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who go on to develop a kyphotic deformity. On CT, bilateral injury will result in a
similar injury pattern to that seen with unilateral facet injury, with the exception
that a translational deformity is often also seen. Bilateral facet capsule will often-
times result in anterolisthesis and/or angulation of the superior vertebral body rela-
tive to the inferior with both inferior articular processes of the level above
dislocating and locking anterior to the superior articular processes of the level
below. Although likely less common in unilateral facet dislocation, with bilateral
facet dislocation, it is important to recognize the risk of vertebral artery injury
(VAI) and investigate it accordingly with vascular imaging (angiogram or
CT-angiogram (CTA)) [61]. The facet capsuloligamentous structures impart a large
stabilizing force within the cervical spine [62, 63], and in order to injure and/or
dislocate both facet capsules, a large traumatic force is necessary. It is not surpris-
ing then that these patients are much more likely to have an accompanying spinal
cord injury [64].
Treatment: Unilateral Facet Injury (With/Without Fracture)
Management of patients with a unilateral facet injury may vary depending on the
extent of injury. Patients with a minor injury (unilateral facet capsuloligamentous
distraction, with or without a small, nondisplaced fracture (F1)) may be treated in
rigid cervical orthosis (with the risk of instability being commonly accepted as
much higher, the fracture fragment is >40% of the lateral mass or 1 cm) [65].
Although patients with a neurological decit are typically treated surgically, this is
still not necessarily a standard of care. Many argue that in the event of radiculopathy
in the context of a facet fracture, nonoperative immobilization will result in bony
fusion and facet remodeling and subsequent improvement of the patient’s radicu-
lopathy. In the case of a unilateral jumped facet, controversy again exists as to the
best treatment for these patients. Not infrequently patients with this injury pattern
will present in a delayed fashion complaining of neck pain due to a missed diagno-
sis at the time of injury. Many use this point in arguing the stability of this type of
injury. Although previous studies exist supporting both surgical and nonsurgical
approaches in managing these injuries, it is likely that surgical treatment of these
injuries results in both more predictable and favorable patient outcomes [66].
In the event of either operative or nonoperative management, a closed reduction
may be attempted rst in the case of a unilateral jumped facet (although relatively
contraindicated in the presence of an acute disc herniation). However, if attempted,
it is the authors’ opinion that only a brief period of traction be attempted with a low
threshold for surgical intervention as this particular type of injury has been shown
to be quite difcult to reduce with traction alone (again, arguing the mechanical
stability of the injury). The goals of surgical treatment for these patients include
reduction, decompression if warranted, and stabilization and fusion. Much like
other aspects of these types of injuries, the optimal approach is controversial. Both
anterior (ACDF with plating) and posterior approaches (usually PSIF) have been
advocated and reported [67–69]. In the absence of discoligamentous injury or a
J. R. Chapman et al.
333
traumatic disc herniation, the authors would advocate a posterior approach with
facet reduction, nerve root decompression if necessary, and stabilization and fusion
using a screw-rod construct.
Treatment: Bilateral Facet Injury (With/Without Fracture)
Management of patients with a bilateral facet injury is largely conned to surgical
treatment. Similarly to unilateral facet injury, surgical goals consist of reduction,
decompression if necessary, and stabilization and fusion. The majority of these
patients present with a spinal cord injury, and as such decompression as soon as
safely possible is warranted [70]. This may be via closed traction-reduction (again,
usually in the absence of acute traumatic disc herniation) or surgically [69, 71].
Although most agree that bilateral facet injury warrants surgical stabilization (with
the role of halo vest external immobilization being mainly historical), many groups
argue the merit of anterior, posterior, and combined approaches [67–69]. Although
the technical description of each surgical treatment option and its respective advan-
tages and disadvantages are beyond the scope of this chapter, the authors advocate
that the optimum approach for these injuries is likely going to depend on each case’s
unique injury pattern (e.g., facet subluxation or dislocation, accompanying unilat-
eral or bilateral facet fractures, and vertebral body endplate fractures, among
others).
Key Concepts
• Injury to the subaxial cervical spine facet complexes, either unilaterally or bilat-
erally, is common with a unique AOSpine classication system modier.
• Diagnosis is primarily made via CT scan, with limited role of cervical spine XR
and MRI.
• Depending on the severity of injury, a broad range of clinical patient presenta-
tions may be seen: patients with unilateral facet complex dislocation classically
present with ipsilateral radiculopathy (either acutely or in a delayed fashion),
whereas those with bilateral facet dislocation classically present with SCI.
• Management of these injuries is dependent on presence of unilateral or bilateral
facet injury and associated fracture patterns:
– Unilateral: controversy exists as to best treatment, whether surgical or nonsur-
gical (although surgical likely portends more predictable and better patient-
reported outcomes long-term) as well as the surgical approach (anterior or
posterior).
– Bilateral: surgical treatment warranted with external halo vest immobilization
now primarily an antiquated option; best surgical approach (anterior, poste-
rior, or combined) remains controversial with best approach likely dependent
on accompanying injuries and patient factors.
36 Cervical Spine Trauma
334
Complex Fracture-Dislocation
General Description
Complex fracture-dislocations are classied as a Type C injury according to the
AOSpine classication, as shown in Fig.36.8. As the name implies, this injury
pattern results in a complex combination of spinal column fracture and injury. In
a similar pattern to that described above with bilateral facet dislocation, Type C
fracture- dislocations typically result in translation and anterolisthesis of the
superior vertebral body relative to the inferior level, other vertebral body frac-
tures (Type A or B AOSpine injury), ligamentous injury (Type B AOSpine injury),
and unilateral and/or bilateral facet capsuloligamentous injury with/without frac-
ture (Type F AOSpine modier). As would be expected, these injuries can result
from a complex interaction and combination of mechanistic forces during the
traumatic event, though the predominant mechanism being a exion-distraction
force.
Type C.
Translation Injuries
C. Translational injury in any axis-
displacement or translation of one
vertebral body relative to another in any
direction
Fig. 36.8 AOSpine
subaxial cervical spine
Type C translation injury
classication
J. R. Chapman et al.
335
Diagnosis
Diagnosis of this pattern of complex cervical spine fracture-dislocation is relatively
straightforward. Although it is possible to diagnose this injury on XR, as in the case
of facet injuries, CT has largely replaced XR as the diagnostic investigation of
choice for complex fracture-dislocations. As mentioned above, patients may have a
various types of bony and ligamentous injuries, including for example vertebral
body fractures, facet fracture-dislocations, discoligamentous injury, among others.
Similarly to facet dislocations, there is a signicant risk of VAI with this injury pat-
tern. It is recommended that this be investigated with vascular imaging (usually
CTA) as diagnosis may alter management. Furthermore, MRI is recommended in
these patients to examine ongoing spinal cord compression. Clinically, patients suf-
fering complex fracture-dislocation cervical spine injury will typically present with
a SCI.Although the degree of SCI may vary from injury to injury, it is important to
recognize the high likelihood of a SCI being present as often these patients can be
difcult to examine due to concomitant traumatic brain injury (being designated
with an “NX” modier as per the AOSpine classication) and the necessity of SCI
management that follows according the clinical guidelines.
Treatment
Management of these patients can often be difcult and requires a multidisciplinary
team in an intensive care unit (ICU) setting. Although the medical treatment of SCI
is beyond the scope of this chapter, it is of note that management and treatment of
these patients is likely best accomplished in large tertiary care, level-1 trauma cen-
ters and in accordance with institutional and established SCI guidelines. The surgi-
cal treatment of these injuries should be achieved as quickly as safely possible, [70]
and goals should include reduction, decompression, and stabilization and fusion.
Although somewhat controversial, complex fracture-dislocations often require a
combined anteroposterior instrumented fusion in order to achieve adequate stability.
More controversial yet is the order and manner in which surgical decompression
and stabilization occurs. Many prefer an anterior rst approach with decompression
via discectomy and/or corpectomy, followed by a posterior approach for instru-
mented stabilization (and possible decompression if still necessary), and return to
the front for denitive graft xation. Others argue the merit of performing a poste-
rior rst approach acutely with reduction, long posterior decompression to accom-
modate for potential spinal cord swelling and instrumented fusion, followed by a
delayed and supplemental anterior approach if necessary, once the patient is no
longer in the acute SCI time window. Much like bilateral facet dislocations, the
advantages and disadvantages of each approach are debatable, although the optimal
outcome is likely going to depend on the specic complex radiological fracture
characteristics, patient factors, and surgeon- and institution-related factors, among
others.
36 Cervical Spine Trauma
336
Key Concepts
• Complex fracture-dislocation injury is typically a Type C AOSpine classication
system injury with potential A, B, F, N, M, and “+” modiers.
• Diagnosis for this type of injury is relatively straightforward with CT and MRI
and vascular imaging to rule out VAI being necessary.
• Patients typically present with a SCI of varying severity and should be treated in
an ICU at a tertiary care, level-1 trauma center according to established SCI
management guidelines.
• Management is surgical, usually consisting of a combined anteroposterior
approach, the order and timing of which remain controversial.
Case
A 29-year-old male was brought to the emergency room by ambulance after being
extricated from his vehicle that had been involved in a motor vehicle collision at
approximately 60miles per hour. After initial stabilization and resuscitation, he has
a Glasgow Coma Scale score of 15, and his clinical examination revealed him to
have a spinal cord injury AIS A, neurological level C7. Initial CT exam of his cervi-
cal spine revealed a complex fracture-dislocation with bilateral jumped facets, a
vertebral body fracture, and a unilateral fractured facet complex (Fig. 36.9)
(AOSpine classication C6–7: Type C (C7 Type A3, C6–7 B2, F4, F4, N4)). After
Fig. 36.9 A 29-year-old male involved in a motor vehicle collision. CT exam of his cervical spine
revealed a complex fracture-dislocation with bilateral jumped facets, a vertebral body fracture, and
a unilateral fractured facet complex. MRI demonstrates realignment after closed reduction and was
eventually treated with combined anterior and posterior decompression and fusion
J. R. Chapman et al.
337
initial closed traction-reduction (postreduction MRI below), the patient underwent
denitive surgical decompression, open reduction, and internal xation and fusion
via a combined anteroposterior approach with postoperative XR.
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341© Springer Nature Switzerland AG 2020
J. R. O’Brien et al. (eds.), The Resident’s Guide to Spine Surgery,
https://doi.org/10.1007/978-3-030-20847-9_37
Chapter 37
Anterior Approach
totheLumbosacral Spine
JosephC.Babrowicz Jr.
Introduction
Retroperitoneal exposure of the lumbosacral spine may be accomplished via an
anterior approach, thus enabling anterior lumbar interbody fusion (ALIF). This
approach to the lumbosacral spine represents a special and valuable skill for a sur-
geon. These operations require knowledge of vascular, general, and spine surgery
anatomy and techniques. In most cases, these operations are accomplished by the
joint efforts of a general or vascular surgeon working with a spine surgeon. The
importance of this teamwork has been long recognized. Sacks, in a 1965 report of
anterior lumbar interbody fusion of the lumbar spine, emphasized that “The best
results are obtained by teamwork between an orthopedic and general surgeon.” He
went on to declare that “Undoubtedly the patients are benetted by saving of time
and the increased safety produced by this cooperation.” [1]. It continues today that
when done well, retroperitoneal exposure enhances the quality, efciency, and
safety of lumbosacral spinal interbody fusion.
Historical Perspective
Retroperitoneal approach to the lumbar spine appears to have been borne out of the
need to treat tuberculous spondylitis of the lumbar spine and Pott’s disease.
Traditionally, Pott’s disease of the lumbar spine was treated by immobilizing proce-
dures designed to provide rest and relief of weight bearing on the diseased vertebra.
J. C. Babrowicz Jr. (*)
Department of Surgery, Inova Fairfax Medical Campus, Inova Vascular Surgery,
Falls Church, VA, USA