Spine Trauma (eBook)

Spine Trauma 1
Preface 5
Acknowledgment 6
Contents 7
Part 1: Cervical 10
1: Cervical Spinal Stability and Decision Making 11
1.1 Introduction 11
1.2 Cervical Stability 11
1.3 Classification Systems 12
1.3.1 Holdsworth 12
1.3.2 Mechanistic Systems 12
1.3.3 White and Panjabi 13
1.3.4 AO (Arbeitsgemeinschaft für Osteosynthesefragen) System 13
1.4 Advances in Cervical Trauma Classification 14
1.4.1 Cervical Spine Injury Severity Score 14
1.4.2 Subaxial Cervical Spine Injury Classification (SLIC) 14
1.5 Summary: Critical Clinical Variables 17
1.6 Conclusions 17
References 17
2: Clearing the Cervical Spine 18
2.1 Introduction 18
2.2 Cervical Spine Clearance: Definition, Rationale, Objectives 19
2.3 Cervical Spine Clearance: Patient Groups 19
2.3.1 Group I (Asymptomatic) 20
2.3.2 Group II (Symptomatic) 20
2.3.3 Group III (Nonevaluable) 21
2.4 Patient Management Before and During Cervical Spine Clearance 22
2.5 Clinical Clearance of the Cervical Spine 22
2.5.1 History 22
2.5.2 Physical Examination 23
2.6 Imaging Clearance of the Cervical Spine 24
2.6.1 Plain Radiography 24
2.6.2 Flexion–Extension Radiography 26
2.6.3 Dynamic Fluoroscopy 26
2.6.4 Computed Tomography 26
2.6.5 Magnetic Resonance Imaging 27
2.7 Current Cervical Spine Clearance Guidelines 27
2.7.1 ATLS Recommendations 27
2.7.2 EAST Guidelines 29
2.7.3 NEXUS Guidelines 30
2.7.4 Canadian C-Spine Rule 30
2.7.5 Obtunded Patient Clearance Protocols 31
2.7.6 Authors’ Cervical Spine Clearance Algorithm 32
2.8 Summary and Conclusions 34
References 36
3: Imaging of Spinal Trauma 39
3.1 Introduction 39
3.2 To Image or Not To Image the Cervical Spine? 39
3.2.1 Who Should Be Imaged? 40
How Should We Image the Cervical Spine? 42
3.2.3 Ligamentous/Soft Tissue Evaluation 46
3.3 Special Considerations 47
3.3.1 Pediatric Patients 47
3.3.2 Elderly Patients 49
3.3.3 The Ankylotic Spine 50
3.3.4 The Athlete 50
3.3.5 Neurovascular Injury 51
3.4 Cervical Spine Injury 53
3.4.1 Normal Cervical Spine Radiographs 53
3.4.2 Mechanisms of Injury 55
3.4.2.1 Axial Load: Occipital Condyle Fractures 56
3.4.2.2 Axial Load: Jefferson Burst Fracture 58
3.4.2.3 Axial Load: Cervical Burst Fracture 59
3.4.2.4 Hyperflexion: Hyperflexion Sprain 60
3.4.2.5 Hyperflexion: Bilateral Facet Dislocation 62
3.4.2.6 Hyperflexion: Hyperflexion Teardrop 64
3.4.2.7 Hyperflexion: Wedge Compression Fracture 64
3.4.2.8 Hyperflexion: Clay Shoveler’s Fracture 64
3.4.2.9 Hyperflexion with Rotation: Unilateral Facet Dislocation 64
3.4.2.10 Hyperextension: Dens Fractures 66
3.4.2.11 Hyperextension: Hangman’s Fracture 68
3.4.2.12 Hyperextension: Hyperextension Teardrop 69
3.4.2.13 Hyperextension: Hyperextension Avulsion of Anterior Arch of C1 70
3.4.2.14 Hyperextension: Hyperextension Sprain/Fracture Dislocation 70
3.5 Injury to the Thoracic and Lumbar Spine 71
3.5.1 Indications for Imaging 71
3.5.2 Concept of Thoracic and Lumbar Fracture Stability 71
3.5.3 Wedge Compression Fracture 72
3.5.4 Burst Fracture 72
3.5.5 Chance Fracture 73
3.6 Conclusion 74
References 75
4: Immunological Response to Spinal Cord Injury: Impact on the Timing of Spine Fixation 78
4.1 Pathophysiology of Spinal Cord Injury (SCI) 78
4.1.1 Primary SCI 78
4.1.2 Secondary SCI 78
4.2 Posttraumatic Immunological Response 79
4.2.1 Disruption of the Blood-Spinal Cord Barrier 79
4.2.2 Cellular and Molecular Neuroinflammatory Reactions 79
4.2.3 “No-Go” – The Future Way to Go? 82
4.3 Impact on the Timing of Surgery 82
4.3.1 Timing of Surgery – Is It Important? 82
4.3.2 The Concept of “Spine Damage Control” 83
4.4 Conclusion 83
References 87
5: The Role of Orthosis in Spinal Injury 89
5.1 Introduction 89
5.2 Principles of Spinal Orthotic Immobilization 90
5.3 Motion Control 90
5.4 Orthoses as a Treatment for Spine Fracture 92
5.5 Postsurgical Orthoses 94
5.6 Summary 94
5.6.1 Cast Application for Burst Fracture 95
5.6.1.1 Equipment Needed 95
5.6.1.2 Technique 95
References 97
6: The Halovest 98
6.1 Description [1] 98
6.2 Key Principles 98
6.3 Expectations 98
6.4 Indications [4] 98
6.4.1 Trauma 98
6.4.2 Other 98
6.5 Contraindications 107
6.6 Special Considerations [3] 107
6.7 Special Instructions, Positions and Anaesthesia [5, 6] 107
6.8 Tips and Pearls 108
6.9 Pitfalls 108
6.10 Challenges 108
6.11 Complications [2] 108
References 109
7: Direct Anterior Screw Fixation of Odontoid Fractures 110
7.1 Case Example 110
7.2 Background 110
7.3 Indications 111
7.4 Potential Contraindications 112
7.4.1 Age of the Fracture 112
7.4.2 Age of the Patient 112
7.5 Procedure 112
7.6 Technical Pearls and Pitfalls 116
7.6.1 Surgical Technique 116
7.6.2 One or Two Screws 117
7.7 Postoperative Considerations 118
7.7.1 Postoperative Bracing 118
7.7.2 Follow-up Monitoring 118
7.7.3 Potential Complications 118
7.8 Conclusions 119
References 119
8: Occiput–Cervical Fixation 121
8.1 Case Example 121
8.2 Background 121
8.3 Indications and Advantages for Procedure 122
8.4 Contraindications for Procedure 122
8.5 Procedure 122
8.5.1 Equipment 122
8.6 Anesthetic and Neuromonitoring Considerations 123
8.7 Patient Positioning and Room Setup 123
8.8 Surgical Approach 124
8.9 Technical Pearls and Pitfalls 126
8.9.1 Pearls 126
8.9.2 Pitfalls 127
8.10 Potential Intraoperative Complications 127
8.11 Bailout/Salvage for Procedure Failure 128
8.12 Postoperative Considerations 128
8.12.1 Bracing 128
8.12.2 Activity 128
8.12.3 Follow-up 128
8.12.4 Potential Complications 128
8.12.5 Treatments/Rescue for Complications 128
References 129
9: C1–2 Fixation: Transarticular Screws 130
9.1 Case Example 130
9.2 Background 130
9.3 Indications and Advantages for Procedure 132
9.3.1 Indications 132
9.3.2 Advantages 132
9.4 Contraindications and Disadvantages for Procedure 132
9.4.1 Contraindications 132
9.4.2 Disadvantages 132
9.5 Procedure 132
9.5.1 Equipments Needed 132
9.5.2 Anesthetic and Neuromonitoring Considerations 132
9.5.3 Patient Positioning and Room Setup 132
9.5.4 Surgical Approach 134
9.5.5 Reduction Technique 136
9.5.6 Fixation Technique 136
9.6 Technical Pearls and Pitfalls 141
9.6.1 Pearls 141
9.6.2 Potential Intraoperative Complications 142
9.6.3 Bailout/Salvage for Procedure Failure 142
9.7 Postonsiderations 142
9.7.1 Bracing 142
9.7.2 Activity 142
9.7.3 Follow-Up 142
9.7.4 Potential Complications 142
9.7.5 Treatments/Rescue for Complications 143
References 143
10: C1–2 Fixation: Lateral Mass/Pars ­Screw-Rod Fixation 145
10.1 Case Example 145
10.2 Background 145
10.3 Indications and Advantages for Procedure 146
10.4 Contraindications and Disadvantages for Procedure 148
10.5 Procedure 149
10.5.1 Anesthetic and Neuromonitoring Considerations 149
10.5.2 Patient Positioning and Room Setup 150
10.5.3 Surgical Approach 150
10.5.4 C1 Lateral Mass Screw Fixation 151
10.5.5 C2 Pedicle/Pars Screw Fixation 152
10.6 Technical Pearls and Pitfalls 154
10.7 Postoperative Considerations 154
References 155
11: Closed Reduction of Unilateral and Bilateral Facet Dislocations 156
11.1 Case Example 156
11.2 Introduction 156
11.3 Indications/Contraindications 156
11.4 Timing 157
11.5 Equipment Required 158
11.6 Reduction Technique 158
11.7 Conclusion 159
11.8 Pearls 159
11.9 Pitfalls 160
11.10 Complications 160
11.11 Bailouts/Salvage 160
11.12 Post Procedure 160
Further Reading 160
12: Cervical Open Posterior Reduction of Facet Dislocation 161
12.1 Case Example 161
12.2 Background 161
12.3 Indications and Advantages for Procedure 163
12.3.1 Contraindications and Disadvantages for Procedure 163
12.4 Procedure 163
12.4.1 Equipment Needed 163
12.4.2 Anesthetic and Neuromonitoring Considerations 163
12.4.3 Patient Positioning and Room Setup 163
12.4.4 Surgical Approach 164
12.4.5 Reduction Technique 164
12.4.6 Fixation Technique 164
12.4.7 Closure 164
12.5 Technical Pearls and Pitfalls 164
12.5.1 Pearls 164
12.5.2 Potential Intraoperative Complications 166
12.5.3 Bailout/Salvage for Procedure Failure 166
12.6 Postoperative Considerations 166
12.6.1 Bracing 166
12.6.2 Activity 166
12.6.3 Follow-Up 166
12.6.4 Potential Complications 167
12.6.5 Treatments/Rescue for Complications 167
References 167
13: Open Anterior Reduction of Cervical Facet Dislocation 168
13.1 Introduction 168
13.2 Mechanism of Injury 168
13.2.1 Unilateral Facet Dislocations 168
13.2.2 Bilateral Facet Dislocation 169
13.3 Surgical Technique 169
13.4 Unilateral Facet Dislocation 169
13.4.1 Bilateral Facet Dislocation 170
13.4.2 Irreducible Reduction 171
13.5 Postoperative Considerations 171
13.5.1 Pitfalls 172
13.5.2 Pearls 172
13.5.3 Complications 172
13.5.5 Occult body fracture 172
References 172
14: Anterior Cervical Discectomy and Fusion for Traumatic Disc Herniation 173
14.1 Case Example 173
14.2 Background 174
14.3 Indications and Advantages 175
14.4 Contraindications and Disadvantages 175
14.5 Procedure 175
14.5.1 Equipment Needed 175
14.5.2 Anesthetic and Neuromonitoring Considerations 176
14.5.3 Surgical Approach, Pearls, and Pitfalls 177
14.5.4 Reduction Technique 178
14.5.5 Fixation Technique 178
14.5.6 Potential Intraoperative Complications 179
14.6 Pearls 179
14.7 Postoperative Considerations 180
References 180
15: Posterior Cervical Fusion for Trauma 181
15.1 Case Example 181
15.2 Background 181
15.3 Indications and Advantages of Technique 181
15.4 Contraindications and Disadvantages 181
15.5 Procedure 181
15.5.1 Equipment needed 184
15.5.2 Anesthetic considerations 184
15.5.3 Patient positioning 184
15.5.4 Pearls 184
15.5.5 Pitfalls 185
15.5.6 Bailout 185
15.5.7 Bracing 185
15.5.8 Complications 185
References 185
16: Corpectomy for Burst Fracture 186
16.1 Case Example 186
16.2 Background 187
16.3 Indications and Advantages for Procedure 187
16.4 Contraindications and Disadvantages for Procedure 188
16.5 Procedure 188
16.5.1 Equipment Needed 188
16.5.2 Anesthetic and Neuromonitoring Considerations 188
16.5.3 Patient Positioning and Room Setup 188
16.5.4 Surgical Approach 189
16.5.5 Reconstruction and Fixation Technique 189
16.6 Technical Pearls and Pitfalls 190
16.6.1 Pearls 190
16.6.2 Potential Intraoperative Complications 191
16.6.3 Bailout/Salvage for Procedure Failure 191
16.7 Postoperative Considerations 192
16.7.1 Bracing 192
16.7.2 Activity 192
16.7.3 Follow-up 192
16.7.4 Potential Postoperative Complications 192
16.7.4.1 Soft Tissue Hematoma 192
16.7.4.2 Dysphagia 192
16.7.4.3 Recurrent Laryngeal Nerve (RLN) Injury 192
16.7.4.4 Other Nerve Injuries 192
16.7.4.5 Continuous CSF Leak 193
16.7.4.6 Hardware Failure and Nonunion 193
References 193
17: Posterior Pedicle Screw Fixation 194
17.1 Case Example 194
17.2 Background 194
17.3 Indications and Advantages for Procedure 194
17.4 Contraindications and Disadvantages for Procedure 198
17.5 Preoperative Imaging Study 198
17.6 Timing of Surgery 198
17.7 Procedure 198
17.7.1 Equipment Needed 198
17.7.2 Anesthetic and Neuromonitoring Considerations 198
17.7.3 Patient Positioning and Room Setup 199
17.7.4 Surgical Approach 199
17.7.5 Reduction Technique 200
17.7.6 Fixation Technique 200
17.8 Technical Pearls and Pitfalls 201
17.8.1 Pearls 201
17.8.2 Pitfalls 202
17.8.3 Potential Intraoperative Complications 203
17.8.4 Bailout/Salvage for Procedure Failure 203
17.9 Postoperative Considerations 203
17.9.1 Bracing 203
17.9.2 Activity 203
17.9.3 Follow-Up 204
17.9.4 Potential Complications 204
17.9.5 Treatments/Rescue for Complications 204
References 204
Part 2: Thoracic 206
18: Thoracic Spinal Stability: Decision Making 207
18.1 Introduction 207
18.2 Anatomic and Biomechanical Considerations 207
18.3 Evaluation and Imaging 208
18.4 Spinal Cord Injury 209
18.5 Classification of Thoracic Spine Injuries 209
18.6 Fracture Types 210
18.6.1 Compression Fractures 211
18.6.2 Burst Fractures 218
18.6.3 Fracture Dislocation 219
18.6.4 Flexion-Distraction Injuries 219
18.7 Summary 219
References 221
19: Anterior Corpectomy with Fixation, Thoracic 223
19.1 Case Example 223
19.2 Background 223
19.3 Indications and Advantages 225
19.4 Contraindications and Disadvantages 226
19.5 Procedure 226
19.5.1 Equipment Needed 226
19.5.2 Anesthetic and Neuromonitoring Considerations 226
19.5.3 Patient Positioning and Room Setup 227
19.5.4 Surgical Approach 227
19.5.5 Thoracic Corpectomy and Decompression of Neural Structures 228
19.5.6 Reduction Technique 230
19.5.7 Placement of Interbody Graft 230
19.5.8 Fixation Technique 231
19.5.9 Closure 232
19.6 Technical Pearls and Pitfalls 232
19.6.1 Pearls: Decompression 232
19.6.2 Pearls: Interbody Fusion 232
19.6.3 Pearls: Anterior Instrumentation 233
19.6.4 Potential Intraoperative Complications 233
19.6.5 Bailout/Salvage for Failed Procedures 234
19.7 Postoperative Considerations 234
19.7.1 Bracing 234
19.7.2 Activity 234
19.7.3 Follow-Up 234
19.7.4 Potential Postoperative Complications 234
19.7.5 Treatment of Postoperative Complications 234
References 235
20: Kyphoplasty, Osteoporotic and Traumatic 236
20.1 Case Example 236
20.2 Background 236
20.3 Indications and Advantages for Procedure 236
20.4 Contraindications and Disadvantages for Procedure 237
20.5 Procedure 238
20.5.1 Equipment Needed (Fig. 20.3) 238
20.5.2 Anesthetic and Neuromonitoring Considerations 238
20.5.3 Patient Positioning and Room Setup 238
20.5.4 Surgical Approach 239
20.6 Technical Pearls and Pitfalls 243
20.6.1 Pearls 243
20.6.2 Intraoperative Complications and Bailout/Salvage Procedures 243
20.7 Postoperative Considerations 243
20.7.1 Bracing, Activity, Follow-Up, Complications 243
References 244
21: Costotransversectomy 245
21.1 Case Example 245
21.2 Background 245
21.3 Indications and Advantages of the Procedure 245
21.3.1 Indications 245
21.3.2 Advantages of the Procedure 246
21.4 Contraindications and Disadvantages of the Procedure 246
21.4.1 Contraindications 246
21.4.2 Disadvantages of the Procedure 247
21.5 Procedure 247
21.5.1 Equipment Needed 247
21.5.2 Anesthesia and Neuromonitoring 247
21.5.3 Surgical Procedure 247
21.6 Technical Pearls and Pitfalls 250
21.6.1 Pearls 250
21.6.2 Potential Intraoperative Complications 250
21.6.3 Salvage Procedure 250
21.7 Postoperative Considerations 250
21.7.1 Bracing 250
21.7.2 Activity 250
21.7.3 Follow-Up 251
21.7.4 Potential Postoperative Complications 251
Reference 251
Part 3: Thoracolumbar and Lumbar 252
22: Lumbar Spinal Stability: Decision Making 253
22.1 Introduction 253
22.2 Anatomic and Biomechanical Considerations 253
22.3 Evaluation and Initial Management of the Trauma Patient 254
22.4 Classification of Thoracolumbar and Lumbar Spine Injuries 255
22.5 Spinal Stability and General Principles of Management 257
22.6 Summary 259
References 260
23: Posterior Instrumentation for Thoracolumbar and Lumbar Fracture Dislocation 261
23.1 Case 1 261
23.2 Background 261
23.3 Classification and Indications 262
23.4 Contraindications 263
23.5 Advantages 263
23.5.1 Disadvantages 264
23.6 Surgical Technique 264
23.6.1 Positioning 264
23.7 Equipment 265
23.8 Neuromonitoring 265
23.9 Approach 266
23.9.1 Pedicle Screw Insertion 266
23.9.2 Fusion 269
23.10 Technical Pearls 269
23.10.1 Pitfalls 270
23.11 Intraoperative Complications 270
23.12 Bailout and Salvage Procedures 270
23.13 Postoperative Course 270
23.13.1 Bracing 270
23.13.2 Activity 271
23.13.3 Follow-Up 271
23.14 Complication Management 271
References 271
24: Posterior Decompression Technique for Thoracolumbar Burst Fracture 273
24.1 Background 273
24.2 Technique 273
24.3 Equipment Needed 275
24.4 Anesthesia/Neuromonitoring 276
24.5 Pearls 276
24.6 Pitfalls 276
24.7 Intraoperative Complications 278
24.8 Bailout 278
24.9 Bracing 278
24.10 Potential Complications 278
References 278
25: Anterior Treatment of Thoracolumbar Burst Fractures 280
25.1 Case Example 280
25.2 Background 280
25.3 Indications and Advantages for Procedure 281
25.4 Contraindications and Disadvantages for the Procedure 282
25.5 Procedure 282
25.5.1 Preoperative Planning 282
25.5.2 Patient Positioning 282
25.5.3 Surgical Approach 282
25.6 Technical Pearls and Pitfalls 286
25.7 Postoperative Considerations 287
Recommended Reading 287
26: Anterior and Posterior Surgery and Fixation for Burst Fractures 288
26.1 Case Example 288
26.2 Background 288
26.3 Indications and Advantages for Procedure 291
26.4 Contraindications and Disadvantages of the Procedure 292
26.4.1 Preoperative Imaging 292
26.4.2 Timing of Surgery 292
26.5 Procedure 292
26.5.1 Equipment Needed 292
26.5.2 Anesthetic and Neuromonitoring Considerations 292
26.5.3 Posterior Surgery 293
26.5.4 Anterior Surgery 294
26.6 Technical Pearls and Pitfalls 297
26.6.1 Pearls 297
26.6.2 Pitfalls 297
26.7 Potential Intraoperative Complications 297
26.8 Bailout/Salvage for Procedure Failure 297
26.9 Postoperative Considerations 297
26.9.1 Bracing 297
26.9.2 Activity 297
26.9.3 Follow-Up 298
26.9.4 Potential Complications 298
26.9.5 Treatments/Rescue for Complications 298
References 298
27: Percutaneous/Minimally Invasive Treatment for Thoracolumbar Fractures 299
27.1 Case Report 299
27.2 Background 299
27.3 Indications 300
27.4 Advantages 300
27.5 Equipment 301
27.5.1 Procedure 301
27.5.2 Technical Peals and Pitfalls 305
27.5.3 Postoperative Considerations 305
27.5.4 Conclusion 305
References 305
Part 4: Sacral 307
28: Surgical Stabilization Options forFractures and Fracture-Dislocationsat the Lumbosacral Junction and forPosterior Pelvic Ring Reconstruction 308
28.1 Indications 308
28.2 Contraindications 309
28.3 Techniques 309
28.4 Treatment Options and Decision-Making 309
28.4.1 External Fixation 310
28.4.2 Transiliac Sacral Bars 310
28.4.3 Transverse Transiliac Plating 310
28.5 Open Reduction and Internal Fixation with Small Fragment Plate and Screw Devices 311
28.5.1 Iliosacral Screws 311
28.5.2 Segmental Lumbopelvic Fixation 312
28.6 Results 313
28.6.1 Exposure 313
28.6.2 Neural Decompression, Fracture Reduction, Lumbopelvic Fixation 313
28.7 Postoperative Management 317
28.8 Avoiding Pitfalls and Complications 317
Further Reading 318
29: Sacral Screw Fixation 321
29.1 Introduction 321
29.2 Relevant Anatomy 321
29.3 Bone Mineral Density 322
29.4 Cortical Fixation 322
29.5 Screw Length 323
29.6 Biomechanical Comparisons 323
29.7 Technique of Screw Placement 323
29.7.1 Anteromedial (Pedicle) S1 Screw 323
29.7.2 Anterolateral (Alar) S1 Screw 324
29.7.3 S2 Screws 324
29.8 Choice of Technique 325
29.9 Conclusions 326
References 326
30: Percutaneous Placement of Iliosacral Screws 327
30.1 Case Example 327
30.2 Background 327
30.3 Indications and Advantages for Procedure Contraindications and Disadvantages for Procedure 328
30.4 Procedure 330
30.4.1 Equipment Needed 330
30.4.2 Anesthetic and Neuromonitoring Considerations 330
30.4.3 Patient Positioning and Room Setup 330
30.4.4 Surgical Approach, Reduction Technique, and Fixation Technique 330
30.5 Complications and Postoperative Considerations 333
31: Iliac Fixation in Trauma 336
31.1 Introduction 336
31.2 Technique 336
31.2.1 Exposure 336
31.2.2 Screw Placement 336
31.2.3 Connecting the Construct 337
31.2.4 Closure 340
31.3 Conclusion 340
References 340
Part 5: Special Circumstances 342
32: Minimally Invasive Treatment for Ankylosing Spondylitis and DISH Thoracolumbar Fractures 343
32.1 Case Example 343
32.2 Background 343
32.3 Advantages 343
32.4 Procedure 344
32.5 Technical Perils and Pitfalls 344
32.6 Postoperative Considerations 345
32.7 Results 345
32.8 Conclusions 346
References 347
33: Surgical Treatment of Thoracic orThoracolumbar Fractures of AnkylosingSpondylitis (AS) or Diffuse IdiopathicSkeletal Hyperostosis (DISH) 348
33.1 Case Report 348
33.2 Introduction 348
33.3 Equipment 349
33.4 Patient Positioning 350
33.5 Procedure 350
33.6 Complications 350
References 350
34: Traumatic Dural Tears 351
34.1 Case Example 351
34.2 Background 352
34.3 Indications and Advantages for Procedure 352
34.4 Contraindications and Disadvantages for Procedure 352
34.5 Procedure 353
34.5.1 Suture Material 353
34.5.2 Dural Substitutes 353
34.5.3 Sealants 354
34.5.4 Surgical Technique 354
34.5.5 Surgical Adjuvants 355
34.6 Technical Pearls and Pitfalls 356
34.7 Postoperative Considerations 356
34.7.1 Activity 356
34.7.2 Treatment of CSF Hypotension Headache 357
34.7.3 Rescue Procedures 357
34.7.4 Disclosure 357
References 357
35: Civilian Gunshot Injury to the Spine 358
35.1 Introduction 358
35.2 Initial Assessment of Patients with Spinal Gunshot Injury 358
35.2.1 General Evaluation of Patients 358
35.2.2 Spine Injury Evaluation 361
35.2.3 Imaging 362
35.3 Initial Treatment 363
35.4 Pharmacologic Management 364
35.4.1 Antibiotics 364
35.4.2 Steroids 365
35.5 Surgical Management 366
35.5.1 Surgery for Neurologic Deficit 366
35.5.2 Surgery for Retained Missile Fragments 366
35.5.3 Surgery for Debridement 367
35.5.4 Bullet Metal Toxicity 367
35.5.5 Surgery for Spine Instability 368
35.6 Complications 368
35.7 Conclusions 369
APPENDIX 369
Epidemiology of Spinal Civilian Gunshot Injury 369
Ballistic Principles of a Gunshot Injury 369
Wounding Potential 370
Impact Energy 370
Distance to the Target 370
Missile Design 371
Target Tissue Characteristics 371
Missile Behavior Within the Target Tissue 371
Clinical Determinants of Gunshot Injury Severity 371
Injury Energy 371
Anatomic Structure Involvement 372
Types of Gunshot Wound 372
Gunshot Injuries to Bone 373
Infection Risk Secondary to Gunshot Injury 373
Gunshot Injury to the Spine Neural Elements 373
Injury Pathomechanism 373
Patterns of Neurologic Deficit 374
Spinal Stability Following Gunshot Injury 375
References 376
36: Complications in Spine Surgery 379
36.1 Introduction 379
36.2 Preoperative Planning 379
36.2.1 Imaging and Clinical Impressions 379
36.2.2 Equipment 379
36.2.3 Preoperative Evaluation of the Patient and Documentation is Extremely Important 380
36.3 Intraoperative Complications 380
36.3.1 Underestimation of Trauma 380
36.3.2 Bleeding 380
36.3.3 Soft Tissue Coverage 381
36.3.4 Fixation Failure 381
36.4 Postoperative Complications 381
36.4.1 Neurological Complications 381
36.4.2 Postoperative Infection 382
36.4.3 Misplaced Instrumentation 382
36.4.4 Pseudoarthrosis 382
36.5 Summary 382
36.6 Pearls 382
References 383
Index 384