CHAPTER
David H. Kim
131
Anterior and Posterior
Instrumentation Techniques
Used in the Thoracic Spine for
Treatment of Fractures
INTRODUCTION
There exists relatively little trauma-specific clinical outcomes
data to support formulation of guidelines with respect to surgi-
cal instrumentation of the unstable thoracic spine. Most surgi-
cal instrumentation principles and techniques for the thoracic
spine borrow heavily from scoliosis studies. The degree to
which such principles can reasonably be transferred to acute
traumatic situations remains unclear.
This chapter will discuss the most commonly utilized and
widely accepted surgical instrumentation techniques for stabi-
lizing the thoracic spine following acute or subacute trauma.
Such principles will be presented in the setting of relevant
reported studies or consensus expert opinion. Full discussion
regarding preoperative evaluation and surgical indications is
included in the chapter addressing trauma classification.
Similarly, detailed discussion of decompression techniques,
perioperative complication management, and thoracolumbar
junction injuries is included in other chapters.
USE OF INSTRUMENTATION IN
THORACIC SPINAL TRAUMA
Early surgery for acute thoracic spinal trauma is generally per-
formed for purposes of spinal canal/cord decompression in
the setting of an incomplete neurological injury and/or to pro-
vide immediate stabilization of three-column injuries. Immedi-
ate stability is provided by use of instrumentation that restores
and maintains spinal alignment. Three instrumentation options
are in common use: posterior segmental hook and screw fixa-
tion systems, anterior interbody cages, and anterior plate/rod
fixation with vertebral body screws. Detailed techniques for
applying thoracic laminar, pedicle, and transverse process
hooks can be found in the chapter discussing surgical treat-
ment of scoliosis.
Since publication of the previous edition of this textbook,
there has been exponential growth in the number of implant
LWBK836_Ch131_p1411-1423.indd 1411
Jeffrey A. Rihn
Todd J. Albert
systems available. Formal discussion of technical differences
among specific implant systems will not be attempted. Rather,
this chapter will focus on general principles of thoracic pedicle
screw (TPS) instrumentation, the use of interbody cages in the
thoracic region, and anterior vertebral body screw fixation that
are commonly shared by all systems.
THORACIC PEDICLE SCREWS
Use of TPS implants for spinal stabilization provides several
advantages over other posterior instrumentation options. Com-
pared with segmental hook and wire fixation, pedicle screws pro-
vide significantly greater fixation strength; therefore, comparable
stability may be achieved through fusion and instrumentation of
fewer levels. Torsional strength of long thoracic constructs is
superior to segmental hook constructs even with the addition of
cross-links.35 Secondly, avoidance of implant placement within
the spinal canal, such as that occurs with laminar hooks or wires,
may reduce the risk of iatrogenic neurological injury.27 Finally,
pedicle screws can be placed at levels with laminar fractures or
where laminectomies have been performed.
Although initial concerns regarding the potential for seri-
ous injury to the spinal cord and pleural and vascular tissue
slowed widespread adoption of this technique, clinical studies
have suggested that rates of neurological injury as well as vis-
ceral organ and vascular injury are very low.
RELEVANT ANATOMY
There have been several anatomic studies reporting pedicle
dimensions in the thoracic spine (Table 131.1).2,6,18,26,29,37
Despite small differences in reported mean pedicle diameters
among studies, Panjabi et al26 have suggested the concept of
three distinct anatomic zones within the thoracic spine. The
proximal zone consists of the T1 through T4 vertebrae and rep-
resents a transition zone from cervical to thoracic vertebral
morphology. The middle thoracic zone includes the T4 through
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 1412 Section XII Trauma

TABLE 131.1 Measurements of the Thoracic Vertebrae*

Parameter T4 T5 T6 T7 T8 T9 T10 T11 T12

Chord length of 44.1  8.2 39.3  3.8 38.9  5.4 43.6  3.5 44.7  3.1 43.5  5.0 44.1  5.1 40.8  5.8 46.6  5.2
pedicle (n = 12) (n = 12) (n = 8) (n = 16) (n = 18) (n = 24) (n = 22) (n = 20) (n = 12)
(mm)
Transverse diameter of 4.5  61.2 4.4  1.1 4.6  1.1 4.9  1.1 5.1  1.2 5.8  1.5 6.7  1.6 8.0  1.9 7.8  2.0
pedicle (mm)
Angle of insertion of 13.9  3.6 12.6  3.7 8.6  3.6 7.4  3.8 6.9  5.0 7.1  4.6 4.1  6.1 0.7  3.3 0.3  2.7
pedicle (degrees)
Length of pedicle (mm) 16.1  3.0 16.7  2.9 17.0  3.3 17.5  2.9 18.3  3.4 19.1  3.5 17.9  3.4 17.9  3.6 18.8  4.1
Height of pedicle (mm) 10.1  1.5 10.0  1.6 10.1  1.4 10.8  1.4 11.1  1.4 12.3  1.6 14.1  1.4 15.0  1.5 14.7  1.4
Length or width of 18.8  2.9 20.5  2.9 21.5  3.2 23.3  3.3 23.5  2.9 24.2  2.7 24.8  3.1 25.3  3.6 26.3  2.6
vertebral body (mm)
Distance from spinous 7.3  1.5 7.1  1.4 7.3  0.9 7.2  1.0 7.3  1.1 7.5  1.0 7.5  0.9 7.8  1.2 8.9  1.3
process to medial
wall of pedicle (mm)
Distance from spinous 12.5  1.7 12.4  1.8 12.8  1.7 12.8  1.7 13.0  1.7 13.7  2.0 14.7  2.6 16.1  2.7 17.4  3.4
process to lateral
wall of pedicle (mm)
Distance from margin 13.7  1.7 14.0  1.5 14.5  1.3 15.1  1.4 14.9  0.9 15.3  1.6 16.4  0.2 17.4  2.3 19.5  1.7
of inferior facet to
outer wall of
pedicle (mm)
*
The values are given as the mean and standard deviation.

Thirty-four measurements were performed for each parameter except chord length; for that parameter, the number of pedicles that were
measured is given in parentheses for each vertebral level.
Reprinted with permission from Vaccaro AR, Rizzolo SJ, Allardyce TJ, et al. Placenent of pedicle screws in the thoracic spine. Part I:
morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am 1995;77(8):1195, Table 1.

T10 vertebrae. The distal zone is composed of the T10 through
T12 vertebrae and represents a transition between thoracic and
lumbar morphology.
Narrowness of the thoracic pedicles compared with those in
the lumbar region represents the major challenge for placement
of pedicle screws. Mean pedicle width at T1 is 8.4 mm and
decreases to a mean of 6.3 mm at T3-T8 then increases approxi-
mately 0.7 mm/level to T12 where the mean pedicle width is
8.7 mm.26 Conceptualizing the thoracic pedicle as an oval in
cross-section facilitates discussion, but in reality, the true cross-
sectional profile of the thoracic pedicle is more typically kidney-
or teardrop-shaped with a convex medial border and concave
lateral border. This irregular shape further decreases the effective
transverse pedicle diameter with respect to screw placement.
Although nerve root injury is possible with inferiorly malpo-
sitioned screws, the rate of such complications appears rela-
tively uncommon. The cross-sectional height of the thoracic
pedicles is disproportionately large and ranges from a mean of
9.6 mm at T1 through a mean of 11.9 mm at T3-T9 to a mean
of 16.6 mm at T12.26 As a result, pedicle height is not a limiting
factor in terms of screw placement.
Pedicle axis angulation with respect to the sagittal and trans-
verse planes is fairly symmetric. Relative to the sagittal plane,
the pedicle demonstrates a mean angle of 27 at T1-T2 and
progressively decreases to 10 at T12.26 The transverse plane
inclination demonstrates a mean of approximately 9 at T3-11
but jumps from 7.6 at T1 to 17.9 at T2 and from 8.7 at T11 to
5.0 at T12. Significant variation in sagittal plane orientation
occurs in the midthoracic region further increasing the diffi-
culty of pedicle screw placement.
Histologically, cross-sectional examination of the thoracic
pedicles has revealed that cancellous bone predominates and
represents 61.3% to 71.6% of the pedicle width. The cancellous
bone content of the thoracic pedicle does not affect bending
characteristics but does have a significant effect on pullout
strength. The medial pedicle wall is two to three times thicker
than the lateral wall at all levels.
BIOMECHANICAL PRINCIPLES
Pedicle screw instrumentation of the lumbar spine is generally
considered to provide superior fixation strength compared
with laminar hooks and wires. Although screw fixation has been
reported to provide superior deformity correction compared
with hooks and wires when utilized in the thoracic spine, bio-
mechanical studies have provided conflicting data. When
reviewing this data, it is critical to consider study design. Screw
diameter and length strongly affect performance as does inser-
tion technique, loading parameters, and specimen quality.
In the setting of weaker osteoporotic bone, paired hooks in
a claw configuration may provide superior fixation. This is not
surprising given the implantbone contact relations of pedicle
screws compared with hooks. With standard intrapedicular
placement of screws, threads largely engage cancellous bone,
while the contact area of hooks involves mostly cortical bone,
which is much less affected by osteoporosis.
SURGICAL TECHNIQUE
STARTING POINT
Selecting an appropriate starting point for pilot hole prepara-
tion is critical for minimizing the risk of implant malposition.

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 Chapter 131 Anterior and Posterior Instrumentation Techniques Used in the Thoracic Spine for Treatment of Fractures
SF
P intersection of the superior border of the transverse process
TP
Figure 131.1. Line drawing depicting the starting point for tho-
racic pedicle screw placement in the thoracic vertebrae from T4 to
T10, as described by Vaccaro et al.30 The superior facet (SF), pedicle
(P), and the transverse process (TP) are depicted. The starting point
for pedicle screw insertion is located at the intersection of a horizon-
tal line drawn parallel to the superior border of the TP and a vertical
line drawn through the middle of the SF.
Vaccaro et al proposed pedicle screw starting points based on
a cadaveric study of 17 mostly central Asian specimens
(Fig. 131.1).31 From T4 to T10, the center of the pedicle was
found to be located at the intersection of a longitudinal line
drawn through the center of the superior articular facet and
a horizontal line at the superior border of the transverse pro-
cess. Caudad to T10, there was a gradual shift of the pedicle
toward the middle or caudad border of the transverse process.
This finding is similar to the suggested starting point of Roy-
Camille et al as 1 mm caudad to the inferior margin of the
cephalad facet joint in the midarticular line.28 Important
additional observations from this study included significant
variability in pedicle diameter among specimens. Mean trans-
verse diameter ranged from a mean of 4.5 mm at T4 to 7.8
mm at T12. Mean pedicle angulation in the horizontal plane
decreased from 13.9 medially at T4 to 0.3 medially at T12.
In approximately half the specimens, the pedicle angle
diverged laterally at T12. The authors recommended use of
preoperative computed tomography (CT) when practical to
assist in determining pedicle screw placement and implant
size selection.
There has been significant variation in suggested pedicle
screw starting points from different anatomic studies. Cinotti et
al4 examined 11 cadaveric spines and reported that, contrary to
the findings of Vaccaro et al and Roy-Camille et al, the pedicle
axis most commonly intersected the lateral two thirds of the
superior facet as opposed to the middle. Among all 99 thoracic
vertebrae evaluated, no pedicle axis was found medial to the
LWBK836_Ch131_p1411-1423.indd 1413
1413
middle of the superior facet. A comparison of starting point
selection based solely on local anatomic landmarks was made
comparing the intersection of the superior border of the trans-
verse process and the middle of the superior facet versus the
and the external one third of the superior facet. The latter
starting point was found to result in fewer pedicle violations
and anterior cortical penetrations. The same study also reported
less variability in the sagittal location of the pedicle axis with
respect to the superior border of the transverse process com-
pared with the superior facet, supporting use of the transverse
process as an anatomic landmark. Despite these findings, sig-
nificant variation in pedicle location relative to both the trans-
verse process and superior facet was found. Of note, the small-
est average pedicle diameter was found at T6 (4.3 mm) followed
by T7 (4.7 mm), T8 (4.8 mm), and T5 (4.9 mm). The authors
suggested that T4 through T8 pedicles may be too small for
intrapedicular screw fixation in many cases. Wide variability in
horizontal plane angulation was confirmed in this study as
well.
A path of least resistance technique can be used to deter-
mine the angle of screw insertion.32 With this method, a high-
speed burr or a rongeur is used to remove a small area of pos-
terior cortical bone over the pedicle starting point. An awl is
then advanced along a general anteromedial trajectory while
the surgeon uses tactile feedback to confirm that the awl is
smoothly advancing through the cancellous bone. However, in
a cadaveric study using 5-mm screws, and without the benefit of
radiographic imaging, this technique was associated with a high
cortical penetration rate of 41%.32 Violations were fairly evenly
divided between the medial cortex (21 screws) and the lateral
cortex (16 screws). In the same study, cadaveric dissections and
CT scans were utilized to determine nearby anatomic structures
at risk from excessively long or errant screw placement.
Depending on the level and side, these structures included the
crus of the diaphragm, aorta, azygous vein, esophagus, hemi-
azygous vein, inferior vena cava, cardiac atrium, parietal pleura,
and lung (Fig. 131.2).
A variation of this approach that may be particularly useful
in patients with scoliosis is the funnel technique.33 After esti-
mating the location of the pedicle based on local anatomic
landmarks, a 6- to 10-mm cortical opening in the posterior lam-
ina is created with a rongeur. A small curette is used to gradu-
ally remove cancellous bone until the pedicle opening is visual-
ized. Cancellous bone is then progressively removed to create a
cortical funnel from the mouth of the pedicle leading into the
isthmus. The pedicle is then sounded with a 2-mm pedicle
probe to confirm its integrity.
Following initial probing of the pedicle with an awl, metallic
marker pins can be placed and intraoperative radiographs or
fluoroscopy utilized to confirm intrapedicular location of the
markers. Appropriate screw length can be estimated from the
lateral radiographic view.
The technical demands of accurate TPS placement have
generated interest in use of the so-called image-guided surgical
navigation systems. Studies of different proprietary systems sug-
gest that these modalities can improve placement accuracy but
at the expense of significantly greater operative time.
The authors of this chapter favor use of intraoperative fluo-
roscopic imaging whenever possible. Screw path inclinations
can be estimated from an intraoperative lateral radiograph.
These estimates are then used to position fluoroscopy to achieve
perfect anteroposterior views sequentially for each vertebral
8/26/11 10:09:45 PM
 1414 Section XII Trauma
E
L risk of major vascular injury to the aorta and vena cava, inten-
Az
Ao
8 gested that medial breeches of up to 4 mm may be acceptable
RP LP
Figure 131.2. Anatomical structures anterior to the T8 vertebral
body, which are at risk when placing thoracic pedicle screws. Depicted
are the intended trajectories of the left and right pedicle screws and
the anatomical structures that fall within these trajectories. L, lung;
Az, azygous vein; Ao, aorta; E, esophagus. (Used with permission from
Vaccaro AR, Rizzolo SJ, Balderston RA, et al. Placement of pedicle
screws in the thoracic spine. Part II: An anatomical and radiographic
assessment. J Bone Joint Surg Am 1995;77[8]:1204, Figure 3).
level instrumented. The horizontal pedicle angle is determined
from a preoperative CT study, and the fluoroscopy unit is
angled appropriately to achieve an axial view down the pedicle
on one side. The center of the pedicle outline is marked with a
high-speed burr, and a straight 2-0 curette is used to probe the
posterior portion of the pedicle. Because of the greater medial
angulation of upper thoracic pedicles, a small laminotomy can
be helpful in guiding preparation of screw holes at T1 and T2.
A ball-tip probe is placed and visualized fluoroscopically to con-
firm position. A pedicle probe is then used to complete the
pedicle pathway to an appropriate depth.
Matching of screw diameter to pedicle width represents a
critical decision with respect to this fixation technique. Selection
of screw diameter strictly on the basis of measured pedicle
diameter would result in a number of cases in which several
levels would be considered unavailable for pedicle screw instru-
mentation. Although the smallest available screw diameter
often exceeds the smallest thoracic pedicle diameter measured
on preoperative CT images, expansion of the pedicle during
placement of such screws can occur and is not always associated
with detectable pedicle wall fracture. The use of progressively
larger diameter taps can provide tactile feedback informing the
surgeon when full cortical purchase has been achieved through
the isthmus. If a pedicle fracture occurs, the effect in terms of
overall construct stability remains largely unknown, although
reported clinical series suggest that any compromise is likely
small. It has been suggested that pedicle fracture during screw
insertion may reduce pullout resistance by 11%.11
Greater screw insertion depth is associated with a higher
number of cycles to failure in cephalocaudal and mediolateral
loading in the laboratory, and bicortical fixation through the
anterior vertebral cortex appears associated with the greatest
LWBK836_Ch131_p1411-1423.indd 1414
resistance to pullout.17,38 However, routine intraoperative fluo-
roscopic visualization provides limited protection against exces-
sive anterior cortical penetration, and due to the significant
tional bicortical fixation is generally not recommended. Safe
screw lengths have been suggested as 30 mm at T1-2, 35 mm at
T4-5, and 40 mm at T5-6.22 Maximizing screw length, thread
area, and minor diameter given limitations of local anatomy
appears to yield optimal resistance to both pullout and bending
loads.
Although cortical breech occurs at a relatively high rate with
pedicle screw placement in the thoracic spine, it has been sug-
due to a safety zone provided by a 2-mm epidural space and
2 mm of subarachnoid space.12 In terms of lateral pedicle viola-
tions, breeches of up to 6.8 mm may also be acceptable due to
protection from the rib head.7 Anterior cortical vertebral body
penetrations of greater than 4 mm may threaten major vascular
or visceral structures.32
EXTRAPEDICULAR TECHNIQUE
When narrowness of pedicle diameter prevents placement of a
fully intrapedicular screw, an extrapedicular placement tech-
nique has been suggested.7,15 Utilizing this technique, a starting
point is selected along the lateralmost portion of the dorsal
aspect of the transverse process. This point is located within the
rostral one third of the tip of the transverse process. Alterna-
tively, a starting point can be selected just rostral to the tip of
the transverse process. An awl is advanced by hand between the
transverse process and the adjacent rib. If the starting point is
within the tip of the transverse process, an insertion angle per-
pendicular to the plane of the posterior elements is selected to
avoid injury to the neurovascular bundle. Using the alternative
starting point cephalad to the articulation of the transverse pro-
cess and adjacent rib, a slightly caudally directed angle is
selected obliquely following the adjacent rib medially toward
the costovertebral junction (Figs. 131.3A and B). Tactile feed-
back from the rib is used to guide preparation of the screw path
throughout its course from the transverse process to its entry
point into the superolateral portion of the anterior pedicle as
it joins the vertebral body. Given direct apposition of the pleu-
ral lining to the inferolateral pedicle, hugging the rib through-
out the extrapedicular screw path reduces the risk of injury to
pleura, lung, and neural elements. The ideal point of entry into
the vertebral body is at the superior costal facet. A depth gauge
is utilized to determine appropriate screw length and confirm
the presence of bone margins circumferentially. A properly
positioned screw is contained within the pedicle rib unit,
defined as a space between the lateral pedicle cortex and
medial rib cortex. Although dimensions in the general popula-
tion have not been reported, the average width of this space in
scoliosis patients has been reported as 11 to 14 mm increasing
from cephalad to caudad.20
Screws placed extrapedicular are often observed to traverse
a portion of the superior end plate of the vertebral body. This
tendency is greatest in the proximal thoracic spine and may be
due to under inclination of the screw path in a caudad direc-
tion. Underinclination places the supradjacent neuroforamen
at risk, and end plate violation may contribute to adjacent seg-
ment degeneration.
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 Chapter 131 Anterior and Posterior Instrumentation Techniques Used in the Thoracic Spine for Treatment of Fractures 1415

A B

Figure 131.3. Axial (A) and sagittal (B) illustrations demonstrating the proper positioning of the extrape-
dicular thoracic screw as described in the text (Used with permission from Husted DS, Yue JJ, Fairchild TA,
Haims AH. An extrapedicular approach to the placement of screws in the thoracic spine: an anatomic and
radiographic assessment. Spine 2003;28[20]:2325, Figures 1A and B.)

Suggested advantages of extrapedicular screw insertion
include potentially greater fixation strength from the ability to
place a larger diameter and longer screw that engages three or
four cortices. Nevertheless, biomechanical testing of screws
placed with the extrapedicular technique has yielded somewhat
conflicting results. In general, data suggest that extrapedicular
screws provide approximately 75% of the strength of trans-
pedicular screws.24,34 White et al compared axial and sagittal
loading of 5.0-mm screws placed transpedicular versus extrape-
dicular and found that transpedicular screws were stronger in
both load conditions. In axial pullout, failure loads were 584
and 826 N, respectively, while with sagittal force, failure loads
were 696 and 863 N, respectively. Although Dvorak et al7 origi-
nally reported superior strength associated with extrapedicular
fixation, their study has been criticized for employing external
fixator pins and an anterior vertebral cortical penetration tech-
nique that is not typically performed in clinical practice.
Although increased safety has also been suggested as a poten-
tial advantage of extrapedicular insertion, the risk of inadver-
tent canal entry may be as great as with standard intrapedicular
fixation. Using local anatomic landmarks and a 30 to 45 inser-
tion angle, Dvorak et al7 reported a high rate of canal encroach-
ment and recommended use of preoperative CT measurements
to guide extrapedicular screw placement.
Potential disadvantages of this technique include violation
of costotransverse and costovertebral joints. Whether this
results in clinically significant pain or other symptoms is
unknown.
In the upper thoracic spine, transverse process screws may
be a fixation option if there is excessive concern regarding the
ability to safely place pedicle screws. Biomechanical testing has
demonstrated that transverse process screws provide approxi-
mately half the pullout strength compared with pedicle screw
fixation.13 In cadaveric specimens, reported load to failures for
T1 through T4 transverse process 3.5-mm cortical screws were
562.5, 373.0, 241.0, and 287.0 N, respectively.
The number of vertebral levels and fixation points required
to provide adequate construct strength in the setting of specific
patterns of thoracic fractures and dislocations has not been
clearly established. Decreased range of motion following multi-
level fusion in the thoracic spine is not as functionally significant
as it is in the cervical or lumbar spine. Constructs that end at the
level of maximum thoracic kyphosis should be avoided if possi-
ble to minimize patient discomfort and to reduce pullout forces
at the terminal fixation anchors, which are most vulnerable to
failure. In general, two to three levels of fixation cephalad and
caudad to the levels of injury are considered sufficient in bone
with normal mineral density. In osteopenic or osteoporotic bone,
a greater number of levels may be required.
In many cases involving posterior-only stabilization, indirect
decompression of the spinal canal and correction of traumatic
kyphosis can be accomplished by careful patient positioning
and undercontouring of the rods. The cephalad screws and
hooks are captured first, and then the rods are reduced to cap-
ture the caudad screws and hooks. Despite successful stabiliza-
tion and eventual fusion, some loss of correction over time can
be expected unless supplemental anterior interbody recon-
struction is performed (Figs. 131.4A to E).
Cross-linking of long constructs provides significantly greater
resistance to screw pullout failure by creating a trapezoidal
transverse profile that is secured by a wedge of bone between
each pair of converging screws. However, the decreased conver-
gence of TPSs compared with lumbar screws reduces the effect
of cross-linking.
In osteopenic or osteoporotic bone, consideration should
be given to protecting screws at the end of a long construct.

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 1416 Section XII Trauma

Figure 131.4. These images represent a thoracic injury that

occurred in a 30-year-old man who was a restrained passenger
in a high-speed, head-on motor vehicle crash. This patient was
neurologically intact. (A) A sagittal reconstruction of the tho-
racic computed tomography (CT) scan demonstrates a flexion
distraction type injury with a burst component that involves the
T5 and T6 vertebral bodies. Also evident are fractures of the
spinous processes of T3, T4, and T6. (B) The axial CT image of
the T6 vertebral body shows fractures of the anterior, middle,
and posterior columns (i.e., lamina fracture), but no evidence
of retropulsion of bone into the canal. (C) A sagittal
T2-weighted magnetic resonance image demonstrates fracture
of the T5 and T6 vertebral bodies as well as probable disruption
of the posterior ligamentous complex at this level. This patient
underwent a posterior fusion from T2 to T12 using a pedicle
screwrod construct and iliac crest autograft as shown in the
postoperative (D) anteroposterior and (E) lateral radiographs.
An anterior approach and decompression was not necessary in
C
this patient because of his intact neurological status. (continued)

End screws are exposed to significant bending moments and
are susceptible to pullout or fatigue fracture of the respective
vertebra. Maximizing resistance to bending loads is most impor-
tant in the proximal thoracic spine rostral to the apex of kypho-
sis. In this region, if larger diameter convergent screws cannot
be utilized, consideration should be given to employing a
paired hookclaw construct or protecting the most cephalad
screw with an associated hook anchor.
CLINICAL OUTCOMES
Three prospective clinical studies have been reported concern-
ing the use of TPSs in treatment of traumatic spine injury. Yue
et al36 reported their consecutive series of 32 patients with
unstable thoracic spine injuries. About 222 screws were placed
at T2-L1. Of note, patients with pedicle diameters of less than
7 mm on preoperative CT were excluded. In general, four
screws were placed above and four screws placed below the
level of injury, while avoiding placement of the construct end
at the level of maximum thoracic kyphosis. At median 22-month
follow-up, there were no implant-related complications reported.
Sagittal plane correction was well maintained with no cases dem-
onstrating significant loss of reduction.
Kuntz et al19 reported their experience with 29 trauma
patients undergoing placement of TPSs using fluoroscopic
guidance One hundred eleven of 209 screws placed exceeded

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 Chapter 131 Anterior and Posterior Instrumentation Techniques Used in the Thoracic Spine for Treatment of Fractures
D E
Figure 131.4. (Continued)
the measured diameter of the respective pedicle based on pre-
operative imaging. Nevertheless, there were no implant-related
neurological deficits, visceral injuries, or screw failures observed.
One patient underwent reoperation for repositioning of a mal-
positioned screw.
Fisher et al10 described their experience with 23 patients
and 201 TPSs. Although postoperative CT imaging revealed a
high 33.8% rate of pedicle violation (36 lateral, 27 medial, and
5 anterior), the authors felt that 98.5% of screws were in accept-
able position in terms of threats to local anatomy. No neuro-
logical, vascular, or visceral implant-related complications were
identified.
ANTERIOR INTERBODY CAGES
In the setting of acute thoracic spinal trauma, and exclusive of
thoracolumbar-level injury, the use of anterior instrumentation
is most commonly indicated for immediate stabilization follow-
ing anterior surgical decompression of the spinal canal. In the
absence of a possible incomplete spinal cord injury and ongo-
ing cord compression, the fixation strength afforded by con-
temporary posterior segmental implant options is such that
posterior-only stabilization is often sufficient to allow early
patient mobilization and rehabilitation. An exception may
occur in cases of significant kyphotic deformity in which case
the provision of supplemental anterior interbody support can
greatly reduce the stress on posterior fixation and promote
healing without loss of reduction and recurrent sagittal plane
deformity. In this setting, the addition of an anterior interbody
cage significantly reduces the forces borne by the posterior
fixation. The two most frequently utilized forms of anterior
instrumentation in the thoracic region are interbody cages and
anterior plate/screw (or anterior rod/screw systems).
LWBK836_Ch131_p1411-1423.indd 1417
1417
The use of an interbody cage carries several advantages
compared with structural bone graft alternatives. The harvest
site morbidity associated with iliac crest or doubled stacked
autologous fibula is avoided. The early period of graft resorp-
tion and structural weakness is eliminated. Well-designed cage
systems now also provide a wide array of options in terms of
cross-sectional diameter, length, and end plate angulation to
accommodate the vast majority of reconstruction needs encoun-
tered.
Theoretical disadvantages of interbody cage constructs
include the relative absence of compressive forces acting on
bone graft material housed inside a rigid cage device. Delayed
fusion or increased rates of nonunion may result. Nevertheless,
an evolving theory of interface bioincorporation resulting in
macrolock stability has been proposed to explain the long-
term stability apparently provided by contemporary interbody
cage reconstruction even in the absence of radiologic evidence
of solid osseous fusion.30 This concept supports the use of bio-
integratable glass ceramics to coat implants to promote
osteointegration of such devices.
BIOMECHANICAL PRINCIPLES
Biomechanical studies addressing the use of interbody cages in
the thoracic spine are sparse. The most common complication
observed with use of interbody cages is postoperative subsid-
ence. Lowe et al21 performed biomechanical testing with cadav-
eric specimens and demonstrated that the maximum load to
failure of the vertebral end plate occurs in the posterolateral
regions anterior to the pedicles. Minimum load to failure
occurs in the center of the end plate between T1 and T6 and
in the anterocentral region of the end plate in the lower tho-
racic spine. Reduced load to failure was also observed with
smaller diameter hollow rod indenters. These findings suggest
8/26/11 10:09:47 PM
 1418 Section XII Trauma
that the risk of subsidence may be lowered by maximizing cage
diameter so as to take advantage of the increased strength of
the peripheral end plate as well as by using cage endcaps to
enhance surface area contact. It should be noted, however, that
the use of endcaps significantly decreases the area of direct
contact between graft material and end plate and may be asso-
ciated with greater nonunion risk.
In the same study, Lowe et al reported only a marginal
decrease in end plate compressive strength following removal of
the anterior third of the end plate. The authors concluded that
a reasonable reconstruction strategy included partial removal of
the anterior end plate followed by positioning of the interbody
implant on the remaining end plate to provide the optimal
combination of stability and a favorable fusion environment.21
SURGICAL TECHNIQUE
Principles of anterior interbody cage reconstruction derive
from techniques developed for anterior stabilization with struc-
tural bone grafts. The patient is placed in a strict lateral decu-
bitus position to simplify visualization of implant orientation.
Exposure of the fractured level(s) includes identification of the
anterior and posterior borders of the vertebral body and the
location of the spinal canal. Anatomic orientation is most read-
ily achieved by beginning the dissection at the vertebral bodies
cephalad and caudad to the level of injury.
Once adequate exposure has been achieved, decompression
of the canal is performed as necessary. Minimizing removal of
vertebral body bone to that which is necessary for canal decom-
pression and to allow placement of an interbody cage in direct
opposition to adjacent end plates provides the optimal biologi-
cal environment for rapid fusion. Sufficient bone must be
removed from the vertebral body on the side contralateral to
the side of approach to allow midline positioning of the cage.
Preservation of the anterior and posterior longitudinal liga-
ments when possible provides a tensile counterforce against a
well-positioned cage that promotes immediate stability and
reestablishes normal anatomic length and alignment. Complete
removal of end plate cartilage and avoidance of end plate corti-
cal fracture enhance fusion and stability. Controlled perfora-
tions of the central end plate not in contact with the cage cir-
cumference may promote neovascularization without significant
loss of end plate support. Creating a small posterior lip in the
end plates with a high-speed burr provides added security
against posterior migration of the cage into the canal. With use
of a static cage, intervertebral distraction assists in placement of
an optimally sized implant. An assistant can apply anteriorly
directed pressure on the back of the patient to provide lordosis
and additional space for the cage. Intraoperative fluoroscopic
or radiographic imaging is used to assess implant position.
Often, additional tissue resection is required to achieve mid-
line cage positioning. Tactile feedback when the cage is bal-
loted can provide useful information regarding the type of tis-
sue that must be removed. A soft springy recoil suggests that
disc tissue is blocking placement.
In addition to cage diameter and length, in many systems
end plate angulation must also be selected. A combination
should be fashioned that yields maximum area of contact with
the end plates of the adjacent intact vertebrae and results in a
cage axis as vertical as possible when the patient is in the upright
position.
LWBK836_Ch131_p1411-1423.indd 1418
Use of newer expandable cages reduces the requirement of
performing distraction prior to implant placement. In the set-
ting of intact anterior and posterior longitudinal ligaments,
cage expansion restores anatomic height and provides addi-
tional immediate stability. As with static cages, maximizing end
plate contact between cage and adjacent vertebrae allows opti-
mal load sharing while minimizing point-loading that increases
the risk of subsidence. However, the versatility of expandable
cages comes at the expense of reduced cage volume for con-
taining graft material. It should also be noted that cage expan-
sion leads to creation of new voids within the cage that may
benefit from supplemental graft material. Ideally, the interbody
cage should lie on the sagittal gravity line of the anterior col-
umn when the patient is in the upright position. This align-
ment promotes stability of the implant while minimizing shear
forces that may lead to progressive tilting of the implant and
possible dislocation.
In most cases, interbody cage placement is insufficient to
restore adequate stability to the thoracic spine following trau-
matic destabilization and supplemental anterior and/or poste-
rior fixation is required (Figs. 131.5A to F). When used as a
stand-alone device following corpectomy, interbody cages are
at risk for gradual displacement through a mechanism described
as pole-vaulting. This term describes a situation in which the
cephalad vertebra translates anteriorly relative to the caudad
vertebra resulting in progressive tilting of the interposed cage.
TRANSPEDICULAR CAGE PLACEMENT
Although most thoracic-level cages are currently placed through
an open thoracotomy approach, the introduction of expand-
able cages allows anterior interbody placement through a pos-
terior transpedicular approach. This technique avoids the risks
and morbidity associated with thoracotomy but requires signifi-
cantly greater dissection and surgical manipulation directly
around the spinal canal and regional nerve roots.
For a single-level thoracic burst fracture, through a poste-
rior surgical approach, a hemilaminectomy is performed of the
injured level on the side of greatest canal compromise until the
ipsilateral pedicle stalk is well visualized. Although the trans-
verse process is freed from the pedicle, it is not removed and
serves as a protective barrier for the exiting nerve root. A hemi-
laminectomy of the cephalad level is performed as well.
Discectomies are then performed cephalad and caudad to the
fractured vertebra. The ipsilateral pedicle is completely
resected. If adequate canal decompression requires, a complete
laminectomy and bilateral pedicle resection can be performed.
Through the transpedicular space, resection of the posterior
two thirds of the fractured body can be accomplished with
curettes, rongeurs, or a high-speed burr. This step serves to
decompress the spinal canal as well as prepare the space for
cage placement. Pedicle screws are placed in the vertebrae
cephalad and caudad to the level of injury and distraction is
performed across these screws to assist with cage placement.
Bone graft material is placed within the expandable cage, which
is then inserted in collapsed configuration and expanded in
situ. Additional graft material can then be placed within the
voids created by cage expansion. The cage should be positioned
in direct contact with end plates of the adjacent intact verte-
brae. Compression across the posterior pedicle screws estab-
lishes final correction of sagittal alignment.1
8/26/11 10:09:49 PM
 Chapter 131 Anterior and Posterior Instrumentation Techniques Used in the Thoracic Spine for Treatment of Fractures 1419

A B

C D

Figure 131.5. These images represent a thoracolumbar injury that occurred in a 24-year-old man
restrained backseat passenger in a head-on motor vehicle crash. Upon presentation, the neurological status
of this patient was a grade B on the American Spinal Injury Association scale. (A) A sagittal reconstruction of
the thoracic computed tomography (CT) scan demonstrates a flexiondistraction type injury with a burst
component that involves the T12 vertebral body and superior end plate depression of the T9, T10, and T11
vertebral bodies. Also evident are fractures of the spinous processes of T10, T11, and T12. (B) The axial CT
image of the T12 vertebral body shows fractures of the anterior, middle, and posterior columns with signifi-
cant comminution and canal compromise. (C) A sagittal T2-weighted magnetic resonance image demon-
strates fracture of the T9 to T12 vertebral bodies as described above, as well as disruption of the posterior
ligamentous complex posterior at the T11-T12 level. There is significant retropulsion of bone into the canal
with spinal cord compression and edema. This patient had a staged procedure. Initially, he underwent an
anterior T12 corpectomy with implantation of a titanium expandable cage, the center of which was packed
with local autograft. This fixation was supplemented anteriorly with a single pedicle screwrod construct.
Four days later, the patient underwent a posterior spinal fusion from T8 to L2 using a pedicle screwrod
construct and iliac crest autograft. The postoperative (D) anteroposterior and (E) lateral radiographs are
shown. (continued)

LWBK836_Ch131_p1411-1423.indd 1419 8/26/11 10:09:49 PM

 1420 Section XII Trauma
E F
CLINICAL OUTCOMES
There is relatively little published data regarding trauma-
specific outcomes following anterior interbody cage recon-
struction of thoracic spinal trauma. Most studies involve
heterogeneous patient populations that include a majority of
nontrauma-related indications. In such mixed patient popula-
tions, the use of titanium interbody cages appears associated
with durable radiographic and clinical results. Eck et al9
reported minimum 2-year follow-up on 50 patients surgically
treated with anterior titanium cage reconstructions in the tho-
racic and lumbar spine and observed cage settling greater than
2 mm in 47% of corpectomy levels but no cases of cage migra-
tion or failure.
Although different cage materials are currently available,
titanium cages are currently in widest use. Metallic cages are
readily imaged with standard radiography allowing easy
follow-up in terms of implant position and stability. Development
of a fusion mass within metallic cages is often difficult, however.
Eck et al9 observed greater radiographic fusion rates when
bone graft is placed outside as well as within metallic cages but
attributed this difference to the greater ease of assessing fusion
status outside such cages as opposed to a true difference in
fusion rates. Using the Bridwell grading system for assessing
anterior interbody fusion, an 81% rate of definite or probable
fusion was observed at minimum 2-year follow-up.3,9
The use of titanium mesh cage reconstruction may be asso-
ciated with higher failure rates in the thoracic spine compared
with the thoracolumbar or lumbar spine. Dvorak et al8 retro-
spectively reported their experience using titanium mesh cages
following thoracic and lumbar vertebral body resection in 43
mostly traumatic cases. In all cases, supplemental anterior plate
or rod and/or posterior pedicle screw and rod fixation was uti-
lized. Early loss of deformity correction was observed in 16%
requiring surgical revision in 14%. Eighty-three percent of the
LWBK836_Ch131_p1411-1423.indd 1420
Figure 131.5. (Continued) (F) A postoperative sagittal
reconstruction CT image demonstrates the location of the
expandable cage and the bone graft within the center of the
cage. The decision to proceed with an anterior corpectomy
and fusion initially was made due to the patients incomplete
neurological status upon presentation.
revision cases involved thoracic-level surgery. All failed thoracic
reconstructions involved cage reconstruction with supplemen-
tal posterior instrumentation alone.
In the same study, using the Bridwell grading system, a grade
1 or 2 osseous fusion was observed on plain radiographs in 93%
of patients at average 32-month follow-up. This rate compares
favorably to previous fusion rates of 93% reported for struc-
tural autograft.5 Reliable fusion was observed despite a mean of
4 mm of cage subsidence. The authors noted their practice of
packing morselized autograft anterior to the cage to promote
fusion in this location where it is readily visualized radiographi-
cally and serves to resist anterior column forces. Because of the
relatively high failure rate observed in the thoracic spine, the
authors also comment on their increased use of both supple-
mental anterior and posterior instrumentation to augment
thoracic-level cage reconstructions. These findings are sup-
ported by similar results reported by Karaeminogullari et al16
using titanium mesh cages in which supplemental anterior-only
fixation or short-segment posterior fixation was associated with
loss of deformity correction and cage settling.
ANTERIOR PLATE/ROD AND
SCREW FIXATION
Anterior plate/rod and vertebral body screw fixation can add
significantly to spinal stability and may be particularly critical in
supplementing interbody cage reconstruction in the thoracic
spine. Regional variation in vascular and visceral anatomy
should be considered when deciding whether to utilize ante-
rior plate/rod and screw fixation systems in the thoracic spine.
Such implants are often positioned in proximity to such vulner-
able structures and pose potential risk if there is device loosen-
ing and migration. As a result, such anterior instrumentation is
8/26/11 10:09:50 PM
 Chapter 131 Anterior and Posterior Instrumentation Techniques Used in the Thoracic Spine for Treatment of Fractures 1421

most commonly utilized in the lower thoracic and thoracolum-
bar spine. Increased caution must be exercised in using this
technique in the thoracic spine proximal to T9.
BIOMECHANICAL PRINCIPLES
The first vertebral body screws were placed midbody and paral-
lel to the end plates. Subsequently, Horton et al14 demonstrated
that proximity to the end plates was important for improving
fixation strength of vertebral body screws. Ogon et al25 also
showed that triangulated double-screw fixation provides 79%
greater resistance to pullout and 73% greater resistance to per-
pendicular loads compared with single-screw fixation. The use
of two-rod constructs is associated with increased construct
strength and resistance to fatigue failure compared with single-
rod constructs. Finally, increasing screw diameter improves
fixation strength but may increase the risk of crack propagation
and fracture-related failure of fixation. Although these observa-
tions should be kept in mind while planning anterior instru-
mentation strategies, options are typically limited by the
constraints of local anatomy, particularly the small size of more
proximal thoracic vertebrae and vulnerable regional anatomic
structures. Mohamad et al23 performed a biomechanical study
using cadaveric thoracic vertebral specimens and demonstrated
significantly greater failure loads with two-screw constructs
compared with single-screw constructs, but the increased resis-
tance to pullout was only 25%.23 The same study also revealed
different failure modes with single-screw constructs plowing
through bone while two-screw constructs failed by acute frac-
ture of the body or pedicles.
SURGICAL TECHNIQUE
In the trauma setting, anterior thoracic plate/rod fixation is
most commonly applied after placement of an interbody graft
or cage (see Figs. 131.5D and E). Exposure includes the verte-
bral body cephalad and caudad to the level(s) of injury. In par-
ticular, the pedicles, infrapedicular neuroforamen, posterior
body margin, anterior body margin, and cephalad discend
plate junction must be clearly defined. The postoperative rela-
tionship between adjacent vascular structures and the planned
anterior instrumentation must be predicted, and if there is sig-
nificant risk that implants will directly contact the aorta or vena
cava then alternative implants should be considered or the use
of anterior instrumentation abandoned altogether.
Different systems allow for variation in terms of the number
of vertebral body screws utilized per level and the selection of
reinforcing staples, plates, or rods. In general, if two screws are
utilized at a given level, the posterior screw is positioned first.
The starting point for the posterior screw is positioned approx-
imately 1 cm below the cephalad end plate and 1 cm anterior to
the posterior body margin. The screw hole is directed approxi-
mately 10 anteriorly away from the spinal canal. Inadvertent
anterior positioning of the starting point can result in a screw
directed toward the spinal canal and neurological injury or
prominent instrumentation that is in increased proximity to
the great vessels.
If the system incorporates a plate as the longitudinal stabi-
lizer, the flare of the proximal vertebral body can be reduced
with a burr or rongeur to allow the plate to site flat. Screw
length is estimated from preoperative CT imaging if available

A B

Figure 131.6A. This patient had an L1 burst fracture with significant canal compromise and a neurologi-
cal deficit and underwent an L1 corpectomy with an allograft humerus strut supplemented with local
autograft bone and stabilized with a double-pedicle screw/rod construct. This is depicted in the postopera-
tive (A) anteroposterior and (B) lateral radiographs. Note that the posterior and anterior pedicle screws in
the T12 and L2 bodies converge on one another in the anteroposterior and/or lateral views in order to
increase pullout strength.

LWBK836_Ch131_p1411-1423.indd 1421 8/26/11 10:09:51 PM

 1422 Section XII Trauma
Neurological deficit with anterior
compression
Yes
Posterior ligamentous injury
Yes No
Combined anterior/ Anterior decompression Significant compromise
posterior approach and fusion of anterior column
Yes
Posterior fusion/
Consider additional
anterior approach
for anterior column
support if necessary
and confirmed by use of a depth gauge after pilot hole prepara-
tion. Caution should be exercised in using fluoroscopy to assess
screw length. The circular perimeter of the vertebral body gen-
erates a blind spot on fluoroscopic imaging such that excessive
penetration of the distal cortex is not clearly visualized. Not all
systems require pilot hole preparation prior to screw place-
ment. The cancellous bone of the vertebral body typically allows
placement of screws that are not self-tapping after defining the
starting point with an awl.
The position of the anterior screws, if they are used, is typi-
cally determined by posterior screw position but is often
designed to be placed directly transverse across the body paral-
lel to the posterior vertebral wall. Ideally positioned screws lie
parallel and immediately subjacent to the superior vertebral
end plates. Pairs of screws are convergent to enhance pullout
strength, and any distal cortical penetration should be less than
5 mm. This can be confirmed by direct digital palpation (Figs.
131.6A and B).
Although anterior screw distraction is typically not per-
formed with an interbody device in position, screw compres-
sion can correct a small degree of scoliosis across the instru-
mented level(s) as well as assist in locking in the interbody
implant. A plate or rods are placed according to system-specific
instructions. The final relationship between implants and
nearby vascular structures is reassessed before wound closure.
Systems have been developed for application with minimally
invasive thoracoscopic approaches. This technique is described
and discussed in detail in another chapter (Fig. 131.7).
CONCLUSION
Although there exists little trauma-specific clinical data with
which to establish strict guidelines for surgical instrumentation
of thoracic spinal fractures, extrapolation from surgical princi-
ples of deformity surgery has yielded generally favorable results.
Modern implant systems provide versatility in this challenging
patient population. Segmental posterior fixation with screws
and/or hooks can provide sufficient immediate stability to
allow early mobilization and facilitate ongoing treatment of
LWBK836_Ch131_p1411-1423.indd 1422
No
Posterior ligamentous injury
Yes No
No
Figure 131.7. Algorithm for surgical
decision making for thoracolumbar frac-
ture. The two most important factors in
Treat in brace with close making the decision of which surgical
radiographic follow-up approach is necessary are the neurologi-
cal status of the patient and the status of
the posterior ligamentous complex.
polytrauma victims. For patients requiring anterior decompres-
sion or with significant kyphosis and sagittal plane instability,
the use of supplemental anterior interbody cages and anterior
plate/rod fixation systems provides additional stability that may
reduce the risk of recurrent deformity and posterior fixation
failure. Good understanding of biomechanical principles gov-
erning implant fixation in the thoracic spine as well as comfort
with the unique regional anatomy of the thoracic spine allows
safe and effective application of these contemporary implant
options.
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