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284 Spine Core Knowledge in Orthopaedics
Direction
of force
A
Vertical
compression
BCD
Figure 21–16: Allen and Ferguson classification of vertical
compression injuries.
A, Normal. B, Stage I—Cupping of superior or inferior
vertebral endplate. C, Stage II—Cupping and fracture of
vertebral endplates and minimal displacement. D, Stage III—
Vertebral fragmentation or displacement into spinal canal.
(Reprinted from Klein et al. 2003).
Figure 21–18: A CT scan of a distraction–flexion bilateral
facet dislocation.
Table 21–14: Treatment of Vertical Compression
Injuries
STAGE TREATMENT
I and II Cervical orthosis or halo vest immobilization
III Halo vest immobilization or surgery (anterior decompression,
reconstruction)
Direction
of force
Flexion
A B C
DE
Figure 21–17: Allen and Ferguson classification of
distraction–flexion injuries.
A, Normal. B, Stage I—Less than 25% subluxation of facets.
C, Stage II—Unilateral facet dislocation. D, Stage III—
Bilateral facet dislocation. E, Stage IV—Bilateral facet
dislocation with displacement of the full vertebral width.
(Reprinted from Klein et al. 2003).
Figure 21–19: A lateral plain radiograph illustrating a C4-C5
bilateral facet dislocation.
Table 21–15: Allen and Ferguson Classification of
Distraction–Flexion Fractures*
STAGE DESCRIPTION OF FRACTURE
I <25% subluxation of facets
II Unilateral facet dislocation
III Bilateral facet dislocation
IV Bilateral dislocation with displacement of the full vertebral width
* (Allen et al. 1982.)
CHAPTER 21 Cervical Spine Trauma 285
Successfull Reduction
MRI
Anterior or posterior
fusion depending on
presence of an
intervertebral disc
herniation
Direction
of force
A
Failed Reduction
Preoperative MRI
No evidence of herniated disc
Posterior open reduction and
fusion or anterior open reducion
and fusion
Figure 21–20: Algorithm for
MRI use in reduction of
compression–flexion injuries.
Presence of cervical
herniated disc
Anterior discectomy,
an attempted reducion
and fusion or anterior
discectomy (with or without
presence of bone graft) followed
by open posterior reduction and
fusion (subsequent placement of
anterior graft if not done at time
of anterior discectomy)
Figure 21–21: Allen and Ferguson
classification of compression–extension
injuries.
A, Normal. B, Stage I—Unilateral
laminar fracture. C, Stage II—Bilateral
laminar fracture. D, Stage III—
Bilateral, nondisplaced fracture. E,
Stage IV—Bilateral, partially displaced
fracture. F, Stage V—Full
displacement.
(Reprinted from Klein et al. 2003).
B1 B2 B3
CD
F E
286 Spine Core Knowledge in Orthopaedics
Figure 21–22: A sagittal MRI of a high-grade
compression–extension injury.
Figure 21–23: A sagittal MRI of a distraction–extension injury
at the C4-C5 level.
Table 21–16: Allen and Ferguson Classification and Treatment of Compression–Extension Injuries*
STAGES DESCRIPTION OF FRACTURE TREATMENT
I Unilateral laminar Cervical orthosis or halo vest immobilization
II Bilateral laminar—Multiple levels Cervical orthosis or halo vest immobilization
III Bilateral, nondisplaced Cervical orthosis or halo vest immobilization
IV Bilateral, partially displaced Posterior cervical fusion
V Full displacement Posterior cervical fusion
* (Allen et al. 1982.)
Figure 21–24: Allen and Ferguson classification of
distraction–extension injuries.
A, Stage I—Anterior longitudinal ligament disruption and
possible transverse body fractures. B, Stage II—Displacement
and injury to the posterior column.
(Reprinted from Klein et al. 2003).
A
B
CHAPTER 21 Cervical Spine Trauma 287
Table 21–17: Allen and Ferguson Classification and Treatment of Distraction–Extension Injuries*
STAGE DESCRIPTION OF FRACTURE TREATMENT
I Anterior longitudinal ligament disruption, transverse fracture of body Halo vest immobilization
II Displacement—Injury to the posterior column Anterior decompression or fusion
* (Allen et al. 1982.)
BA
Figure 21–26: Allen and Ferguson classification of lateral
flexion injuries.
A, Stage I—Asymmetric centrum and unilateral arch. B, Stage
II—Displacement and contralateral ligamentous failure.
(Reprinted from Klein et al. 2003).
Figure 21–25: A transaxial CT of a lateral flexion injury.
Table 21–18: Allen and Ferguson Classification and Treatment of Lateral Flexion Injuries*
STAGE DESCRIPTION OF FRACTURE TREATMENT
I Asymmetric centrum, unilateral arch Cervical orthosis
II Displacement, contralateral ligamentous failure Posterior cervical fusion
* (Allen et al. 1982.)
References
Allen BL, Ferguson RL, Lehman TR et al. (1982) A mechanistic
classification of closed, indirect fractures and dislocations of the
lower cervical spine. Spine 7: 1-27.
In this article, 165 cases of lower cervical spinal trauma are
categorized into six groups, each with multiple stages.
American Spinal Injury Association. (1992) Standards for
Neurological and Functional Classification of Spinal Cord Injury,
revised edition. Chicago: American Spinal Injury Association.
ASIA’s classification of spinal cord injuries according to level of
impairment.
Anderson PA, D’Alonzo RT. (1974) Fractures of the odontoid
process of the axis. J Bone Joint Surg 56A(8): 1663-1674.
The authors present a classification system for odontoid
fractures.Three types of fractures are described with a proposed
management protocol.
Anderson PA, Montesano PX. (1988) Morphology and treatment
of occipital condyle fractures. Spine 13(7): 731-736.
The authors present a classification system and suggest
treatments for this rare injury.
Daffner RH. (1992) Evaluation of cervical vertebral injuries. Semin
Reontgenol 27: 239-253.
Patients who are suspected of cervical spine trauma
should undergo specific imaging studies such as CT,
polydirectional tomography, and MRI to confirm the
initial impression based on plain radiographic findings.
Cervical injuries may be diagnosed, looking for irregularities
of spinal alignment in regards to the bony anatomy, cartilage or
joint spaces, and changes in soft tissue measurements.
Effendi B, Roy D, Cornish B et al. (1981) Fractures of the ring of
the axis—A classification based on the analysis of 131 cases. J Bone
Joint Surg 63B: 319-327.
288 Spine Core Knowledge in Orthopaedics
The authors reviewed 131 patients with an axis injury.The data
was then analyzed for the creation of a classification system. In
addition, management recommendations are presented.
Feuerstein G, Rabinovici R. (1993) Recent advances in the
pharmacology of spinal cord injury.Traum Quart 9: 5-64.
This article explains the pharmacologic management of spinal
cord injuries.
Fielding JW, Hawkins RJ. (1977) Atlantoaxial rotatory fixation
(fixed rotatory subluxation of the atlantoaxial joint). J Bone Joint
Surg 59A(1): 37-44.
The authors developed a classification system for atlantoaxial
rotatory fixation.They explain the management principles of
this disorder.All 13 patients were treated with skeletal traction
followed by atlantoaxial arthrodesis (successful in 11 of 13
patients).
Fujimura Y, Nishi Y, Kobayaski K. (1996) Classification and
treatment of axis body fractures. J Orthop Trauma 10(8): 536-540.
The authors describe the classification and treatment of axis
body fractures using data from 31 patients.
Goldstein SJ,Woodring JH,Young AB. (1982) Occipital condyle
fracture associated with cervical spine injury. Surg Neurol 17:
350-352.
The authors report a case of this extremely rare injury and
review the literature.
Hadley MN, Browner CM, Lui SS, Sonntag VK. (1998) New
subtype of acute odontoid fractures (type IIa). Neurosurgery 22
(1 pt 1): 67-71.
Herkowitz HN, Rothman RH. (1984) Subacute instability of the
cervical spine. Spine 9: 348-357.
Subacute instability of the cervical spine manifested itself 3
weeks following injury.The authors recommend collar
immobilization during the period of cervical spasm followed
by delayed dynamic plain radiography to assess occult
instability.
Klein GR,Vaccaro AR. (2003) Cervical spine trauma: Upper and
lower. In: Principles and Practice of Spine Surgery (Vaccaro AR
et al., eds.). Philadelphia: Mosby.
Kraus JF, Franti CE, Riggins RS et al. (1975) Incidence of
traumatic spinal cord lesions. J Chron Dis 28: 471-492.
This article describes the frequency and demographics of spinal
column and cord injuries.
Lasfargues JE, Custis D, Morrone F et al. (1995) A model for
estimating spinal cord injury prevalence in the United States.
Paraplegia 33: 62-68.
After reviewing the data on incidence, mortality, and prevalence
of spinal cord injuries in the United States, a model was
designed to show trends in populations of people with spinal
cord injuries at the national and state level.The information
garnered from this model is essential in planning and allocating
resources for spinal trauma.
Levine AM, Edwards CC. (1989) Traumatic lesions of the
occipito–atlantoaxial complex. Clin Orthop 239: 53-68.
This article describes the incidence, diagnostic criteria, and
treatment methods used in the management of injuries to the
occipito–atlantoaxial complex.
Levine AM, Edwards CC. (1991) Fractures of the atlas. J Bone Joint
Surg 73A: 680-691.
The authors studied 34 patients studied for an average of 4.5
years after their atlas fractures.The authors grouped the 34
injuries into five main fracture categories.
Mazur JM, Stauffer ES. (1983) Unrecognized spinal instability
associated with seemingly simple cervical compression fractures.
Spine 8: 687-692.
Here, 27 patients with cervical compression fractures were
treated with a cervical orthosis. None of the patients were
managed with a halo vest or with surgery. Of the patients, 20
healed without incident; the other 7 developed a spinal
deformity or instability. Most of the patients with instability
underwent surgery. The paper demonstrates the need for better
assessment of potential spinal instability and the need for close
follow-up in the peritrauma period.
Mori S, Nobuhiro O, Ojima T et al. (1983) Observation of “tear
drop” fracture dislocation of the cervical spine by CT. J Jpn Orthop
Assoc 57: 373-378.
Five cases of tear-drop fracture dislocations of the cervical spine
were studied using CT and conventional radiographs.
Conventional radiographs were insensitive in detailing the
degree of spinal canal narrowing and vertebral comminution.
The CT imaging was effective in illustrating the nature and
severity of the injury.
Scher AT. (1977) Unilateral locked facet in cervical spine injuries.
AJR 129: 45-48.
A unilateral facet dislocation is easy to miss radiographically
because often there is little vertebral displacement. Rotational
misalignment of one vertebra in relation to another usually
identifies the injury.
Slucky V, Eismont FJ. (1994) Treatment of acute injury of the
cervical spine. J Bone Joint Surgery 76-A: 1882-1896.
This article outlines the protocol for treating an acute injury to
the cervical spine. Initial management, pharmacologic therapy,
nonsurgical, and surgical treatments are described.
Traynelis VC, Marano GD, Dunker RO et al. (1986) Traumatic
atlanto-occipital dislocation. J Neurosurg 65: 863-870.
The article covers a system for classification for this decreasingly
fatal injury. Radiographic criteria and rationale for treatment are
proposed.
Vaccaro AR. (1999) Cervical spine trauma. In: Orthopaedic
Knowledge Update (Beaty JH, ed.). Rosemont, IL: American
Academy of Orthopaedic Surgeons.
A contemporary review of the natural history, diagnosis, and
nonoperative and operative management principles in regards to
cervical trauma.
Vaccaro AR,An HS, Betz RR et al. (1997) The management of
acute spinal trauma—Prehospital and in-hospital emergency care.
Instr Course Lec 46: 113-125.
CHAPTER 21 Cervical Spine Trauma 289
A detailed protocol outlining the prehospital and in-hospital
management of a patient with a cervical spinal column or cord
injury.
Vaccaro AR,An HS, Lin S et al. (1992) Noncontiguous injuries of
the spine. J Spinal Disord 5(3): 320-329.
Of the 372 consecutive spinal injury patients evaluated at the
Regional Spinal Cord Injury Center of Delaware Valley, 39
patients (10.5%) were found to have noncontiguous spinal
column injuries.
Vaccaro AR, Zlotlow DA. (2001) Fractures and dislocations of the
lower cervical spine. In: Rockwood and Green’s Fractures in Adults
(Bucholz RW et al., eds.). Philadelphia: JB Lippincott Co.
A contemporary book chapter covering all of the aspects of
lower cervical spine injury management including its natural
history and nonoperative and operative management.
Webb JH. (1976) Hidden flexion injury of the cervical spine.
J Bone Joint Surg 55B: 322-327.
This paper describes clinical and radiological features of cervical
flexion injuries and explains the importance of appropriate and
timely management.
Westurlund LE, Dafner S,Vaccaro AR. (1999) Cervical spine
trauma—Indications for surgical decompression and stabilization
In: Spine Surgery—Techniques, Complication Avoidance, and
Management (Benzel EC, ed.). Philadelphia: Churchill Livingstone.
A concise treatise on the indications for surgical intervention in
the management of cervical spine trauma.
Woodring JH, Goldstein SJ. (1982) Fractures of the articular
processes of the cervical spine.Am J Radiol 139: 341-344.
Of 77 patients with cervical spine fractures, 16 (20.8%) had
fractures of the articular processes of the cervical spine. CT
imaging identified all of these fractures; plain films identified
only 2. CT scanning should be considered in selected cases to
evaluate for articular process fractures in patients following
cervical trauma who develop a radiculopathy.
Zeidman SM, Ling GS, Ducker TB et al. (1996) Clinical
applications of pharmacologic therapies for spinal cord injury.
J Spinal Disord 9: 367-380.
The literature on the effects of glucocorticosteroids, tirilazad,
and GM1 ganglioside on spinal cord injuries is reviewed and
critiqued and recommendations are made for the
pharmacologic management of a spinal cord injury patient.
CHAPTER
22
Thoracic and Lumbar Spine
Trauma
Kern Singh*, Arjun Saxena §, and Alexander R. Vaccaro †
* M.D., Assistant Professor, Department of Orthopedic Surgery, Rush University Medical
Center, Chicago, IL
§ B.S.,Thomas Jefferson Medical College, Philadelphia, PA
† M.D., Professor of Orthopaedic Surgery,Thomas Jefferson University and the Rothman
Institute, Philadelphia, PA
Introduction
●
The thoracolumbar spine is the most common site of
spinal injuries.
●
Most of these injuries occur in males (15-29 years)
usually as the result of a significant-force impact, such as
a motor vehicle accident or fall (Gertzbein 1992).
●
Most injuries (52%) occur between T11 and L1 followed
by L1 through L5 (32%) and T1 through T10 (16%)
(Gertzbein 1994, Gertzbein 1992, Kraus et al. 1975).
●
Depending on the type of fracture, associated injuries
occur in up to 50% of patients mainly as a result of a
distraction force.
●
Associated injuries include intra-abdominal bleeding
from liver and splenic injuries, vessel disruption, and
pulmonary injuries (20% of patients).
●
Contiguous and noncontiguous spine injuries are present
in 6% to 15% of patients (Box 22–1).
Initial Treatment
and Examination
●
Initial evaluation should begin with the “ABCs” (airway,
breathing, and circulation) of trauma care (Fig. 22–1).
●
It has been found that 30% of patients with persistent
localized tenderness after trauma to the thoracolumbar
spine and absence of an obvious radiographic deformity
may have an occult spinal fracture (Chapman et al. 1994).
●
The neurological examination should include motor
testing, dermatomal sensory testing, lumbar sacral root
motor evaluation, and an examination of reflexes.
●
“Spinal shock” refers to flaccid paralysis because of a
physiologic disruption of all spinal cord function.
●
The presence of the bulbocavernosus reflex heralds the
end of spinal shock and allows an accurate assessment of
Box 22–1:
●
The thoracic spinal cord is protected from injury by the
surrounding paraspinal musculature, the vertebral elements, and
the thoracic rib cage.
●
The thoracolumbar junction is a transitional region between the
less mobile thoracic spine and the more flexible lumbar spine.
●
Decreasing the spinal canal diameter to spinal cord ratio,
particularly between T2 and T10, makes this region more
susceptible to spinal cord injury.
●
Physiologic kyphosis of the thoracic spine may predispose it to
flexion-axial load–type injuries.
●
Spinal injuries in this region are associated with a high incidence
of neurological injury.
●
Thoracic vertebral bodies are not as large as the lumbar vertebral
bodies; thus, they are less able to resist deformity following
specific load applications.
Thoracolumbar Anatomy
290
CHAPTER 22 Thoracic and Lumbar Spine Trauma 291
Thoracolumbar Injury Patient
Extrication
Spinal stabilization
Transportation
ATLS protocols
Resuscitation
Plain radiographs
entire spine
Clinical /
Radiographic
Instability
?
NO
Further
diagnostic studies
as needed
CT scan, MRI
Worsening
neurologic
deficit
YES
MPS protocol
for Spinal Cord Injury if
within 8 hrs from injury
YES
Emergent
NO
Neurology
intact
?
MRI
R/O disc herniation
Closed
realignment
traction
Rotorest Bed
Alignment
adequate
?
NO
MRI
R/O disc herniation
YES
YESYES
Plain radiographs
YES
diagnostic studies
Entire Spine
Clinical /
Radiographic
Instability
?
NO
Further
as needed
CT scan, MRI
NO
Neurology
incomplete
?
NO
Complete injury
Figure 22–1: An approach to the patient with a thoracolumbar spine injury.
(ATLS, advanced trauma life support.)
YES
YES
reduction/decompression
OR
"Elective"
Surgical
"Elective"
stabilization
OR
Definitive closed
treatment
292 Spine Core Knowledge in Orthopaedics
the patient’s neurological status typically 48 hours after
the injury (Figs. 22–2 through 22–4).
●
A “complete” neurological injury is marked by an
absence of sensory and motor function below the
anatomic level of injury in the absence of spinal shock
(Fig. 22–5).
●
In an incomplete lesion, residual spinal cord function,
nerve root function, or both exist below the anatomic
level of injury.
●
An incomplete spinal cord lesion may manifest as one
of four syndromes (Fig. 22–6,Table 22–1; also see
Fig. 5–1).
●
Hypotension secondary to neurogenic or hemorrhagic
shock must be reversed through fluid replacement, blood
replacement or both with or without the use of
vasopressors.
L3-L4
L1-L2
L5-S1
C5
C6
C7
S1
Figure 22–4: Reflex testing of the lower extremity with the
corresponding nerve root innervations.
●
Intravenous methylprednisolone is routinely administered
within 8 hours of a spinal cord injury in the absence of
specific contraindications (Table 22–2).
●
Deep venous thrombosis prophylaxis is paramount.The
use of intermittent external pneumatic compression
devices, static compression stockings, and—in select
patients—subcutaneous (5000 units subcutaneously every
12 hours) or intravenous low-molecular weight heparin
helps to minimize potentially fatal pulmonary emboli.
L4
L5
S1
Figure 22–2: A schematic of a lower extremity examination
with the corresponding nerve root innervations.
Figure 22–3: A schematic of the bulbocavernosus reflex.
(Reprinted from Leventhal 2003).
Radiologic Evaluation
●
All patients who have injuries suspicious for spinal
trauma should undergo plain radiographic imaging
(anteroposterior or lateral) of all vertebral levels.
●
Plain x-ray film is the initial screening modality with
computed tomography (CT) scanning or magnetic
resonance imaging (MRI) used as an adjunct depending
upon whether the surgeon needs to further evaluate
bony or soft tissue anatomy (Table 22–3).
Posterior
Ascending
(
)
Sensory
Dorsal column
(
position, vibration
sense, light touch)
Lateral
spinothalamic tract
(
pain, temperature
Anterior
spinothalamic tract
(
pain, temperature
Tracts
S
L
T
)
)
Anterior
Figure 22–5: Schematic of a transverse section of the spinal
cord at the thoracic level, showing the anatomic organization
of the corticospinal tract and posterior column.
(L, lumbar; S, sacral; T, thoracic).
Descending
(
)
Motor
Tracts
S
L
T
Anterior
corticospinal tract
Lateral
corticospinal tract
(
voluntary motor
)
CHAPTER 22 Thoracic and Lumbar Spine Trauma 293
patterns: compressive flexion, distractive flexion, lateral
flexion, translational, torsional flexion, vertical
compression, and distractive extension injuries (Ferguson
et al. 1984) (Table 22–4).
AB
Ipsilateral
Contralateral
C D
Figure 22–6: Types of spinal cord injury (shaded zones) that
produce the four main incomplete injury patterns seen
clinically.
A, Central cord syndrome. B, Anterior cord syndrome. C,
Posterior cord syndrome. D, Brown-Séquard’s syndrome.
(Reprinted from Klein et al. 2003).
Classification Methods
●
The three-column theory of spinal instability by
Denis is commonly used to define vertebral
column injuries (Denis et al. 1992, Denis 1983)
(Fig. 22–7).
●
Denis divided thoracic and lumbar spinal injuries into
minor and major injures.
●
Fractures of the spinous and transverse processes, the
pars interarticularis, and the facet articulations were
categorized as minor injuries.
●
Major spinal injuries were divided into compression
fractures, burst fractures, flexion–distraction injuries,
and fracture dislocations.
●
Ferguson and Allen presented a mechanistic classification
of thoracolumbar injuries, describing seven injury
Surgical Decision Making
●
The goals of surgical management include maximizing
patient function, facilitating nursing care, preventing
deformity and instability, and possibly improving
neurological function.
●
Surgery is often determined by the integrity of the
posterior osteoligamentous complex (Box 22–2).
●
The choice of surgical approach is dictated by the spinal
level, the degree and nature of canal compromise, and the
experience of the surgeon.
●
Multiple variations on the approach to the
thoracolumbar spine exist based upon three methods of
decompressing the thecal sac: anterior, posterior, and
posterolateral (Table 22–5).
Spinal Instrumentation
●
Since the introduction of Harrington rod internal
fixation, there has been progressive development of
various spinal fixation systems based on segmental
fixation of the spine.
●
The choice of spinal implant is determined by the
nature, degree, or biomechanics of the existing
instability, the quality (bone density) of the spinal
elements, and the medical condition of the patient
(Box 22–3).
Anterior Instrumentation
●
Of the axial load transmitted through the spine,
80% is through the intact anterior and middle spinal
column.
●
A functional posterior osteoligamentous complex is
critical to the success of healing of an anterior spinal
fusion (Figs. 22–8 and 22–9).
Table 22–1: Spinal Cord Injury Syndromes
SYNDROME CHARACTERISTICS PROGNOSIS
Central Most common Fair
Upper extremity > lower extremity
Motor and sensory loss
Anterior Loss of motor function with possible sparing of proprioception Poor
and pressure sensation
Posterior Rare Good
Loss of proprioception and pressure sensation
No motor loss
Brown-Séquard Ipsilateral motor loss and contralateral pain and temperature loss Good
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