.4% incidence of new or increased neurologic decit after patients were admitted to trauma centers. He noted, however, that this group of patients had a signicantly increased return of neurologic function after initiation of treatment in comparison to those who initially had a neurologic decit. For patients whose neurologic function deteriorates after the initial evaluation, surgical treatment is recommended. In addition, progressive deformity with associated late neurologic deterioration may develop in fractures managed nonoperatively, even if initially stable.114 Neurologic decit occurring during or after treatment is one of the most serious complications associated with the surgical treatment of spinal injuries. The reported incidence is approximately 1%.175 Neurologic deterioration may be associated with overdistraction, overcompression, direct injury resulting from the introduction of instrumentation into the spinal canal, or loss of position or reduction. Overdistraction can be reduced to a minimum, or its possibility anticipated, by careful preoperative assessment of the mechanism of injury and prediction of the presence of an intact anterior longitudinal ligament. With this ligament intact and with proper contouring of the posterior instrumentation system to place the spine in some degree of lordosis and the anterior longitudinal ligament under tension, overdistraction can usually be avoided. MRI may provide useful information concerning the status of the anterior longitudinal ligament before any reduction requiring distraction.36, 155 Neurologic injury related to compression instrumentation can generally be avoided if this construct is used primarily when the posterior cortex of the involved vertebral bodies is intact and the mechanism of injury does not strongly suggest an accompanying discal injury, which may frequently occur with exion-distraction injuries (Fig. 3052).
Segmental wires, sublaminar hooks, and pedicle screws can all provide signicant intrusion into the spinal canal and transiently or permanently injure or compress the spinal cord or nerve roots. Proper positioning of the instrumentation and awareness of this complication may reduce the incidence of occurrence but cannot completely eliminate it. During instrumentation, if evoked potentials deteriorate, if an intraoperative wake-up test is not achieved successfully, or if radiographs show overdistraction or overcompression, the instrumentation system should be altered. The alteration may be as simple as relieving some degree of the distraction or compression or removing one or two segmental wires. Alternatively, it may be necessary to remove the entire implanted system, insert a different instrumentation system, or leave it out altogether. The injury pattern, the preceding portion of the procedure, and co-morbid conditions may affect this decision. Neurologic deterioration observed in the postoperative period may be related to disc herniation, loss of reduction, spinal cord edema, hematoma, or some combination of these complications. Immediate study with myelography, CT scanning, or MRI should be considered, and the patient should be returned to the operating room as necessary to relieve any neural compression. INJURY RESULTING FROM INSERTION OF PEDICLE SCREWS The spinal nerves are particularly susceptible to injury if the pedicle is violated medially or inferiorly. In addition, a screw that is too long can transgress the anterior cortex of the vertebral body and injure a major vascular structure. The risk of neural damage can be minimized if the surgeon is aware of the spinal anatomy and familiar with the process of localizing and entering the pedicle. Careful identication of the pedicle and proper screw placement under radiographic control help minimize potential injuries. In earlier studies, some authors reported a 10% to 20% rate of inaccurate pedicle screw placement, even in well-controlled environments. This rate reportedly increased to as high as 41% in the thoracic spine.254 It may also be increased with deformity and instability. Fortunately, not all errant screws lead to clinical consequences. Neural damage can result from direct contact by a screw or by a drill, curette, or tap. Late screw cutout through the pedicle may also result in nerve damage.26 If a postoperative radiculopathy is noted, CT evaluation of the screw and bone should be performed, with consideration of screw removal if the results are positive. However, stability issues must also be considered when making these decisions. Rose and associates described a technique involving persistently electried pedicle stimulation instruments, which can be used to detect whether the pedicle screws have fractured or broached the cortical bone during placement. This technique may help conrm intraosseous placement of pedicle screws and prevent neurologic injury.240 Kothe and colleagues simulated pedicle fractures in an in vitro model to determine the effect on multidirectional stability when pedicle instrumentation is used. After simulation of an intraoperative pedicle fracture, the results of three-dimensional exibility testing showed a signicant
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FIGURE 3052. A, An anteroposterior (AP) radiograph shows abnormal calcication within the disc spaces at T11T12 and T12L1. This nding should arouse expectations of detecting a herniated thoracic disc in this symptomatic patient. B, A computed tomographic (CT) scan at T11T12 documents a large herniation of a calcied disc fragment with signicant compromise of the spinal canal. C, Midsagittal, T1-weighted magnetic resonance imaging (MRI) conrms the signicant extent of extrusion of the T11T12 disc. D, T1-weighted transverse MRI correlates well with the CT scan and again shows the severe extent of spinal canal compromise. E, T2-weighted transverse MRI best shows the extent of spinal cord compression and actual spinal cord deformation secondary to herniation of the disc. F, This patient was treated by transthoracic T11T12 discectomy and fusion. G, A follow-up AP radiograph conrms satisfactory alignment of the spine.
decrease in axial rotation and lateral bending stability provided by the instrumentation.163 If screw loosening occurs, loss of correction may develop before the fusion heals. Loss of xation can result from errant placement of a screw, fracture of the pedicle, inadequate purchase of the screw into bone, poor bone
quality, or inadequate screw size.194 Pedicle fracture may occur if too large a screw is placed into the pedicle or the screw is driven out of the pedicular cortex. Sjostrom and associates255 used CT scans to study the pedicles of patients after removal of pedicle screw instrumentation following successful fusion for burst fractures. They found
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that 65% of instrumented pedicles increased in width, as did 85% of those in which the screw diameter was greater than 65% of the diameter of the pedicle. This result, however, may not have clinical consequences. The authors emphasized the importance of correct screw size to avoid injury to the pedicle and subsequent loosening of the implant. Occasionally, with severe deformity, maximal bone screw interface strength is required and necessitates placement of the screw deep within the vertebral body or through the anterior cortex. This situation is more common in a patient with an osteoporotic spine than in one with normal bone density. The need for anterior cortical xation must be balanced against the risk of injury to the anterior vascular structures. This problem may be handled by adding screws at other levels or by augmenting the xation with polymethyl methacrylate (rarely used in trauma). However, in fractures, alternatives are usually available, including noninstrumented fusion, bedrest, and alteration of the instrumentation to a system with laminar xation. INJURY RESULTING FROM PLACEMENT OF LAMINAR HOOKS Dislodgment of laminar hooks occurs most commonly in the lower lumbar segments. However, proximal dislodgment also occurs, particularly when the reduction is inadequate and viscoelastic properties are not taken into consideration after the initial distraction. If hooks are not properly seated or are placed into laminar bone rather than deep to the anterior lamina or if the rod is not properly contoured, the hooks may cut out, fracture the lamina, or angulate into the underlying neural tissue. The incidence of neurologic complications after placement of hooks and rods is reportedly about 1%. The use of anatomic hooks helps limit some of these problems. Hook dislodgment may be associated with excessive force, weak bone, or technical errors (e.g., faulty surgical technique, improper implant selection, improper contouring). Edwards and Levine80 found that dislodgment of distal hooks placed proximal to L4 occurred in only 4% of their large series of patients, but that percentage almost doubled at L4 and tripled at L5. To avoid these complications, the proper instrumentation should be selected, particularly one with a more anatomic design. Adequate rod contouring or the addition of a rod sleeve is useful to minimize late failure. Excessive bone resection at the laminotomy site should be avoided, particularly at the upper lamina. It is often necessary to remove only a small portion of the superior lamina to square the edge before inserting the hook. Excessive notching leads to the formation of a stress riser and increases the risk of subsequent fracture. The lateral joint ligaments should also be protected, as much as possible, because they help resist lateral hook cutout. Inferiorly, the laminotomy should not be extended too far laterally because the pars interarticularis may be weakened. Many of the problems with hook dislodgment from the lamina or dislodgment of the rod from the hook have now been eliminated with the newest generation of segmental xation hook-rod systems.
Dural Tears
A dural laceration and concomitant leak of cerebrospinal uid may result from the injury or from surgery (see Fig. 3024). Intraoperatively, laceration can occur during exposure, instrumentation, or decortication. Regardless of the cause, the site of the injury, once identied, should be adequately visualized (with bone removed as necessary) and the dura repaired.83, 84 If primary repair is not possible, muscle or fascia grafting should be performed to close the defect. In addition, if the seal is less than adequate, a lumbar transdural drain can be placed to reduce cerebrospinal uid pressure and permit dural healing.
Infections
Infections can occur after spine surgery, but they are relatively less common than after instrumentation and fusion for degenerative conditions. Infections supercial to the fascia can be treated with early and aggressive debridement and either open packing of the wound or closure over a drainage tube. Deep infections should also be treated by aggressive irrigation and debridement as soon as the infection is noted. If this complication occurs, we attempt to leave the bone graft and the metal instrumentation system in place. After thorough irrigation, outow tubes are placed deep to the fascia and all layers are tightly closed. The outow drainage system is maintained for at least 4 days until cultures from the efuent are clear. Inow-outow systems can also be used. They usually require early high ow (up to 500 mL /hr) of saline solution through the system to keep the tubes patent and functioning. Because superinfections have been noted to occur after 7 to 10 days, the tubes should be removed after this length of time, even if culture results are still positive. If the infection persists, the procedure can be repeated once, again trying to salvage the bone graft, the instrumentation, and the reduction. Occasionally, this treatment fails and it is necessary to remove the metal, the bone graft, or both to help eradicate the infection. An alternative is to pack the wound open, deep to the fascia, and change the dressing at least daily.
Associated Medical Conditions

Improved medical management has reduced the complications associated with spinal cord injury and is responsible for a marked increase in life expectancy. However, head injury, musculoskeletal trauma, and visceral damage, which occur concomitantly in up to 60% of patients with spinal cord injury, often complicate treatment. If the patient is unconscious at initial evaluation, the diagnosis of spinal cord injury may be difcult to make. Screening radiographs of the spine and all long bones below the level of injury should be performed in all patients with head or spinal cord injury. Additionally, after blunt trauma, a signicant number of spinal cordinjured patients have an associated abdominal injury and may be unable to feel or communicate the underlying problem. Reid and coworkers228 reported a 50% incidence of intra-abdominal
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injury associated with Chance fractures in children and adolescents. Anderson and colleagues10 reported a 66% incidence of hollow viscus lesions associated with seat belttype injuries, which climbed to 86% in a pediatric subset. A perforated viscus with associated peritonitis may go undetected. Because this complication is responsible for signicant morbidity and death, peritoneal lavage should be a routine part of the initial evaluation of all patients with spinal cord injury. Renal failure is a frequent occurrence in patients with spinal cord injury. A gradual decline in the incidence of this problem, particularly as a cause of death, has occurred as a result of advances in bladder drainage techniques (e.g., intermittent catheterization). Once the uid status (inow and outow) is normalized in the acute injury state, intermittent bladder catheterization should be used in the management of a neurogenic bladder. After further urologic evaluation, individualized treatment may be instituted. Pulmonary complications, already increased in neurologically injured patients, are further worsened if the anterior transthoracic approach is used.11 Late complications in a spinal cordinjured patient can relate to painful nonunion of the spine, limited neurologic recovery of spinal cord or root function (particularly because limited recovery leads to persistent nerve compromise and pain), and medical complications associated with prolonged bedrest, many of which can be avoided by early, rigid immobilization, as discussed earlier in this chapter. In particular, disuse osteoporosis is a common problem in paraplegic patients immobilized for even short periods, and it increases their susceptibility to recurrent injuries.85 Finally, individuals with spinal cord injuries may experience intractable spasticity. For this condition, studies have shown the efcacy of implantable intrathecal baclofen pumps.65
Avoidance of complications associated with the surgical treatment of spine injuries requires a thorough knowledge of the anatomy, an accurate diagnosis, and an understanding and experience with the implants chosen.238 However, although complications can be minimized, they cannot be eliminated.
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CONCLUSION
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The major objective of any treatment is to construct the most stable environment for the spinal cord, nerve roots, and spinal column to allow neurologic improvement. Although the emphasis in this chapter has been on rigid spinal stabilization, it should be stressed that such stabilization is only one means of achieving this goal. Its major advantage at this time, in addition to stabilizing and protecting the spinal cord, is that it allows the patient to rapidly initiate rehabilitation. Reversibility of spinal cord injury remains an unsolved medical and surgical problem. However, rehabilitation has greatly improved the quality of life of patients with spinal injuries. Intensive rehabilitation should begin as early as possible, with the major objective being attainment of functional independence. The nal functional level depends primarily on the level and severity of the neurologic decit. Surgical instrumentation of the spine and effective spinal orthoses permit earlier mobilization of the patient in the acute phase and may allow patients to reach their functional level sooner. The best selection of treatment depends on understanding the anatomy, the mechanics of the injury and the forces involved, and the options that are available to stabilize and protect the spinal column and cord.
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SECTION II Spine 212. OBrien, J.P.; Stephens, M.M.; Prickett, C.F et al. Nylon sublaminar .; straps in segmental instrumentation for spinal disorders. Clin Orthop 203:168171, 1986. 213. Okuyama, K.; Abe, E.; Chiba, M.; et al. Outcome of anterior decompression and stabilization for thoracolumbar unstable burst fractures in the absence of neurologic decits. Spine 21:620625, 1996. 214. Olerud, S.; Karltrom, G.; Sjostrom, L. Transpedicular xation of thoracolumbar vertebral fractures. Clin Orthop 227:4451, 1988. 215. Osebold, W.R.; Weinstein, S.L.; Sprague, B.L. Thoracolumbar spine fractures: Results of treatments. Spine 6:1334, 1981. 216. Panjabi, M.M.; Brand, R.A., Jr.; White, A.A, 3rd. Three-dimensional exibility and stiffness properties of the human thoracic spine. J Biomech 9:185192, 1975. 217. Panjabi, M.M.; Oxland, T.R.; Kifune, M.; et al. Validity of the three-column theory of thoracolumbar fractures. A biomechanical investigation. Spine 20:11221127, 1995. 218. Parke, W.W.; Gammall, K.; Rothman, R.H. Arterial vascularization of the cauda equina. J Bone Joint Surg Am 63:5362, 1981. 219. Patterson, R.H.; Arbit, E. A surgical approach through the pedicle for protruded thoracic discs. J Neurosurg 48:768772, 1978. 220. Paul, R.L.; Michael, R.H.; Dunn, J.E.; Williams, J.P. Anterior transthoracic surgical decompression of acute spinal cord injuries. J Neurosurg 43:299307, 1975. 221. Perot, P.H.; Munro, D.D. Transthoracic removal of midline thoracic disc protrusions causing spinal cord compression. J Neurosurg 31:452458, 1969. 222. Pinzur, M.S.; Meyer, P.R., Jr.; Lautenschlager, E.P.; et al. Measurement of internal xation device support in experimentally produced fractures of the dorsolumbar spine. Orthopedics 2:28, 1979. 223. Place, H.M.; Donaldson, D.H.; Brown, C.W.; et al. Stabilization of thoracic spine fractures resulting in complete paraplegia: A long-term retrospective analysis. Spine 19:17261730, 1994. 224. Post, J.L.; Green, B.A.; Quencer, R.M.; et al. The value of computed tomography in spinal trauma. Spine 7:417431, 1982. 225. Purcell, G.A.; Markolf, K.L.; Dawson, E.G. Twelfth thoracicrst lumbar vertebral mechanical stability of fractures after Harringtonrod instrumentation. J Bone Joint Surg Am 63:7178, 1981. 226. Purnell, M.; Drummond, D.S.; Keene, J.S.; et al. Hex-nut loosening following compression instrumentation of the spine. Clin Orthop 203:172178, 1986. 227. Regan, J.J.; Mack, M.J.; Picetti, G.G., 3rd; et al. A technical report on video-assisted thoracoscopy in thoracic spinal surgery. Preliminary description. Spine 20:831837, 1995. 228. Reid, A.B.; Letts, R.M.; Black, G.B. Pediatric chance fractures: Association with intra-abdominal injuries and seatbelt use. J Trauma 30:384391, 1990. 229. Rennie, W.; Mitchell, N. Flexion dislocation fractures of the lumbar spine. J Bone Joint Surg Am 55:386390, 1973. 230. Reuben, M.; Schultz, A.; Denis, F et al. Bulging of lumbar .; intervertebral discs. J Biomech 104:187192, 1982. 231. Riebel, G.D.; Yoo, J.U.; Fredrickson, B.E.; et al. Review of Harrington rod treatment of spinal trauma. Spine 18:479491, 1993. 232. Riggins, R.S.; Kraus, J.F The risk of neurological damage with . fractures of the vertebrae. J Trauma 17:126133, 1977. 233. Rimoldi, R.L.; Zigler, J.E.; Capen, D.A.; et al. The effect of surgical intervention on rehabilitation time in patients with thoracolumbar and lumbar spinal cord injuries. Spine 17:14431449, 1992. 234. Rissanen, P.M. The surgical anatomy and pathology of the supraspinous and interspinous ligaments of the lumbar spine with special reference to ligament ruptures. Acta Orthop Scand 46(Suppl):1, 1960. 235. Roaf, R. A study of the mechanics of spinal injuries. J Bone Joint Surg Br 42:810, 1960. 236. Roberts, J.B.; Curtiss, P.H., Jr. Stability of the thoracic and lumbar spine in traumatic paraplegia following fracture or fracturedislocation. J Bone Joint Surg Am 52:11151130, 1970. 237. Rockwell, H.; Evans, F .G.; Pheasant, H.C. The comparative morphology of the vertebral spinal column: Its form as related to function. J Morphol 63:87, 1938. 238. Rof, R.P.; Waters, R.L.; Adkins, R.H. Gunshot wounds to the spine associated with a perforated viscus. Spine 14:808811, 1989. 239. Rogers, L.F The roentgenographic appearance of transverse or . Chance fractures of the spine: The seat belt fracture. AJR Am J Roentgenol 111:844849, 1971.
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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

Transverse width (mm)

Sagittal width (mm)

16 Print Graphic 14 12 10 Presentation 8 6 L5 L4 L3 L2 L1 T T T T9 T8 T7 T6 T5 T4 T3 T2 T1 12 11 10 Spinal level

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Transverse angle (deg)

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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Denis Classication of Spinal Injuries

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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OPERATIVE VERSUS NONOPERATIVE TREATMENT

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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TREATMENT OF SPECIFIC INJURIES

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

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CHAPTER 30 Thoracic and Upper Lumbar Spine Injuries

Soft Tissue Injuries

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Copyright 2003 Elsevier Science (USA). All rights reserved.