Operative Treatment of Blunt Spinal Trauma

Operative Planning

Dorsal versus anterolateral approach

Depends on individual surgeon’s expertise and mechanism of spinal injury

Treatment should address instability and preserve intact structures

Dorsal approach

Flexion injuries

Translational injuries

Minimal trauma to vertebral bodies

Absence of anterior compression of spinal cord and nerves

Includes instability of posterior ligament, subluxation, locked facets, simple wedge compression fractures

Anterolateral approach

Indicated with

Most extension injuries

Fractured vertebral body with retropulsed bone into canal

Extensive fractures of posterior elements that prevent posterior stabilization and fusion

Three-column injury including posterior ligament tear

If injury occurred greater than 3 weeks previous

Anterior vertebral bodies and dura better visualized

Anterior compressive pathology more easily extracted

Combined dorsal and anterolateral approach

Indicated with

Profound damage to anterior weight-bearing column

Absence or compromise of lamina or spinous processes
The following discussion focuses on decompression, with stabilization procedures covered in greater detail elsewhere.

Special Equipment

Spinal tray including distraction instrumentation and interlaminar Halifax clamps
High-speed drill optional
Mayfield head holder

Anesthetic Issues

Arterial line for blood-pressure monitoring
Intravenous antibiotic prophylaxis (cefazolin 2 g or vancomycin 1 g for adults) should be given 30 minutes prior to incision

Positioning

For posterior approach
- Patient in prone position
- Head fixation with Mayfield head holder for posterior cervical approaches
For anterior approach
- Lower thoracic and lumbar regions
  - Lateral decubitus position
  - Surgeon stands on abdominal side
- Cervical
  - Patient protected in skeletal traction
  - Patient in supine position

Technique

For posterior

Midline incision centered over the level(s) of injury that allows exposure of several levels rostral to injury
Paraspinal muscles are reflected in the subperiosteal plane: avoid plunging into the spinal canal through a bony defect with the Bovie cautery
Laminectomy, decompression of all neuronal structures, fusion

Dura and any osseous protrusion into spinal canal is visualized
Ligamentous and osseous damage are assessed
Decompression of all neuronal structures
- Bony fragments removed with high-speed burr
- Corpectomies as necessary

If present, can be impacted anteriorly out of canal with Sypert spinal impactors

Reassessment of alignment with myelography, computed tomography scan, and anteroposterior/lateral radiographs
- Consider anterior retroperitoneal decompression if neuronal compression still present
Patients should begin ambulating in molded orthosis 4 days after surgery