Seguimiento

A dorsal approach is the m ainstay approach for all spine surgeons. Dorsal techniques perm it un lim ited spin al level of decom pression , re-du ct ion , an d st abilizat ion , w h ereas ven t ral approach es, even w ith extension, provide a re-stricted exposure to the ventral spine. Poste-rior decom pression via lam inectom ies should be accom panied by instrum ented stabilization to prevent kyphotic deform it y at the CTJ.⁶ The extensions of this approach are the posterior lateral approaches: transpedicular, costotran

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versectom y, an d lateral ext racavit ar y. Th e t ran spedicular approach enables lateral de-com pression (Fig. 12.3c,d). The costotransver-sectom y involves rem oval of the transverse process, 2 to 3 cm of the proxim al rib, and the pedicle; th is rem oval p rovides access to th e an terolateral spinal cord. The lateral extracavi-tar y approach (w hich requires m uch longer rib resection) enables ipsilateral ventral decom -pression and reconstruction of the anterior colum n. W hen done bilaterally, the lateral ex-tracavitar y approach provides circum ferential access to the thecal sac, but this bilateral ap -proach is technically challenging. Resnick and Ben zel²⁰ reported a high incidence of adverse events (55%), w ith pulm onary events as the m ost com m on . The dorsal approach is the ap -proach of choice for m ost spine surgeons for surgical m anagem en t of CTJ injuries, because it perm its decom pression, realignm ent, and spine stabilizat ion via a single incision.

■ Chapter Summary

The CTJ region is a un ique transition zone in w h ich injur y is in frequen t , but w h en it does occur it is often associated w ith severe im pair-m ent. CTJ injuries are challenging to diagn ose, requiring CT an d MRI. Early diagn osis and dis-location reduction m ay im prove the clinical outcom e; how ever, in cases w ith com plete spi-nal cord injur y, the prognosis is poor. Nonoper-ative m anagem ent should be considered for stable CTJ injuries; an orth osis should be con-sidered w ith close follow -u p to iden t ify de-layed in stabilit y. Un st able inju ries sh ou ld be treated surgically, w ith ventral, dorsal, or com

-bination approaches for neural decom pression, realignm ent of spine, and stabilization of the CTJ. Despite advances in techniques and instru-m entation, prevention of coinstru-m plications still de-pends on the surgeon’s understanding of the pertinent an atom y based on preoperative im -aging, and on the surgeon’s experience w ith the chosen approach. CTJ injuries should be approached w ith caution due to the com plex-it y of this region and the potential high perils of detrim ental com plications.

Pearls

Physicians should maintain a high level of suspi-cion for CTJ injury when assessing patients in-volved in high-energy trauma, until such injury is excluded with adequate imaging.

Early closed reduction and decompression of the spinal cord may improve prognosis.

A surgical approach (ventral, dorsal, or combi-nation of both) should be considered based on the clinical and radiographic presentation, and on the surgeon’s experience with appropriate approaches.

Pitfalls

Do not settle for poor visualization of the CTJ re-gion on imaging.

Do not operate on neurologically intact patients without neurophysiological monitoring.

Avoid dorsal decompression of the CTJ without stabilization.

Purely ligamentous injuries are unstable and re-quire stabilization.

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■ Introduction

During assessm ent of a traum a patient in th e em ergency departm ent, the cervical spine is protected un til fract ures or ligam entous dis-ruptions have been identi ed or ruled out be-yond a reasonable doubt.¹ After com pletion of th e prim ar y sur vey and treat m ent of the im -m ediate life-threatening injuries, attention -m ay focus on the cer vical spine. Follow ing the inte-grat ion of th e prin cipal in form at ion , in clud-ing traum a m echanism , ndclud-ings on the physical exam ination, and im aging studies, the presence or absence of clin ically signi cant cer vical in-juries can t ypically be ascertained w ith a high level of con dence and reliabilit y. Under som e circum stances, however, the inform ation needed to determ ine the degree of cer vical injury can be m isleading, resu lt ing in a late or even an in correct diagnosis and, subsequently, a sub-optim al outcom e. Speci cally, for patients w ith ankylosis of the spinal colum n suspected of a cer vical injur y, the traum a m echanism and results obtained from physical an d radiograph -ical exam inat ion m ay be m arkedly di erent com pared w ith a general traum a population.^2,3 Spinal ankylosis is caused m ainly by t w o distinct pathological processes: ankylosing spon -dylit is (AS) an d di u se idiopath ic skelet al hyperostosis (DISH). The presence of both AS

and DISH is increasingly being recognized as an im portant m odi er for the diagnostic w orkup, treatm ent, rehabilitation, and, ultim ately, clin-ical outcom e of traum a patien ts.⁴ This chapter discusses how AS and DISH m ay in uence de-cision m aking during various critical phases, from the initial (prehospital) assessm ent to discharge and follow -up of patien ts w ith cervi-cal injury.

■ Etiology and Epidemiology