Legacy: "Atlast of Neurosurgery" / L.Karaguiosov, A. Ramadan, K.Karaguiosov / Kiwait/ 1998
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12. SURGICAL TREATMENT OF SPINAL INJURY
When the structures of the spine fail to dissipate an impact sufficiently, this results in damage of bony, muscular and ligamentous structures and possible affection of the spinal cord. Several types of forces can provoke excessive flexion, extension, rotation, compression, dislocation and shearing. As a consequence, bone fractures, ligamentous and disc ruptures, dislocations or subluxations may occur. Secondary impact on the cord can be induced by displaced vertebras, fragments of bone and discs or by the primary impact. After the mechanical cord injury, additional damage can follow through intrinsic mechanisms, leading to ischaemia, calcium influx, lipid peroxidation and free radical activation. As a whole, the existing pathological changes can be summarized under two major groups: biomechanical for the spine and neurological for cord and roots. They determine the principles of surgical treatment: alignment of the spine, stabilization, and decompression of neural structures.
Diagnostic evaluation should include assessment of these three major problems to solve: alignment, stability and the presence of compression. Radiological diagnosis is crucial. Initiating the work up with X-ray of the presumably affected area on admission, imaging is extended to CT scan visualization in different planes and MRI or myelography to detect neural damage. Spinal trauma most often affects segments bordering mobile to relatively immobile areas, such as the cervical and thoracolumbar segments. Immobilization is the first and most important temporary measure to undertake when spinal injury is suspected; it must be maintained until instability is not ruled out. If alignment is found compromised and instability is possible, a strategy for restoration must be established.
The presence of any neurological deficit requires the exclusion of neural compression, and if such is found, appropriate decompression must be undertaken. Alignment can be obtained by external or internal repositioning, or simply by axial skeletal traction. Stabilisation is either internal or external. The latter is relying on natural stabilization by healing, especially bone repair. Decompression is adjusted to the existing type of compression in such a way, that minimal additional destabilization is inflicted by the approach, and any compressing agent is removed reducing to a minimum manipulation of neural tissue. Often decompressive and stabilizing techniques are combined.