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27
Management Techniques for Spinal Injuries

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Ronald W. Lindsey, M.D. Spiros G. Pneumaticos, M.D. Zbigniew Gugala, M.D.

Many treatment techniques have been used for managing injuries involving the spine. Initially, most were nonoperative, but over the past century, numerous surgical techniques have also been described. Various types of spinal instrumentation systems have been devised, and the surgical indications for spinal injuries have been better dened to facilitate the success of operative management. However, many types of spinal injuries can still be satisfactorily treated by nonoperative methods without many of the inherent risks of surgery; others can be treated by either operative or nonoperative methods. Therefore, it is imperative that the clinician understand the role of nonoperative treatment and remain facile with techniques such as spinal traction, reduction by manipulation, and orthotic immobilization. Traditionally, the term conservative care has been synonymous with nonoperative treatment. Recent advances in our understanding of the different types of spinal injuries and their risk for complications have allowed the term conservative care to be used for either nonoperative or operative treatment. Optimal management must consider early patient mobilization, maintenance of acceptable spinal alignment and stability, the presence of associated injuries, and the risk and severity of potential complications associated with each type of treatment. Being familiar with both surgical and nonsurgical treatment approaches allows the clinician to individualize treatment based on the nature of the injury and the demands of the specic patient. The objectives of nonoperative management of spinal injuries are similar to those of operative treatment and include the following: 1. Avoiding progression of neurologic decit and, when decit is present, enhancing its resolution 2. Reducing unacceptable spinal deformity or malalignment to an acceptable functional range 3. Maintaining spinal alignment within a functional range throughout the course of treatment
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4. Healing the spine in a functional alignment sufcient to permit return of physiologic loads through the spine Nonoperative management should consist of immobilization that is well tolerated, permit timely mobilization, and allow for healing within a reasonable period. Therefore, the ultimate success of nonoperative treatment requires proper patient selection, as well as complete understanding and strict adherence to the principles of nonoperative management. Detailed descriptions of modern spine biomechanics and pathomechanics, as well as the classication systems used to determine spine stability, are included in the subsequent chapters dealing with each specic injury type. In this chapter, factors determining optimal treatment for spine injuries are presented. Regardless of the treatment method used, the objectives of preserving neurologic function, minimizing post-traumatic deformity, and achieving a stable functional spine remain the standard of care.

CERVICAL TRACTION

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Cervical traction is frequently indicated for the treatment of cervical spine injury to achieve the following objectives: (1) reduce cervical spine deformity, (2) indirectly decompress traumatized neural elements, and (3) provide cervical spine stability. Familiarity with the use of cervical traction is essential in the treatment of cervical spine trauma because of its ease of application and low morbidity when applied properly. The modes by which cervical traction can be applied include a head halter, tongs, or a halo ring. Head halter traction consists of straps that attach to the head at the chin and the occiput, and only small amounts of weight (5 to 10 lb) can be applied safely. In addition to reduced traction weight, limitations of head halter traction

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CHAPTER 27 Management Techniques for Spinal Injuries

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FIGURE 271. Gardner-Wells tongs have angulated pins designed to better counteract traction forces. The tongs can be made from magnetic resonance imagingcompatible materials (carbon ber, titanium), which obviates the need for removal of the tongs and facilitates head and cervical spine imaging.

include poor attachment to the head and the ability to control only axial compression through distraction. Excessive weight over an extended period can cause pressure ulcerations at the chin or occiput. Currently, halter traction is rarely indicated for spine trauma.

Asymmetric pin placement, either slightly posterior to affect exion or slightly anterior to affect extension, can either facilitate or inhibit fracture reduction. The use of Gardner-Wells tongs does not require shaving of the pin site. The skin and hair are prepared with an iodine solution, and the pin can be inserted directly into the skin without an incision. Before pin placement, local anesthetic is injected into the skin with care taken to inltrate the periosteum down to the galea. The pins, which must be sterile and handled accordingly, are positioned orthogonally on either side of the skull before tightening. Tightening the pins by alternating from side to side will maintain pin symmetry. Gardner-Wells tongs are spring-loaded and thereby prevent perforation of the inner table of the skull. The force of pin insertion is gauged by the spring-loaded force indicator contained in one of the pins, and optimal insertion torque is typically 6 to 8 in-lb. After the tongs are in place, the pins should be cleaned once a day with hydrogen peroxide at the skinpin interface. After the rst 24 hours of tongs application, the spring-loaded pins must be retightened; additional tightening should not be done to avoid the risk of perforating the inner table.

Tongs Traction
When applying traction with tongs, in contrast to head halters, xation into the skull is achieved through the use of special pins with a pointed tip that abruptly ares out. This design allows for pin insertion through the outer cortex of the skull without penetration of the inner cortex. The ared nature of the pin design distributes pin pressure over its entire width on insertion while engaging the outer table. Several types of tongs presently exist and include the Gardner-Wells or Trippi-Wells models. Tongs, similar to head halters, essentially control motion in a single plane through the application of longitudinal traction. GardnerWells tongs (Fig. 271) have achieved the widest acceptance because of their ability to withstand high loads and their ease of application. Gardner-Wells tongs can be applied quickly by a single physician. Trippi-Wells tongs consist of the same pins as Gardner-Wells tongs, but they are used in a multipin fashion. Because of the ability of tongs to resist motion in only one plane, they are associated with a high incidence of loosening. Tongs are typically indicated when longitudinal traction is to be temporarily applied or the patient is to remain bedridden. APPLICATION OF TONGS In preparation for the application of tongs, the patient is positioned supine with the head resting on the table top and no pillow support. The physician stands at the top (head) of the table above the patient for easy access to either side of the head. Pins should be placed just below the greatest diameter (equator) of the skull in a manner that avoids the temporalis muscle and supercial temporal artery and vein (Fig. 272). The standard site for pin insertion is approximately 1 cm posterior to the external auditory meatus and 1 cm superior to the pinna of the ear.

Halo Ring Traction


Cervical traction can be applied more efciently through a halo ring. The multipin attachment of the halo to the skull reduces the distribution of the pin load, thereby allowing for higher traction loads to be applied for an extended period. Experimentally, the measured pull-out strength for a halo ring is almost twice that of Gardner-Wells tongs (440 versus 233 lb).72 Furthermore, the circumferential pin xation to the skull better resists multiplane spine motion and allows for traction in exion, extension, or simultaneous bivector traction techniques.110 Finally, a major advantage of halo ring traction is that it can be rapidly converted to a halo vest orthosis once spinal reduction has been achieved.

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FIGURE 272. Pins for traction tongs are placed below the cranial brim or the widest diameter of the skull (equator), anterior and superior to the earlobe. Care must be taken to position the pins posterior to the temporalis muscle. Precalibrated indicator pins are set to protrude at 8 lb of pressure.

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Blank pins (back)

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Spring-loaded pins (front)

FIGURE 273. The halo ring is held in a temporary position equidistant from the patients head, 1 cm above the eyebrows and 1 cm above the tip of the ears, with the use of blunt positioning pins (A). With the halo ring held in place, sharp halo pins are then placed just below the skull equator. Spring-loaded pins are placed in front and a blank pin on the back (B). The pins are inserted and tightened in a diagonal fashion.

The design of the halo ring has dramatically improved since its advent as a device for stabilization of facial fractures.19 Currently available halo rings are made of light and radiolucent materials (titanium, carbon composites) that permit computed tomography (CT) and magnetic resonance imaging (MRI). More recently, open-ring and crown-type halo designs that encircle only a part of the head have also been developed. These devices are open posteriorly to avoid the need to pass the head through a ring and thus ease application and improve safety. With some crown designs, the posterior ends of the incomplete ring must be angled inferiorly to ensure posterior pin placement below the equator of the skull. Halo rings are available in a variety of sizes to t virtually any patient, including young children. A properly tted halo ring provides 1 to 2 cm of clearance around every aspect of the patients skull. The appropriate ring size can usually be determined by measuring the circumference of the skull 1 cm above the ears and eyebrows and then referring to the manufacturers chart for preferred ring sizes.

HALO RING APPLICATION A halo ring is routinely applied under local anesthesia; occasionally, light pharmacologic sedation may be necessary. The patient is positioned supine, and to permit application of a full-ring halo, the patients occiput is elevated with a folded towel or the head is gently positioned beyond the edge of the bed. Open-back halo rings can be applied without these maneuvers and are therefore preferred. Before application of a halo ring, all patients should be in a hard collar, including those undergoing conversion of traction tongs to halo immobilization. The halo ring is temporary positioned equidistant from the patients head, 1 cm above the eyebrows and 1 cm above the tip of the ears. It is extremely important that the ring be positioned just below the greatest circumference of the patients skull to prevent the halo ring from becoming displaced upward and out of position. The halo ring is provisionally stabilized with three blunt positioning pins, and locations for the sharp head pins are then determined (Fig. 273). The optimal location for the anterior pins is 1 cm superior and two thirds lateral to the orbital rim, just below the greatest circumference of the skull (Fig. 274A). Along the medial aspect of the safe zone lie the supraorbital and supratrochlear nerves and the underlying frontal sinus. Placement of pins in the temporalis region behind the hairline confers a cosmetic advantage but is, however,

anatomically and biomechanically inferior.18, 47 Insertion sites for the posterior pins are less critical because neuromuscular structures are lacking and the skull is thicker and more uniform in that area. The posterior sites should be inferior to the widest portion of the skull, yet superior enough to prevent impingement of the ring or crown on the upper helix of the ear (see Fig. 274B). While the halo is held in position, the skin is shaved and prepared with an iodine solution. Local anesthetic, typically a 1% lidocaine solution, is injected with the needle passed through the holes for the sharp pins until the periosteum is elevated. Small stab incisions are made and the pins inserted in a diagonal fashion to maintain equal distance between the halo ring and skull. Pins should be inserted perpendicular to the skull because angulated pin insertion has been reported to be biomechanically inferior.122 The pins are tightened with a torque screwdriver, and during this maneuver the patient is asked to close the eyes and relax the forehead to prevent eyebrow tenting or tethering. When all sharp pins are in place, the blunt pins are removed and the sharp pins tightened in a diagonal fashion up to a torque of 6 to 8 in-lb.17 Pin torque should never exceed 10 in-lb because of the risk of penetration of the outer cortex.17 Breakaway wrenches can be used to prevent the pins from being tightened past the maximal torque; however, torque limits are more reliably measured with a calibrated torque screwdriver. Locknuts are then placed on each pin and gently tightened to secure

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FIGURE 274. The safe zone for the anterior pins is located 1 cm superior and two thirds lateral to the orbital rim, just below the greatest circumference of the skull. On the medial aspect of the safe zone are the supraorbital (SO) and supratrochlear (ST) nerves (A). The zone for the posterior pins is inferior to the widest portion of the skull, yet superior enough to prevent ring or crown impingement on the upper helix of the ear (B).

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FIGURE 275. A, Admission lateral radiograph showed no abnormal distraction. B, After cervical traction was initiated at 20 lb, it resulted in marked overdistraction. Traction should always be initiated at 10 lb.

the pin to the ring. Once the halo application is complete, a traction bow can be mounted. The traction weight protocol for halo rings can be much more aggressive than that for tongs, and weights can exceed 100 lb when indicated.

Cervical Traction Weight


After tongs or a halo ring has been applied, cervical traction can begin at approximately 10 to 15 lb, with immediate evaluation by lateral radiographs to avoid overdistraction (Fig. 275). Traction weight can be increased by 5- to 10-lb increments, depending on the size and weight of the patient. Serial lateral radiographs should be obtained approximately 10 to 15 minutes after each application of weight to allow for soft tissue creep. Fluoroscopy can be used instead of plain radiographs to facilitate this process. The patient must be completely relaxed, and analgesics or muscle relaxants can often assist in minimizing muscle spasm or tension. At higher weights (greater than 40 lb), 30 to 60 minutes should elapse before further load increase. The head of the bed should be slightly elevated to provide body weight resistance to traction. The maximal amount of weight that can safely be applied for closed traction reduction of the cervical spine remains controversial. It has been suggested that a slow, gradual increase in traction weight will effect spinal reduction at a lower total traction load.90 Some physicians support a more rapid incremental increase in weight and have applied weights up to 150 lb without any adverse effects.70 Typically, the maximal weight tolerated will be

limited by the skeletal xation used, and for cranial tongs, the limit is up to 100 lb. The objective of using cervical traction is to achieve the maximal effect of the weight being applied. The maximal traction weight should be considered to be a function of the patients size, body weight, or body habitus (or any combination of these attributes) rather than an absolute number (100-lb cervical traction may be well tolerated by a burly 300-lb male weightlifter, but not appropriate for a 115-lb female). The greater the associated ligamentous disruption, the less total weight that is appropriate. The maximal weight should also correspond to the level of the cervical injury; specically, upper cervical injuries require less weight than do injuries at the cervicothoracic junction. When these parameters are respected and sufcient time is permitted between incremental increases in traction weight, the maximal weight can usually be limited to 70 lb or less for lower cervical injury in an average-sized adult. Regardless of whether spinal reduction has been achieved, it is imperative that the maximal traction weight be decreased to 10 to 15 lb once the monitored reduction process has been terminated. Most cervical spine injuries can be reduced with only longitudinal traction, but small changes in the vector of traction (i.e., slightly more exion or more extension) can be helpful in some cases. Spinal manipulation can be hazardous and is therefore controversial.82 Lee and associates compared cervical traction and manipulation under anesthesia and determined that traction alone was preferable.70 Cotler and co-workers suggested that gentle manipulation in combination with traction could be of benet in

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

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Percent of motion allowed in halo-vest orthosis

awake patients.30 Manual manipulation as a means of achieving cervical spine reduction should never be performed in a patient under general anesthesia or in an unconscious patient. Light sedation in an otherwise alert patient allows the physician to detect neurologic alterations. In general, the authors do not support manual manipulation and prefer that patients who do not respond to traction be treated surgically.

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SPINAL BRACING

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The Halo-Vest Orthosis


The advent of the halo ring inspired the development of the halo vest apparatus by Perry and Nickel in 1959.96, 100 The original halo consisted of a complete ring attached to a body cast and was used to immobilize a patient with poliomyelitis. Since then, the halo vest orthosis has undergone dramatic changes in design and currently provides the most effective stabilization available for a cervical orthosis (Fig. 276). The stabilizing property of any halo vest orthosis is most dependent on adequate tting of the vest to the patients torso. The appropriate size of vest is determined after measurement of the patients chest circumference and torso length. The most common body jackets that are attached to the halo ring are adjustable double-shell plastic vests. Occasionally, a plaster body cast can be used for patients who are noncompliant or extremely difcult to t. The vest is attached to the halo ring with four upright bars. The posterior and anterior shells of the vest can be applied

C2-C3

C3-C4

C4-C5 C5-C6 Motion segment

C6-C7

C7-T1

FIGURE 277. Halo vest immobilization does not restrict all cervical spine movement. The proportion of normal cervical spine motion allowed in a halo vest at each level averages 31% and ranges from 42% in the upper cervical spine to 20% in the lower cervical spine. (From Koch, R.A.; Nickel, V.L. Spine 3:103107, 1978.)

before or after halo ring xation. Care is taken to apply manual traction before the upright bars are completely tightened. The cast or vest must be well tted to the torso and shoulders to prevent vertical toggle of the apparatus. Although the halo vest is the most stable orthosis for cervical spine immobilization, it does not completely restrict motion across the spine. Despite adequate t, the halo vest has been shown to permit up to 31% of normal cervical spine motion, depending on the patients position, activity, and degree of spinal instability6, 65 (Fig. 277). The most restricted motion was typically below C2, and the least restricted was above C2.76 Despite the effectiveness of halo skeletal xation in achieving cervical spine immobilization, complications are common and include pin loosening, pin site infection, pressure sores, headache, loss of reduction, dural puncture, and dysphagia (Table 271). Most of these complications usually result from either improper halo ring application or an ill-tted vest. In a series of 126 patients treated with halo immobilization, Kostuik reported his experience with halo vest complications.66 A single case of skull perforation occurred in a patient with severe osteoporosis. Decubitus ulcers, pressure sores, and respiratory compromise were especially prevalent in quadriplegic patients immobilized with a halo cast/vest.
TABLE 271

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Complications of Halo Ring Immobilization


Complication

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% of Patients 36 20 18 11 2 2 2 1

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Pin loosening Pin site infection Severe pin discomfort Pressure sores Nerve injury Dysphagia Bleeding at pin sites Dural puncture FIGURE 276. Halo vest orthosis.

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From Garn, S.R., et al. J Bone Joint Surg Am 68:320325, 1986.

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CHAPTER 27 Management Techniques for Spinal Injuries

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Acute pin infection and subsequent loosening remain the most common problems associated with halo vests and can occur in up to 60% of patients. Pin sites should be cleaned with hydrogen peroxide twice daily, and antibiotic ointments or sterile dressings are not usually necessary. Focal erythema about the pin typically suggests pin loosening, local infection, or both. A loose pin can be gently retightened once; however, multiple attempts at retightening will risk penetration of the internal cortex and should be avoided. In the face of recurrent loosening, a new pin should be placed in an adjacent location and the loose pin removed. Pin site infection can usually be treated with oral and topical antibiotics and retention of the pin. When pin site drainage or abscess formation persists, the pin should be removed only after a new pin is inserted at a different site. Loss of cervical reduction is a major concern with any halo vest and occurs in about 10% of patients. Poorly tted vests and patient noncompliance with the orthosis are the major causes of loss of reduction if the original indication for a halo vest is appropriate. Regardless of the reason, an inability to maintain reduction with the halo vest necessitates either longitudinal traction or operative stabilization.

direction, and variation of movements. As a result of the inability of the vital structures in the neck to withstand prolonged compression, cervical braces use the cranium and thorax as xation points. The effectiveness of any cervical brace is a function of (1) orthotic design and stabilizing properties, (2) specic injury biomechanics, and (3) the patients compliance. Cervical orthoses (COs) can be used as denitive therapy for some spinal injuries or as a temporary immobilizer for postinjury transport or during the early hospital diagnostic process. These braces can generally be divided into two basic types: COs and high and low cervicothoracic orthoses (CTOs) (Fig. 278). COs include both soft and rigid cervical collars. The former are basically foam cylinders that encircle the neck (Fig. 279A). The mechanical function of soft collars is minimal, and they permit up to 80% of normal cervical motion.59, 60, 64 Soft collars act principally as proprioceptive reminders for the patient to voluntarily restrict neck

Spinal Orthoses
Spinal orthoses are external devices that can restrict motion of the spine by acting indirectly to reinforce the intervening soft tissue. Because of a lack of standard regulations, spinal orthotic appliances are currently available in a wide diversity of designs and materials. The reported claims touting the stabilizing properties of many spinal braces parallel the paucity of scientic data soundly documenting their clinical efcacy. Additionally, the effectiveness of cervical bracing for the specic injury is difcult to determine because it is entirely dependent on the willingness of the patient to comply with orthotic use. Despite the heterogeneity of designs, the theoretical functions of all spinal braces are analogous and include restriction of spinal movement, maintenance of spinal alignment, reduction of pain, and support of the trunk musculature. In conjunction with these mechanical functions, spinal braces also function psychologically as kinesthetic reminders for the patient to modify activity. Spinal braces achieve their stabilizing effects indirectly, with their effectiveness being a function of the rigidity of the spineenveloping tissues, the distance between the spine and the brace (i.e., thickness of the intervening tissue), the length and rigidity of the orthosis, the degree of mobility of the spinal segment to be stabilized, and the presence of potential anatomic xation points. Although spinal braces are generally applied to stabilize a specic spinal motion segment, their immobilization properties affect the entire spinal region (i.e., cervical, thoracic, and lumbar). The materials used for bracing (rubber, foam, plastics) should be lightweight and elastic and allow for ventilation, improved hygiene, and comfort. CERVICAL BRACES Cervical spine bracing is particularly challenging because of the wide range of normal spinal motion in extent,
FIGURE 278. Basic classication of cervical and cervicothoracic braces: cervical orthoses (A), high CTOs (B), and low CTOs (C). (Redrawn from Sypert, G.W. External spinal orthotics. Neurosurgery 20:642649, 1987.)

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FIGURE 279. Cervical braces: the soft collar (A) is made of rm foam held around the neck with Velcro closure; the Philadelphia collar (B), which is made of exible polymer molded to the mandible and occiput, supports and extends down to the upper part of the thorax; and the SOMI (sternal-occipital-mandibular immobilizer) (C) is an extended cervicothoracic orthosis that consists of a rigid metal frame that rests on the thorax and padded metal strips that pass over the shoulders.

motion and provide some psychologic comfort. Patient compliance with soft collars is usually high because of the comfort and minimally restrictive nature of the brace. Soft collars are indicated for mild cervical sprains or to provide postoperative comfort after stable internal xation. High-thoracic CTOs have molded occipital-mandibular supports that extend to the upper part of the thorax, typically not lower than the level of the sternal notch
TABLE 272

anteriorly and the T3 spinous process posteriorly22 (see Fig. 278B). Rigid collars encompass a very heterogeneous group of cervical brace designs and include the Philadelphia collar, the Miami J brace, the NecLoc collar, the Newport/Aspen collar, the Stifneck collar, the Malibu brace, and the Nebraska collar, among others. Highthoracic CTOs stabilize the cervical spine by maintaining some tension between the occiput/mandible and the upper part of the thorax. They are signicantly more effective than soft collars. Biomechanical differences, however, exist even among the various high-thoracic CTO designs. The comparative effectiveness of the various COs and CTOs in restriction of total cervical motion is presented in Table 272. The immobilizing properties of selected COs and CTOs for specic cervical motion segments are depicted in Tables 273 and 274. The Philadelphia collar (see Fig. 279B), the most popular high-thoracic CTO, is a very comfortable orthosis for patients.60, 86 It can restrict 71% of normal cervical exion and extension, 34% of lateral bending, and about 54% of normal rotation.42, 59, 60 Despite its popularity, the Philadelphia collar is less effective than the Miami J, NecLoc, or Stifneck in restricting cervical motion. In addition, its higher skin contact pressure on the occiput may result in scalp ulcerations, especially in supine patients.101 The Philadelphia collar is optimally indicated for the management of cervical sprains, as a temporary immobilizer during the spine trauma diagnostic process, or to provide postoperative support for an internally stabilized spine. Among the high-thoracic CTOs, the Miami J collar is the most effective brace in stabilizing all planes of the cervical spine.52 The Miami J collar generally limits 73% of exion-extension, 51% of lateral bending, and 65% of rotation.86 This collar causes less occipital and mandibular skin pressure and is therefore considered an excellent long-term cervical immobilizer for a severely unstable

Comparison of Total Cervical Motion Restricted by Various Cervical Orthoses

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Motion Restricted (%)

Orthosis CO Soft collar59, 64 High-thoracic CTO Philadelphia59, 64, 109* Miami J109* NecLoc64* Newport/Aspen55* Stifneck52* Malibu81 Nebraska2 Low-thoracic CTO SOMI59 Yale59 Four poster59 Minerva113 LMCO2 Halo vest59

Combined Flexion-Extension 26 70 73 80 62 70 87 72 86 79 79 83 96

Flexion 23 74 85 86 59 73 86 74 93 89 78 68

Extension 20 59 75 78 64 63 82 60 42 82 78 66

Lateral Bending 8 34 51 60 31 50 55 75 34 61 54 51 50 99

Axial Rotation 7 56 65 73 38 57 74 91 66 76 73 88 60 96

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*Askins, V.; et al. Spine 22:11931198, 1997. Abbreviations: CO, cervical orthosis; CTO, cervicothoracic orthosis; LMCO, Lehrman-Minerva CO; SOMI, sternal-occipital-mandibular immobilizer.

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CHAPTER 27 Management Techniques for Spinal Injuries TABLE 273

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Comparison of Flexion Restricted by Various Cervical Orthoses at Each Motion Segment

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Normal Flexion Restricted (%)

Orthosis CO Soft collar59 High-thoracic CTO Philadelphia59 Miami J NecLoc64 Newport/Aspen55 Stifneck52 Low-thoracic CTO SOMI59 Yale59 Four poster59 Minerva113 Halo vest59

OccC1 86* 29 27 40 20 2 300 100 210 24 39

C1C2 33 49 70 72 54 54 65 38 43 60 77

C2C3 37 78 51 71 27 38 87 74 76 62 68

C3C4 24 68 62 73 38 57 84 83 78 68 65

C4C5 18 55 56 69 65 47 81 80 82 78 80

C5C6 13 46 57 58 15 49 75 83 74 67 86

C6C7 22 50 62 67 33 43 77 80 70 65 76

C7T1 14 38 65 64 69

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*Negative values demonstrate a snaking effect. Askins, V.; et al. Spine 22:11931198, 1997. Abbreviations: CO, cervical orthosis; CTO, cervicothoracic orthosis; SOMI, sternal-occipital-mandibular immobilizer.

cervical injury.101 Another high-thoracic CTO, the NecLoc collar, is commonly used in the prehospital setting for patient extrication and transport. Its excellent biomechanical properties are further enhanced by its ease of application. The NecLoc collar restricts up to 80% of exionextension, 60% of lateral bending, and 73% of axial rotation.64, 109 The Newport/Aspen collar provides better spine immobilization than the Philadelphia collar but to a lesser extent than the Miami J or the NecLoc55, 81; it limits only 62% of cervical exion-extension, 31% of lateral bending, and 38% of rotation.52, 55, 86 The major advantage of the Newport/Aspen collar is its comfort and low risk of skin ulceration. Plaisier and colleagues studied the risk of skin ulceration with various CTOs by measuring their effect on

local capillary closing pressure.101 Only the Newport/ Aspen CTO had contact pressures below capillary closing pressure. Among high-thoracic CTOs, the Stifneck collar is unique in that it is a one-piece orthosis. The effectiveness of cervical stabilization by the Stifneck is comparable to that of the Philadelphia collar, and its ease of application favors use in the prehospital setting. The Malibu rigid high-thoracic CTO has a design similar to that of an extended Philadelphia collar; however, it is more effective in limiting cervical spine motion. In a study by Lunsford and co-workers, the Malibu brace outperformed the Miami J and Newport/Aspen collars by limiting total cervical motion.81 The Nebraska collar, which is a variation of the Minerva orthosis, has a high support for the occiput along

TABLE 274

Comparison of Extension Restricted by Various Cervical Orthoses at Each Motion Segment

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Normal Extension Restricted (%)

Orthosis CO Soft collar59 High-thoracic CTO Philadelphia59 Miami J* NecLoc64* Newport/Aspen55* Stifneck52* Low-thoracic CTO SOMI59 Yale59 Four poster59 Minerva113 Halo vest59

OccC1 24 62 72 84 57 63 50 59 49 48 80

C1C2 67 25 58 51 51 52 11 42 47 49 57

C2C3 18 63 64 79 65 39 8 66 58 21 85

C3C4 26 56 54 72 56 49 20 64 60 44 100

C4C5 30 41 55 65 53 56 39 58 65 41 97

C5C6 26 44 55 58 58 55 43 61 72 65 84

C6C7 9 30 51 46 37 28 32 53 63 48 76

C7T1 3 51 23 63 64

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*Askins, V.; et al. Spine 22:11931198, 1997. Abbreviations: CO, cervical orthosis; CTO, cervicothoracic orthosis; SOMI, sternal-occipital-mandibular immobilizer.

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with a strap placed around the forehead and a short breastplate.2 The Nebraska collar was found to be even more effective than some low-thoracic CTOs (i.e., SOMI [sternal-occipital-mandibular immobilizer]) in restricting all planes of cervical motion.2 Low-thoracic CTOs, similar to high-thoracic CTOs, attach to the cranium at the occiput and mandible, but they extend to the lower part of the thorax below the sternal notch and T3 spinous process22 (see Fig. 278C). Commonly used low-thoracic CTOs include the SOMI, the Yale brace, the four-poster brace, and the Minerva-type orthoses. All these braces provide better xation to the head and trunk than high-thoracic CTOs and are therefore the most effective of all cervical braces. The major difference between high- and low-thoracic CTOs is the ability of the latter to provide better control of spinal rotation and sagittal motion in the mid and lower cervical spine. The SOMI (see Fig. 279C), the most popular lowthoracic CTO, consists of rigid metal frames with padded shoulder straps, a strap placed around the trunk, and variable sizes of the chest component. The SOMI brace is most effective in stabilizing the C1C5 region, especially in exion-extension, and is therefore recommended for upper cervical fractures that are unstable in the sagittal plane (i.e., type II hangmans fracture). SOMI braces are reported to be comfortable and well tolerated by patients, especially in the upright position. The Yale brace is a modied form of the Philadelphia collar that has a molded plastic shell extending over the front and back of the thorax. The Yale brace restricts 87% of exion-extension, 61% of lateral bending, and 75% of axial rotation.60 This brace is more effective than the SOMI in limiting exion-extension at C2C3 and C3T1, but less effective at C1C2.58 Similar to other CTOs, the Yale brace does not provide sufcient control of motion at the occiputC1 level. Patient comfort and compliance are high with the Yale brace, and the lack of bulky posterior components (similar to the SOMI) can further enhance patient comfort while lying prone. Most four-poster braces

are less accepted by patients because of their bulky posterior components. Minerva-type braces have extended occipital support and are equipped with a forehead strap for better immobilization of the head.113 These braces provide adequate cervical spine immobilization from C1 to C7. When compared with other CTOs, Minerva-type braces offer better control of exion-extension at C1C2 and can limit up to 88% of normal axial rotation.113 In one analysis of total residual cervical motion, the Minerva orthosis had stabilizing characteristics comparable to those of a halo vest orthosis.14 Studies to date have demonstrated that all cervical spine orthoses possess inherent deciencies. Although both high- and low-thoracic CTOs can signicantly restrict upper cervical spine motion, paradoxical motion or snaking can usually occur in sagittal exion at the occiputC1 level. Snaking, which can also occur with halo vest stabilization,60 is least pronounced with Minervatype orthoses.14 Comparative studies of the biomechanical properties of cervical braces reveal signicant variability in all planes of cervical motion measured. Moreover, most clinical studies of cervical bracing typically use healthy volunteers, and it is clear that ultimate orthotic performance may differ signicantly in an unstable cervical spine. The altered spinal biomechanics after injury in combination with associated soft tissue spasms may adversely affect the effectiveness of the orthosis in clinical settings. Finally, although general indications have been established for specic cervical brace applications60 (Table 275), no clinical consensus has been reached on the suitability of each CO for a specic spine injury. Therefore, it is imperative that the physician individualize selection of a particular cervical brace on the basis of injury type and patient prole. The duration that a cervical brace is applied is also controversial and depends on the function that it is serving. Brace use can be limited to protecting the patient during transport or throughout the emergency evaluation process. For conrmed unstable spinal injuries, these orthoses can

TABLE 275

Recommended Orthosis for Selected Cervical Injuries


Injury Ring C1 (Jeffersons fracture) Stable Unstable Odontoid fracture (types II and III) Atlantoaxial instability Hangmans fracture Stable Unstable Midcervical exion injuries Low-cervical exion injuries Midcervical extension injuries Low-cervical extension injuries

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Motion Segment Affected OccC1 OccC2 C1C2 C1C2 C2C3 C2C3 C3C5 C5T1 C3C5 C5T1 Plane of Instability All All All Flexion Flexion All Flexion Flexion Extension Extension Recommended Orthosis Yale brace Halo vest Halo vest SOMI SOMI Halo vest Yale brace, SOMI Yale brace, SOMI, Four-poster brace Halo Yale brace, Four-poster brace

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Abbreviation: SOMI, sternal-occipital-mandibular immobilizer.

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be used in combination with restricted activity until denitive treatment can be implemented. In patients with stable fractures or minor soft tissue injuries, COs can be used for several weeks or months until the patients symptoms and risk have resolved. THORACIC AND LUMBAR BRACES The thoracic spine is unique among spinal regions in terms of its inherent rigidity and location between highly mobile adjacent cervical and lumbar segments. The midspine location of the thoracic segments makes this region particularly amenable to bracing. Furthermore, the rib cage, sternum, and shoulder girdle act as additional stabilizers. However, achieving signicant restriction of movement in an unstable thoracic spine can be difcult because of the continuous breathing movements. In addition, rotation, the principal motion of the thoracic spine, is much more difcult to control than exion and extension. Therefore, thoracic spinal bracing is indicated only for acute spinal trauma or postoperative support, and it is rarely effective for degenerative disorders. The lumbar spine, particular its lower segments, is difcult to brace because of the limited caudal xation points and its physiologic hypermobility. Typically, adequate stabilization requires that the brace extend as much as four or ve vertebral levels proximal and distal to the unstable segment.13 Even when the brace includes a hip spica component, hip exion is not adequately controlled, and this mobility results in inadequate lumbar protection.8 The goal of thoracolumbar bracing is to support the spine by limiting overall trunk motion, decreasing muscular activity, increasing intra-abdominal pressure, reducing spinal loads, and limiting spinal motion. Current available orthoses include lumbosacral corsets, Jewett braces, and full-contact custom-molded orthoses. Selection of the appropriate orthotic is dependent on the type of injury, the extent of spinal stability, associated injuries, body habitus, and the patients age.7, 119 Lumbosacral corsets and elastic bands are generally used to diminish pain, decrease lumbar spine mobility, and support the paraspinal muscles. Although these braces reduce overall upper trunk motion, they have little effect on intersegmental spinal motion or loads. Neither soft nor rigid corsets have any stabilizing effect on sagittal, axial, or transverse intervertebral translation.8 Corsets decrease low back pain primarily because they act as a reminder to the patient to avoid excessive forward or lateral bending. Paradoxically, however, increased motion can occur at L5S1 as a result of long lumbosacral corsets. Corsets should therefore be restricted to patients with stable injury patterns or elderly patients with osteoporosis.7 Among the potential adverse effects of lumbosacral corsets are disuse muscle atrophy, osteopenia/osteoporosis, psychologic dependency, and concentration of forces at the lumbosacral junction. One of the oldest and probably the most reliable thoracolumbosacral orthosis (TLSO) is the Jewett hyperextension brace (Fig. 2710). This brace applies three-point xation anteriorly at the sternum and pubis and posteriorly at the thoracolumbar junction to maintain the thoracolum-

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FIGURE 2710. The Jewett brace is a three-point xation system (arrows) that maintains extension of the thoracolumbar area. The brace has a light adjustable aluminum frame that allows free extension but prevents exion.

bar spine in extension. The brace allows for hyperextension, prevents exion, and is lightweight and easily adjustable. The Jewett brace is generally recommended for patients with injuries at the T6L3 region that are unstable in exion.7 Nagel and associates demonstrated that the Jewett brace reduces intersegmental motion and exion at the thoracolumbar junction whereas lateral bending and axial rotation are not affected because of its lack of pelvic support.93 In a nite-element model simulating thoracolumbar injuries, the Jewett hyperextension brace restored stiffness to normal values in one- and two-column lumbar fractures, but it was ineffective for three-column injuries.99 In a cadaver study, Nagel and colleagues compared the effectiveness of the Taylor-Knight brace, the Jewett brace, and a body cast in immobilizing the L1L2 segment after progressive ligament injury in the posterior, middle, and anterior columns.93 The Taylor-Knight brace effectively reduced exion and lateral bending, but it provided little resistance to axial rotation. The Jewett brace reduced exion 40%, but it also had minimal effect on lateral bending or rotation. Only the body cast markedly reduced intersegmental spinal motion in all planes. The full-contact TLSO is currently the most effective orthosis for nonoperative management of patients with thoracolumbar fractures.99 The advantages of a custommolded full-contact TLSO (Fig. 2711) include distribution of force over a large surface area, improved xation of the pelvis and thorax, better control of lateral bending and axial rotation, consistent patient and nursing acceptance, and improved, nonobscured radiographs.7 Theoretically, the TLSO allows for correction of deformity by patient positioning during the molding process. In patients with compromised sensation, a total-contact orthosis is always preferable to a cast because it can be removed for skin monitoring and readily adjusted to relieve areas subjected to excessive pressure. Reid and co-workers reviewed patients with thoracolumbar burst fractures who were treated with a custom-

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molded TLSO and permitted early ambulation.102 All patients healed without loss of spinal alignment or progression of neurologic decit. Studies by Cantor and colleagues and Mumford and co-workers also reported favorable results without complications for patients with thoracolumbar burst fractures treated with custom-molded TLSOs.25, 92 Studies suggest that custom-molded TLSOs are indicated for patients with instabilities in more than one plane, impaired skin sensation, or multiple osteoporotic compression fractures. A total-contact TLSO may be indicated for very obese or noncompliant patients.7 Custom-molded TLSOs had a greater immobilizing effect than lumbosacral corsets and chair-back braces; however, overall restriction of trunk rotation was limited in all these braces.68 Biomechanically, lumbar braces were found to be most effective at the center and to have increased spinal motion at the ends of the brace.40 The Baycast jacket limited intersegmental spinal motion to 50% to 60% of normal; extension of the Baycast jacket with a leg spica (Fig. 2712) additionally reduced spinal motion at the L4L5 and L5S1 regions to 12% and 8% of the normal range.40 Treatment protocols for application of a thoracolumbar brace vary greatly among physicians. It is preferable that braces be worn at all times, during sleep and all daily activities. Standard total-contact TLSO or other braces do not effectively immobilize segments below L4 and above T8, so a spica TLSO with 15 to 30 of hip exion is recommended for injuries below L4 and a custom-molded cervical extension for injuries above T8.

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FIGURE 2712. Custom-molded thoracolumbosacral orthosis extended with a lumbosacral spica. (Redrawn from Sypert, G.W. External spinal orthotics. Neurosurgery 20:642649, 1987.)

SPECIFIC BEDS FOR SPINE-INJURED PATIENTS

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FIGURE 2711. A custom-molded thoracolumbosacral orthosis must be fabricated by a skilled orthotist. After tting, the skin should be checked for excessive pressure, and if present, the brace should be modied. Molding for the orthosis should be delayed if the patient has abdominal distention or excessive weight gain from uid retention. (Redrawn from Sypert, G.W. External spinal orthotics. Neurosurgery 20:642649, 1987.)

of secondary complications. Standard hospital beds are suitable for most cervical, thoracic, and lumbar injuries in the acute setting but should be modied with an egg crate mattress to prevent decubitus ulcers. These beds are preferable for multitrauma patients so that traction can be applied to both the cervical spine and extremities. Patients can be logrolled if the other injuries allow. Prolonged immobilization can be the principal cause of morbidity in bedridden patients; therefore, early mobilization of spine-disabled patients on special rotating beds was developed for that purpose. The bed is usually maintained in perpetual motion with each patient rotated more than 200 times a day. Bed mobility is generally only interrupted for treatment, feeding, diagnostic tests, and personal hygiene. Two types of beds with turning frames are currently popular. In the Stryker bed, the patient is turned along the longitudinal axis to allow dorsal skin care and personal hygiene. Traction can be applied in the longitudinal axis, but it is very difcult to achieve traction forces in any other plane. The suitability of this frame for cervical spine immobilization has been criticized.87, 114 The Rotorest frame is a table that continuously turns the patient equally from side to side in an afxed posture, with a maximal excursion of 124 every 4.5 minutes (Fig. 2713). Skeletal alignment is achieved by a series of adjustable support packs that create surface compartments. Centrally placed cervical, thoracic, and pelvic hatches permit wound care, personal hygiene, lumbar puncture, chest auscultation, and bowel and bladder hygiene without altering the patients position. The Rotorest frame allows for traction forces in multiple planes, both to the axial skeleton and to the extremities. McGuire and colleagues compared the Stryker frame and the Rotorest in unstable cervical and lumbar seg-

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FIGURE 2713. A rotating bed used for multiple-trauma and spineinjured patients permits access to all areas of the body. Pulmonary and skin problems are reduced by the rotating motion.

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ments and demonstrated that the Rotorest bed was more effective.87 The Stryker frame permitted signicant displacement of both unstable lumbar and cervical segments during transition from the supine to the prone position.

FIGURE 2714. Fixed occipitocervical subluxation in a 12-year-old boy without a neurologic decit.

NONOPERATIVE MANAGEMENT OF SPECIFIC SPINAL INJURIES Occipitocervical Injuries

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Occipitocervical injuries (Fig. 2714) are usually lethal, but when the rare patient is encountered, it is imperative that the physician have a high index of suspicion to properly ensure the patients survival. Occipitocervical malalignment can be determined by using the Powers ratio to assess the lateral radiograph (Fig. 2715). Initially, all occipitocervical subluxations or dislocations should be meticulously immobilized on a backboard with sandbags and tape to secure the position of the head. Type I (anterior) and III (posterior) injuries (Fig. 2716) can be treated with minimal traction (5 lb), but the pins should be placed in a manner that allows slight extension or exion, respectively, to achieve reduction.121 In type II (axial distraction) injuries, occiput alignment is generally acceptable, and traction involving any degree of distraction is strictly contraindicated. This injury is extremely unstable, and posterior occipital-cervical fusion with at least 3 months of halo vest immobilization is more appropriate denitive treatment. Lateral exion-extension stress radiographs are essential to document stability before halo removal. Occipital condyle fractures occur quite frequently and can usually be managed nonoperatively (Fig. 2717). Type I (impacted occipital condyle fracture) and type II (occipital condyle fracture in conjunction with a basilar skull fracture) fractures typically require only in situ immobilization with a cervical collar for 8 weeks.5 The more unstable type III injury (occipital condyle fracture plus an avulsion fracture caused by pull of the alar

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Presentation BC OA 1

FIGURE 2715. The Powers ratio is a value of the distance between the basion (B) and the posterior arch of the atlas (C) divided by the distance between the opision (O) and the anterior arch of the atlas (A). Normally, the Powers ratio is 1 or less. A Powers ratio greater than 1 suggests anterior occipitocervical subluxation or dislocation. (Redrawn from Eismont, F Frazier, D.D. In: Levine A.M.; et al., eds. Spine Trauma. .J.; Philadelphia, W.B. Saunders, 1998, p. 198.)

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ligament) requires halo vest immobilization for 12 weeks. Surgery is warranted for occipital condyle fractures only after an attempt at conservative treatment is unsuccessful because of occipitocervical pain.5

Fractures of the Atlas


Fractures of the atlas can generally be treated nonoperatively if the fracture is stable and in acceptable alignment. Atlas fractures frequently occur in conjunction with other cervical spine injuries, and these other injuries will often determine the optimal method of treatment. Most isolated atlas fractures are stable because of an intact transverse ligament (Fig. 2718), are not associated with neurologic decit, and can usually be treated nonoperatively. Posterior arch fractures are generally stable and nondisplaced and require only a high-thoracic CTO for 2 to 3 months. When the transverse ligament is disrupted, a Jefferson or lateral mass fracture can result in greater than 7 mm of lateral displacement (Fig. 2719). These fractures will benet from cervical traction to achieve reduction and eventual halo vest stabilization (Fig. 2720). Axial traction should be applied through a halo ring (as opposed to tongs) to facilitate eventual vest application. Weight should begin at about 10 lb and typically be increased gradually up to as much as 40 lb before full reduction of the ring can be appreciated on an open-mouth view. Patients must be maintained in traction for at least 4 weeks for sufcient healing to permit placement in a halo vest. Traction is removed while the patient remains supine, and an open-mouth radiograph is taken after 1 hour. If lateral mass symmetry is maintained, a halo vest is applied. If malalignment recurs, traction is reapplied and healing reevaluated at 2-week intervals. Traction may be necessary for up to 6 to 8 weeks before halo vest support can be

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FIGURE 2716. Classication of occipitocervical subluxation and dislocation proposed by Traynelis and colleagues. (From Traynelis, V.C.; et al. J Neurosurg 65:863870, 1986.)

Type I

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Type II Presentation

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Type III
FIGURE 2717. Anderson-Montesano classication of occipital condyle fractures. (From Anderson, P.A.; Montesano, P.X. Spine 13:731736, 1988.) FIGURE 2718. A Jefferson fracture of the atlas with a preserved transverse ligament.

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applied for an additional 6 weeks. When reduction cannot be achieved or maintained or the patient is unable to tolerate prolonged traction or a halo vest orthosis, surgical reduction and fusion are warranted. Transverse ligament disruptions without fractures of the atlas are extremely unstable. Additionally, these injuries are inherently at great risk for neurologic compromise and are best managed operatively.

Odontoid Fractures
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Type I odontoid fractures (apical ligament and bony avulsion) (Fig. 2721) are essentially stable and require limited if any external support.4 Type III fractures (extension extending below the waist of the odontoid into the body of C2) usually heal uneventfully. Reduction is achieved by axial halo traction, and to ensure that dens alignment is maintained, these injuries are optimally immobilized in a halo vest because other COs are associated with up to a 15% incidence of nonunion.28 Type II odontoid injuries (fracture through the waist of the odontoid) have an extremely high incidence of nonunion and usually warrant operative management. Nonoperative treatment is reasonable if the injury is recognized early, the displacement is minimal and can be reduced, reduction is maintained, and the patient is not elderly.15, 28 Nonoperative treatment is initiated with halo ring traction. Traction is usually effective with relatively light weight (10 to 20 lb), and application of bivector traction can assist in correcting translation (if >5 mm) and angula-

Presentation

FIGURE 2719. A Jefferson fracture of the atlas with a disrupted transverse ligament results in laterally displaced masses of C1 more than 7 mm in total (a + b).

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FIGURE 2720. Open-mouth view of a signicantly displaced C1 fracture taken at the time of injury (A). Traction (30 lb) reduces the deformity (B) and must be maintained for at least 6 weeks before halo vest application. Late follow-up shows maintenance of reduction (C).

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Type I

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Type II Presentation

Type III
FIGURE 2721. Anderson and DAlonzo classication of odontoid fractures.

sion, whereas residual translation often requires elevation of the torso by placing a rolled towel at the cervicothoracic junction, which permits the upper cervical spine to translate posteriorly. Postreduction immobilization consists of a halo vest if the reduction can be maintained within 3 to 6 mm of normal alignment. If greater than 6 to 8 mm of translation persists, the patient is preferably maintained in halo traction for 4 to 6 weeks and then secondarily placed in a halo vest. Type II injuries will typically heal at the pars and anteriorly with some degree of C2C3 ankylosis. Type IIA hangmans fractures (oblique midpars fractures with severe angulation and no translation) are also extremely unstable injuries that can be reduced with simple extension, but distraction is absolutely contraindicated because of complete disruption of the anterior longitudinal ligament and annulus and the risk of pronounced axial displacement (Fig. 2724). Once the neck is extended into a reduced position, a halo vest should be applied under uoroscopic control and worn for 2 to 3 months. Type III fractures are uncommon and consist of C2 pars fractures associated with unilateral or bilateral C2C3 facet dislocation. Nonoperative management (i.e., traction, manipulation) is contraindicated in these injuries because of loss of continuity between the C2 body and the posterior elements/facets.

tion (if >10). When lateral radiography has conrmed the reduction, a halo vest can be applied. After the patient is upright, serial follow-up radiographs are essential until the fracture has healed. Loss of reduction warrants adjustment of the halo by neck exion-extension or sagittal-plane translation. When malalignment or instability persists, treatment should be operative.

Lower Cervical Spine Injuries


Ligamentous injuries of the lower cervical spine can range from simple sprains without malalignment, to subluxation with partial loss of cervical spine ligamentous stability, to frank dislocation with total ligamentous disruption. Lower cervical spine instability has been described by White and co-workers (Table 276) and is based on the extent of segmental angular or translation displacement129, 130 (Fig. 2725). Dislocations may spontaneously reduce with supine positioning, and the degree of instability is often not easily appreciated on a static radiograph. Likewise, dislocations may become xed or locked in a malaligned position and require cervical traction or open manipula-

Traumatic Spondylolisthesis of the Axis (Hangmans Fractures)


Bipedicular or pars interarticularis fractures (hangmans fractures) of the second cervical vertebra have varying degrees of angular or translational stability that determine the appropriate treatment (Fig. 2722). Type I fractures result from hyperextension and axial loading and have minimal (less than 3 mm) displacement and angulation (less than 11) (Fig. 2723).73 Reduction is not required, and after stable lateral exion-extension radiographs, a high- or low-thoracic CTO for 2 to 3 months is sufcient immobilization. A similar treatment protocol is appropriate for type IA fractures (less than 3-mm translation, but without angulation). It is critical that the physician accurately distinguish between a stable type I injury and the more unstable type II injury. Type II hangmans fractures (vertical pars fracture adjacent to the body with signicant translation and exion angulation) are extremely unstable. The patients supine hyperextended neck position may spontaneously reduce the fracture, and slight exion stress views may be warranted to conrm the injury pattern. Reduction is achieved by halo ring application and, with the head slightly extended, gentle cervical traction under uoroscopic control. Angulation may correct easily with exten-

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FIGURE 2722. The severity of traumatic spondylolisthesis of the axis (hangmans fractures) is characterized by angulation () and translation (D). (Redrawn from Levine, A.M. In: Levine A.M.; et al., eds. Spine Trauma. Philadelphia, W.B. Saunders, 1998, p. 280.)

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FIGURE 2723. Levine and Edwards classication of traumatic spondylolisthesis of the axis (hangmans fracture).

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Type I

Type II

Type IIA

Type III

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FIGURE 2724. Type IIA hangmans fracture before traction (A) and after cervical traction has been applied (B). Traction is contraindicated for type IIA hangmans fractures because it leads to signicant overdistraction.

tion for reduction. After reduction and depending on the extent of disruption of the posterior ligamentous complex, cervical immobilization in a cervical orthosis for 6 to 8 weeks is sufcient. If reduction cannot be maintained or pain persists after adequate immobilization, operative stabilization is indicated. Cervical compression fractures involve less than 50% loss of anterior vertebral body height and maintenance of posterior ligamentous integrity. Usually, a CO for symptomatic relief is sufcient treatment for this stable fracture. When compression of the anterior vertebrae exceeds 50% of the vertebral body height, exion-distraction occurs in conjunction with posterior ligamentous disruption. Flexionaxial compression loading injuries associated with disc disruption plus an anterior vertebral body fracture are more challenging because CO or halo vest immobilization alone is plagued by a high incidence of persistent fracture displacement and loss of alignment.29 Moreover, when the injury pattern also includes disruption of the facet capsule

TABLE 276

Checklist for the Diagnosis of Clinical Instability of the Lower Cervical Spine
Element Anterior elements destroyed or unable to function Posterior elements destroyed or unable to function Radiographic criteria Sagittal displacement >3.5 mm 2 Relative sagittal angulation >11 2 Positive stretch test Spinal cord injury Nerve root injury Abnormal disc narrowing Dangerous loading anticipated
*A total of 5 or more points represents instability. Source: White, A.A.; et al. Spine 1:1527, 1976.

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Points* 2 2 4 2 2 1 1 1

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FIGURE 2725. Angular displacement 11 greater than that at the adjacent vertebral segments suggests instability from posterior ligamentous disruption, just as translation greater than 3.5 mm does. (From White, A.A.; Panjabi, M.M. Clinical Biomechanics of the Spine. Philadelphia, J.B. Lippincott, 1978, pp. 236251.)

Presentation

and posterior ligamentous structures, a signicant risk for late instability exists.27, 126 Although unilateral or bilateral facet subluxations, dislocations, or fractures (or combinations of these injuries) are variations of the same injury patterns, determination of optimal treatment requires that distinctions be made between these specic injuries. As unilateral or bilateral facet injuries progress from subluxation to perched facets and nally to frank dislocation, the extent of cervical spine malalignment reects the degree of facet capsule or posterior ligament disruption, or both (Fig. 2726). Facet subluxations or unilateral dislocations may achieve some degree of segmental stability after reduction and nonoperative treatment. However, a facet fracture suggests persis-

tent rotational and exion instability and is most appropriately managed surgically.

Reduction of Unilateral or Bilateral Facet Injuries


Unilateral and bilateral facet injuries should be reduced by closed means with skeletal traction in patients who are oriented and able to be assessed neurologically. After reduction, unilateral facet dislocations can often be treated in closed fashion with a halo vest, whereas bilateral facet dislocations are best managed with operative stabilization. Gardner-Wells tongs should be applied if operative stabilization is anticipated, whereas a halo ring is used for unilateral facet dislocations that are to be maintained in a halo vest. The patient is placed supine on a bed with approximately 20 of head elevation to offset the skeletal traction to be applied. If sedation is used, only mild doses of analgesics or muscle relaxants (or both) are warranted. Throughout the maneuver, the patient has to remain responsive and neurologically stable. Initially, a weight of 10 to 15 lb is applied through traction in line with the spine. Serial static radiographs or dynamic uoroscopy should assess spinal alignment after the initial weight is applied and after each subsequent addition of 5 to 10 lb. Static radiographs are best obtained 15 to 20 minutes after each weight increase to allow for soft tissue distraction. If the facets unlock, the neck should be slightly extended and the traction weight decreased to approximately 10 lb to permit the facets to spontaneously reduce (Fig. 2727). Changing the direction of the traction vector can facilitate the reduction of unlocked facets and assist in maintaining the reduction (Fig. 2728). When spinal reduction has been achieved, halo vest application or surgical stabilization should be performed before permitting upright mobilization. Occasionally, resistant unilateral facet dislocations will benet from the head and neck being slightly turned away

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FIGURE 2726. Normal position (A) of the cervical vertebrae in the lateral projection. A subluxated position (B) is recognized by fanning of the spinous process, increased angulation of the vertebrae, and excessive separation of the facets. Perched facets (C) are recognized by the tip of the inferior facet resting on the tip of the superior facet. Dislocated facets (D) are determined by the displacement of the inferior facet anterior to the superior facet.

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FIGURE 2727. Initial position of a unilateral facet dislocation in both the sagittal and the axial planes (A). Traction permits some distraction but not reduction (B). Flexion of the neck increases distraction, but the facet is still dislocated (C). Lateral tilt away from the side of dislocation unlocks the dislocation (D), and after extending and putting the neck in a neutral position, the reduction is completed (E).

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from the side of dislocation to facilitate disengagement of the facet. Bilateral facet dislocations are extremely unstable and will generally reduce with low traction weight and slight exion, followed by neck extension without rotational manipulation. If the patients neurologic status becomes altered during any of these maneuvers, all traction and manipulation should be terminated and the spine secured in a neutral position. Open surgical reduction is absolutely indicated in these patients, as well as those who simply fail attempts at closed treatment. Reduced unilateral or bilateral facet dislocations can still fail because of persistent instability and pain despite halo vest immobilization and therefore warrant surgical stabilization. Eismont and coauthors reported the risk of neurologic decit from an associated disc herniation after closed reduction of cervical spine facet dislocations.37 Although other authors have reported similar ndings,82, 106 the actual incidence of this catastrophe remains relatively low. Rizzolo and colleagues recommended that immediate closed cervical skeletal traction reduction be performed without a previous MRI scan only in alert, oriented patients who are neurologically intact.105 MRI is absolutely indicated for patients with neurologic decit before traction and for patients who require open surgical reduction.

Sears and Fazl reviewed 70 patients with facet injuries treated in a halo vest and found that stability and anatomic reduction could be maintained with a halo in only 44% and 21% of patients, respectively.111 These results corroborated an earlier study by Koch and Nickel, who demonstrated that maintaining facet reduction requires constant distraction and that halo vest patients typically experience axial compression during standing and walking.65 Rorabeck and colleagues reviewed a group of patients with facet fractures, 14 of whom were treated operatively without pain or any need for secondary surgery.108 These patients were compared with a separate injury group that was treated nonoperatively; in this second group, seven patients had pain and ve patients required secondary surgical procedures. Therefore, although unilateral facet fractures can respond to nonoperative management, a successful outcome is not guaranteed. Fracture separation of the lateral articular mass, unlike facet injuries, results from hyperextension or axial loading and lateral bending instead of exion-rotation. This particular injury is often missed on plain radiography, which depicts segmental translation and rotation without exion or facet displacement. When the patient is supine, the displaced lateral mass can reduce spontaneously even before the application of traction. Nonoperative treatment

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Neutral B

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Presentation A B

FIGURE 2728. Reduction of a facet dislocation by traction. Facets treated with traction in the neutral position will unlock and remain perched. Changing the direction of the traction vector above neutral (to point A) permits reduction of the unlocked facets. Changing the traction vector below neutral (to point B) allows maintenance of reduction at lower traction weights.

facet fractures) and injuries associated with signicant soft tissue disruption. Soft tissue or ligamentous injuries are extremely difcult to accurately diagnose with static radiographs, and dynamic or stress radiographs are often necessary. Dynamic radiographs are also recommended at the completion of brace treatment. Although nonoperative treatment is quite effective, the medical and economic impact of such treatment has been challenged.31 Operative treatment results in less time in bed, earlier physical therapy, and an overall decrease in total cost to society. Therefore, the clinician must carefully determine the injuries that are likely to respond favorably to nonoperative treatment without any risk of late instability, pain, or neurologic decit. Teardrop fractures are unique exion/compression injuries in the mid to lower cervical spine (C3C7) and are extremely dangerous because of the high incidence of associated instability and neurologic decit. Even when seemingly well aligned, these injuries can progress rapidly to signicant deformity as a result of their extensive ligamentous disruption. Extension teardrop fractures can be stable (no posterior ligamentous disruption), and thus are suitable for cervical brace immobilization for 3 months, with lateral exion-

consists of a halo vest and is indicated only if the injury is nondisplaced. Unfortunately, even a nondisplaced fracture separation may displace secondarily, so surgical stabilization is preferable for this injury.

Vertebral Body Fractures


Compression fractures of the lower cervical spine are caused by exion-induced axial compression forces that result in loss of anterior body height and some degree of distraction posteriorly. When exion is combined with signicant rotation or translation, subluxation of the injured vertebra can occur. When the force of injury is predominantly axial, burst fractures are produced along with disruption of the anterior and middle columns and are frequently associated with neurologic injury (Fig. 2729). Treatment of both these injury patterns should initially consist of halo traction beginning at 15 to 20 lb and increasing in 5-lb increments until normal alignment has been restored. Pronounced instability frequently persists in patients with signicant posterior ligamentous disruption or a large anterior teardrop fracture. Nonoperative treatment consisting of a halo vest should be restricted to neurologically intact patients with pure exion injuries and minimal residual deformity (less than 20 of anterior body compression). Patients with unstable injuries who are not candidates for surgery or a halo vest because of polytrauma require extended bedrest with halo traction until early healing has been achieved. Most lower cervical spine injuries will heal with sufcient stability if they can be anatomically reduced and the reduction is maintained throughout treatment. Exceptions include torsionally unstable fractures (i.e., lateral mass or

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Presentation

FIGURE 2729. Burst fracture of the C6 vertebra with partial displacement of the body into the canal (arrow).

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extension radiographs obtained to document stability. Radiographically, unstable teardrop fractures have greater than 3 mm of retrolisthesis or more than 11 of angulation or give rise to neurologic decits (or any combination of these ndings); such fractures should be placed in tongs traction to restore alignment before surgical stabilization.

TABLE 277

Checklist for the Diagnosis of Clinical Instability of the Thoracic and Thoracolumbar Spine
Element Anterior elements destroyed or unable to function Posterior elements destroyed or unable to function Radiographic criteria Sagittal displacement >2.5 mm 2 Relative sagittal angulation >5 2 Spinal cord or cauda equina damage Disruption of costovertebral articulations Dangerous loading anticipated

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Points* 2 2 4 2 1 2

Thoracic Spine Injuries


The thoracic spine is inherently stable because of the rigidity created by the structural conguration of the spine, sternum, and rib cage. Injuries in this region usually require a signicant component of axial load or exion (or both), and more severe injuries also involve a component of torsion130 (Table 277). Associated injuries occur in approximately 75% of thoracic spine injuries and can include rib fractures, pulmonary contusions, pneumothorax, cardiac contusions, and vascular injuries. Profound neurologic decit occurs more frequently in the thoracic spine than in the cervical or thoracolumbar regions. In a series of 376 thoracic spine fractures, 235 (63%) resulted in complete neurologic injuries.89 This high incidence of complete neurologic injury is due to the small size of the neural canal, the tenuous arterial blood supply to the thoracic cord, and the high energy required to inict injury.

*A total of 5 or more points represents instability. Source: White, A.A.; Panjabi, M.M. Clinical Biomechanics of the Spine. Philadelphia, J.B. Lippincott, 1978, pp. 236251.

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Thoracic spine fractures can usually be managed nonoperatively when the patient is neurologically intact. Even patients with axial load or burst fractures are generally neurologically intact, unless the fracture has a component of signicant exion or angulation, rotation, or translation. An injured thoracic spine is more inherently stable than its cervical or lumbar counterparts; however, orthotic support is still essential in allowing earlier mobility and maintaining spinal alignment (Fig. 2730). The standard

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Presentation

FIGURE 2730. Fractures of the high thoracic region (T1T6) are difcult to control. In this typical fracture of T3, no immobilization was used, and at 4 weeks the fracture had collapsed with a kyphotic deformity of 38.

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orthotic device, the TLSO, can include a cervical extension (CTLSO) for a high thoracic injury. Despite appropriate bracing, certain thoracic spine fractures may be complicated by late collapse and deformity. Therefore, these patients must be carefully monitored and occasionally maintained on an initial regimen of strict bedrest before brace application. Surgical intervention is warranted if the fracture is extremely unstable or bracing is poorly tolerated. Fractures secondary to gunshot injury are usually amenable to bracing even in the presence of a complete neurologic decit.

Thoracolumbar Spine Fractures


Nonoperative measures have traditionally been the standard treatment of most thoracolumbar spine fractures and are most appropriate for stable thoracolumbar fractures. Before the advent of modern surgical techniques, the only treatment available for thoracolumbar fractures was postural reduction with hyperextension and immobilization.9, 10, 44, 97 Fracture reduction was achieved by gravity, pillows, and manual manipulation in injuries with or without neurologic decit. Although the risk of early or late neurologic loss was low, the recommended length of bedrest could approach 12 weeks. Union occurred in up to 98% of these patients,9 and the initial indications for nonoperative treatment have even included irreducible fracture-dislocations, locked facets, and gunshot wounds. Frankel and coauthors reported on a series of 205 thoracolumbar spine fractures treated with postural reduction, bedrest, and orthotic support.44 Partial neurologic decit improved in 72% of patients, whereas neurologic deterioration was noted in only 2% and late instability occurred in only two patients. These authors reserved surgery for patients with signicant or progressive neurologic decit. Currently, nonoperative treatment should be reserved for patients who are neurologically stable or intact and retain spine stability131 (Table 278). Post-traumatic
TABLE 278

Checklist for the Diagnosis of Clinical Instability of the Lumbosacral Spine


Element Anterior elements destroyed or unable to function Posterior elements destroyed or unable to function Radiographic criteria Flexion-extension radiographs Sagittal translation >4.5 mm or 15% Sagittal rotation >15 at L1L2, L2L3, L3L4 >20 at L4L5 >25 at L5S1 Resting radiographs Sagittal displacement >4.5 mm or 15% Relative sagittal angulation >22 Cauda equina damage Dangerous loading anticipated

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Points* 2 2 4 2 2 2 2 2 2 3 1

*A total of 5 or more points represents instability. Source: White, A.A.; Panjabi, M.M. Clinical Biomechanics of the Spine. Philadelphia, J.B. Lippincott, 1978, pp. 236251.

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kyphosis of up to 30 has been deemed acceptable in patients with stable burst fractures and no neurologic decit.67 Weinstein and co-workers reported on the long-term outcome of 42 patients with unstable thoracolumbar burst fractures managed nonoperatively.127 Neurologically intact patients did not have any worsening of their neurologic decit. Spinal kyphosis was 26 in exion and 17 in extension, and although some back pain was present in 90% of patients, only three required late operations. Interestingly, canal patency improved by 22% at follow-up as a result of resorption of bone fragments and canal remodeling. No correlation was found between the initial radiographic severity of the injury and residual deformity or symptoms at follow-up. These authors recommended nonoperative treatment of thoracolumbar fractures in patients with a nonpathologic single-level burst fracture and no neurologic decit. Denis reviewed 52 burst fractures without neurologic decit that were treated nonoperatively and compared these patients with 13 who were stabilized with Harrington rods.34 The large sagittal diameter of the spinal canal at the thoracolumbar junction appeared to also favor nonoperative treatment of selected burst fractures. However, 25% of the nonoperative patients were unable to return to work full-time, and late neurologic deterioration developed in 18%. Finn and Stauffer determined that the extent of thoracolumbar spinal canal encroachment did not directly correlate with the degree of neurologic decit.41 Nonoperative treatment of thoracolumbar fractures typically begins with a period of recumbency ranging from 3 to 8 weeks. During this time, acceptable alignment of the spine should be achieved and maintained. Afterward, the patient is maintained in a TLSO for 3 to 4 months and permitted to ambulate as tolerated. Nonoperative treatment is preferred for stable burst fractures in patients without neurologic decit or signicant canal compromise (<50%) and with an initial kyphosis of less than 30. All nonoperative patients required serial clinical and radiographic assessment to detect potential deformity or progression of neurologic decit. Factors associated with a successful outcome in the nonoperative treatment of burst fractures of the thoracolumbar spine have been identied by several authors and include the degree of initial kyphosis, the extent of anterior and posterior body height collapse, the number of columns injured, and the degree of initial canal compromise.20, 25, 49, 67, 104 James and associates suggested that an intact posterior column was the best predictor of success in treating a stable burst fracture nonoperatively.56 Reconstitution of canal size over time with conservative treatment was found to be age dependent, with greater canal reconstitution occurring in younger patients. Other predictors have been reported to be residual motion at the fracture site and the extent of the initial kyphosis.25, 67, 92, 131 Fredrickson and colleagues recommended that nonoperative treatment be reserved for patients without signicant neurologic involvement (single nerve root or less), signicant posterior ligamentous disruption, and translation injuries and with less than 25 of initial kyphosis.45 Immobilization in a standard hospital bed and special turning frames (i.e., Rotorest bed) were re-

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served for polytraumatized patients restricted to prolonged bedrest. Nonoperative patients are initially treated with a period of bedrest that can range from several days to 8 weeks, depending on the degree of fracture instability. Before ambulation, the patient is tted for a molded body cast or custom TLSO. Injuries treated in this manner must be able to withstand normal weight bearing, but more strenuous activities (excessive bending, exercising, or lifting) are prohibited. Serial radiographs are taken throughout the treatment course to ensure that the kyphosis is less than 30 and canal compromise is less than 50%. Clinically, pain should progressively decrease and the patient should remain intact neurologically; otherwise, surgery is indicated.

SURGICAL MANAGEMENT OF CERVICAL AND THORACOLUMBAR INJURIES Goals of Surgical Management

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Most spine fractures can be treated nonoperatively. Only a small select group of unstable spine injuries with or without neurologic involvement warrant surgical treatment. Objectives of surgery include (1) restoration of spinal alignment, (2) restoration and maintenance of spinal stability, and (3) decompression of compromised neural elements. The rst goal of surgery is to reduce signicant spine deformity to functionally acceptable alignment. The ability of any spinal instrumentation system to achieve this goal is based on its ability to effectively oppose the deforming forces and counteract the existing instability. Selection of appropriate instrumentation should therefore be determined by the mechanism of the fracture and its subsequent deforming forces. For example, the use of distraction instrumentation for a exion-distraction type of fracture will further destabilize the spine. By contrast, the application of extension and compression type of instrumentation posteriorly would correct this deformity. In cases with associated facet dislocations, care must be taken when performing the reduction maneuver to avoid extruding disc material into the spinal canal.74 The second goal of surgery is to restore and maintain spinal stability in an unstable spine. The appropriate selection of instrumentation is again crucial in preventing recurrence of the deformity. Modern xation devices for both anterior and posterior surgical procedures permit better stabilization while compromising a minimal number of motion segments. Advocates of anterior surgical stabilization contend that posterior xation provides insufcient support for either axial or compressive loads on a compromised anterior spinal column.35 The disadvantage of anterior surgery is the increased risk of morbidity because of the proximity of great vessels, chest and abdominal viscera, and the spinal cord. Furthermore, deformity reduction and stabilization seem to be less reliable with anterior techniques than with posterior procedures despite the recent improvements in anterior instrumentation.3, 46, 62

Posterior xation, particularly with the evolution of pedicle screws, has achieved excellent correction of deformity through indirect reduction techniques. Aebi and colleagues used limited segmental xation in one clinical series and reported correction of kyphosis from 15.8 to 3.5.1 Lindsey and co-workers demonstrated similar short-term results with these techniques, although the initial kyphotic deformity had recurred by the 2-year follow-up.78, 79 A principal goal of surgical management is adequate decompression of the neural elements to allow for maximal restoration of neurologic function. Decompression can be performed anteriorly, posteriorly, posterolaterally, transpedicularly, indirectly, or any combination of these approaches. Usually, the type of injury and timing of surgical intervention will determine the most appropriate type of decompression (i.e., posterior versus anterior). Indirect decompression secondary to posterior restoration of spinal alignment has been shown to be very effective in patients undergoing surgery within 48 to 72 hours.50 By applying distraction and correcting angulation with posterior instrumentation, indirect reduction is achieved through ligamentotaxis. The posterior longitudinal ligament becomes taut and can reduce retropulsed bony fragments away from the spinal canal (Fig. 2731). The literature suggests that the results of anterior direct versus posterior indirect spinal canal decompression are similar in patients with incomplete neurologic decits.26, 54, 71, 92 Gertzbein and colleagues reviewed the outcomes of patients with thoracolumbar fractures and incomplete neurologic decits treated by anterior (direct) versus posterior (indirect) decompression.48 In patients treated posteriorly versus anteriorly, neurologic status improved in 83% and 88%, respectively. Neurologic improvement in both groups was signicantly better than the 60% to 70% recovery rate with nonoperative treatment cited in the literature. In a separate multicenter study49 of 1019 patients with thoracolumbar spine fractures who were monitored for 2 years, the neurologic outcome of anterior and posterior surgery was similar. Currently, the posterior indirect reduction technique is the standard method of treatment of most thoracolumbar spine fractures. Absolute indications for anterior decompression include a neurologically incomplete patient with greater than 50% canal compromise and one or more of the following: (1) more than 72 hours postinjury, (2) failed attempt at posterior reduction, and (3) signicant loss of anterior and middle column (vertebral body) support despite posterior reduction.

Timing of Surgery
The optimal timing of surgery after spinal injury remains controversial. Some clinicians contend that surgery is urgent and should be performed as soon as possible, whereas others support a delay in surgery to allow for resolution of post-traumatic swelling. The only absolute indication for immediate or emergency surgery is progressive neurologic deterioration in patients with spinal fracture-dislocations and incomplete or no neurologic decit.16

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Presentation

FIGURE 2731. L1 burst fracture reduced intraoperatively with ligamentotaxis and stabilized with posterior segmental instrumentation.

Acute spinal deformity in a traumatized patient always warrants immediate spinal realignment to restore spinal canal diameter, effect some degree of neural decompression,16 and theoretically maximize the potential for neurologic recovery. Currently, no clear scientic evidence has demonstrated that immediate surgical intervention will improve neurologic recovery in patients with acute spinal cord injury. One retrospective study suggests that surgery within 72 hours of injury might improve neurologic recovery and decrease hospitalization time in those with cervical spinal cord injuries.91 In a prospective study, however, Vaccaro and associates found no signicant neurologic benet associated with post-traumatic surgical decompression performed less than 72 hours after injury versus waiting more than 5 days.124 Furthermore, comparison of the two groups demonstrated no signicant difference in the length of postoperative intensive care stay or the length of inpatient rehabilitation. Early stabilization and mobilization of patients with long bone fractures have proved advantageous in avoiding

complications such as adult respiratory distress syndrome and deep venous thrombosis.51, 57 Such treatment appears to also be advantageous for spinal injury patients.21, 39 Surgical intervention should be performed expediently to avoid these complications, as well as to allow for early mobilization, proper skin care, and upright patient positioning. In the absence of neurologic decit, it is reasonable to delay surgery to facilitate surgical planning and decrease spinal cord and nerve root edema. Furthermore, hematoma organization occurs at about 48 hours after injury and decreases intraoperative blood loss.44 An excessive delay in surgery, however, may have adverse effects on the surgeons ability to reduce the fracture and achieve canal clearance. Other reports have shown that optimal canal clearance is realized when spine surgery is performed within 4 days and no later than 7 to 10 days after injury.36, 49, 131 Management of a polytrauma patient with an associated spinal injury presents a particularly difcult problem, depending on the severity of the other injuries, the degree of spinal instability, and the patients neurologic status.

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Multiple trauma with c-spine injury

Multiple trauma with thoracolumbar injury

Neurodeficit

No neurodeficit

Thoracoabdominal surgery

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Incomplete Supine position OK Closed reduction Consider ORIF Thoracolumbar fx Supine position unsafe

Presentation

Thoracoabdominal surgery

Long-bone fx ORIF

Long-bone fx ORIF

C-spine fx ORIF

Thoracolumbar fx ORIF

FIGURE 2732. Algorithm for the surgical management of polytrauma patients with cervical (A) and thoracolumbar fractures (B). Abbreviation: ORIF Open reduction internal xation. ,

Surgical planning in these patients can be facilitated with the use of a simple algorithm (Fig. 2732). The effects of early versus late stabilization of spinal fractures in polytrauma patients have been the focus in several recent clinical studies.24, 88, 112 These studies consistently demonstrated that surgery performed within 72 hours in patients with an Injury Severity Score greater than 18 signicantly decreased overall patient morbidity and hospital stay (Table 279). No signicant difference in the rate of perioperative complications was associated with early surgery in polytrauma patients, but blood loss was noted to be signicantly higher in those requiring early anterior spinal approaches. In most institutions, stabilization of spinal fractures is performed in a semiurgent fashion once medical optimization of the patient has been accomplished, preferably within 3 days of the injury. Within this time frame, the

surgical approach/technique should be predicated only on the nature of the injury. When a prolonged delay is anticipated, every effort should be made to maintain spinal alignment within an acceptable range. Late surgical intervention may require more extensive surgery (i.e., both anterior and posterior approaches or more extensive decompression) to achieve adequate spinal alignment, decompression, and stability.

Anesthesia
Induction of anesthesia can be very challenging in patients with spinal trauma, particularly those with unstable cervical spine fractures and incomplete neurologic decit. Maintaining alignment of the cervical spine during intubation is vital in preventing neurologic deterioration. Awake berscopic intubation is the safest method to achieve airway control, especially in a medically stable patient who does not require urgent intubation. Fiberscopic intubation can be performed through either the nasotracheal or orotracheal route. Nasotracheal intubation is preferred in patients with associated maxillofacial fractures, but it is absolutely contraindicated in those with basilar skull fractures. Multiple reports have shown the benecial effects of hypotensive anesthesia in the intraoperative reduction of estimated blood loss.43, 69, 83, 116 Similar ndings were reported by Ullrich and co-workers in a retrospective study comparing normotensive anesthesia with hypotensive anesthesia in patients stabilized with Harrington rod instrumentation for thoracolumbar fractures.123 Blood loss was signicantly reduced with hypotensive anesthesia, and no neurologic deterioration was noted intraoperatively with either the Stagnara wake-up test or somatosensory evoked potentials (SEPs). Theoretically, low oxygen ten-

TABLE 279

Effect of Surgical Timing for Patients with Spine Fractures and an ISS Greater Than 18
Timing of Stabilization Early (<48 hr) Patients (n) GCS AISShead AISSchest Ventilator days ICU days Hospital days Average cost 16 14 1 2 1.0 3.9 11.0 $26,250

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Late (>48 hr) 46 13 3 2 11.0 14.0 26.0 $54,130

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Abbreviations: AISS, Abbreviated Injury Severity Score; GCS, Glasgow Coma Scale; ICU, intensive care unit; ISS, Injury Severity Score.

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sion can potentially inict further ischemic injury to the already traumatized cord, and it is recommended that mean arterial pressure be kept between 80 and 90 mm Hg during hypotensive anesthesia.77, 118 Selection of the anesthetic agent is also of critical importance and may inuence the surgical procedure. It has been well documented that some inhalation agents have an effect on evoked potentials. Sloan maintains that the most effective anesthetic regimen used in conjunction with SEPs is low-dose inhalation agents in combination with intravenous infusion of sedatives, preferably propofol with an analgesic.115 This regimen not only allows for reliable recording of SEPs but is also readily reversible and thus facilitates the use of a wake-up test. In patients with spinal cord injury, succinylcholine, a depolarizing agent, should not be used because it can lead to the rapid release of potassium and thereby increase the risk for ventricular arrhythmias and cardiac arrest.

The head is turned away from the incision site. A left- or right-sided approach can be carried out, depending on the surgeons preference. Advocates of the left-sided approach claim that it is preferable because of the recurrent laryngeal nerves more consistent course on the left side; proponents of the right-sided approach maintain that it is more convenient for a right-handed surgeon. For anterior cervical spine surgery we prefer the use of a regular operating table with the occiput placed on a well-padded circular foam pillow with a center cutout. Gardner-Wells tongs are used to maintain alignment and apply traction intraoperatively. Exposure of the fracture site is carried out through a left-sided surgical approach. CERVICAL SPINEPOSTERIOR APPROACH After general anesthesia has been induced, the patient is turned in the prone position on a regular operative table with longitudinal chest rolls to allow decompression of the abdominal and chest cavities. Turning of the patient can also be facilitated with the Stryker frame. The principal surgeon must maintain control of the head and neck of the patient during all turns. The head can be placed in a Mayeld horseshoe head cushion. Positioning must avoid circumferential pressure around the eye, which could result in retinal artery thrombosis or globe injuries. The Mayeld headrest attaches to the outer layer of the skull and rigidly xes the head and the neck in the prone position without any pressure on the face or the eyes. This frame can be adjusted to exert longitudinal traction and exion or extension as needed through the universal joints and nally x the entire head and neck rigidly before surgery. Alternatively, the Mayeld skull clamp can be used to securely x the head and neck in the desired position. Furthermore, in situations in which a halo vest is in place, the halo ring can be secured to the three-pin Mayeld skull clamp (Fig. 2733), as described by Rhea and coauthors.103

Operative Positioning
The surgical positioning of patients with spinal trauma is a delicate endeavor. Care must be taken to avoid any neurologic deterioration, yet positioning should not compromise the exposure for the planned surgical approach. Care must be taken to avoid pressure around the eyes and prevent injury to the globe or retinal artery thrombosis. Padding of all bony prominences and protection of supercial neural structures are important. Proper positioning of the upper extremities when the patient is prone is crucial to avoid brachial plexus injury. For that purpose, the shoulder should not be overextended and not abducted beyond 90. Similarly, the ulnar nerve must be protected with the arm either secured at the patients side or exed 90 on a padded arm board. Compression stockings on the lower extremities are useful in preventing venous congestion. Finally, after positioning, it is important to check for the presence of distal pulses, especially when the patient is in the prone position. CERVICAL SPINEANTERIOR APPROACH The patient can be placed on a regular bed or Stryker frame in the supine position. During positioning, care is taken to maintain spinal alignment. The occiput is padded with a circular foam pillow with a center cutout or placed in a Mayeld horseshoe cushion. In that position, axial traction may be applied in the form of head halter traction or skull tongs traction (Gardner-Wells tongs). The elbows are carefully padded to protect the ulnar nerve, and the arms are tucked at the patients side. The shoulders may be retracted distally, and longitudinal tape strips can be applied to allow better intraoperative radiographic evaluation of the cervical spine. Care must be taken to avoid excessive constriction of the arms with the tape and taping directly over the nipples. A roll is placed longitudinally between the scapulae to allow for shoulder retraction and extension of the cervical spine for better exposure of the operative eld. Extreme cervical extension should be carefully avoided to prevent increased spinal cord compression under anesthesia.

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Presentation

FIGURE 2733. In cases in which a halo ring has previously been applied, the three-pin Mayeld skull clamp can be used to secure the halo ring.

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FIGURE 2734. Kyphotic deformity occurs in most thoracolumbar spine Presentation fractures. Sagging the spine between two rolls both decompresses the abdomen and permits postural reduction.

Padding is applied, particularly over the bony prominences. The hips and knees are slightly exed with a pillow placed between the knees to prevent pressure injury. An axillary roll is placed under the axilla on the down side, approximately 6 inches from its apex to prevent injury to the brachial plexus. When a thoracotomy is planned, intubation should be done with a doublelumen tube so that the lung on the side of the approach can be selectively deated.

The operating table should be placed in a slight reverse Trendelenburg position to prevent sliding of the patient and provide the surgeon with comfortable access to the operative eld. The presence of distal pulses must be documented. The arms are tucked along the side of the patient, and care is taken to protect the ulnar nerves at the elbows. The shoulders are retracted distally and secured in that position with longitudinal tape to facilitate radiographic access. For posterior cervical spine surgery, it is our preference to position the patient prone on chest rolls on a regular operating table, using a Mayeld skull clamp to secure the patients head and neck. THORACOLUMBAR SPINE Operative positioning for the posterior approach to the thoracolumbar spine can be accomplished with the use of a regular or radiolucent operating table and well-padded chest rolls. The rolls are positioned transversely at the level of the sternum and the iliac crests. Most thoracolumbar spine fractures have some degree of kyphosis, and the position of the rolls will allow the thoracolumbar junction to sag, thereby both decompressing the abdomen and allowing for postural reduction (Fig. 2734). The arms should not be overly extended nor abducted past 90 to prevent brachial plexus injuries. The elbows are padded to protect the ulnar nerves, and the arms are rested on well-padded arm boards. The knees are exed with care taken to avoid pressure on the patellas and feet, and the presence of distal pulses must be documented. Alternatively, the Stryker frame can be used for the posterior approach and will facilitate rotational positioning of the patient. We prefer the use of a four-poster frame on a regular operating table for patient positioning in the posterior approach to the thoracolumbar spine. This frame will allow postural reduction of the spine and will also facilitate access for intraoperative radiographs. Anterior thoracolumbar spinal surgery is recommended for patients who require direct decompression of the dural sac. This technique is accomplished by making a left anterolateral incision with the patient in the right decubitus position on a regular operating table, although in some instances a right-sided approach may be used. The patient is positioned so that the fracture is located at the exion break of the table. It is critical that the patient be in the true lateral position, especially if instrumentation is to be used. Hip supports are used to maintain the relative position of the patient on the operating table. The arm on the side of the operative approach is placed on a Mayo stand, and the other is allowed to rest on an arm board.

Intraoperative Monitoring
Prevention of neurologic deterioration is one of the major objectives of spinal surgery after trauma. Intraoperative monitoring, though not benecial in patients with complete spinal cord injuries, may be helpful in a neurologically intact or incomplete patient.125 Spinal monitoring techniques, traditionally used in spinal deformity surgery, are also becoming popular for treatment of spine fractures.11, 12 The most commonly used intraoperative spinal monitoring measures are SEPs and the Stagnara wake-up test. STAGNARA WAKE-UP TEST The concept of waking the patient during the surgery to determine the integrity of the spinal cord was introduced in 1973 by Vauzelle and colleagues.125 The wake-up test, named after one of its originators, is a simple, costeffective, and very reliable test for assessing gross motor function when administered appropriately. The patient, after having been informed preoperatively about the details of the test, is awakened intraoperatively and asked to perform specic voluntary movements to demonstrate gross motor function. If the patient demonstrates symmetric motor function on command, the test is negative, the patient is reanesthetized, and the surgical procedure resumes. If the test is positive, a motor decit has been detected, immediate corrective measures (i.e., removal of spinal instrumentation, more extensive decompression) must be undertaken, and the examination is then repeated. The results are usually very reliable, provided that the patient is adequately awakened and able to cooperate. The Stagnara wake-up test has two major weaknesses: it is a test of gross motor function that provides no information regarding specic nerve root integrity, and it does not evaluate sensory function. Medical considerations include hypertension, which could potentially precipitate a cardiac insult in patients with preexisting cardiovascular disease, and the greater risk of air embolism from increased intrathoracic pressurehence the recommendation to ood the operative eld with irrigation uid before the test. Thus far, however, no reports have evaluated the efcacy of the wake-up test for spinal trauma surgery. SOMATOSENSORY EVOKED POTENTIALS SEPs are widely used for spinal monitoring during surgery.38, 94, 95, 120 They are elicited by stimulating a mixed peripheral nerve, preferably the tibial or peroneal nerve in the lower extremities and the median and ulnar nerves in

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the upper extremities, to record responses from levels caudal and cephalad to the level of the surgery. The data are recorded and the amplitude and latency are compared with baseline values. Monitoring of the tibial and peroneal nerves predominantly reects the function of the L5 and S1 roots, respectively. Robinson and colleagues demonstrated the efcacy of femoral SEPs for monitoring the midlumbar roots during surgical treatment of thoracolumbar fractures, particularly those involving the T12L4 levels.107 Interestingly, SEPs are used to monitor the motor function of the spinal cord. Such monitoring is based on the close proximity of the sensory tracts to the motor tracts and the assumption that trauma to the motor tracts will affect the sensory responses. This reasoning is generally valid when the mechanism of injury is trauma, but it is not always the case when a vascular insult has occurred.61 A decrease in amplitude of greater than 50% or prolongation of latency by 10% in comparison to baseline values (or both) is signicant.32, 98 Muscle relaxation, core temperature, and mean arterial pressure of 60 mm Hg and higher seem to have no signicant effect on SEPs. In contrast, anesthetic agents have a dose-related effect.115 SEPs are typically elicited by stimulating a peripheral mixed nerve and recording a response at sites caudal and cephalad to the level of the surgery. Delays in conduction or depression of the spinal response may indicate cord damage or a physiologic block of function. On the other hand, absence of conduction is associated with severe and usually irreversible cord damage.33, 53, 75 The mean SEP was shown to have the strongest individual relationship to the outcome of improvement in the Motor Index Score at 6 months.75 In contrast to this study, Katz and associates reviewed 57 patients who were studied with SEPs and dermatomal evoked potentials and monitored for more than 1 year.63 The study examined the ability of these tests to predict motor recovery after acute spinal cord injury. Evoked potentials added little or no useful prognostic information to the initial physical examination in patients with either complete or incomplete spinal cord injury. The benecial role of SEP monitoring in spine injury surgery is limited and yet to be determined.

Postoperative Care
Patients whose spine injuries are treated surgically also require special postoperative management. In the immediate postsurgical period, vital functions are meticulously monitored. Observation of upper airway function is especially important after anterior cervical spine surgery. Airway obstruction can be due to local edema, wound hematoma, postoperative dryness, or gland hypersecretion. The patients neurologic function should clearly be monitored in the immediate postoperative period, and monitoring should include both motor and sensory examinations. Progressive deterioration of the patients neurologic status is suggestive of an epidural hematoma and is an indication for immediate decompressive surgery. The postoperative use of orthotic devices, despite internal spine xation, further restricts excessive spine motion, allows for soft tissue healing, and decreases postoperative pain. Spinal bracing also has a psychologic effect in

assisting the patients postoperative pain tolerance. Furthermore, postoperative bracing results in a lower incidence of hardware failure, surgical loss of correction, and pseudarthrosis. Indications for postoperative bracing depend on the severity of injury, the degree of spinal instability, the presence of neurologic decit, the type and quality of internal xation, bone quality, and the patients individual prole. The specic characteristics and indications for spinal braces have been presented earlier in this chapter. Rigid internal xation of the cervical spine usually obviates the need for a halo vest. A halo vest is still recommended when instability persists after internal xation or when the risk of loosening after operative reduction is high. Cervical braces, such as high- or low-thoracic CTOs, usually provide sufcient additional postsurgical external stabilization. The duration of bracing can vary from 2 to 6 weeks and has to be individualized to the specic patient. A total-contact thoracolumbar orthosis (TLO) is recommended for the postoperative management of thoracolumbar injury. The TLO should be applied during the immediate postoperative period. A TLSO is used for fractures extending between T8 and L4. A hip spica TLSO can be used for injuries to the lumbosacral junction, whereas a sternal pad can be tted for injuries above T8 to counteract kyphotic forces. After uneventful spine surgery, patients are routinely discharged from the hospital on the second or third postoperative day. Return to sedentary occupational activity can be expected within 2 weeks, and full functional recovery can range from 6 weeks to 3 months, depending on the specic injury. Postoperative follow-up visits are usually scheduled at 7 to 10 days, 6 weeks, and 3 months. At the completion of spine healing, dynamic stress radiographic should be taken to document recovery of the spine injury. Postoperative management of a neurologically impaired spinal injury patient requires special attention. Bedridden patients must be frequently turned to avoid skin breakdown over pressure areas. Custom-molded braces are provided as soon as possible to facilitate early mobilization. Occasionally, orthoses are tted on the upper and lower extremities to prevent contractures and maintain joint exibility. Physical therapy is a crucial component of the overall care and must be instituted as soon as possible. Depending on the level of spinal injury, patients must become procient with transfers, self-catheterization, and maintenance of a bowel routine. Emotional and psychologic support should be readily available to both the patient and family. Unfortunately, these injuries usually involve young adults and are an enormous individual tragedy; they also incur considerable socioeconomic cost and require a short- and long-term multidisciplinary approach.

Complications
Complications of surgical treatment of spinal trauma have been reported frequently. Most complications are the result of failure to understand the patients altered spinal mechanics, poor surgical technique, or poor choice of instrumentation. Failure to achieve and maintain adequate reduction

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can be related to the severity of the fracture, the quality of the patients bone, and technical difculties with the surgery. McAfee and co-workers reviewed the complications of 40 patients with thoracolumbar fractures treated with Harrington distraction rods.85 Twenty-six of the 30 patients who were monitored for more than 2 years required additional spine surgery. Deep wound infection occurred in 15% of patients and wound dehiscence in 7%; ve patients experienced neurologic deterioration. In approximately 30% of patients, dislodgement or disengagement of the instrumentation occurred along with loss of xation. Loss of xation was more likely in translational injuries because Harrington distraction instrumentation relies on intact ligamentous structures for stability. The use of a claw-type conguration of hooks placed segmentally cephalad and caudal to the lamina appears to decrease this complication. The development of pedicle screws for spinal segmental instrumentation has provided more rigid and reliable posterior xation; however, complications have accompanied the use of pedicle screws. Lonstein and coauthors reported their experience with 4790 pedicle screws inserted in 915 operative procedures.80 Penetration of the cortex of the pedicle occurred in 2.2%, and penetration of the anterior cortex of the vertebral body, the most common type of perforation, occurred in 2.8%. Late-onset discomfort or pain caused by pseudarthrosis or the instrumentation and requiring removal of the instrumentation occurred with 23% of the screws. Nerve root irritation was caused by 0.2% of the screws, and 0.5% of the screws had broken. Failure of instrumentation can be attributed to improper implant selection or implant construct for a specic spinal injury. The choice of an implant and its mode of application is always determined by the biomechanical stability of the segment to be instrumented. Poor bone quality or poor xation technique can result in hardware dislodgement and cause the construct to fail. Finally, all hardware will eventually fail in the presence of pseudarthrosis, regardless of the design, strength, or the manner in which the instrumentation is applied. Postoperative wound infections are also a common complication after spine surgery. The risk of infection ranges between 1% and 6% and is highly dependent on expedient surgery, meticulous surgical technique, and the use of perioperative prophylactic antibiotics. The most frequent offending organism, Staphylococcus aureus, is responsible for about 50% of cases. Aggressive treatment is the mainstay of management of postoperative spinal wound infection. Irrigation and debridement of the wound must be performed as soon as possible, cultures obtained, and empirical antibiotic administration started until culture results are available. The implants, along with viable bone graft, must be retained if they are well tolerated and provide stability to the spine. Repeat debridement is performed as needed. Wounds can be closed over drains or can be packed open. Some recommend the use of inowoutow systems for deep infections. Most reports concur that a satisfactory outcome can be achieved after this form of treatment.84, 117, 128, 132 The most devastating complication in spinal trauma surgery is neurologic deterioration. Most situations of neurologic decompensation result from inadequate decom-

pression of neural structures. When an incomplete decit persists, repeat imaging (i.e., myelography, CT, and other techniques) is indicated to determine whether the patient would benet from additional surgery. Postoperative neurologic deterioration may be caused by several factors, including direct neural injury from manipulation, instrumentation, or correction of a deformity during the surgery. Rapid postoperative deterioration when the patient is initially improved may be the result of an expanding epidural hematoma. The treating physician must be alert for this potentially catastrophic complication and evacuate the hematoma emergently to minimize residual long-term neurologic decit. Finally, leakage of cerebrospinal uid may complicate spinal trauma surgery. The leakage can be a result of an iatrogenic laceration or may be caused by the initial injury. When cerebrospinal uid leakage is recognized intraoperatively, an attempt should be made to repair the injury. Leakage of cerebrospinal uid because of a dural tear at the injury level is a special concern in spinal trauma. Cammisa and colleagues reviewed 30 patients with a laminar fracture in association with a burst fracture of the thoracic or the lumbar spine.23 Eleven of the 30, all with preoperative neurologic decits, had evidence of a dural laceration at surgery; 4 of the 11 had neural elements entrapped in the laminar fracture site. Therefore, a high index of suspicion is warranted in any patient with a neurologic decit and a burst fracture in association with a laminar fracture. If leakage of cerebrospinal uid is recognized postoperatively, treatment may include reoperation and repair of the leak in the lumbar spine or antibiotics, recumbency, and lumbar subarachnoid drains for both the cervical and lumbar spine.

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