Nonoperative Management and Treatment of Spine Injuries

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Chapter 69 Nonoperative Management and Treatment of Spine Injuries

Mark L. Prasarn, Glenn R. Rechtine, II

The morbidity and mortality associated with injuries to the spine have been known since antiquity. Nonoperative methods have been a mainstay of care for such injuries since ancient Egypt. Even with modern-day surgical techniques, the majority of spine injuries should be managed nonoperatively with the goal of healing the spine without any of the inherent risks of surgery. In most spine injuries, a good functional outcome and no long-term disability can be expected with nonoperative care.

Nonsurgical treatment is used in all cases of spine injuries. Nonoperative treatment techniques are employed at the initial evaluation and management at the scene of the accident. In the vast majority of cases, nonsurgical principles are extended as a definitive treatment plan. In addition, during every step of diagnosis and treatment, strict adherence to principles of immobilization must be followed to minimize motion to the injured spine and prevent neurologic injury or deterioration.

The objectives of nonoperative management of spine injuries are the same as those for operative treatment. These include (1) preservation of neurologic function, (2) improvement in neurologic deficit if already present, (3) reduction of spinal deformity and maintenance of acceptable alignment, (4) minimization of loss of spinal mobility, and (5) achievement of a healed and stable spinal column.

At the Scene

According to Advanced Trauma Life Support (ATLS) protocol, life-threatening compromise to airway, breathing, and circulation should be promptly addressed. Although the greatest risk for spinal cord injury occurs at the time of high-energy impact, neurologic deficits can develop thereafter during treatment. In 1983 Podolsky et al. reported that up to 25% of spinal cord injuries had been caused by or aggravated after the patient had come under medical care.1 Immobilization of the injured spine is the key to preventing such catastrophic decline.

The care of spine trauma patients at the scene has dramatically improved over the past several decades. Extrication and transport of trauma patients with immobilization techniques and adherence to ATLS protocols for resuscitation have been credited for this improvement. ATLS protocol mandates that a spine injury be assumed for all injured patients and rigid immobilization employed. At the scene, the patient should be immobilized with a cervical collar, head immobilization device, and spine backboard.

At the Hospital

The patient should arrive in the emergency department on a backboard with a cervical collar in place. In the face of a global instability, motion can still occur in spite of all attempts at rigid immobilization. The patient should be moved on and off the backboard as few times as possible until the stability of the spine can be adequately assessed. For most injuries the collar provides an increased level of stability. However, it does not provide complete immobilization.2 With a complete ligamentous disruption, the collar has minimal effect. The person stabilizing the spine is much more significant in restricting motion.3

Moving the patient off the backboard for CT should be coordinated so that imaging of the brain, spine, chest, abdomen, pelvis, sinus, or orbits or any other appropriate study is obtained in one trip to the scanner and one movement off and on the backboard.

The risk of decubitus ulceration is directly proportional to the length of time on a backboard—8 hours on a backboard is associated with a 100% likelihood of a decubitus ulcer.4 The patient should be moved from the board as soon as possible. Appropriate spine immobilization must be continued at all times.

Contrary to all available evidence suggesting that the log roll is an ineffective and potentially dangerous technique for spine immobilization, it is still almost universally used. In fact, studies conducted prior to 2004 showed dramatic and unacceptable motion with a log roll.5 Recently, many studies have reevaluated this controversial subject. Compared with any other method of transfer, the log roll maneuver has been shown to cause more segmental motion at the level of the unstable, injured segment.6–13 Lift and slide techniques are far superior since they tend to create less motion at the injured segment.10

Imaging Studies

Following review of the initial CT scan, another assessment of spinal stability can be performed. When a closed reduction of a dislocated segment is needed, it should be performed expediently in the awake and alert patient. Serial neurologic examinations are performed during such a reduction maneuver. If the patient is obtunded or reliable neurologic examinations are impossible, then an emergent MRI should be obtained prior to attempting reduction to rule out significant disc herniation.14

In the absence of a facet dislocation and in the presence of significant spine injury, the appropriateness of an MRI scan must be determined. The spinal motion necessary to transfer the patient on and off the MRI table must be kept in mind when deciding the necessity of this imaging modality. The strongest argument for an MRI is a suspected neurologic deficit that is not explained by the injury seen on the CT scan. If the patient has an unstable injury that requires surgery that is identified clinically or by other imaging studies, it is not necessary to obtain an MRI just to assess the dorsal ligamentous complex.

Anteroposterior and lateral radiographs of the cervical, thoracic, lumbar, and sacral spine are standard imaging studies obtained in cases of high-energy impact with suspected spinal injury. Distracting injuries can often mask symptoms secondary to significant spine injury, and meticulous assessment of the spine must always be performed (Figs. 69-1 to 69-3). It is necessary to image the entire spinal column due to a 10% incidence of noncontiguous spinal injuries.15 Specific injury mechanisms and fracture patterns should prompt the treating team to search for commonly associated nonspinal injuries. Flexion-distraction injuries are highly associated with potentially life-threatening intra-abdominal injuries, so these must be ruled out. Patients with transverse process fractures at L5 have a 61% incidence of a pelvic fracture.16 Falls from a height with resulting burst fractures are often associated with significant lower-extremity fractures, in particular those of the tibia and calcaneus.

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FIGURE 69-1 Initial imaging of a 53-year-old male involved in a motor vehicle accident with bilateral hip pain who was neurologically intact and had no complaints of neck or arm pain. A, Anteroposterior (AP) radiograph of the pelvis demonstrating bilateral proximal femur fractures. AP (B) and lateral (C) radiographs of the cervical spine showing an extension-distraction injury at C6-7 in the same patient.

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FIGURE 69-2 Further imaging of the cervical spine in the same patient as in Figure 69-1. Sagittal (A) and coronal (B) CT images demonstrating the ankylosed cervical spine and injury at C6-7.

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FIGURE 69-3 The same patient as in Figure 69-1 was taken emergently for open reduction and internal fixation of the cervical spine fracture. Anteroposterior (A) and lateral (B) radiographs at 1 year follow-up after posterior spinal fusion.

Closed Reduction of the Cervical Spine

Decompression of the spinal cord through closed reduction should be performed as soon as the patient can medically tolerate it. Closed reduction is a means of reducing cervical spine deformity, indirectly decompressing neural elements, and providing stability. It has been shown to be safe and can dramatically improve neurologic status if performed within the first few hours following injury. In animal studies, Carlson et al. showed that decompression within 3 hours showed better and quicker neurologic recovery.17 A small series of patients with no cord function who received reduction in an emergent manner immediately began to recover.18 Although this is anecdotal, it is extremely important. The timing question is answered after consideration of the risk-benefit ratio between waiting to obtain a prereduction MRI and proceeding directly with reduction.

Considerable controversy surrounds the order of the reduction and obtainment of an MRI in an acute cervical spine dislocation. Eismont et al. reported on a series of six patients who roentgenographically demonstrated herniation of an intervertebral disc with marked protrusion of disc material into the spinal canal following subluxation or dislocation of a cervical facet. For the first patient in this series, no myelogram or CT scan was performed, and the patient awoke with complete quadriplegia following dorsal open reduction and internal fixation. Following a myelogram and ventral decompression surgery, the cause was identified as an extruded intervertebral disc. The authors recommended obtaining an MRI in all patients prior to attempted closed reduction and definitive surgery.19–21 Several other cases with neurologic deficits after open reduction under general anesthesia have been reported.20,21 There have also been reports of progression of neurologic deficits during traction while the patient was awake and participating that later resolved.22

The group from Thomas Jefferson University advocates performing immediate closed reduction in the patient that is awake and can reliably participate in serial neurologic examinations. Vaccaro et al. published their series of 11 patients who underwent successful awake closed reduction without any neurologic worsening. In their series, two patients had herniated discs prior to reduction, and another five had herniated discs following reduction.14 Darsaut et al. attempted to determine the effect of disc herniation during closed reduction in a series of 17 patients who had a cervical dislocation that was reduced under MRI monitoring. They demonstrated that at least as a research tool this technique was possible.23

A commonly used algorithm is based on the patient’s neurologic status. If the patient is unable to participate reliably in the physical examination, then an MRI is obtained as expediently as possible. In cases of mild radicular deficit, MRI has the principal disadvantage of requiring vital time. If the patient has a significant spinal cord injury, the risk is that the cord will remain compressed for a longer time. Therefore, if the patient has minimal or no neurologic dysfunction, an MRI should be obtained. If the patient has an American Spinal Injury Association (ASIA) A, B, or C injury and is able to cooperate with the reduction and serial neurologic examinations, consideration should be given to an immediate, rapid reduction. In this situation, the MRI would be obtained after reduction.

Reduction Techniques

Reduction of a cervical spine dislocation must be performed under image guidance and in a very controlled manner. Gardner-Wells tongs are applied with the pins placed 1 cm above the pinna of the ear just below the equator of the head. Pins are tightened to 3.6 kg of pressure. This is indicated once the precalibrated indicator pins protrude a measured amount. If using weights over 25 kg, titanium pins and MRI-compatible tongs are insufficient. Weights of over 60 kg have been used safely for closed reduction of such injuries.24 In such instances, stainless steel pins or two sets of tongs must be used. Another option includes the use of a halo that provides four titanium pins to distribute the forces over more pins. The major disadvantage of stainless steel pins is their MRI incompatibility.

It is recommended that the initial applied weight be no more than 4.5 kg. Using more weight can be catastrophic if the patient has an unrecognized instability such as an occipital cervical dislocation. After applying the initial 4.5 kg, a neurologic examination should be performed, followed by a radiograph. Additional weight should be added incrementally until reduction is obtained. Serial examinations, as well as serial roentgenograms, are performed to look for any neurologic deficit following each addition of weight. After reduction, the weight should be decreased to the minimum needed to maintain the reduction. Routine examinations are continued, as are efforts to stabilize the instability when medically appropriate. Pulmonary and skin issues can be addressed with use of a kinetic treatment table until surgery.

Definitive Treatment

Closed treatment remains the standard of care for most spinal injuries. In a few situations surgical intervention is clearly required, including skeletal disruption in the presence of a progressive neurologic deficit and purely ligamentous injuries in a skeletally mature patient. Such ligamentous injuries require spinal fusion to obtain stability. It should also be noted that the presence of a neurologic injury is not an absolute indication for surgery. The remaining gamut of spinal injuries can be treated without surgery. Closed treatment options include bedrest, halo apparatus, external orthosis, or a cast. Many unstable injuries can be treated with an initial period of bedrest in a kinetic treatment bed followed by bracing and mobilization once some early healing has been achieved. The absence of significant pain should be the clinical indicator of the patient’s readiness to be cleared from the kinetic treatment bed and mobilized. Upright films in the external orthosis should be obtained to confirm that the spinal column is stable at this point.

Timing of Surgical Intervention

Debate continues over the appropriate timing of traction or surgery in cases of acute spinal cord injury. It is difficult to demonstrate improvement in neurologic function from acute surgical intervention.25 Complete cord injuries and neurologically intact patients are very likely to remain neurologically unchanged with appropriate surgical or nonoperative care. Incomplete lesions typically improve with either surgical or nonsurgical care. Late surgery with decompression of the spinal canal in incomplete cord injuries has been shown to improve neurologic function even several years following the traumatic event.26,27 In the acute setting, there is sparse and unconvincing evidence supporting early surgery. Surgery for the purpose of spinal canal decompression in a neurologically intact patient is difficult to defend considering that several series have shown dramatic spinal canal remodeling over time in patients with and without surgery.28–35

Upper Cervical Injuries

Occipitocervical injuries are most often fatal and typically found postmortem. When encountering a patient with such an injury, the treating physician must be vigilant about the diagnosis to ensure the patient’s survival. Initially, such patients should be meticulously immobilized on a backboard with a collar and the head secured with sandbags and tape. Atlanto-occipital disassociation is then stabilized with a halo vest until definitive surgical stabilization is performed.36 It should be noted that traction for type II injuries (axial distraction) can be catastrophic and is strictly contraindicated. The injury is treated with dorsal occipital cervical fusion with at least 3 months of halo vest immobilization. Occipital condyle fractures and Jefferson or atlas ring fractures are typically managed with an orthosis or a halo.37

Odontoid fractures depend on the injury itself. Many can be treated with a rigid orthosis or halo vest. Type I and type III fractures typically heal uneventfully and have a good prognosis without surgery. Transverse type II fractures through the waist of the odontoid have a high associated nonunion rate and are therefore the ideal fractures for surgical treatment. A dorsally displaced odontoid fracture is more likely to be treated with surgery.38–43 Polin reported on a series of patients treated with a rigid collar as opposed to a halo. More nonunions were associated with the type II fractures. However, there was no statistically significant difference between the orthoses used.43 Chronic odontoid nonunions in the elderly can often be followed and may not require surgical intervention. In a series of persistent nonunions, no progression of atlantoaxial instability or neurologic deficit was noted or myelopathic symptoms during the follow-up period.44

At later reassessment of stability, transverse ligament ruptures can be managed in an orthosis if a bony avulsion occurs.45,46 If successful, this avoids the significant loss of motion following an atlantoaxial arthrodesis. Dickman et al. demonstrated a 100% failure to heal in complete ligamentous disruptions. These injuries often result in a significant incidence of neurologic injury, and there is frequent association with other upper cervical injuries. They should be treated with C1-2 arthrodesis.47

The vast majority of other axis injuries can be stabilized with an orthosis or a halo vest. Traumatic spondylolisthesis of the axis most commonly occurs secondary to a hyperextension and axial load mechanism. Neurologic deficit rarely occurs, with the exception for the atypical fracture that occurs ventral to the dorsal vertebral body cortex.48 These atypical fractures may require surgery to prevent neurologic decline. Severe hangman’s fractures with instability through the C2-3 disc space require surgery. Most other axis injuries can be managed successfully nonoperatively.37,40,49–52

Subaxial Injuries

Isolated minimally displaced subaxial lamina and spinous process fractures can be treated with a cervical collar. Single-level axial compression fractures with intact ligaments can be managed similarly. Minor ventral column injuries due to a flexion-compression mechanism with intact dorsal ligaments should also be stabilized in an orthosis.

The treatment of burst-type fractures is controversial due to how imprecisely mechanical stability is determined. Fractures that are thought to be mechanically stable can be treated nonoperatively but require close follow-up. In the setting of cord compression from retropulsed bone fragments in the neurologically compromised patient, ventral decompression and fusion is clearly indicated. In between is a gray area that certainly requires greater investigation to guide treatment.

In subaxial facet dislocations, the nonoperative management is reduction as soon as medically appropriate. After reduction, surgical stabilization is usually necessary because up to 40% of cases remain unstable even after 3 months of halo immobilization.53–55

Hyperextension injuries are common after falls in the elderly and can result in spinal cord injury in the absence of mechanical instability. The resulting central cord syndrome results from neural compression due to narrowing of the canal from long-standing spondylosis and the hyperextended position at impact. Surgery is not performed to address instability but may be utilized to decompress the cord or to prevent further injury. A collar may be placed acutely for patient comfort.

Table 69-1 summarizes the treatment options for cervical fractures.

TABLE 69-1 Treatment Options for Cervical Injuries

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Thoracic and Thoracolumbar Fractures

Transverse process fractures that are isolated require no treatment and can be mobilized as tolerated. With multiple transverse process fractures, a thorough assessment must be made to determine instability or a fracture-dislocation. An L5 transverse process fracture has a 61% association with a pelvic or sacral fracture.16 These should be critically evaluated with a pelvic CT scan to rule out an associated pelvic injury.

Compression fractures without injury to the dorsal ligamentous complex can be mobilized as tolerated with an orthosis for comfort. Ohana et al. have even suggested that an orthosis may not be necessary.56 Multiple-level compression fractures in a young healthy individual suggest a high-energy mechanism. Particular attention must be paid to the dorsal ligamentous complex at all injured levels. If a dorsal ligamentous injury is present, surgical treatment is necessary.

Burst Fractures

Most lumbar and thoracolumbar burst fractures can be managed nonsurgically (Table 69-2). Several excellent studies have shown comparable functional outcome to surgery, with less morbidity from nonsurgical treatment. The key to establishing stability is the intact dorsal ligamentous complex. Wood et al. demonstrated in a prospective, randomized series comparable or better outcomes than in those patients treated surgically.57 Although Denis et al. in 1984 reported a 17% increase in neurologic deficit with nonoperative treatment, this has not since been reported.58 There are multiple reports with minimal complications and almost no progression of neurologic deficits. There appears to be little correlation to long-term pain and disability with degree of kyphosis.28,29,31,32,57–87

TABLE 69-2 Treatment Options for Thoracic and Lumbar Injuries

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Although the dorsal ligamentous complex is the key to deciding on operative versus nonoperative treatment, a definitive way of defining stability can be elusive in many cases. A palpable interspinous gap or pain that occurs with deep palpation is a good indicator of dorsal ligamentous involvement. Although it has been popularized that kyphosis can be an indicator of dorsal injury, this has not been conclusive. Many utilize MRI to assess the dorsal ligaments, although the findings can often be ambiguous.83 Lee et al. reported that a fat-suppressed T2 sagittal MRI was the most reliable way to assess the dorsal ligamentous complex. In their series of 34 burst fractures they identified 30 patients with dorsal ligamentous instability,88 which seems to be an extremely high number of unstable fractures. Instead, it may be that MRI changes may not necessarily correlate with competency. Oner et al. did a similar study and was unable to correlate the MRI to an Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification to determine treatment.89 The treating physician must therefore exercise a great deal of judgment in deciding which fractures require surgical intervention.

Multiple-Level and Noncontiguous Injuries

In cases of multiple-level injuries, particularly noncontiguous injuries, bear in mind that surgical intervention requires multiple-level fusions at multiple levels of the spine or one long fusion mass. This fact has dramatic effects on the final range of motion, function, and long-term outcome. Avoiding fusion, therefore, greatly benefits this patient population (Figs. 69-4 and 69-5). Another alternative is the Jacobs rod long and fuse short technique (i.e., using long rods to reduce fractures while fusing the minimum number of segments). In this technique, the instrumentation is later removed to restore motion at the unfused segments.90

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FIGURE 69-4 Thirty-year-old male involved in a motorcycle accident. A and B, Sagittal CT images demonstrating a burst fracture of L3 and multilevel posterior injury. C, Coronal CT image with a sagittal fracture line through L3 and an oblique fracture through the right side of L4. D, Axial CT image demonstrating canal compromise.

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FIGURE 69-5 The same patient as in Figure 69-4 returned to work 3 months following injury, after being treated conservatively in a RotoRest bed. Anteroposterior (A) and lateral (B) radiographs at 2-year follow-up demonstrating adequate alignment and healing of the fractures. C, Axial CT image showing canal remodeling at 2 years.

Kinetic Therapy

Whether used as a temporary measure or for definitive treatment, kinetic therapy is a useful adjunct to the management of spinal injury. A specially designed hospital bed achieves kinetic therapy by continually rotating the patient through a minimum of 40 degrees. The Kinetic Concepts, Inc. (KCI, San Antonio, TX) RotoRest bed stabilizes the spine while providing kinetic therapy. The Hill-Rom (Batesville, IN) SPO2RT and KCI TriaDyne beds provide patient rotation but are not adequate for spinal stabilization. Use of kinetic therapy has demonstrated shorter ICU stays, decreased time on a ventilator, better pulmonary outcomes, and a lower incidence of adult respiratory distress syndrome (ARDS) in trauma patients.91–103

Initial Emergency Department Stabilization

A trauma patient who cannot be immediately mobilized can be treated very effectively with kinetic therapy. Until the spine is stabilized surgically or sufficient time passes for bony healing, the KCI RotoRest bed can provide 24-hour-a-day mobilization and pulmonary benefit as well as maintaining spine stabilization.5,104,105 Even after spine stabilization surgery, kinetic therapy with a SPO2RT or TriaDyne bed can minimize postoperative pneumonia and ARDS.

Short-Term Treatment

In the setting of multiple-level noncontiguous fractures, the patient can be maintained on a RotoRest bed or in traction to allow for initial osseous healing of some of the fractures.106 Cancellous vertebral body fractures heal rapidly if the patient is receiving adequate nutrition. A period of 2 to 3 weeks of initial healing may allow for single-level fusion or no surgery at all instead of a multiple-level procedure.

Long-Term Definitive Treatment

For polytrauma patients with multiple fractures and life-threatening associated injuries, surgery is not an attractive solution and in many instances is contraindicated. Four to six weeks of recumbency in a kinetic therapy bed can allow for enough healing to mobilize the patient in a brace.79

Neurologic Complete Cord Injuries

Although many advocate immediate stabilization for earlier rehabilitation in a patient with a complete cord injury, there is a dramatically increased risk of infection in the long term. In the neurologically complete patient, the incidence of acute wound infection has been reported to be as high as 25% to 40%.107 Furthermore, these patients experience multiple urinary tract infections over the course of their lifetimes, and these transient episodes of bacteremia or septicemia can lead to late infections.

Penetrating Injuries and Gunshot Wounds

Low-velocity missile wounds to the spine rarely require surgical stabilization. Exploration of missile tracts for vessel or hollow viscous injuries should be determined by the general surgery trauma team. Removal of foreign bodies for spinal canal decompression is not routinely warranted at spinal cord levels. Some investigators report improved neurologic function with canal decompression in the region of the cauda equina. The risk of such acute complications as spinal fluid fistulas, infections, and wound dehiscence is increased with surgical intervention.108–111 Blood levels can be monitored over time if there is concern of plumbism. In the setting of increased serum lead levels, the bullet fragments can be removed later. This is an uncommon occurrence.112–114

High-velocity gunshot injuries (muzzle velocity >1000 fps) require a thorough debridement in the operating suite, a repeat debridement 48 to 72 hours later, and possible spinal stabilization. Fusion may be necessary as the tissue destruction and energy absorbed are orders of magnitude greater than with a nongunshot injury. The energy causing the tissue destruction is directly proportional to the square of the projectile velocity.

Osteoporosis Fractures

All osteoporotic fractures should be treated nonsurgically if possible. Short-term bedrest, bracing, or cement augmentation is usually preferable to surgical stabilization. Constructs that are usually effective in the nonosteoporotic spine may not hold in soft bone. The difference in stiffness between the instrumentation and bone presents a problem at the bone-implant interface, with a high likelihood of implant pullout or failure. Adjacent segment fractures also pose a significant problem due to the stiff instrumented segment producing a stress riser and the presence of osteoporotic bone.115,116

Keys to Nonoperative Care

The spine must be accurately assessed and then reassessed to ensure the accurate determination of spinal stability. Stability is reevaluated when the patient is able to be mobilized and examined upright. Upright radiographs in the orthosis or definitive method of treatment provide another chance to determine the level of stability and effectiveness of treatment. Mehta et al. reported that in 25% of their patients, the upright radiographs resulted in a change in treatment.117

In cervical injuries, imaging studies must be scrutinized for any subluxation to determine if any ligamentous or facet instability was not previously appreciated. In thoracic or lumbar injuries, the initial upright radiograph is another opportunity to assess dorsal ligamentous instability. Once again, kyphosis alone does not mean dorsal ligamentous disruption. It must be determined whether the kyphosis is a result of ventral column collapse or dorsal column distraction. One of the most effective ways to determine the significance of the dorsal ligamentous injury is to simply palpate the spinous processes.

The original upright radiograph is then used to measure for progressive kyphosis. Keep in mind that increased kyphosis from the original supine film on a backboard may not be meaningful since normal individuals show more kyphosis when standing in the absence of spinal injury.

Summary

Nonoperative management is initiated at the time of injury in all spinal cases, regardless of the method of definitive treatment. In the field, during transport, and while the patient is being evaluated at the hospital, principles of spinal immobilization must be strictly followed. After an appropriate evaluation via history, physical examination, and imaging, an individualized treatment plan is developed. All treatment options should be thoroughly evaluated and considered. The patient should always be involved in the decision-making process. Few spinal injuries actually require surgical intervention.

Key References

Brunette D.D., Rockswold G.L. Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury. J Trauma. 1987;27(4):445-457.

Denis F., Armstrong G.W., Searls K., Matta L. Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment. Clin Orthop Relat Res. 1984;189:142-149.

McGuire R.A., Neville S., Green B.A., et al. Spinal instability and the log-rolling maneuver. J Trauma. 1987;27(5):525-531.

Pape H.C., Remmers D., Weinberg A., et al. Is early kinetic positioning beneficial for pulmonary function in multiple trauma patients? Injury. 1998;29(3):219-225.

Podolsky S., Baraff L.J., Simon R.R., et al. Efficacy of cervical spine immobilization methods. J Trauma. 1983;23(6):461-465.

Rechtine G.R.2nd, Cahill D., Chrin A.M. Treatment of thoracolumbar trauma: comparison of complications of operative versus nonoperative treatment. J Spinal Disord. 1999;12(5):406-409.

References

The complete reference list is available online at expertconsult.com.

References

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2. Del Rossi G., Heffernan T.P., Horodyski M., et al. The effectiveness of extrication collars tested during the execution of spine-board transfer techniques. Spine J. 2004;4(6):619-623.

3. Rechtine G.R., Del Rossi G., Conrad B.P., et al. Motion generated in the unstable spine during hospital bed transfers. J Trauma. 2004;57(3):609-611. discussion 611–612

4. Curry K., Casady L. The relationship between extended periods of immobility and decubitus ulcer formation in the acutely spinal cord-injured individual. J Neurosci Nurs. 1992;24(4):185-189.

5. McGuire R.A., Neville S., Green B.A., et al. Spinal instability and the log-rolling maneuver. J Trauma. 1987;27(5):525-531.

6. Bearden B.G., Conrad B.P., Horodyski M., et al. Motion in the unstable cervical spine: comparison of manual turning and use of the Jackson table in prone positioning. J Neurosurg Spine. 2007;7(2):161-164.

7. Conrad B.P., Horodyski M., Wright J., et al. Log-rolling technique producing unacceptable motion during body position changes in patients with traumatic spinal cord injury. J Neurosurg Spine. 2007;6(6):540-543.

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15. Gupta A., el Masri W.S. Multilevel spinal injuries. Incidence, distribution and neurological patterns. J Bone Joint Surg [Br]. 1989;71(4):692-695.

16. Nork S.E., Jones C.B., Harding S.P., et al. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma. 2001;15(4):238-246.

17. Carlson G.D., Minato Y., Okada A., et al. Early time-dependent decompression for spinal cord injury: vascular mechanisms of recovery. J Neurotrauma. 1997;14(12):951-962.

18. Brunette D.D., Rockswold G.L. Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury. J Trauma. 1987;27(4):445-447.

19. Eismont F.J., Arena M.J., Green B.A. Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. Case report. J Bone Joint Surg [Am]. 1991;73(10):1555-1560.

20. Jeanneret B., Magerl F., Ward E.H., Ward J.C. Posterior stabilization of the cervical spine with hook plates. Spine (Phila Pa 1976). 1991;16(Suppl 3):S56-S63.

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22. Wimberley D.W., Vaccaro A.R., Goyal N., et al. Acute quadriplegia following closed traction reduction of a cervical facet dislocation in the setting of ossification of the posterior longitudinal ligament: case report. Spine (Phila Pa. 1976). 2005;30(15):E433-E438.

23. Darsaut T.E., Ashforth R., Bhargava R., et al. A pilot study of magnetic resonance imaging-guided closed reduction of cervical spine fractures. Spine (Phila Pa 1976). 2006;31(18):2085-2090.

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27. Bohlman H.H., Kirkpatrick J.S., Delamarter R.B., et al. Anterior decompression for late pain and paralysis after fractures of the thoracolumbar spine. Clin Orthop Relat Res. 1994;300:24-29.

28. Dai L.Y. Remodeling of the spinal canal after thoracolumbar burst fractures. Clin Orthop Relat Res. 2001;382:119-123.

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