8

Compression (AO Type-A Injuries)

Nuno Neves

■■ Introduction and compression fractures. Original papers and

reviews were selected based on their relevance.
The cervical spine is injured in 2 to 3% of pa- Other articles were found through the refer-
tients who sustain blunt trauma, and the vast ences of the selected papers.
majority of these fractures and dislocations
occurs in the subaxial spine.1,2 The subaxial
cervical spine is anatomically and biomechani-
cally similar to the thoracolumbar spine, in
■■ Classification of Injuries of
both its osseous and ligamentous elements, the Subaxial Cervical Spine
but its smaller dimensions and higher range
of motion in all planes makes it more prone to An effective classification system establishes
injuries. easy-to-remember, standardized terminology
Although compression injuries are the most that both facilitates communication between
common type in the thoracolumbar spine, in health care providers and guides treatment.4
the cervical spine they are relatively rare and Furthermore, intra- and interobserver reliabil-
account for less than 15% of all injuries.3 ity should be high.
Characteristically, A-type compression frac- The AO (Arbeitsgemeinschaft für Osteosyn-
Copyright © 2015. Thieme Medical Publishers, Incorporated. All rights reserved.

tures result from axial compression with or thesefragen) classification for spine injuries, as
without flexion, have reduced vertebral body described by Magerl et al,5 was originally de-
height, and have an intact posterior ligamen- veloped for the thoracolumbar spine, and is a
tous complex. This chapter reviews the classifi- comprehensive system primarily based on the
cation, clinical and diagnostic features of A-type morphology and mechanism of injuries. This
compression fractures of the subaxial cervical system has three main types: type A, vertebral
spine, and discusses their management. body compression; type B, disruption of the
anterior and posterior elements with distrac-
tion; and type C, disruption of the anterior and
posterior elements with rotation. Each type is
■■ Methods further divided into three groups and three
subgroups, for a complete description of every
A literature search was performed on the Na- injury.
tional Library of Medicine (PubMed) database, Although specifically developed for the tho-
using the following as the major search terms: racic and lumbar spine, the idea of expanding
cervical spine, fractures, injuries, burst fractures, its use for the cervical spine has been met with

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 84 Chapter 8

Table 8.1 AO Classification of Subaxial Cervical Spine Compression Injuries

A—Compression

A1—Impaction fractures A2—Split fractures A3—Burst fractures

A1.1—end-plate impaction A2.1—sagittal or coronal A3.1—incomplete burst

A1.2—wedge impaction A2.2—sagittal and coronal A3.2—burst-split
A1.3—vertebral collapse A2.3—pincer fracture A3.3—complete burst

Source: From Blauth MKA, Mair G, Schmid R, Reinhold M, Rieger M. Classification of injuries of the subaxial cervical spine.
In: Aebi M, Arlet V, Webb JK, eds. AOSpine Manual: AOSpine International. New York: Thieme; 2007:21–38. Reproduced
with permission.

interest, because it represents a unified, com- ent patterns of injury, and identifying a specific
prehensive classification for the whole subaxial mechanism from a certain injury may be trou-
mobile spine. In a retrospective study of 448 blesome. Additionally, the classification fails to
patients, Blauth et al3 applied the AO thoraco- consider ligamentous stability or neurologic in-
lumbar classification to the cervical spine, volvement, so its clinical applicability is limited.
which the authors felt differed very little from More recently, based on modern imaging,
its thoracolumbar counterpart (Table 8.1). Com- two new classification systems have been de-
puted tomography (CT) is mandatory for the veloped, enabling a continuous quantification
full classification of a cervical spine injury, and of stability and aiding in decision making.
flexion-extension X-rays or magnetic resonance The Cervical Spine Injury Severity Score
imaging (MRI) may also be required to identify (CSISS) independently analyzes four columns
possible injuries to the posterior ligamentous (anterior, posterior, right lateral column, and
complex. Intraoperative findings may modify left lateral column) and scores each using a 0
even further the initial classification. Although to 5 analogue scale.7 Scores increase propor-
it is comprehensive, this system may become tionally to either displacement of fracture frag-
too complex beyond the type (A, B, or C) and ments or separation as a result of soft tissue
group classification to apply in everyday prac- injury. Each column is scored independently
tice, making it more useful for academic de- and summed, yielding a score range of 0 to 20.
scription of injuries. The AO is in the process Excellent intra- and interobserver reliability
of refining the AO subaxial cervical spine clas- was obtained using this scale. Patients with a
sification, combining elements of the Thoraco- score ≥ 7 are treated surgically. AO A-type com-
Copyright © 2015. Thieme Medical Publishers, Incorporated. All rights reserved.

lumbar Injury Classification and Severity Score pression injuries score low on the CSISS (0–3),
(TLICS) system along with the principles of the as they are limited to the anterior column.
original AO Magerl system. The Subaxial Cervical Spine Injury Classifi-
A widely used classification system is the cation (SLIC) system evaluates three parame-
Allen-Ferguson system, which is based on the ters: fracture morphology, the discoligamentous
mechanism involved in each lesion inferred complex (DLC), and neurologic function.4 Each
from the radiographic images.6 There are six is assigned a specific number of points, creat-
categories: (1) flexion-compression, (2) vertical ing a score that aids treatment decision mak-
compression, (3) flexion-distraction, (4) exten- ing. An injury that scores below 4 can be
sion-compression, (5) extension-distraction, treated nonoperatively, whereas surgery is
and (6) lateral flexion. recommended with a score above 4. Injuries
These systems rely on morphological char- scoring equal to 4 can be managed either way.
acteristics and inferred mechanisms, which AO A-type compression injuries score low in
poses several questions regarding their valid- the SLIC system (1–2) unless a neurologic defi-
ity. The same mechanism may produce differ- cit is present.

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 Compression (AO Type-A Injuries) 85

■■ Epidemiology ing of the vertebral body, which usually occurs

along the superior end plate. Because the pos-
According to Blauth et al,3 A-type fractures terior body cortex is intact, and commonly
represent 14.7% of all subaxial spine injuries. In there is no injury to the posterior ligamentous
this study, A3 were the most common (9.8%) complex (PLC), the risk of neurologic injury is
and A1 and A2 accounted for only 2.9% and low. However, damage to the PLC can occur with
2.0%, respectively. This is in stark contrast with A1-type fractures creating an unstable lesion,
the thoracolumbar spine, where compression and the association of a vertebral compression
and burst fractures are largely predominant. fracture with interspinous space widening, ver-
In a study of 203 vertebral fractures in 127 pa- tebral subluxation, and loss of cervical lordosis,
tients, burst fractures accounted for 38% of the indicates a probable ligamentous disruption,
fractures, but only 10% were located in the the so-called hidden flexion injury.12 A high
cervical spine.8 Importantly, all patients with a level of suspicion is necessary to identify these
single spine fracture should undergo imaging injuries, as they can be spontaneously reduced
of the entire axis, as at least 10% of patients in supine lateral X-rays, and flexion-extension
may have a noncontiguous spinal fracture.8,9 images under fluoroscopic control or advanced
Axial compressive cervical spine fractures imaging modalities may be indicated.
are typically observed in the third and fourth Split fractures (group A2) are rare lesions.
decades of life, and men are predominantly af- Because pure coronal or sagittal plane fracture
fected, with falls and sports activities (e.g., div- lines are uncommon, this group presents a
ing head first in shallow water) being the main minor change from its thoracolumbar classifica-
causes of injury.9,10 tion counterpart, including combined sagittal
Spinal cord injuries (SCIs), either complete and coronal plane fractures. In the pincer-type
or incomplete, are frequently associated with fracture (A2.3), there is marked displacement
burst fractures. According to Blauth et al,3 neu- of the anterior fragment and small comminu-
rologic injuries (ranging from radicular symp- tion zones, leading to reduced resistance to
toms to severe complete SCI) were observed in compression and increased susceptibility to
54.5% of all cervical spine burst fractures. Only nonunion.
15.3% and 22.2% of neurologic injuries were Burst fractures (group A3) result from se-
associated with A1 and A2 types, respectively, vere axial loading, affecting both the anterior
representing the groups with the least com- and middle columns of the cervical vertebrae
plications. Young men in their early 30s are and usually occur at C6 and C7 rather than the
the group at higher risk of sustaining SCI, but middle or upper cervical spine.4,6 With axial
the demographics are variable throughout the loading, pressure increases rapidly inside the
Copyright © 2015. Thieme Medical Publishers, Incorporated. All rights reserved.

world, and a recent shift toward more women disc, pushing the superior end plate inside the
and older age has been described.11 vertebral body, which fails with retropulsion
of fragments to the spinal canal. The posterior
vertebral body cortex is injured, leading to de-
creased anterior and posterior vertebral height
■■ Diagnostic Features and a variable degree of segmental kyphosis.
Incomplete burst fractures are less common
A-type fractures characteristically result from than in the thoracolumbar spine, as usually
axial compression. They are usually associated the whole posterior wall of the vertebral body
with variable degrees of flexion, and they have bulges into the spinal canal. Because the head
reduced vertebral body height and an intact is often slightly flexed, posterior ligamentous
posterior ligamentous complex. complex disruption can occur and must be
Impaction fractures (group A1) are rare in- ruled out by appropriate methods.
juries that result from axial loading forces in In anteroposterior (AP) views (Fig. 8.1a),
flexion. The disc is pressurized, leading to wedg- X-rays reveal a vertical fracture line, pedicle

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 86 Chapter 8

a b

Fig. 8.1a–e A 48-year-old man

suffered an injury in a motor vehicle
accident. He was admitted to the
hospital with neck pain and an
incomplete spinal cord injury (Ameri-
can Spinal Injury Association [ASIA]
grade B). (a,b) X-rays and (c) com-
puted tomography (CT) scan revealed
a C5 complete burst fracture with
vertebral body comminution and
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retropulsion of the posterior cortex.

The patient was put in skull traction
for immediate reduction and indirect
spinal cord decompression and
underwent a C5 corpectomy, C4-C6
fusion with iliac crest bone graft, and
c plate fixation.

widening, and variable degrees of comminution cal fractures in the laminae or spinous processes
and displacement of fragments of the vertebral can also be seen. Failure of the anterior col-
body. On lateral views (Fig. 8.1b), there is soft umn, severe kyphosis, interspinous widening,
tissue swelling, shortening of both anterior and forward subluxation of the adjacent vertebral
posterior vertebral body heights, variable ky- body, facet subluxation, fracture, or dislocation,
phosis, and convexity of the posterior vertebral are highly suggestive of disruption of the DLC.
body wall as compared with the normal verte- A CT scan can precisely define bone commi-
brae. As the pedicles are pushed laterally, verti- nution, posterior wall retropulsion, and facet

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 Compression (AO Type-A Injuries) 87

d e
Fig. 8.1a–e (continued) (d,e) One year later the fusion has healed uneventfully and the neurologic status
improved to ASIA grade D.

subluxation or fractures, which are difficult ■■ Initial Management

to visualize in conventional radiography (Fig.
8.1c). However, because retropulsed fragments Patients with A-type injuries are kept immobi-
often have recoiled from the most displaced lized with a hard cervical collar with the spine
position, the CT scan can significantly under­ in a neutral position. A cadaveric study demon-
estimate the amount of canal narrowing that strated that flexion or extension can decrease
occurs during the impact, and so there is no canal diameter in a patient with a burst frac-
Copyright © 2015. Thieme Medical Publishers, Incorporated. All rights reserved.

direct correlation between postinjury occlu- ture of the cervical spine.14 Once the neck has
sion and neural damage.13 Moreover, CT scan been properly immobilized, periodic neurologic
can easily image the occipitocervical and cer- exams should be performed.
vicothoracic spine, which are difficult to assess Although there is little high-quality evidence
with plain radiographs. on closed reduction of cervical burst fractures
Magnetic resonance imaging is used to eval- by skull traction, it can be performed as a
uate ongoing neurologic compression and soft means of achieving indirect neural decompres-
tissue injuries, and is indicated in all patients sion in an emergent setting.15 Even if surgical
with a neurologic deficit unless obtaining the treatment has already been decided, this tem-
study would lead to a substantial delay in porizing measure may help restore the anatomic
treatment. A hyperintense signal through liga- alignment and make surgery easier. Gardner-­
mentous regions on T2 or short tau inversion Wells tongs are initially applied with 5 kg to
recovery (STIR) images is indicative of a liga- counter the weight of the head; sequentially,
mentous injury. Still, there is no definitive clin- and under close supervision, 2 kg for each seg-
ical correlation between increased ligamentous ment is added, and radiographs or fluoroscopy
signal and mechanical instability.4 are used to control reduction. For burst fractures,

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 88 Chapter 8

additional weight is rarely needed to achieve DLC (intervertebral disc, anterior and posterior
acceptable alignment and reduction. Alterna- longitudinal ligaments, interspinous ligaments,
tively, a halo may be used both for reduction facet capsules, and ligamentum flavum). An in-
and definitive nonoperative treatment. tact DLC is defined as normal spinal alignment,
normal disc space, and ligamentous appear-
ance, and is awarded zero points. Disruption
of the DLC may be inferred by the presence of
■■ Definitive Management abnormal facet alignment (articular apposition
< 50% or diastasis > 2 mm through the facet
There are three main factors to consider when joint), widening of the anterior disc space,
deciding whether or not to surgically stabilize translation or rotation of the vertebral bodies,
a subaxial cervical spine injury: spinal stabil- kyphotic alignment of the cervical spine, or
ity, neurologic status, and individual patient high signal intensity seen horizontally through
factors.16 a disc involving the nucleus and anulus on T2
A significant portion of A-type injuries has or STIR sagittal MRI, and is assigned two points.
neither neurologic compromise nor mechani- An indeterminate injury exists when radio-
cal instability, so these injuries can be treated graphic disruption of the DLC is not obvious,
nonoperatively. The AO subaxial spine classifi- but a hyperintense signal is found through
cation system does not consider the neurologic ­either the disc or the posterior ligaments on
status of the patient, but rather relies on mor- MRI; this is assigned one point. Finally, neuro-
phological characteristics and the mechanism logic status is assessed, and zero to four points
of injuries to establish the severity of the frac- are assigned. Injuries scored above four should
ture. However, defining instability has been a be treated surgically, and nonoperative treat-
challenge and a matter of intense debate and ment can be recommended for those scoring
confusion. White and Panjabi’s group17 defined below four. Injuries scoring equal to 4 can be
stability as “the ability of the spine under phys- managed either operatively or conservatively.
iologic loads to limit patterns of displacement In anterior column injuries (impaction, split,
so as not to damage or irritate the spinal cord or burst), the integrity of the DLC must be
or nerve roots and, in addition, to prevent inca- carefully evaluated before deciding between
pacitating deformity or pain due to structural the treatment options.
changes,” and developed a checklist to assist Only one study has specifically compared
in the determination of spinal stability. They the results of nonoperative and anterior opera-
identified radiographic parameters for subaxial tive treatment of cervical spine compression
cervical spine instability including more than injuries.18 Sixty-nine consecutive patients with
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3.5 mm horizontal displacement of one verte- both cervical burst and flexion teardrop frac-
bra in relation to an adjacent vertebra, or more tures were reviewed retrospectively. Thirty-­
than 11 degrees of rotation difference from that four were treated with skull traction or halo
of either adjacent vertebra. Although helpful vest, and 35 with anterior decompression, bone
and reliable in extreme cases, this definition grafting, and plate fixation. Surgically treated
may be inadequate in subtle cases, as instabil- patients had significantly better neurologic re-
ity is a continuum of situations rather than a covery, and had less narrowing of the spinal
dichotomous condition. canal and kyphotic deformity at the end of the
The SLIC system carefully analyzes each of follow-up period. These results should be care-
three components of the injury: fracture mor- fully analyzed, because no distinction was made
phology, integrity of the DLC, and neurologic between the two fracture types or between
function.4 For morphology, A1- and A2-type neurologically intact and injured patients. More-
injuries are assigned one point and A3 frac- over, the study was performed before the SLIC
tures are assigned an additional point. The system was in use, and so the integrity of the
SLIC system then evaluates the integrity of the DLC was not reported.

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 Compression (AO Type-A Injuries) 89
Nonoperative Treatment sure sores, subdural abscess, nerve palsies, and
fracture overdistraction. The use of a halo vest
Because A1 and A2 type fractures are uncom- is relatively contraindicated in the presence of
mon, there is no study comparing surgical severe cachexia, in patients with severe defor-
versus conservative treatment in these specific mity (ankylosing spondylitis or scoliosis), in
types of injuries. Nevertheless, they are inher- morbid obese patients, in the elderly, and in
ently stable lesions that have a low SLIC score, noncompliant or tetraplegic patients.
and a strong recommendation can be made for
nonoperative management in neurologically
intact patients. The association of interspinous
Surgical Treatment
space widening, vertebral subluxation, and loss Accepted indications for surgery in anterior
of cervical lordosis indicates a possible liga- column compression injuries are as follows:
mentous disruption, and these patients require (1) neurologic deficit; (2) disruption of the DLC;
close follow-up, as these injuries may displace and (3) inability to proceed with conservative
later on. Pincer-type fractures (A2.3) without treatment (e.g., fractured skull precluding halo
disruption of the DLC should undergo initial application) or to maintain satisfactory reduc-
nonoperative management, and similarly many tion and alignment.
burst fractures without injury to the DLC can As mentioned above, in the only study avail-
be treated nonsurgically. able that compared nonoperative management
The use of braces or a halo vest immobilizes with anterior operative management of cervical
the spine during healing, maintaining spinal spine compression injuries, the results favored
alignment, and controls pain by restricting surgical treatment.18 However, no definitive
movement. Stable impaction or split fractures indications can be drawn from this study,
can be treated with a cervical collar. Burst ­because results were reported without clear
fractures may need a hard cervical thoracic or- distinction between neurologically intact and
thosis (CTO) or a halo vest, especially in those injured patients, and the DLC was not specifi-
cases where prior reduction was performed. cally assessed.
Frequent radiographs must be obtained to No class I or II evidence addressing the sur-
closely monitor the reduction and alignment gical approach in compression and burst frac-
until union is achieved, which can take up to tures is available, and only eight class III studies
12 weeks. Dynamic flexion-extension radio- were identified.20–27 Reports include mixed frac-
graphs should be taken at the end of the im- ture patterns and small numbers of patients,
mobilization period to detect any residual and most were performed before contempo-
dynamic instability. Inability to maintain align- rary classification systems were in use.
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ment and reduction may predispose to late pain Brodke et al20 compared the results of an-
or de novo neurologic deficits, and may war- terior versus posterior surgery in 57 patients
rant surgical stabilization. Physical therapy is with unstable cervical spine lesions and asso-
usually prescribed at the end of treatment. ciated spinal cord injuries, but only seven had
Nonoperative treatment can result in sig- isolated burst fractures (four in the anterior
nificant complications.19 Cervical orthoses may group and three in the posterior group). Twelve
be associated with discomfort, inadequate im- patients had a burst fracture associated with
mobilization, muscle atrophy, psychological de- a clear distraction injury. Neurologic improve-
pendence, pain, skin breakdown, and worsened ment and a high fusion rate were observed
pulmonary function. Optimized fit and ade- in each group, with no significant differences;
quate, soft materials at skin contact sites can en- however, in the anterior group, 70% improved
hance comfort and compliance with treatment. at least one Frankel grade, compared with 57%
Halo vest use can significantly impair daily in the posterior group.
life and result in multiple complications, such Toh et al21 reviewed the surgical treatment
as pin loosening, penetration and infection, pres- of 31 patients with burst or flexion distraction

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 90 Chapter 8

injury in the middle and lower cervical spine Belirgen et al26 retrospectively analyzed the
who were treated with anterior instrumen­ results of anterior versus posterior surgery in
tation, posterior instrumentation, or both. Be- a group of 33 patients with reducible cervical
cause all burst fractures were approached subaxial fractures. There were only four com-
anteriorly, a comparison of treatments for this pression-type injuries, and the results were
specific type of injury is not possible. Never- not reported specifically for this subgroup.
theless, anterior decompression and fusion re- Posterior surgery was associated with longer
stored the spinal canal diameter significantly operative times and more blood loss, and en-
better, and improved neurologic function in tailed a larger number of fused segments. The
nine of 24 patients, whereas no improvement authors concluded that anterior instrumenta-
was observed in those treated posteriorly. tion with interbody grafting can be the initial
Complications and overall alignment were choice of treatment for stabilization of these
evaluated in a study of 29 patients with an un- patients, and that posterior surgery is indi-
stable cervical vertebral fracture or a fracture-­ cated if radiographs show failure after anterior
dislocation treated with posterior spine fusion instrumentation.
and lateral mass instrumentation.22 There were The Spine Trauma Study Group developed
seven vertical compression burst fractures. A an evidence-based algorithm for surgical ap-
mean loss of 2 degrees in sagittal alignment at proaches to the management of subaxial cervi-
the final follow-up examination was observed, cal spine injuries based on a systematic review
with no differences between the various types of the literature, expert opinion, and antici-
of injury patterns. Six complications were re- pated patient preferences.27 The algorithm is
ported: four wound infections, one hardware derived from the SLIC system and addresses
failure, and one C5 nerve root injury. both the indication for surgery as well as the
Lambiris et al23 performed a retrospective surgical approach. Compression and burst
study of patients with different subaxial cervi- fractures without disruption of the DLC are
cal spinal injuries to summarize the compli­ awarded one or two points and commonly zero
cations of instrumented anterior or posterior for an intact DLC. Hence, the neurologic status
stabilization of cervical spine injuries. No dif- and the presence of residual compression of
ference in the complication rate between ante- the spinal cord are the strongest determinants
rior (74 patients) and posterior (23 patients) of treatment. With complete or incomplete neu-
fixation was observed. Nevertheless, nearly all rologic injury, the SLIC system will add two to
eight compression wedge injuries and 13 burst four points to the morphology score, leading
fractures were treated anteriorly, as proposed to an overall score of four to six. Surgery is pre-
by their treatment algorithm. ferred with scores of five or above. Scores of
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The use of pedicle screw instrumentation four should be decided case by case, depending
was also evaluated in a retrospective series of on the surgeon’s preferences and experience,
144 unstable cervical injury patients.24 An over- and the patient’s factors and expectations. The
all low rate of instrumentation-related and other authors recommended anterior decompression
complications was observed with this surgical and stabilization for surgically treated burst
technique. fractures.
Kasimatis et al25 reported on 74 patients From the aforementioned studies we can
with unstable lower cervical spine injuries who conclude that anterior decompression and sta-
underwent anterior surgery over a 15-year bilization is favored when surgery is indicated
period. There were seven compression wedge for burst fractures. Patient positioning is safe
and 13 burst fractures, and the results were and straightforward for an anterior approach,
not stratified according to injury type. Overall, and surgical dissection is performed with min-
90% of incomplete lesions improved, there was imal soft tissue damage. Because spinal cord
no neurologic deterioration and no instrumen- compression is ventral, optimal decompression
tation failure, and all fusions healed. of neural elements can be done under direct

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 Compression (AO Type-A Injuries) 91
visualization. Corticocancellous autogenous strut • Inability to achieve or maintain correct re-
graft, allograft, or a cage can be inserted and duction and alignment is an indication for
supplemented by a plate (Fig. 8.1d,e). Because surgery.
of its ready availability, low cost, and predict-
able fusion rate, we usually prefer iliac bone
autograft. After surgery, a cervical collar can be Neurologically Injured Patients
worn, especially in more unstable cases, but • Neurologic injury warrants immediate re-
there are no strict indications on either its use duction and indirect decompression using
or the duration of immobilization. skull tongs or halo traction, particularly if
Impaction wedge and split fractures with surgery is delayed.
surgical indication can be stabilized by anterior • Surgery is indicated, especially in incom-
or posterior fixation. Posterior monosegmental plete spinal cord lesions and continuous cord
fusion with lateral mass screws is an easy, reli- compression, by direct anterior decompres-
able, and biomechanically valid surgery for the sion, interbody grafting, and plating.
treatment of these injuries. However, we prefer
anterior stabilization. A wedge-shaped graft is
inserted and a variable-angle screw plate is ap-
plied to take purchase in the intact lower por- ■■ Chapter Summary
tion of the vertebral body. With contemporary
implants and a correctly fashioned graft, the A-type compression fractures (impaction, split
risk of subsidence is probably minimal. and burst fractures) characteristically result
from axial compression, and commonly have
a reduced vertebral body height and an intact
posterior ligamentous complex. Contrary to
■■ Treatment what happens in the thoracolumbar spine,
Recommendations where compression fractures are the most
common type, in the cervical spine they are
relatively rare and account for less than 15% of
Neurologically Intact Patients all injuries.
• A-type fractures without disruption of the Typically, these injuries occur in young men,
DLC can be treated nonoperatively with a and falls and sports activities are the main
collar, a hard cervical thoracic orthosis, or a causes of injury. More than half of cervical
halo vest, depending on the severity of the burst fractures can be associated with either
injury. complete or incomplete spinal cord injury.
Copyright © 2015. Thieme Medical Publishers, Incorporated. All rights reserved.

• Impaction and split fractures with disrup- A-type fractures, without neurologic dam-
tion of the DLC can be treated conserva- age can be treated nonoperatively with a collar,
tively, but careful, frequent monitoring of a hard cervical thoracic orthosis, or a halo vest,
reduction and alignment is needed, as these depending on the severity of the injury, as long
injuries may displace. as the DLC has been thoroughly evaluated. Dis-
• Burst fractures with disruption of the DLC ruption of the DLC is not an absolute operative
can be treated either conservatively or sur- indication, as compression and split fractures
gically. Surgical treatment may be preferred with disruption of the DLC can still be treated
because of the risk of displacement, neuro- conservatively. Importantly, patients with a pos-
logic compromise, late pain, and the mini- sible DLC disruption require frequent monitor-
mal risks of anterior stabilization. However, ing, as these injuries may displace.
because the long-term morbidity of losing Burst fractures in neurologically intact pa-
two mobile levels may be significant, strong tients with disruption of the DLC can be treated
consideration must be given to conservative either conservatively or surgically. Because of
treatment, especially in the young patient. the risk of displacement, neurologic compro-

AOSpine Masters Series, Volume 5: Cervical Spine Trauma, Thieme Medical Publishers, Incorporated, 2015. ProQuest Ebook Central,
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 92 Chapter 8

mise, and late pain, and considering safety

surgery, especially in those patients where co­
and efficacy of anterior stabilization, surgical
existing injuries delay definitive intervention.
treatment may be preferred. However, strong ◆◆ Most A-type fractures in neurologically intact pa-
consideration must be given to conservative tients can be treated nonoperatively, provided
treatment, because the morbidity of losing two that DLC disruption has been appropriately ruled
mobile levels may be significant in the long out.
◆◆ If feasible and adequate, conservative treatment
term, especially in a young patient.
of burst fractures with disruption of the DLC in
Neurologic injury warrants immediate closed neurologically intact patients can be used, con-
or open reduction, and surgery is indicated for sidering the long-term morbidity of losing two
all patients with a persistent neurologic deficit. mobile levels.
Our preferred approach is a direct anterior de- ◆◆ Anterior decompression, interbody grafting, and
plate stabilization are the preferred treatment in
compression, interbody grafting, and plating.
neurologically injured patients.
In addition to neurologic injuries, the failure
to achieve or maintain correct reduction and Pitfalls
alignment is also an indication for surgery.
◆◆ A high level of suspicion is necessary to identify
ligamentous disruption in compression injuries,
Pearls as they can be spontaneously reduced in supine
lateral X-rays, and flexion-extension images under
◆◆ A-type compression fractures represent less than fluoroscopic control or advanced imaging modal-
15% of all subaxial spine injuries. ities may be indicated.
◆◆ Axial compressive cervical spine fractures are ◆◆ Patients with burst injuries should be kept immo-
typically observed in men in the third and fourth bilized with a hard cervical collar, with the spine
decades of life, and falls and sports activities are in neutral position, because either extension or
the main causes of injury. flexion has been associated with an increase in
◆◆ Burst fractures usually affect the lower cervical the occlusion of the spinal canal.
spine (C6 or C7), and neurologic injuries are pres- ◆◆ If conservative treatment is undertaken, fre-
ent in more than half of the patients. quent radiographs should be obtained to closely
◆◆ Skull traction can be performed for indirect neu- monitor the reduction and alignment until union
ral decompression in an emergent setting, even if is achieved. Loss of reduction or alignment may
surgical treatment has already been decided, as warrant surgical stabilization.
this will enable anatomic alignment and an easier

References
Five Must-Read References
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Copyright © 2015. Thieme Medical Publishers, Incorporated. All rights reserved.

AOSpine Masters Series, Volume 5: Cervical Spine Trauma, Thieme Medical Publishers, Incorporated, 2015. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/usfq/detail.action?docID=5254071.
Created from usfq on 2024-07-16 05:50:36.