CHAPTER
Reames
133
Anterior Decompression Techniques
for Thoracic and Lumbar Fractures
INTRODUCTION
The anterior approach for traumatic thoracolumbar fractures
is used most often for unstable burst fractures when there is
severe spinal canal compromise in intact patients or those
with incomplete neurological deficits or when the surgical
alternative commonly involves a long-segment posterior
fusion. As a general rule, stand-alone anterior approaches
fuse fewer spinal segments with equivalent clinical and radio-
graphic outcomes compared with short-segment posterior
instrumentation and fusion procedures. Although a uniform
algorithm has not been established, the present literature
describes many relative indications as well as contraindica-
tions, which may aid in determining the approach of choice
for a particular patient.
Approximately 150,000 people sustain spinal column frac-
tures per year, while resultant spinal cord injury occurs in an
estimated 10,000 to 17,000. There is a bimodal age distribution
composed of young men and elderly women. Motor vehicle
accidents account for more than 40% of cases of spinal cord
injury, and more than half of all spine fractures occur within
the thoracolumbar spine. The thoracolumbar spine encom-
passes the transition point from the kyphotic thoracic spine
supported by the thoracic cage, to the unsupported yet struc-
turally larger lordotic lumbar spine. The considerable inci-
dence of high-velocity trauma such as motor vehicle accidents,
together with the susceptibility of the thoracolumbar spine to
the resultant force vectors, necessitates a comprehensive review
of the various treatment options when considering these inju-
ries to appropriately select when an anterior surgical treatment
of these injuries is appropriate. Severe spinal instability is a rela-
tive contraindication for an anterior alone procedure and
appropriate identification of fracture pattern is critical to avoid
construct failure.
CLINICAL AND RADIOLOGICAL
ASSESSMENT
All spinal trauma patients warrant a thorough neurological
assessment in addition to their full trauma workup. A compre-
hensive motor/sensory examination including reflexes, evalua-
tion for signs of external trauma, including step-offs, lacerations,
LWBK836_Ch133_p1439-1448.indd 1439
Davis L.
D. Kojo Hamilton
Toomas Anton
Christopher I. Shaffrey
abrasions, swelling, and ecchymoses provides clues about
potential locations and mechanisms and severity of injury. The
presence of deformity or tenderness and the determination of
coexisting injury are critical in determining if an anterior
approach is appropriate. Anterior approaches are most com-
monly performed for patients with incomplete neurological
deficits where posterior-alone approaches are frequently used
with severe injuries with complete neurological deficits. There-
fore, a rectal examination should be performed in all cases,
with assessment of the bulbocavernosus reflex in patients who
are suspected to be in spinal shock. The presence of rectal tone
and sensation in the perineal region may confer functional
neuroanatomical integrity and may change prognosis and thus
clinical decision making.
Initial imaging should include anterior/posterior as well as
lateral plain films of the entire spine. In almost every case
where surgical intervention is contemplated, computed
tomography (CT) scan is indicated, which should include sag-
ittal and coronal reconstructed images to better visualize
osseous abnormalities (Figs. 133.1 and 133.2). Magnetic reso-
nance imaging (MRI) is warranted in any patient who has
neurological deficits not explained based on imaging with
plain film or CT or when the severity of ligamentous injury
could alter the surgical approach. In these cases, a herniated
disc, hematoma, or other soft tissue mass may be the cause of
injury, potentially only observed with MRI. In addition, if a
patients baseline neurological status begins to deteriorate, an
MRI may also be indicated.
Cobb angle, vertebral body translation percentage, anterior
vertebral body compression percentage, and percentage canal
occlusion should be determined for each fracture. This allows
for sagittal alignment assessment, demonstration of traumatic
anterolisthesis, expression of vertebral body compression and
total cross-sectional area of the central canal, the sagittal to
transverse canal diameter ratio, and overall canal dimensions,
respectively.
The posterior ligamentous complex (PLC) (interspinous liga-
ment, supraspinous ligament, facet capsules, and ligamentum
flavum) is, however, thought to be an important element in deter-
mining stability in thoracolumbar burst fractures. Some authors
feel that MRI can help change the surgical approach when the
extent of damage to the anterior and posterior longitudinal liga-
ments and spinal cord parenchyma are elucidated.3 MRI has been
1439
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 1440 Section XII Trauma
Figure 133.1. Axial computed tomography demonstrating burst
fracture through L2 with significant canal compromise.
found to be highly reliable for detecting interspinous and supras-
pinous ligament damage and moderately reliable for posterior
longitudinal ligament damage. The correlation of MRI findings
with neurologic function or severity of fracture has been more
difficult, however, and MRI has not been routinely recommended
as necessary for the routine ruling out of occult ligamentous
injury in thoracolumbar burst fractures. Lee et al12 in their Spine
Trauma Study Group survey analysis for assessing injury to the
PLC when plain radiography is normal, found that most respon-
dents preferred a combination of abnormal signal intensity on
sagittal T1-weighted MRI, diastasis of facet joints on CT, and high
signal intensity on T2/short T1 inversion recovery or fat-saturated
sagittal MRI to be most helpful in determining PLC injury.
A common indication for anterior surgical treatment is the
unstable burst fracture. Burst fractures are a heterogenous
group of fractures representing 10% to 20% of all spinal frac-
tures characterized by retropulsion of the middle column into
the vertebral canal with associated loss of anterior vertebral
body height.11 Although stability is not always a straightforward
concept, there are radiographic criteria to assist with diagnosis.
Interspinous widening, increased interlaminar distance, greater
than 2 mm translation, kyphosis measured at greater than 20,
greater than 50% loss of height, dislocations, and fractures of
the articular processes are all demonstrated with burst fractures
and taken in clinical context can imply instability. Loss of height
of the intervertebral disc proximal to the fracture has been cor-
related with postoperative dysfunction and pain. The presence
of neurological deficits usually is an indicator of spinal instabil-
ity and when present in burst fractures is the most common
indication for surgical intervention.
THORACOLUMBAR SPINE
FRACTURE CLASSIFICATION
A variety of classification systems exist for thoracolumbar
trauma, with a basis ranging from anatomical morphology, to
LWBK836_Ch133_p1439-1448.indd 1440
Figure 133.2. Sagittal computed tomography demonstrating burst
fracture through L2 with significant canal compromise and focal
kyphosis.
mechanisms of injury, to functionality. In the modern era, the
concept of the vertebral column as a composite of vertical sup-
ports has become integral in spinal trauma models. This con-
cept, based on anatomical structures, was initially introduced
by Kelly and Whitesides,9 later to be modified by Denis. Denis5
devised a classification scheme based on a review of radiographs
of 412 thoracolumbar injuries, CT scans of 53 patients, and
surgical notes from 120 cases. His goal was to emphasize the
pathologic anatomy of different types of spinal injuries, each of
which was based on a different mechanism of injury. To accom-
plish this, Denis introduced the three-column concept of spinal
stability. This included an anterior (anterior longitudinal liga-
ment and anterior half of the vertebral body), middle (poste-
rior longitudinal ligament, posterior annulus fibrosis, and
posterior wall of the vertebral body), and posterior column
(posterior elements and pedicle). Denis argued that the mode
of failure of the middle column correlated to stratified fracture
types and risk of neurologic injury. Other studies have since
reinforced this concept. Ferguson and Allen6 have since modi-
fied the Denis classification, and base their classification on
proposed mechanisms of injury.
Compression fractures involve failure of the anterior col-
umn in compression without injury to the middle column.
Compression fractures at the thoracolumbar junction typically
are a result of axial loading forces on a flexed spine. As the
posterior column may remain intact or fail in tension, depend-
ing on the energy level of the injury, the integrity of the poste-
rior ligamentous structures are the primary determinants of
spinal stability in this fracture pattern. Because of the lack of
spinal canal compromise, and a relatively low risk of progres-
sive deformity, anterior decompression is rarely needed for this
fracture type.
Unlike compression fractures, burst fractures result in com-
pression failure of both the anterior and the middle column
following a subaxial loading force. Injury to the middle column
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 Chapter 133 Anterior Decompression Techniques for Thoracic and Lumbar Fractures
is considered to be a potentially unstable fracture pattern in
this classification scheme. Burst fractures most commonly result
from high-speed accidents and falls and have a predilection for
the thoracolumbar junction. Following diagnosis of a burst
fracture, a patients spinal stability must be evaluated. In addi-
tion to the radiological criteria mentioned previously, this com-
monly is determined by obtaining upright (dynamic) films with
the patient in a brace. A progressive neurologic deficit, pro-
gressive kyphosis, or radiographic evidence of substantial poste-
rior column injury are indications of instability and may require
surgical correction. Patients with burst fractures with substan-
tial spinal canal compromise are potential candidates for ante-
rior decompression followed by anterior instrumentation and
fusion or posterior instrumentation and fusion. An anterior
approach is almost always indicated in a small subgroup of
patients with a reverse cortical sign. This sign corresponds to
a fragment of the posterior wall of the vertebral body that has
been flipped 180. The cancellous surface of this fragment
faces posteriorly in the spinal canal and the cortical surface
(posterior wall) facing anteriorly. The identification of such
reverse cortical fragment is crucial as ligamentotaxis is classi-
cally contraindicated as the posterior longitudinal ligament is
ruptured making posterior-only approaches contraindicated.1
A chance fracture and other flexiondistraction injuries
occur when an anterior force vector acts along the axis of rota-
tion anterior to the spinal column. Consequently, the posterior
and middle columns fail in tension, whereas the anterior col-
umn may fail in either tension or compression depending on
the location of the axis of rotation (at or anterior to the ante-
rior spinal column). This injury pattern is typically observed
following high-speed motor vehicle accidents in which the lap
belt was used without the shoulder belt (seat belt fracture).
Concomitant abdominal injury as well as spinal epidural hema-
toma are common after flexiondistraction injuries fractures
and should be excluded clinically and radiographically. The
risk of neurologic injury is higher with this injury type than with
compression or burst fractures. Anterior-only stabilization of
these fractures is controversial. Sasso et al18 have reported a
large multicenter series of unstable thoracolumbar fracture
patients who predominantly had flexiondistraction injuries
successfully managed with anterior decompression, instrumen-
tation, and fusion. Other authors have reported higher failure
rates with this approach compared with more traditional
posterior-only or circumferential procedures.
Fracture dislocations are extremely unstable three-column
injuries that involve translation or rotation through the middle
column. They commonly involve the thoracolumbar spine and
are often visible on plain radiographs. These injuries are rarely
treated with an anterior-only approach. Depending upon neu-
rological status and spinal canal compromise, anterior decom-
pression and may be required as part of a circumferential pro-
cedure.
There have been many attempts at introducing a new system
of classification for these fractures. The Spine Trauma Study
Group has developed two systems of classifying thoracolumbar
fractures, called the Thoracolumbar Injury Classification and
Severity Score (TLICS) and the Thoracolumbar Injury Severity
Score (TLISS).19 They recently published a demonstration of
the application of the TLICS through several case studies. The
TLICS system uses fracture morphology rather than mecha-
nism of injury and includes the PLC together with the patients
clinical neurological examination. A numerical grading scale is
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generated from three major categories, including injury mor-
phology (compression, burst, translational/rotational, and dis-
tractive), neurological status (intact, nerve root, cord/conus
designated as complete, incomplete, or cauda equina syn-
drome), and PLC integrity (intact, injury suspected/indetermi-
nate, and injured). The TLISS differs in that it utilizes a mecha-
nistic classification scheme rather than fracture morphology.
Considering injury morphology, neurological status, and PLC
integrity each impact the decision whether to perform an ante-
rior decompression combined with anterior instrumentation
and fusion or as part of a circumferential procedure, these clas-
sifications systems might be an aid in determining the optimal
surgical approach.
TREATMENT ALGORITHM
Goals of treatment of thoracolumbar burst fractures include
decompression and realignment, stabilization of the fracture,
and prevention of further instability, deformity, or neurological
injury. Thoracolumbar trauma can be associated with noncon-
tiguous spinal injury in up to 25% of cases and visceral injury
as high as 40% of cases. The surgeon should also bear in mind
the requirements of rehabilitation and strive to maximize the
patients recovery by facilitating mobilization and reducing
eventual deformity and pain that can result from inadequate
treatment. Morphological considerations include the extent
vertebral body collapse, the severity of kyphosis, and the integ-
rity of the PLC. These are key determinants of spinal stability
and should be considered when deciding between nonopera-
tive and operative treatments and the surgical approach
selected. Although surgical treatment is generally regarded as
standard of care for most two- and three-column injuries, there
has been no definitive support of this management strategy
with randomized controlled studies (Fig. 133.3).
Progressive neurological deterioration in the presence of
substantial canal compromise is an indication for surgical
decompression and stabilization. The treatment of flexion
distraction injuries largely depends on the predominant type of
tissue injury. Pure chance fractures in which disruption occurs
through the bone of the vertebral body, pedicles, laminae, and
spinous process often will heal reliably if immobilized in a
hyperextension orthosis, especially in an immature patient. A
soft-tissue chance variant, however, with an injury vector pass-
ing through the disc space, facet capsules, and interspinous
ligament will not heal predictably in the adult and often
requires operative stabilization. Radiographic evidence of sub-
stantial translational or rotational malalignment indicates a
highly unstable shear injury or fracturedislocation requiring
surgical stabilization.
The anterior approach can be used to decompress neural
elements, to restore normal alignment, and to maintain
stability.7,8 This technique allows for excellent visualization to
the ventral spinal anatomy.14 Another advantage is the ability to
reverse kyphosis by restoring height to the anterior and middle
columns, potentially limiting the number of motion segments
requiring fusion.10 Anterior surgery has demonstrated high
rates of neurologic improvement for the treatment of burst
fractures when performed early in patients with incomplete
injury.2 However, it is an inherently destabilizing procedure
and the resultant vertebral body defect must be replaced with
structural support such as allograft strut, mesh cage, or an
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 1442 Section XII Trauma

Acute thoracolumbar
fracture

Neurological deficit No neurological deficit

Incomplete injury
Cauda equina

OR Kyphosis >30 Brace

(stabilization and/or
decompression)
Anterior instrumentation
Posterior instrumentation
Combined
Canal compromise >50%
Upright AP/Lat films
Vertebral loss of height >50%
Neurological deficit Pain control
Intractable pain
Non-union of fracture

Conservative
management

Figure 133.3. Treatment algorithm for the management of thoracolumbar burst fractures.

expandable cage. The anterior approach limits additional dam-
age to posterior structures such as paraspinal musculature as
well as innervation to the area, ligamentous tension bands, and
bony support. The preservation of these structures may help to
limit the development of posttraumatic kyphosis.
Injuries with limited posterior element damage, significant
ventral pathology and canal compromise, kyphosis (30),
severe anterior comminution, and neurologic impairment have
been noted as relative indications for the anterior approach.10
Using an anterior only approach, Oskouian et al were able
to spare more lumbar motion segments for selective three-
column thoracolumbar burst fractures when compared with
traditional posterior approaches.17 Animal models have also
demonstrated biomechanical advantages and stronger con-
structs when anterior reconstruction is used for anterior and
middle column injuries. Along these principles, an intact mid-
dle column (including posterior longitudinal ligament and
annulus fibrosis) is paramount to deformity correction when
utilizing a multisegmental posterior instrumented fusion.
A transpedicular approach has been suggested as an alterna-
tive approach to provide posterior access to ventral pathology.
However, Lemons et al failed to demonstrate a correlation
between neurological recovery and degree of central canal
reconstruction achieved with this technique, while McLain
et al, albeit with short follow-up and a limited study, speculated
an increase in postoperative kyphosis when transpedicular
decompression is combined with posterior-only short-segment
instrumented fusion.13,16
Although the correction of kyphosis and postoperative
maintenance of vertebral body height is a goal of surgery, a
clear correlation between postoperative kyphosis from any
approach and postoperative pain and work status has been
difficult to demonstrate.17
While access as superior as T5 is often attainable, most
authors agree that the anterior approach is most effective from
T10 to L3.14 As a result of more latitude for compression as a
result of a larger canal/nerve root ratio and lack of cord tissue,
and difficulty of access due to the location of vascular struc-
tures, the lower lumbar spine (L4 and L5) less often requires an
anterior approach.
McCullen et al evaluated patients with thoracolumbar injury
with an incomplete neurological deficit. Fractures that were
suboptimally treated by a posterior approach included those
with 67% central canal compromise, severe anterior body com-
minution, greater than 30 kyphosis, and those more than
4 days from injury. Other patient groups that benefited from
anterior surgery included those with unsatisfactory results after
posterior surgery (residual canal compromise and suboptimal
neurologic improvement), flexiondistraction injuries with
resultant disc herniation, and planned anterior approaches after
short-segment posterior stabilization are all relative indications
for anterior surgery.15 Other authors have recommended

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 Chapter 133 Anterior Decompression Techniques for Thoracic and Lumbar Fractures 1443

additional anterior surgery for residual instability or neural

compression after a posterior approach.10
There is data to support both anterior stabilization and
longer-segment posterior instrumentation and fusion for frac-
tures associated with substantial displacement, kyphosis, and
comminution found in fracturedislocations with at least some
neurological function.10
Contraindications to anterior surgery are severe thoracic or
abdominal concomitant visceral injury. These include concom-
itant cardiorespiratory compromise or reserve, whether acute
or chronic. Patients body habitus and any impairment to
achieving fusion such as osteoporosis or tobacco use would be
expected to compromise either approach.
The ideal management of patients with thoracolumbar spi-
nal injuries is controversial. The wide range spectrum of thora-
columbar injury, associated injuries, and neurological status
complicate the ability to provide absolute recommendations.
Even in cases of well-defined injury such as thoracolumbar
burst fractures, the lack of randomized controlled studies has
precluded a generalized consensus on the optimal manage-
ment of pathology in this region. Treatment of trauma in the
thoracolumbar spine should be individualized to each patient
and is based on evaluation of the patients neurologic condi-
tion, radiographic abnormalities, concomitant injuries, and
general medical condition.

SURGICAL OPTIONS AND TECHNIQUE Figure 133.4. Postoperative lateral plain radiograph after left-
sided retroperitoneal approach for L2 vertebrectomy and L1-3 instru-
mented fusion using screwrod construct.
TIMING TO SURGERY
Most investigators have recommended surgery for patients with
progressive neurological loss or a major neurological deficit in
the setting of substantial canal compromise. In these situations,
the goals of surgery are to provide adequate anatomic decom-
pression of the neural elements and rigid stabilization of the
injured segments until biological fusion occurs. The appropri-
ate timing of surgery following spinal cord injury is the subject
of considerable controversy with conflicting information from
animal and clinical studies. Although animal models have sug-
gested that early decompression may improve neurological
recovery, the window of opportunity appears to be very small,
and the limited class one evidence on spinal trauma has dem-
onstrated no substantial difference in outcome between early
and late surgical decompression and stabilization. Various stud-
ies have reported shorter hospitalizations, less time required in
an intensive care unit (ICU), less systemic complications, and
even improved neurologic improvement when early surgical
repair is compared with late surgery (Figs. 133.4 to 133.6).

SURGICAL APPROACH
Anterior and posterior as well as combined anteroposterior
(AP) surgical approaches each have specific advantages and
disadvantages. Familiarity with approach, predictability of
achieving anatomical alignment, spinal stability, and an accept-
able morbidity are often the reasons surgeons prefer the poste-
rior approach. More consistent anterior decompression,
improved postoperative neurological improvement, and fewer
spinal segments fused with comparable morbidity are often the Figure 133.5. Postoperative anteroposterior plain radiograph
explanation for anterior surgery.4 Danisa et al found that pos- after left-sided retroperitoneal approach for L2 vertebrectomy and
terior surgery to be done faster, with less intraoperative blood L1-3 instrumented fusion using screwrod construct.

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 1444 Section XII Trauma
Figure 133.6. Axial diagram of anterior instrumentation using
screw/plate rigid fixation construct.
loss, and less cost to the patient when compared with anterior
and combined procedures for unstable burst fractures.
Although they could not recommend combined approaches
based on their data, they did state an inability to demonstrate a
significant difference in other factors, such as neurological
function, pain, return to work, or kyphotic correction between
anterior and posterior stand-alone procedures.4 Interestingly,
three of the senior surgeons from this paper subsequently
published a second paper describing a significant improvement
over the posterior-alone approach when they modified their
anterior technique by using a titanium mesh interbody
cage filled with autologous graft harvested from the corpec-
tomy site.20
In addition to reconstruction of the vertebral body defect
with a strut or cage the use of anterior instrumentation has gain
popularity. Rigid fixation devices such as transvertebral screws
with plate or rod constructs have reduced the need for com-
bined approaches. The biomechanics of anterior fixation
devices differ from posterior systems in that they do not rely on
long lever arms to resist flexion forces but rather help to dis-
tribute the major area of compressive forces located in the
anterior vertebral body. Some types of constructs have the dual
role of distribution of axial loading forces while also providing
housing for graft material. The less purchase afforded by the
soft cancellous bone of the vertebral body compared with the
thickness of the pedicles used in posterior fixation and poor
resistance to torsional forces are limitations of the anterior
fusion technique, although the supplementation of a combined
approach may overcome these inherent difficulties in very
unstable injuries. Lastly, although there are fusion-sparing
devices available, no such motion-preserving implant has suc-
cessfully replaced rigid fixation as the construct of choice for
most spine surgeons.
Most burst fractures are amenable to reconstruction through
an anterior thoracoabdominal, a retroperitoneal, or possibly
an endoscopic approach, depending on the level of the injury.
LWBK836_Ch133_p1439-1448.indd 1444
Although anterior surgery is an effective technique for releas-
ing fixed deformity prior to stabilization, anterior-only recon-
struction also appears to be an adequate treatment of most
burst fractures limited to the anterior and middle columns
(i.e., without severe injury to the posterior column). A posteri-
or-only fusion with instrumentation from two or three levels
cephalad to the injury to two levels caudal to it is an acceptable
alternative in patients who do not require decompression, but
it involves fusing a more extensive portion of the spine. A so-
called posterior short-segment fusion with instrumentation and
utilization of pedicle screw fixation from one level cephalad to
the injury to one level caudal to has generally fallen out of favor
because of a relatively high rate of proximal screw pullout and
loss of correction in the setting of substantial anterior column
compromise. In the presence of considerable anterior collapse
and posterior column disruption, a combined anterior and
posterior fusion often provides the greatest degree of spinal sta-
bility. Because of the nature of instability, flexiondistraction
injuries and fracturedislocations are best approached initially
with posterior stabilization, followed by an anterior decompres-
sion and reconstruction if needed.
EVOLUTION OF MODERN
ANTERIOR APPROACHES
The Harrington rod distraction system was the first instrumen-
tation with consistent clinical results. This allowed restoration
of vertebral height, reduction of kyphosis, and indirect decom-
pression of spinal canal. Drawbacks were incomplete decom-
pression of the spinal canal, semirigid construct, high incidence
of pseudarthrosis, and a large number of levels needed to be
fixated. The thoracolateral approach was developed in 1950s
for the treatment of scoliosis and tuberculous abscesses. This
work led to an anterior single-stage procedure to avoid the
morbidity of two stages.
There is no universal consensus as to when to operate on
patients with a thoracolumbar fracture and no neurologic defi-
cit. Most surgeons believe that early fusion will help with mobi-
lization and pain control and may prevent late posttraumatic
kyphosis. Newer literature recommends evaluation of a struc-
tural pattern of the fracture, the integrity of the PLC, and the
neurological status of the patient. Fracture pattern can be clas-
sified as compression, translation/rotation, or extension. The
most common fractures are compression and burst fractures.
In case of incomplete neurological injury anterior approach is
chosen, isolated PLC injury is indication for the posterior
approach. In patients presenting with neurologic deficit, most
surgeons believe operative decompression and fusion is indi-
cated in the first 24 hours. There are several formulated indica-
tions for surgery. These include thoracolumbar fractures involv-
ing the anterior and middle columns with neurological deficit
and retropulsion of bone fragments into the canal, thoracolum-
bar fracture without neurologic deficit, but with 50% loss of the
spinal canal, late burst injuries, including those that occur
10 days or more postinjury with or without neurologic deficit,
painful or progressive posttraumatic kyphotic deformities with
or without neurologic involvement, and nonunion of anterior
and middle column fractures. Advantages of anterior decom-
pression and instrumentation are restoration of the sagittal and
coronal alignment, complete decompression of the spinal
canal, achieving two-column fixation, and vertebral body recon-
stitution. Short fusion will prevent early degenerative changes
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 Chapter 133 Anterior Decompression Techniques for Thoracic and Lumbar Fractures
on adjacent levels, which is particularly important in the lum-
bar spine. Restoring sagittal and coronal balance will result in
better fusion rates. Biomechanically it has been demonstrated
that best results are achieved with rodplate construct with
superior construct stiffness, stability in screwbone interface,
and improved screw pullout strength.
SPECIFIC TECHNIQUES
Upper Thoracic
T2-5 High dorsolateral thoracotomy (Usually right sided)
T6-12 Dorsolateral thoracotomy (Either left or right sided)
Thoracolumbar
Transthoracic/retroperitoneal with division of the diaphragm
T12-L2 Retroperitoneal extracavitary
Lumbar
L2-5 Retroperitoneal extracavitary
Transabdominal
Lumbosacral
L5-Sacrum Ventral retroperitoneal
Upper Thoracic
The patient is placed in a neutral lateral decubitus position. A
vacuum deflatable beanbag can be used to maintain position.
Throughout the procedure direct lateral position needs to be
maintained to not lose the orientation of the spinal canal. The
patient should be thoroughly taped or strapped to the opera-
tive table to permit table rotation during the course of the pro-
cedure without losing positioning. The approach is usually
from the right side except when fracture fragments are located
mainly on the left side, patient has had previous right-sided
surgery or when the surgeon needs to deal with the aortic arch
when operating around levels T4-6. The right-sided approach
reduces the difficulty of manipulating the aortic arch during
the surgical approach. Pressure points are carefully padded,
axillary rolls are used for the axilla, and a pillow is placed
beneath the legs to avoid pressure on the peroneal nerve. A
double-lumen endotracheal tube is used for the anesthesia.
The skin incision should be overlying the intended level of rib
resection. The incision is typically made two ribs above the cor-
pectomy level and one level above the upper instrumented
level. The incision is started at the lateral border of the paraspi-
nal musculature. The latissimus dorsi and serratus anterior
muscles are divided using monopolar cautery, followed by divi-
sion of trapezius and rhomboid muscles for a higher exposure.
The scapula is retracted and a plane is developed above the
chest wall. The operative level is confirmed with intraoperative
C-arm. The periosteum is elevated using periosteal elevator. A
Doyen periosteal dissector is used to remove the periosteum on
the underside of the rib. The rib is cut approximately 5 to 7 cm
from the rib head. Resected rib can be used later for an inter-
body fusion. An extrapleural or intrapleural exposure may be
performed. For the extrapleural exposure the pleura is dis-
sected off from the ribs and vertebrae to be exposed. The
authors prefer this approach for younger trauma patients, and
it eliminates or reduces the duration of needing a chest tube
LWBK836_Ch133_p1439-1448.indd 1445
1445
postoperatively. This gives a direct view to the spine, segmental
vessels, and sympathetic chain. The segmental vessels at the
level of the fracture and the levels above and below are tied, a
vascular clip is applied for additional verification of hemostasis
and they are divided individually. Vessels should be divided at
the midpoint of the vertebral body about 1 to 2 cm from the
aorta. For the intrapleural exposure, plural flaps are created
and then closed after completion of the surgery.
Thoracolumbar Approach
The patient is placed in the lateral decubitus position and pres-
sure points are padded. Usually a left-sided approach is used if
pathology does not dictate otherwise. A beanbag and wide
adhesive tape are used for stabilizing the patient. Intraopera-
tive monitoring is arranged. The length of the incision is dic-
tated by the number of vertebra to be exposed, and ribs are
used for guidance. The skin incision is made in the region of
tenth or eleventh rib. If the T11 or T12 vertebrae need to be
exposed, the T10 or T11 rib should be removed, respectively.
For the T12 exposure T11 rib needs to be notched or removed.
Subperiosteal dissection is carried out to expose the rib or ribs.
The pleura is stripped from the rib, and rib is cut in appropri-
ate length for the exposure. Again a transpleural or retropleu-
ral approach can be utilized for the exposure of the thoracic
spine. To facilitate exposure of the thoracolumbar junction, a
circumferential incision is made in the medial portion of the
diaphragm adjacent to the costal margin to maximize expo-
sure. A more limited exposure can be achieved by detaching
crural attachment of the diaphragm from the bodies of T12
and L1 without incising the periphery of the diaphragm. With
this approach, base of the diaphragm is then retracted superi-
orly exposing the thoracolumbar junction. Although this more
limited exposure is associated with decreased morbidity, it is
difficult to decompress or instrument above the T12 level with
this approach.
The rostral retroperitoneal space is exposed by dividing the
abdominal musculature and blunt dissection of the retroperito-
neal contents is then carried out. The spleen, kidneys, and
stomach are retracted medially and caudally. A self-retaining
retractor system is used to maintain the exposure. The aorta is
mobilized after the selective ligation and division of segmental
vessels. The iliopsoas is stripped from the lateral aspect of the
vertebral body recognizing that the lumbar plexus is contained
in the posterior half of the muscle. Following the anterior spi-
nal procedure, repair of the diaphragm is performed and a
chest tube frequently placed.
Retroperitoneal Approach to L2-5
The patient is placed in the lateral decubitus position and pres-
sure points are padded. If possible, the patient should be placed
left side up to avoid liver manipulation and retraction of vena
cava. The table is flexed to open up the dissection plane
between ribs and the iliac crest, this also helps the viscera to fall
away. The incision is dictated by necessary level. An oblique
flank incision between the lower costal margin and the iliac
crest is performed. The AP distance of the incision is deter-
mined by the number of the vertebra to be exposed and the
body habitus. The latissimus dorsi, external oblique, internal
oblique, and transverses muscles are incised sequentially. The
transversalis fascia is opened and retroperitoneal space is
8/26/11 2:34:58 PM
 1446 Section XII Trauma
entered. The peritoneum is bluntly dissected from the abdom-
inal walls. Sharp dissection for the adhesions should be used.
Dissection is carried out behind kidney in the potential place
between the renal fascia and quadratus lumborum and psoas
muscles. The retroperitoneal fat and ureter are retracted medi-
ally. Usually on the surface of psoas genitofemoral nerve is
noted. A self-retaining retractor is inserted, and abdominal
blades are used to retract the kidney and abdominal contest.
The segmental vessels are ligated, and aorta is mobilized. The
sympathetic trunk should be preserved. Appropriate level is
determined radiographically and anterior decompression is
performed.
Transperitoneal Approach to L3-S1
Exposure of L3-S1 is accomplished through an anterior retro-
peritoneal or transperitoneal route. The patient is placed
supine in the Trendelenburg position to move abdominal con-
tent upwards. Pfannenstiel transverse subumbilical or more
commonly a paramedian vertical incision is used. The abdomi-
nal wall is opened next to the midline at the border of the left
rectus abdominis muscle. At this point, a retroperitoneal or
transperitoneal route can be chosen. Transperitoneally perito-
neum is freed from the abdominal wall and opened in a linear
fashion. The greater omentum, small bowel, and mesentery are
retracted rostrally. The mesocolon is retracted laterally and sig-
moid caudally. The dorsal peritoneum is opened along the left
common iliac artery from the bifurcation of the aorta to the
bifurcation of the common iliac arteries. The hypogastric
plexus and ureter should be preserved. L3 and L4 can also be
exposed with mobilization of the great vessels. For the retro-
peritoneal approach, the anterior rectus fascia is opened and
the rectus abdominis muscle is mobilized laterally. The poste-
rior rectus fascia is opened above the arcuate line and the ret-
roperitoneal space entered. The ureter is retracted with the
retroperitoneal contents. Ligation of the segmental vessels
enables vascular mobilization. Repair of the posterior and
anterior rectus fascia is performed at the conclusion of the
procedure.
Instrumentation
After exposure is achieved, the intervertebral discs above and
below the fractured vertebra are identified and aggressive dis-
cectomy is performed. Identification of the neural foramina
and ipsilateral pedicle will help for the orientation and position
of the spinal canal. A corpectomy is performed using the high-
speed drill, curettes, and rongeurs. The anterior longitudinal
ligament is left intact to protect the aorta and inferior vena
cava. The vertebra is resected to the opposite pedicle and the
canal is completely decompressed. The posterior longitudinal
ligament must be identified and removed. Diligence is required
when removing bone fragments from the spinal canal to pre-
vent neurological injury. This may be performed using a curette
and a no 4 Penfield. There are bone fragments frequently
retained behind the ipsilateral pedicle and removing the pedi-
cle will improve the decompression. Reduction is performed
when necessary using manual pressure over the dorsal spine at
the apex of the kyphosis. This can be assisted using laminal
spreader between end plates or distraction applied through
transvertebral spinal instrumentation. Reduction can be main-
tained using a distractor attached to the transvertebral screws.
LWBK836_Ch133_p1439-1448.indd 1446
The dissection can be carried out dorsolaterally to decompress
the nerve root. It is important to remove cartilaginous end
plates from the adjacent vertebral bodies to enhance the fusion
rates. The curettes, drill, or osteotome can be used for this pur-
pose. Interbody fusion is performed using structural autograft
iliac crest, structural allograft, titanium mesh, carbon fiber
cages, or polyethylethylketone (PEEK) or titanium expandable
cages. Copious amounts of bone graft are generally required.
Bone from the surgical approach (rib) can be mixed with local
bone graft obtained during the course of the anterior decom-
pression. Occasionally the size of the defect will require addi-
tional grafting material. Iliac crest bone graft, allograft, and a
variety of osteobiological agents have all been reported to have
been used successfully in these circumstances. A template is
used to measure the appropriate length for the structural graft
or cage. A variety of instrumentation systems have been devel-
oped for the instrumentation, most maintain similar principles
of restoring sagittal balance and achieving biomechanically
solid and lasting fusion. Works by Wenger, Dunn, Zielke, and
Kaneda have contributed success to stand-alone anterior instru-
mentation and fusion. Most major spinal instrumentation com-
panies have a system designed for treatment of these injuries.
Most use two transvertebral bicortical screws placed in the ver-
tebra above and below the injured segment. These screws are
attached to either a plate or rods to maintain stability. Regard-
less of the system used, the lateral aspects of vertebral bodies
need to be prepared such that the implant rests flush against
the bodies. The plate should sit approximately 5 mm from the
end plates to reduce adjacent-segment degeneration. For bolt
insertion an awl is used first to penetrate the outer cortex, fol-
lowed by the tap, before screws are inserted using the 0 angle
for the anterior screw and 10 trajectory away from the spinal
canal for the posterior screw. Monoaxial screws are typically
employed but polyaxial screws are available. Instrumentation
where rostral and caudal staples are designed for 10 conver-
gence is also available. If reduction is required prior to inser-
tion of graft, a parallel distractor can be used, which screws in
place. If double rod system is used, a posterior rod is inserted
first. A French rod bender or in situ benders are available if
contouring of the rod is necessary. Final compression utilizing
a compressor and insertion of cross-link to improve torsional
rigidity is performed. Prior to closure, lateral and AP radio-
graphs are taken to verify placement of hardware and correc-
tion of the deformity. The wound is closed in standard fashion
utilizing chest tube if necessary. If feasible, closure of the pari-
etal pleura over hardware is advisable.
Newer Techniques
Conventional surgical approaches for the thoracolumbar
trauma are associated with muscle atrophy, scarring, intercostal
neuralgia, postthoracotomy syndromes, hemiparesis of the dia-
phragm, significant blood loss, and pain. Considering all these
clinical effects, more minimally invasive techniques have been
developed over the last 10 years. The rational for this is to
reduce all the aforementioned complications. In the 1980s
video-assisted thoracoscopic surgery (VATS) was developed by
cardiothoracic surgeons. VATS technique is successfully utilized
by spinal surgeons who report large clinical series.
Minimally invasive techniques were first used for the tho-
racic discectomies, thoracic sympathectomies, and paraspinal
nerve sheath tumor resections, among other indications. These
8/26/11 2:34:58 PM
 Chapter 133 Anterior Decompression Techniques for Thoracic and Lumbar Fractures 1447

techniques were eventually developed to include corpectomies Postoperatively aggressive pulmonary toilet is required to avoid
for trauma. The patients were positioned in standard lateral atelectasis and pneumonia. Drains should be inserted to avoid
position. Working channels were inserted, and decompression postoperative hematoma. Deep venous thrombosis should be
and fusion were performed endoscopically. Fixed landmarks administered immediately postoperatively, and it should be
and screws were routinely placed prior to decompression. A supplemented with thigh high stockings and intermittent com-
steep learning curve is associated with the VATS technique; pressive boots. Early mobilization is a key to avoid prolonged
however, advantages include the significantly minimized injury postoperative ileus. It is strongly recommended using intraop-
to the chest wall, decreased blood loss, improvement in the erative electromyogram (EMG) and somatosensory evoked
postoperative pain, and shorter recovery. potential (SSEP) monitoring to detect any changes in neuro-
Mini approaches have also been described, which avoid vio- logical function. Should any change occur, immediate evalua-
lation of pleural and peritoneal cavities, eliminating the need tion of placed hardware and reduction construct is required.
for a chest tube and avoiding extensive dissection. This Decompression should be started after location of spinal canal
approach is used for accessing thoracolumbar junction using and cord is identified. A careful staged approach to complete
5-cm incision and creating access to the spine through splitting decompression reduces the risk of injury. Decompression needs
the abdominal muscles and retracting diaphragm and to be complete with exposure of the contralateral pedicle. All
peritoneum. the defects to vascular structures, diaphragm, ureter, abdomi-
nal wall, and thoracic duct should be repaired immediately.
Incidental durotomies should be repaired primarily with a non-
ADVANTAGES AND LIMITATIONS OF
absorbable suture. In poorly visualized defects, DuraSeal com-
MINIMALLY INVASIVE TECHNIQUES
bined with Duragen should be used. Intraoperative C-arm
should be used to verify proper placement of instrumentation.
Advantages Limitations In insertion of graft or cage direct visualization confirmed with
Better cosmesis Steep learning curve C-arm should be utilized to avoid violation of spinal canal.
Decrease of intercostal Need for specialized equipment Proper graft placement with appropriate end plate preparation
neuralgia will help with fusion rates. When inserting vertebral screws
Lesser trauma to chest wall Contraindication on multitrauma proper angle away from a spinal canal should be maintained.
patient We use 10 angle away from spinal canal to assure safety on our
Reduced blood loss Difficulties with the redo surgeries posterior screw. In case of breach of any vascular structures
Decrease in postoperative consultation from a vascular surgeon should be obtained imme-
pain diately. Meticulous approach in attention to the detail will help
Early mobilization
to avoid any of these complications.

COMPLICATIONS RELATED TO OPERATIVE

POSTOPERATIVE MANAGEMENT AND PERIOPERATIVE PERIOD
Patients are taken to ICU postoperatively. AP/lateral radio- Perioperative
graphs are obtained immediately after surgery. If a chest tube
is in place daily chest radiographs should be obtained. Early Peripheral nerve injury caused by improper positioning
mobilization and pulmonary toilet are of paramount impor- Bleeding
tance. We continue postoperative antibiotics until drains or Infection
chest tube is discontinued. Early mobilization is also important Anesthesia complications (related to deflation of the lung,
to prevent postoperative ileus. In addition, prophylactic antac- myocardial infarction [MI], etc.)
ids to prevent stomach ulcers are standard. Blood transfusions Postoperative hemo/pneumothorax
are often necessary in the postoperative period. Patients are Deep venous thrombosis
usually ready for discharge 5 to 8 days postoperatively after Pulmonary embolism
detailed physical therapy evaluation. Unless a patient has sus-
tained a three-column injury, we do not generally brace patients Operative
in a postoperative orthosis. If indicated, orthosis is usually con-
tinued for 8 to 12 weeks in an upright position. Wrong level
New neurologic deficit
Inadequate decompression
Cerebrospinal fluid (CSF) leak
COMPLICATION AVOIDANCE Vascular injury
Injury to a lung, liver, spleen, thoracic duct, sympathetic chain
Complication related to the perioperative period include inap- Improper placement of the hardware
propriate positioning or padding, which is necessary to avoid Failure of the hardware
peripheral nerve injury, which is especially important as these Failure to restore sagittal and coronal balance
surgeries may take up to 6 to 8 hours. Preoperative antibiotics
should be administered 30 minutes before the incision and
then redosed accordingly. Having a good anesthesia team is SUMMARY
required considering unilateral ventilation. Blood loss should
be replaced promptly. Adequate blood pressure optimal to spi- The anterolateral approach to the thoracolumbar spine was
nal cord perfusion should be sustained during the procedure. first developed for the drainage of tuberculosis abscesses.

LWBK836_Ch133_p1439-1448.indd 1447 8/26/11 2:34:58 PM

 1448 Section XII Trauma
Through advances in the treatment of scoliosis with improved
understanding in spinal biomechanics and improved instru-
mentation techniques, anterior approaches have gained popu-
larity for the decompression and stabilization of thoracolumbar
fractures.
Although a uniform standard for the use of anterior
approach spinal decompression and fusion in thoracolumbar
spinal trauma has not been developed, ideal candidates for this
technique are likely those patients suffering from a burst frac-
ture with a limited involvement of the posterior complex and in
whom ventral pathology primarily accounts for the resultant
incomplete neurological deficit. The excellent visualization of
the ventral dura mater and ability to directly decompress neu-
ral elements and reconstruct the anterior and middle columns
are a major advantage of this technique. There are a multitude
of various constructs, materials, techniques, and patient factors
to consider in the treatment of complex thoracolumbar spinal
trauma. More prospective randomized controlled trials are
needed to standardize a reproducible treatment algorithm.
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