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Spinal Neurosurgery
ii
NEUROSURGERY BY EXAMPLE
Key Cases and Fundamental Principles
Series edited by: Nathan R. Selden, MD, PhD, FACS, FAAP
Volume 1: Peripheral Nerve Surgery, Wilson and Yang

Volume 2: Surgical Neuro-Oncology, Lonser and Elder
Volume 3: Spinal Neurosurgery, Harrop and Maulucci
Spinal Neurosurgery
Edited by
James S. Harrop, MD, FACS

Professor, Departments of Neurological and Orthopedic Surgery
Director, Division of Spine and Peripheral Nerve Surgery
Neurosurgery Director of Delaware Valley SCI Center
Thomas Jefferson University
Philadelphia, Pennsylvania
and
Christopher M. Maulucci, MD, FACS

Associate Professor of Neurological Surgery
Director of Spine Surgery
Tulane University
New Orleans, Louisiana
1
iv
1
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Library of Congress Cataloging-in-Publication Data

Names: Harrop, James S., editor. | Maulucci, Christopher M., editor.
Title: Spinal neurosurgery /edited by James S. Harrop, Christopher M. Maulucci.
Description: New York, NY : Oxford Unversity Press, [2019] | Includes bibliographical references.
Identifiers: LCCN 2018029143 | ISBN 9780190887773 (pbk.)
Subjects: | MESH: Spine—surgery | Spinal Diseases—surgery | Spinal
Injuries—surgery | Neurosurgical Procedures—methods
Classification: LCC RD533 | NLM WE 727 | DDC 617.4/71059—dc23
LC record available at https://lccn.loc.gov/2018029143
This material is not intended to be, and should not be considered, a substitute for medical or other professional
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Contents
Series Editor’s Preface vii

Contributors ix
1. Odontoid Fracture Type II 1

Daniel Tarazona and Alexander R.Vaccaro
2. Cervical Fracture Dislocation 11
Jason Liounakos, G. Damian Brusko, and Michael Y.Wang
3. Occipitocervical Dislocation 21
Alexander B. Dru and Daniel J. Hoh
4. Central Cord Injury 31
Bizhan Aarabi, Charles A. Sansur, David M. Ibrahimi, Mathew Kole, and Harry Mushlin
5. Atlantoaxial Instability 41
Jonathan M. Parish and Domagoj Coric
6. Basilar Invagination and Cranial Settling 49
Benjamin D. Elder and Jean-Paul Wolinsky
7. Cervical Myelopathy: Lordosis 63
Randall J. Hlubek and Nicholas Theodore
8. Cervical Myelopathy: Kyphosis 71
Mario Ganau, So Kato, and Michael G. Fehlings
9. Ossification of the Posterior Longitudinal Ligament: Cervical 81
Todd D.Vogel, Hansen Deng, and Praveen V. Mummaneni
10. Cervical Radiculopathy Due to Central Disc: ACDF/Arthroplasty 93
Mazda K.Turel and Vincent C.Traynelis
11. Cervical Radiculopathy: Lateral Disc Foramintomy 101
Michael Karsy, Ilyas Eli, and Andrew Dailey
12. Thoracic Disc Herniation 109
Derrick Umansky and James Kalyvas
13. Thoracolumbar Burst Fractures 123
Omaditya Khanna, Geoffrey P. Stricsek, and James S. Harrop
14. Thoracic Cord Compression: Extradural Tumor 133
Tej D. Azad, Anand Veeravagu, John K. Ratliff, and Atman Desai
v
vi
Contents
15. Spinal Cord Tumor: Intramedullary 141

Rajiv R. Iyer and George I. Jallo
16. Spinal Cord Tumor: Intradural Extramedullary 149
Michael A. Galgano, Jared Fridley, and Ziya Gokaslan
17. Radiation-Sensitive Spine Tumor 159
Adam M. Robin and Ilya Laufer
18. Cauda Equina Syndrome 175
Emily P. Sieg, Justin R. Davanzo, and John P. Kelleher
19. Lumbar Stenosis 183
Miner N. Ross and Khoi D.Than
20. L4–L5 Degenerative Spondylolisthesis 191
Rani Nasser, Scott Zuckerberg, and Joseph Cheng
21. Isthmic Spondylolisthesis 199
Evan Lewis and Charles A. Sansur
22. Lumbar Degenerative Scoliosis 207
Michael LaBagnara, Durga R. Sure, Christopher I. Shaffrey, and Justin S. Smith
23. Flat Back Deformity 215
Yusef I. Mosley and James S. Harrop
24. Diskitis 225
Jacob R. Joseph, Brandon W. Smith, and Mark E. Oppenlander
25. Epidural Abscess 235
Hector G. Mejia Morales and Manish K. Singh
26. Nonsurgical Spinal Diseases 243
Lahiru Ranasinghe and Aimee M. Aysenne
Index 253
vi
Series Editor’s Preface
I am delighted to introduce this volume of Neurosurgery by Example: Key Cases and

Fundamental Principles. Neurosurgical training and practice are based on managing a
wide range of complex clinical cases with expert knowledge, sound judgment, and
skilled technical execution. Our goal in this series is to present exemplary cases in the
manner they are actually encountered in the neurosurgical clinic, hospital emergency
department, and operating room.
In this volume, Dr. Jim Harrop, Dr. Christopher Maulucci, and their contributors
share their extensive wisdom and experience with all major areas of spinal neurosur-
gery. Each chapter contains a classic presentation of an important clinical entity, guiding
readers through assessment and planning, decision-making, surgical procedure, after
care, and complication management. “Pivot points” illuminate the changes required to
manage patients in alternate or atypical situations.
Each chapter also presents lists of pearls for the accurate diagnosis, successful treat-
ment, and effective complication management of each clinical problem. These three
focus areas will be especially helpful to neurosurgeons preparing to sit for the American
Board of Neurological Surgery oral examination, which bases scoring on these three
topics.
Finally, each chapter contains focused reviews of medical evidence and expected
outcomes, helpful for counseling patients and setting accurate expectations. Rather than
exhaustive reference lists, the authors provide lists of high-priority additional reading
recommended to deepen understanding.
The resulting volume should provide you with a dynamic tour through the prac-
tice of spinal neurosurgery, guided by some of the leading experts in North America.
Additional volumes cover each subspecialty area of neurosurgery using the same case-
based approach and board review features.
Nathan R. Selden, MD, PhD
Campagna Professor and Chair
Department of Neurological Surgery
Oregon Health and Science University
Portland, Oregon
vii
vi
Contributors
Bizhan Aarabi, MD, FRCSC, FACS Domagoj Coric, MD

Professor, Neurosurgery Chief, Department of Neurosurgery
Director of Neurotrauma, R. Adams Carolinas Medical Center
Cowley Shock Trauma Center Carolina Neurosurgery and Spine
Department of Neurosurgery Associates
University of Maryland School of Charlotte, North Carolina
Medicine
Baltimore, Maryland Andrew Dailey, MD
Professor
Aimee M. Aysenne, MD, MPH Department of Neurosurgery
Director of Neurocritical Care University of Utah
Department of Clinical Neurosciences Salt Lake City, Utah
Tulane University, School of Medicine
New Orleans, Louisiana Justin R. Davanzo, MD
Department of Neurological Surgery
Tej D. Azad, BA Penn State Health Milton S. Hershey
Medical Student Medical Center
Department of Neurosurgery Pennsylvania, Pennsylvania
Stanford University School of Medicine
Stanford, California Hansen Deng, BS
Medical Student
G. Damian Brusko, BS Department of Neurological Surgery
Department of Neurological Surgery University of California, San Francisco
The Miami Project to Cure Paralysis San Francisco, California
University of Miami Miller School of
Medicine Atman Desai, MD
Miami, Florida Assistant Professor
Department of Neurosurgery
Joseph Cheng, MD, MS Stanford University School of Medicine
Professor of Neurosurgery Stanford, California
Frank H. Mayfield Chair
Department of Neurological Surgery Alexander B. Dru, MD
University of Cincinnati Health University of Florida
Cincinnati, Ohio Department of Neurosurgery
Gainesville, Florida
ix
x
Contributors
Benjamin D. Elder, MD, PhD James S. Harrop, MD, FACS

Assistant Professor of Neurosurgery, Professor, Departments of Neurological
Orthopedic Surgery, and Biomedical and Orthopedic Surgery
Engineering Director, Division of Spine and Peripheral
Mayo Clinic School of Medicine Nerve Surgery
Rochester, Minnesota Neurosurgery Director of Delaware Valley
SCI Center
Ilyas Eli, MD Thomas Jefferson University
Resident Philadelphia, Pennsylvania
University of Utah Randall J. Hlubek, MD
Salt Lake City, Utah Department of Neurosurgery
Barrow Neurological Institute
Michael G. Fehlings, MD, PhD, St. Joseph’s Hospital and Medical Center
FRCSC, FACS Phoenix, Arizona
Vice Chair Research
Professor of Neurosurgery Daniel J. Hoh, MD
McLaughlin Scholar in Molecular Medicine Associate Professor
Co-Chair Spinal Program Dunspaugh-Dalton Endowed Professorship
University of Toronto Department of Neurological Surgery
Gerry and Tootsie Halbert Chair in University of Florida
Neural Repair and Regeneration Gainesville, Florida
Head, Spinal Program
Toronto Western Hospital David M. Ibrahimi, MD
Toronto, Ontario, Canada Assistant Professor
Jared Fridley, MD University of Maryland School of
Assistant Professor of Neurosurgery Medicine
Brown University Baltimore, Maryland
Providence, Rhode Island Rajiv R. Iyer, MD
Michael A. Galgano, MD The Johns Hopkins University School
Clinical Instructor of Neurosurgery of Medicine
Brown University Baltimore, Maryland
Providence, Rhode Island George I. Jallo, MD
Professor of Neurosurgery, Pediatrics
Mario Ganau, MD, PhD, FACS and Oncology
Spine Fellow Director, Institute for Brain Protection
Toronto Western Hospital Sciences
Toronto, Ontario, Canada Johns Hopkins All Children’s Hospital
St. Petersburg, Florida
Ziya Gokaslan, MD
Professor and Chair Jacob R. Joseph, MD
Brown University Department of Neurosurgery
Department of Neurosurgery University of Michigan
Providence, Rhode Island Ann Arbor, Michigan
x
Contributors
James Kalyvas, MD Evan Lewis, MD

Neurosurgeon Neurosurgeon
Ochsner Clinic Foundation Baptist Medical Group–Neurosurgery
New Orleans, Louisiana Pensacola, Florida
Michael Karsy, MD, PhD Jason Liounakos, MD

Resident Resident
Department of Neurosurgery Department of Neurological Surgery
University of Utah Univeristy of Miami Miller School of
Salt Lake City, Utah Medicine
Miami, Florida
So Kato, MD
Spine Fellow Christopher M. Maulucci,
Toronto Western Hospital MD, FACS
Toronto, Ontario, Canada Associate Professor of Neurological
Surgery
John P. Kelleher, MD Assistant Residency Program Director
Department of Neurological Surgery School of Medicine
Penn State Health Milton S. Hershey Tulane University
Medical Center New Orleans, Louisiana
Pennsylvania, Pennsylvania
Hector G. Mejia Morales
Omaditya Khanna, MD Medical student
Resident Tulane University School of Medicine
Thomas Jefferson University Hospital New Orleans, Louisiana
Yusef I. Mosley, MD
Mathew Kole, MD Department of Neurosurgery
Resident in Training Thomas Jefferson University
Department of Neurosurgery Philadelphia, Pennsylvania
University of Maryland School of
Medicine Praveen V. Mummaneni, MD
Baltimore, Maryland Joan O’Reilly Endowed Professor
Vice Chairman
Michael LaBagnara, MD University of California, San Francisco
Assistant Professor of Neurological Neurosurgery
Surgery San Francisco, California
University of Tennessee
Semmes-Murphey Clinic Harry Mushlin, MD
Memphis, Tennessee Resident in Training
Ilya Laufer, MD University of Maryland School of
Department of Neurosurgery Medicine
Memorial Sloan Kettering Cancer Center Baltimore, Maryland
New York, New York
xi
xi
Contributors
Rani Nasser, MD Christopher I. Shaffrey, MD

Clinical Instructor of Neurosurgery John A. Jane Professor of Neurological
University of Cincinnati Health Surgery
Cincinnati, Ohio Division Head Spinal Surgery
Professor of Orthopaedic Surgery
Mark E. Oppenlander, MD University of Virginia Medical Center
Assistant Professor Charlottesville, Virginia
University of Michigan Emily P. Sieg, MD
Ann Arbor, Michigan Department of Neurological Surgery
Penn State Health Milton S. Hershey
Jonathan M. Parish, MD Medical Center
Resident Physician Pennsylvania, Pennsylvania
Carolinas Medical Center
Charlotte, North Carolina Manish K. Singh, MD
Assistant Professor of Neurological
Lahiru Ranasinghe, BS Surgery
Medical Student Director of Spine Surgery Program
Department of Clinical Neuroscience Tulane University School of Medicine
Tulane University School of Medicine New Orleans, Louisiana
Brandon W. Smith, MD, MS
John K. Ratliff, MD Department of Neurosurgery
Professor University of Michigan
Department of Neurosurgery Ann Arbor, Michigan
Stanford University School of Medicine
Stanford, California Justin S. Smith, MD, PhD
Harrison Distinguished Professor
Adam M. Robin, MD Neurological Surgery
Department of Neurosurgery University of Virginia Medical Center
Memorial Sloan Kettering Cancer Center Charlottesville,Virginia
New York, New York
Geoffrey P. Stricsek, MD
Miner N. Ross, MD, MPH Resident
Resident Physician Thomas Jefferson University
Department of Neurological Surgery Philadelphia, Pennsylvania
Oregon Health and Science University
Portland, Oregon Durga R. Sure, MD
Charles A. Sansur, MD University of Virginia
Associate Professor Charlottesville, Virginia
University of Maryland School of Daniel Tarazona, MD
Medicine Department of Orthopedics
Baltimore, Maryland Rothman Institute
xii
Contributors
Khoi D. Than, MD Anand Veeravagu, MD

Assistant Professor Assistant Professor
Neurological Surgery Department of Neurosurgery
Oregon Health and Science University Stanford University School of Medicine
Portland, Oregon Stanford, California
Nicholas Theodore, MD Todd D. Vogel, MD

Department of Neurosurgery Minimally Invasive and Complex
Barrow Neurological Institute Spine Fellow
St. Joseph’s Hospital and Medical Center Department of Neurological Surgery
Phoenix, Arizona University of California, San Francisco
San Francisco, California
Vincent C. Traynelis, MD
Professor Michael Y. Wang, MD
Department of Neurosurgery Chief of Neurosurgery
Rush University Medical Centre University of Miami Hospital
Chicago, Illinois Professor
Departments of Neurological Surgery
Mazda K. Turel, MBBS and Rehabilitation Medicine
Clinical Fellow in Cerebrovascular and University of Miami School of Medicine
Bypass Surgery Miami, Florida
Rush University Medical Centre Jean-Paul Wolinsky, MD
Chicago, Illinois Department of Neurosurgery and
Oncology
Derrick Umansky, MD Clinical Director of the Johns Hopkins
Resident Spine Program
Department of Neurosurgery Johns Hopkins University
Tulane University School of Medicine Baltimore, Maryland
Scott Zuckerberg, MD, MPH
Alexander R. Vaccaro, MD, Co-Director
PhD, MBA Research of the Vanderbilt Sports
Department of Orthopedic Surgery Concussion Center Research Group
Rothman Institute (President) Department of Neurological Surgery
Philadelphia, Pennsylvania Vanderbilt University Medical Center
Nashville, Tennessee
xiii
vxi
Odontoid Fracture Type II
Daniel Tarazona and Alexander R. Vaccaro
Case Presentation
A 79-year-old woman presents to the emergency department after falling at a nursing

1
home. She denies loss of consciousness. She arrived in a cervical collar placed prior to
transfer with a chief complaint of neck pain. She denies any paresthesias or weakness.
She is hemodynamically stable and is awake, alert, and oriented. Upon physical examina-
tion there is midline cervical spine tenderness without step-offs or deformities. A neu-
rological exam revealed 5/5 motor strength throughout, no sensory deficits, 1+ DTR
throughout, and a normal rectal examination.
Questions
1. What is the likely diagnosis?

2. What is the most appropriate imaging modality?
3. How are odontoid fractures classified?
Assessment and Planning
Based on the history and physical exam, the surgeon suspects a cervical spine frac-
ture. The differential diagnosis includes injuries to the upper cervical, subaxial cervical,
and upper thoracic spine. Due to the initial concern for a cervical spine injury, spine
precautions are maintained and a dedicated computed tomographic (CT) scan of the
cervical, thoracic, and lumbar spine is obtained revealing a type II odontoid fracture.
Oral Boards Review: Diagnostic Pearls
1. The Anderson and D’Alonzo classification for odontoid fractures lends prog-
nostic information for risk of nonunion and assists with treatment planning.
2. CT scan is the preferred imaging modality with high inter-and intrarater
agreement. It also assists with diagnosis of concomitant spinal injuries.20
3. CT or magnetic resonate (MR) angiography should be considered if vertebral
artery injury is clinically suspected.
Initial radiographic evaluation of the cervical spine includes anteroposterior (AP),

lateral, and open-mouth odontoid views and CT of the cervical spine. Magnetic
1
2
Spinal Neurosurgery
Anderson and D’Alonzo
Type I
Type II
Type III
Figure 1.1 Anderson and D’Alonzo.
resonance imaging (MRI) is warranted with neurologic injury or concern for concom-
itant ligamentous injury. If posterior instrumentation is anticipated, then a CT angio-
gram may be obtained to evaluate for potential vascular anomalies that would preclude
safe C2 pars, C2 pedicle, C1–C2 transarticular, or C1 lateral mass screw placement.
Odontoid fractures can be classified into three types as described by Anderson and
D’Alonzo (Figure 1.1).3 Type I odontoid fractures represent an avulsion fracture of the tip
of the odontoid through the alar ligament. Type II is the most common C2 fracture pat-
tern and is defined by a fracture line at the base of the odontoid. Type II fractures have the
greatest risk of nonunion due to the disruption of the tenuous blood supply.Type III fractures
occur through the vertebral body and extend into the superior articular facets. Greater vas-
cularity in the C2 body results in a low nonunion rate with cervical orthosis for this frac-
ture type. Grauer and colleagues proposed subclassifying type II fractures to guide treatment
decisions (Figure 1.2).Type IIA are transverse fractures, type IIB are angled anterosuperior to
posteroinferior, and type IIC are either angled from anteroinferior to posterosuperior or are
comminuted fractures.23 This fracture classification is useful when considering an odontoid
screw as patients with a IIC are not appropriate for odontoid screw fixation.
In the present case, CT of the spine demonstrates a displaced type II odontoid frac-
ture with type IIC obliquity (Image 1) and a C3 right transverse process fracture.
There is no apparent cord compression. A CT angiogram does not reveal any vascular
insult or anomalies (Figure 1.3).
2
Grauer
Type II
Subclass A
(Nondisplaced)
Type II
Subclass B
(Displaced transverse
or ant superior to
post inferior)
Type II
Subclass C
(Comminuted or
ant inferior to post
superior)
Figure 1.2 Grauer classification.
Figure 1.3 Sagittal view of cervical spine showing type IIC odontoid fracture.
4
Spinal Neurosurgery
Questions
1. What are risk factors for nonunion?

2. How should management be approached in a patient of advanced age?
3. How do these clinical and radiological findings influence surgical planning?
Decision-Making
No uniform treatment algorithm has been established for odontoid fractures. Instead,
each case should be tailored with special considerations for comorbidities, concomitant
injuries, prior functional status, neurological status, and fracture morphology. Treatment
options are also based on the risk of nonunion, favoring surgical intervention for patients
with a higher risk of nonunion. Known risk factors for nonunion include age 50 years
or greater, comminution, greater than 5 mm of posterior displacement, fracture gap of
more than 1 mm, more than 4 days between injury and treatment, and greater than 10
degrees of angulation. Furthermore, there is extensive literature demonstrating a de-
crease in mortality with operative fixation and an improvement in health-related quality
of life outcomes in type II fractures in the geriatric population.18,19,24
Adults with a type II fracture without nonunion risk factors can be managed in a
hard collar or a halo vest to prevent subsequent displacement. Most commonly, adults
with risk factors for nonunion or geriatric patients who may safely undergo anesthesia
are treated with a posterior C1–C2 fusion. In the properly selected patient, an odontoid
screw may be beneficial, but this has been demonstrated to lead to a high risk of dysphagia
in the elderly as well as screw pull-out in the setting of osteopenia/osteoporosis.16,26
The management of type II odontoid fractures in the elderly has changed in the past
decade. Historically, acceptable outcomes with asymptomatic stable fibrous nonunions
in the elderly have been reported.4 More recent literature supports operative manage-
ment for patients 65 years or older, reporting improved functional outcomes and union
rates, no difference in complications, and a trend toward improved mortality.19 However,
an increased risk of complications can be seen in surgically treated patients 80 years or
older.24 Rigid external immobilization (halo vest) is contraindicated in the elderly due
to high morbidity and mortality rates.5 They generally have lower overall functional
reserve and decreased pulmonary function, so prolonged immobilization could have
morbid implications. Consequently, more surgeons are advocates for early surgical inter-
vention, and there is a growing body of evidence to support this as well.18–20,22,24
There are multiple surgical treatments for odontoid fractures with the most com-
monly used being segmental fixation consisting of C1 lateral mass with either C2 ped-
icle or pars screws. Other options included an anterior odontoid osteosynthesis and
C1–C2 transarticular screw fixation. While posterior instrumentation demonstrated
greater rates of osseous union, anterior odontoid osteosynthesis avoids fusion of the
C1–C2 articulation, which is responsible for 50% of cervical rotation. Each option has
unique advantages and disadvantages which should be balanced with the fracture pat-
tern, body habitus, and patient expectations.
In this case, due to the displacement and instability of the odontoid fracture, as
well as the potential serious complications of immobilization, the surgeon opted
4
for surgical fixation. The surgeon elected for C1–C2 posterior instrumented fusion.
Anterior screw osteosynthesis is often not indicated because of the patient’s age and
potential for fixation failure due to poor screw purchase with osteoporosis, as well as
the fact that lag screw fixation would result in translation and displacement with a type
IIC fracture. Body habitus is also an important consideration as this patient’s obesity
makes anterior odontoid osteosynthesis technically challenging to place a screw due
to the trajectory.
Surgical Procedure
As previously mentioned, there are multiple surgical options for type II odontoid
fracture but here the focus will be on segmental C1–C2 instrumentation and fusion
(C1 lateral mass technique, Figure 1.4).
Positioning and Preparation

The patient should undergo intubation with in-line cervical immobilization to prevent
excessive neck hyperextension. This may be done with a GlideScope or as a fiber-optic
intubation.The Mayfield clamp is applied after intubation. Neuromonitoring is routinely
utilized, and preintubation and prepositioning somatosensory and transcranial motor
evoked potentials (SSEPs and tcMEPs) are recorded. The patient is then positioned
prone with the neck in a slightly flexed position followed by repeat SSEPs and tcMEPs.
The cervical spine is prepped and draped in sterile fashion. If iliac crest bone graft
harvesting is required, then the posterior iliac crest should also be prepped and draped.
Approach
A midline longitudinal incision is utilized. Intraoperative radiographs should be taken to

confirm spinal levels. Particular care should be taken to stay in the midline and follow
the midline raphe for an avascular approach. Subperiosteal dissection of the posterior
elements of C2 and inferior arch of C1 is performed. Avoid sharp dissection lateral to
the C1 lateral masses and cephalad to the C1 ring to reduce risk of injuring the verte-
bral artery. As dissection extends from the base of the C1 arch to the C1 lateral masses,
significant bleeding from the venous plexus in this region may be encountered.
A B
Figure 1.4 (A) C1 lateral mass technique. (B) Retraction of C2 nerve root and
exposure of lateral mass.
5
6
Spinal Neurosurgery
Procedure
Fluoroscopy is initially used to confirm adequate position of C1 relative to C2. Next,

the starting point of the C2 pars screw is determined. A pilot hole is made approxi-
mately 2–3 mm proximal to the C2–C3 facet joint and slightly laterally (2–3 mm) to
the palpated medial border of the C2 isthmus. The drill is angled cephalad and slightly
medial along the path of the C2 isthmus and advanced to the predetermined unicortical
depth. Next, a probe is used to confirm the absence of bony breach, the tract is tapped,
and the screw is placed.
Following placement of C2 pars screw, fluoroscopy is then used to help identify the
starting point and trajectory of the C1 lateral mass screw. Prior to screw placement, the
C2 nerve root must be gently retracted inferiorly, exposing the bony anatomy (Figure
1.5). The entry point is identified 5 mm lateral to the medial aspect of the lateral mass
and just caudal to the C1 posterior arch. A drill can be used to cannulate the lateral
mass, aimed approximately 10 degrees medial with fluoroscopy guiding a cephalad par-
allel trajectory to the midpoint of the C1 anterior arch. Depth gauge measurements
can then confirm the screw length and size prior to its insertion into the lateral mass.
This is repeated for the contralateral C1 lateral mass. Screw positions are checked under
lateral fluoroscopy and rods are placed. The C2 lateral masses and inferior arch of C1
is decorticated and a structural graft is placed in the C1–C2 interspace. Final x-rays are
then taken to confirm hardware positioning.
Oral Boards: Management Pearls
1. Evaluation of vertebral artery anatomy with preoperative imaging,

minimizing sharp dissection around the cephalad edge of the atlas, and using
a superomedial trajectory of C1 lateral mass screw trajectory will reduce the
risk of injury to the vertebral artery.
2. Suboptimal lateral fluoroscopic imaging for C1–C2 instrumentation can re-
sult in improper screw placement and neurologic or vascular injury.
3. C1–C2 polyaxial screw and rod fixation does not require direct odontoid
anatomic reduction, and intraoperative reduction by manipulation can be
achieved using direct manipulation of the C1 posterior arch.
Pivot Points
1. If an aberrant vertebral artery is present, then an alternative operative tech-

nique, such as a C2 laminar screw, should be considered. C1–C2 transarticular
screw and C2 pedicle screw placement should be avoided with aberrant
anatomy.
2. Although the lateral mass screw placement may initially appear to be without
complication, if the screw tip is in close proximity to the vertebral artery,
normal pulsatile flow may result in delayed damage to the vessel. Any concern
for excessive screw length should prompt screw removal, with a shorter screw
subsequently inserted.
6
A B
Figure 1.5 (A,B) Anteroposterior and lateral view of cervical spine with posterior
C1–C2 fusion.
Aftercare
It is recommended that patients undergoing fixation of type II odontoid type fractures

be placed in a cervical orthosis and admitted for close monitoring of potential postoper-
ative complications. In geriatric patients, a soft collar is used, but in high-energy injuries
a hard collar is used. The patient can be mobilized immediately after surgery.
Follow-up imaging should be obtained at 2 weeks and 6–8 weeks to ensure there is
no early hardware failure (Figure 1.5). Also, functional radiographs in flexion and exten-
sion can be obtained to evaluate stability 3–6 months after surgery. Once initial healing
and maintenance of stability is established, the patient may be weaned from the cervical
orthosis.
Complications and Management
The different complications of surgery are largely dependent on the approach and tech-
nique used.These complications can be further categorized into intraoperative and post-
operative complications.
Intraoperative Complications
Neurovascular injuries are the most concerning intraoperative complications. With a

posterior approach, one of the feared complications is injury to the vertebral artery with
screw malposition. An anomalous vertebral artery further increases the risk of injury,
especially with C1–C2 transarticular or C2 pedicle screw placement. Preoperative im-
aging should be closely evaluated for aberrant vessels. Careful intraoperative technique,
avoiding C2 pedicle screws with aberrant vertebral artery anatomy, and directing the C1
lateral mass screw superomedially is essential to avoid vertebral artery damage.13 Damage
to a single vertebral artery may be asymptomatic with intact contralateral supply, but
bilateral injury can be catastrophic.
With an anterior approach, careful retraction and dissection should be used to
avoid injury to the internal carotid and esophagus. Other potential rare complications
7
8
Spinal Neurosurgery
include neurologic injury from past-point drilling or excessive depth of the anterior
odontoid screw.
Postoperative Complications
Following a posterior cervical approach, occipital neuralgia is a common complaint.

To minimize the risk, the C2 nerve root should be gently retracted downward and
protected with a Penfield dissector during lateral mass screw placement. Additionally,
partially threaded screws are used at C1. Wound complications are also more common
with a posterior approach.17 Sterile technique, antibiotics, and proper wound irrigation
help reduce the risk of infection. Surgical site infections with any concern for deep ex-
tension should be addressed with surgical debridement.
Following an anterior approach, dysphagia can be common and may necessitate the
use of a feeding tube.27 This approach can be further complicated by aspiration pneu-
monia, which should be promptly treated with antibiotics.11,27 Hoarseness or vocal cord
paralysis may ensue from neurapraxia or ischemic injury to the superior laryngeal and
recurrent laryngeal nerves, respectively. Patients should also be closely monitored for
signs of respiratory distress as this may be a sign of a retropharyngeal hematoma, which
should be emergently surgically evacuated.
Failure of instrumentation and pseudarthrosis can complicate the postoperative re-
covery. Routine follow-up radiographs are scrutinized for evidence of union. CT scans
can be utilized if the surgeon is concerned for nonunion.
Oral Boards Review: Complications Pearls
1. If there is an inadvertent injury to the vertebral artery, bleeding should be

immediately controlled with primary vascular repair, temporary insertion
of screw into the drilled hole, or by occlusion with a hemostatic agent or
bone wax. If hemorrhage control is not possible and ligation is planned,
intraoperative angiography should be performed.28 Contralateral screw place-
ment should not be attempted to avoid bilateral injury.
2. C2 neuralgia can be a result of C1 lateral mass screw placement or excessive
traction during exposure of lateral mass.
3. Bicortical fixation of lateral mass screw could place the internal carotid artery
at risk for injury.10
4. The congenital arcuate foramen can be confused with the C1 lamina and
must be identified to avoid vertebral artery injury
Evidence and Outcomes
The optimal surgical technique for type II odontoid fractures remains a matter of debate,
with both anterior odontoid screw fixation and posterior cervical atlantoaxial fusion
being acceptable choices.16,24 However, a posterior approach is especially indicated in
geriatric patients and when anterior approaches are contraindicated in cases such as type
IIC odontoid fracture, associated C1–C2 injury, nonreducible fractures, nonunion, large
body habitus with a barrel chest, severe kyphosis, and severe osteoporosis.16 Posterior
8
C1–C2 fusions may also be used for salvage of an anterior fixation failure. Overall, pos-
terior atlantoaxial fixation has been associated with a high rate of fusion, approaching
100%, with a low complication rate thus making it a very effective treatment option for
type II odontoid fractures.12 When appropriately indicated, anterior screw fixation can
provide similar clinical results.24
Another previous area of uncertainty was the optimal management of elderly
patients; however, there has been a significant amount of research in the past decade
demonstrating the superiority of surgery. Vaccaro et al. conducted a multicenter, pro-
spective cohort study comparing operative and nonoperative treatments for patients
65 years of age or older. The study revealed better outcomes, lower nonunion rates, no
difference in complication rates, and a nonsignificant trend toward lower mortality.19
Schroeder et al. performed a systematic review that found a decrease in both short-and
long-term mortality in patients treated surgically. However, there is likely an upper age
to surgery.24 Schoenfeld et al. conducted a retrospective study, and, although patients be-
tween 65 and 74 years old who underwent surgery had lower mortality rates, there was
no difference when patients approached 85 years of age.22
References and Further Readings
1. Boos N, Aebi M, eds. Spinal Disorders: Fundamentals of Diagnosis and Treatment. Berlin:
Springer-Verlag; 2008.
2. Keller S, Bieck K, Karul M, et al. Lateralized odontoid in plain film radiography: Sign of
fractures?—A comparison study with MDCT. RöFo—Fortschritte Auf Dem Geb Röntgenstrahlen
Bildgeb Verfahr. 2015;187(09):801–807. doi:10.1055/s-0035-1553237.
3. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg
Am. 1974;56(8):1663–1674.
4. Pal D, Sell P, Grevitt M.Type II odontoid fractures in the elderly: An evidence-based narrative
review of management. Eur Spine J. 2011;20(2):195–204. doi:10.1007/s00586-010-1507-6.
5. Majercik S, Tashjian RZ, Biffl WL, Harrington DT, Cioffi WG. Halo vest immobilization in
the elderly: A death sentence? J Trauma. 2005;59(2), 350–358.
6. Goel A. Treatment of odontoid fractures. Neurol India. 2015;63(1):7. doi:10.4103/
0028-3886.152657.
7. Robinson Y, Robinson A-L, Olerud C. Systematic review on surgical and nonsurgical treat-
ment of type II odontoid fractures in the elderly. BioMed Res Int. 2014;2014. doi:10.1155/
2014/231948.
8. Posterior C1– C2 Fusion, ClinicalKey. https://www-clinicalkey-com.ezproxy.rowan.edu/
#!/content/book/3-s2.0-B9781437715200000279. Accessed May 1, 2016.
9. Bodon G, Patonay L, Baksa G, Olerud C. Applied anatomy of a minimally invasive muscle-
splitting approach to posterior C1–C2 fusion: An anatomical feasibility study. Surg Radiol
Anat SRA. 2014;36(10):1063–1069. doi:10.1007/s00276-014-1274-x.
10. Seal C, Zarro C, Gelb D, Ludwig S. C1 lateral mass anatomy: Proper placement of lateral mass
screws. J Spinal Disord Tech. 2009;22(7):516–523. doi:10.1097/BSD.0b013e31818aa719.
11. Dailey AT, Hart D, Finn MA, Schmidt MH, Apfelbaum RI. Anterior fixation of odontoid
fractures in an elderly population: Clinical article. J Neurosurg. 2010;12(1):1–8.
12. Harms J, Melcher RP. Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine.
2001;26(22):2467–2471.
9
10
Spinal Neurosurgery
13. Gautschi OP, Payer M, Corniola MV, Smoll NR, Schaller K, Tessitore E. Clinically relevant
complications related to posterior atlanto-axial fixation in atlanto-axial instability and their
management. Clin Neurol Neurosurg. 2014;123:131–135. doi:10.1016/j.clineuro.2014.05.020.
14. Spine Surgery Basics, Springer. http://link.springer.com.ezproxy.rowan.edu/book/
10.1007%2F978-3-642-34126-7. Accessed May 1, 2016.
15. Wang L, Liu C, Zhao Q-H, Tian J-W. Outcomes of surgery for unstable odontoid fractures
combined with instability of adjacent segments. J Orthop Surg. 2014;9:64. doi:10.1186/
s13018-014-0064-9.
16. Joaquim A, Patel A. Surgical treatment of type II odontoid fractures: Anterior odontoid screw
fixation or posterior cervical instrumentation fusion. Am Assoc Neurosurg. 2015:38(4):E11.
17. Harel R, Stylianou P, Knoller N. Cervical spine surgery: Approach-related complications.
World Neurosurg. 2016;94:1–5.
18. Chapman J, Smith JS, Kopjar B, et al. The AOSpine North America Geriatric Odontoid
Fracture Mortality Study: A retrospective review of mortality outcomes for opera-
tive versus nonoperative treatment of 322 patients with long- term follow- up. Spine.
2013;38(13):1098–1104.
19. Vaccaro AR, Kepler CK, Kopjar B, et al. Functional and quality-of-life outcomes in geriatric
patients with type-II dens fracture. J Bone Joint Surg. 2013;95(8):729–735.
20. Barker L, Anderson J, Chesnut R, Nesbit G, Tjauw T, Hart R. Reliability and reproducibility
of dens fracture classification with use of plain radiography and reformatted computer-aided
tomography. J Bone Joint Surg (Am). 2006;88(1):106–112.
21. Koivikko MP, Kiuru MJ, Koskinen SK, Myllynen P, Santavarita S, Kivisaari L. Factors associ-
ated with non-union in conservatively treated type II fractures of the odontoid process. J Bone
Joint Surg (Br). 2004;86-B:1146–1151.
22. Schoenfeld AJ, Bono CM, Reichmann WM, et al. Type II odontoid fractures of the cervical
spine: Do treatment type and medical comorbidities affect mortality in elderly patients?
Spine. 2011;36(11):879–885.
23. Grauer JN, Shafi B, Hilibrand AS, et al. Proposal of a modified, treatment-oriented classifica-
tion of odontoid fractures. Spine J. 2005;5(2):123–129.
24. Schroeder GD, Kepler CK, Kurd M, et al. A systematic review of the treatment of geriatric
type II odontoid fractures. Neurosurgery 2015;77:S6–S14.
25. Smith HE, Kerr SM, Maltenfort M, et al. Early complications of surgical versus conserva-
tive treatment of isolated type II odontoid fractures in octogenarians: A retrospective cohort
study. J Spinal Disord Tech. 2008;21(8):535–539.
26. Andersson S, Rodrigues M, Olerud C. Odontoid fractures: High complication rate associated
with anterior screw fixation in the elderly. Eur Spine J. 2000;9(1):56–59.
27. Vasudevan K, Grossberg JA, Spader HS, Torabi R, Oyelese AA. Age increases the risk of im-
mediate postoperative dysphagia and pneumonia after odontoid screw fixation. Clin Neurol
Neurosurg. 2014;126:185–189.
28. Peng CW, Chou BT, Bendo JA, Spivak JM. Vertebral artery injury in cervical spine sur-
gery: Anatomical considerations, management, and preventive measures. Spine J.
2009;9(1):70–76.
10
Cervical Fracture Dislocation
Jason Liounakos, G. Damian Brusko, and Michael Y. Wang
Case Presentation
A 30-year-old man was transferred to a local level 1 trauma center by emergency med-
2
ical services (EMS) 3 hours after diving into a shallow pond head first. He presents with
a Glasgow Coma Scale (GCS) score of 15, without loss of consciousness, and states that
immediately after the dive he was unable to move his arms or legs. He also complains of
an intermittent burning sensation in his arms and neck pain. He is rigidly immobilized
on a backboard with strict spine precautions. His blood pressure is 90/60 mm Hg with
a heart rate of 55 bpm. Detailed physical examination is significant for 5/5 strength in
deltoids, 4+/5 in biceps, and 0/5 distally. He has absent rectal tone. Biceps reflexes are
2+ bilaterally. Brachioradialis, triceps, patellar, and achilles reflexes are absent bilaterally.
Hoffman sign is negative, and no clonus or plantar response is equivocal. Sensation to
pin prick and light touch is preserved throughout, including the perianal region.
Questions
1. What is the most likely diagnosis?

2. At what level is the suspected injury?
3. What is the international standardized classification system used for spinal
cord injury?
4. What imaging examinations are most appropriate to accurately diagnosis the
injury?
5. Describe common fracture patterns associated with cervical facet dislocations.
Given the acute onset of symptoms in an otherwise healthy patient sustained after an
obvious traumatic injury, the on-call neurosurgeon suspects a traumatic spinal cord in-
jury. Spinal cord injuries in the cervical spine are frequently associated with cervical
fracture dislocation. An initial complete trauma evaluation is necessary to rule out other
injuries, particularly in the setting of neurogenic shock where hypotension may be
related to hemorrhagic shock rather than to a loss of sympathetic tone secondary to
the spinal cord injury. Until the injury has been identified and stabilized, strict spine
precautions are necessary, particularly in the setting of an incomplete spinal cord injury
(as in this case). Instability due to a fracture predisposes the patient to further injury
11
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Spinal Neurosurgery
and risks worsening neurological status so the utmost care must be taken in patient
positioning and transfers.
Assuming a spinal cord injury is present, a complete neurological exam will often
accurately reveal the level of injury. In this patient with grossly intact deltoid and biceps
strength and nothing below, the level of injury is likely C5. Given the presence of in-
tact sensation, this injury is classified as incomplete American Spinal Injury Association
(ASIA) B. The complete guide to the ASIA neurologic exam and ASIA Impairment
Scale is provided in the References and Further Reading section. The neurologic level
is defined as the most caudal level with normal function. Importantly, to accurately di-
agnose a complete (ASIA A) injury, the function of the most caudal spinal segments
(S4–S5) must be evaluated and found to be absent.
Per the 2013 update to the Guidelines for the Management of Acute Cervical Spine
and Spinal Cord Injury provided by the Congress of Neurological Surgeons (CNS),
computed axial tomography (CT) is the recommended initial imaging study for symp-
tomatic trauma patients. CT will quickly and accurately uncover the level of bony injury,
if present, and guide further workup and treatment.
Magnetic resonance imaging (MRI) is extremely useful after the patient has been
initially stabilized to assist in determining the extent of neurologic injury, the presence
of active compression of the spinal cord, and, perhaps somewhat more controversially,
the safety of closed reduction in the presence of facet dislocation. Disrupted or herniated
discs occur in one-third to one-half of patients with cervical facet dislocations. It has
been argued that prereduction MRI is important to identify a traumatic disc hernia-
tion that has the potential to exacerbate spinal cord compression if closed reduction
is performed. In the worst-case scenario, this could potentially lead to an incomplete
injury becoming complete. It is further argued that, in the presence of such a disc
herniation, treatment should proceed with anterior cervical discectomy, followed by
open reduction and internal fixation. Interestingly, however, only a few reports of such
complications exist, and numerous studies have failed to demonstrate an association
between a traumatic herniated disc and postreduction neurologic deterioration in the
awake patient. Even so, the practice at many institutions, including our own, typically
involves urgent MRI in the awake patient with an incomplete spinal cord injury and
cervical fracture dislocation.
In our case, CT demonstrated a grade 2 anterolisthesis of C5 on C6 (Figure 2.1A)
with complete dislocation (“jumped” or “locked” facet) of the right facet joint (Figure
2.1B) and subluxation (“perched” facet) of the left facet joint (Figure 2.1C), associated
with a flexion teardrop-type fracture of C6. An MRI was subsequently obtained (Figure
2.2) that did not demonstrate an obvious disc herniation. Clearly evident injury to the
spinal cord and posterior ligamentous complex was indicated by the presence of high
T2 signal in both.
Cervical facet dislocations are caused by hyperflexion and posterior distraction with
or without a rotational component. Rotational injury is often a major component of
unilateral facet dislocations. They are commonly seen after high-energy trauma such as
motor vehicle and diving accidents. When the inferior articulating process of the rostral
vertebra dislocates anteriorly to the superior articulating process of the caudal vertebra,
the condition is commonly referred to as “jumped” or “locked” facets. When the infe-
rior articulating process sits superior to the superior articulating process, the facets are
12
Figure 2.1 Computed tomography (CT) scan demonstrating cervical fracture

dislocation at the C5–C6 level. A grade 2 anterolisthesis of C5 on C6 exists (A). The
right facet is fully dislocated (jumped) with the inferior articulating process of the
C5 vertebra dislocated anteriorly to the superior articulating process of C6 (B). By
comparison, the left facet is perched (C).
referred to as being “perched.” Unilateral facet dislocation often results in a grade 1

anterolisthesis. Isolated unilateral facet dislocation may present with monoradiculopathy
secondary to nerve root compression at the level of the neural foramen. Bilateral facet
dislocations often result in a more significant degree of anterolisthesis (often greater than
50%) with a high incidence associated spinal cord injury.
In addition to facet dislocation, hyperflexion, distraction, rotational, and axial loading
forces may result in fractures that include simple compression fractures, fractures of
the facet joint including the superior or inferior articulating processes and the pars
interarticularis, and flexion teardrop fractures. In this case, a nonclassical but teardrop-
type fracture of C6 is present. Flexion tear drop fractures are highly unstable as they
involve both the anterior and posterior columns, demonstrating severe ligamentous dis-
ruption of the facet joint, ligamentum flavum, and posterior longitudinal ligament.They
often result in damage to the anterior spinal cord, as in this patient presenting with
motor, but not sensory, deficits. Fractures of the anteroinferior corner of the affected
vertebral body are classically seen, and retrolisthesis of the rostral vertebral body over the
13
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Spinal Neurosurgery
Figure 2.2 T2-weighted magnetic resonance image (MRI) depicting significant spinal
canal comprise as a result of the cervical fracture dislocation at C5–C6 with increased
T2 signal present in the spinal cord but without evidence of a grossly herniated disc at
that level.
caudal one may be present. These fractures require surgical fixation as the primary form
of treatment as they are highly unstable.
1. The physical examination is the most important component in the initial

evaluation of cervical spine trauma.
a. A complete neurologic evaluation and ASIA grade is important in deter-
mining prognosis.
b. A palpable step-off may be felt, likely indicating a severe dislocation injury.
2. Depending on the mechanism of injury, there may be other bodily injuries
associated with cervical spine trauma, and a full trauma evaluation is indicated.
Even in the setting of spinal cord injury, hemodynamic instability should raise
concern for other sites of hemorrhage, rather than simply being attributed to
neurogenic shock.
3. The 2013 update to the Guidelines for the Management of Acute Cervical
Spine and Spinal Cord Injury recommend CT scan as the best first imaging
study to be performed in the setting of cervical spine trauma. If not available,
plain radiographs are recommended.
4. Cervical dislocations occur as a result of flexion and rotational (in the case of
unilateral facet dislocation) forces. Fractures with the same mechanism may
be associated, and these include simple compression fractures, fractures of the
facet complex, and flexion teardrop fractures.
14
5. Much controversy surrounds whether prereduction MRI should be

performed in a patient with a cervical fracture dislocation injury. According
to the most recent guidelines, MRI should be performed prior to closed re-
duction in a patient who cannot reliably be examined during the procedure,
or, if the procedure fails, prior to anterior or posterior open surgical reduction
and fixation. It has been reported that disc herniation may be found on MRI
anywhere between one-third to one-half of the time; however, their clinical
significance remains largely uncertain.
Questions
1. After a diagnosis is made, what is the next best step in management, and
when should this be performed?
2. What different techniques may be used to reduce facet dislocations?
3. How does a patient’s mental status influence the decision to proceed with
closed reduction?
Decision-Making
Cervical facet dislocations are unstable injuries, and their initial management should
focus on reduction followed by internal fixation or external immobilization. Reduction
should be performed expeditiously, particularly in the setting of ongoing spinal cord
compression and/or incomplete spinal cord injury as reduction potentially may lead
to improvement in neurologic status and ongoing compression may lead to worsening
neurologic injury. Closed reduction may be performed via craniocervical traction or via
cervical manipulation under anesthesia. Alternatively, open surgical reduction may also
be performed. Treatment algorithms vary widely between institutions, and no concrete
evidence supports one over the other; however, it appears that craniocervical traction
in an awake patient is likely more safe than cervical manipulation under anesthesia as a
method of closed reduction.
Numerous studies have been conducted on the efficacy of closed reduction for uni-
lateral and bilateral facet dislocation injuries, showing an 80–90% success rate with closed
reduction and an approximately 1% risk of permanent neurological complications. Closed
reduction via craniocervical traction may be performed with Gardner-Wells tongs and
sequential application of weight while closely monitoring the patient’s neurologic exam
and using fluoroscopy to confirm reduction. The CNS’s guidelines for the acute man-
agement of cervical spine and spinal cord injuries suggests that closed reduction not be
performed in a sedated or obtunded patient as they are unable to be adequately assessed
for any neurologic deterioration as a result of the procedure. Rather, an MRI should be
performed first to rule out any complicating injuries that could preclude closed reduc-
tion. If closed reduction fails, MRI is recommended prior to attempting open surgical
reduction and fixation for the purposes of planning the approach and assessing the need
for anterior decompression and discectomy prior to reduction and fixation.
15
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Spinal Neurosurgery
Questions
1. What options are available for internal fixation and external immobilization?
2. How do the results of halo orthosis immobilization compare to surgical
fixation?
3. What are the major complications associated with ACDF?
4. How should the occurrence of a new neurologic complaint or deficit
encountered during the process of closed cervical reduction be managed?
Surgical Procedure
Cervical fracture dislocation injuries are highly unstable, and internal fixation or ex-
ternal immobilization is necessary to prevent recurrent injury and possible neurologic
compromise. After closed reduction, external immobilization via a halo orthosis is an
option. Alternatively, open or closed reduction may be followed by internal surgical fix-
ation. Protocols vary from center to center.
Halo immobilization is a fairly morbid and quality-of-life affecting treatment and, for
this reason, has fallen out of favor at our institution. While external immobilization can
be used to treat these injuries, it does not seem to be as effective or reliable at producing
successful results compared to surgical fixation. A 2002 study directly comparing the
halo orthosis and anterior arthrodesis in the treatment of flexion teardrop fractures
favored surgery, finding a 20% failure rate in the halo group as well as significantly
worsened cervical kyphosis on follow-up. No significant postoperative complications
occurred in the surgical group.
Internal fixation may be performed anteriorly, posteriorly, or circumferentially.
According to the 2013 CNS guidelines, all such procedures are effective, and the deci-
sion on how to proceed must be made on a case-by-case basis. Anterior surgery has the
benefit of supine surgery, a straightforward dissection, the ability to remove a herniated
disc prior to open reduction, and a relatively benign complication profile. A downside
is that open reduction may be somewhat more difficult than a posterior approach. The
posterior approach allows for easier access to the facet joints to facilitate reduction.
This is followed by lateral mass screw and rod placement. Posterior cervical fusion has a
somewhat higher morbidity than anterior cervical discectomy and fusion (ACDF), and a
theoretical risk neurologic injury exists when turning the patient prone. Circumferential
fusion may be necessary for extremely unstable injuries, although surgical morbidity
particularly due to position and time of surgery are significantly higher.
At our institution, we prefer a management strategy of urgent MRI to evaluate for
any compressive anterior pathology, followed by open reduction and ACDF. The patient
is placed in a Mayfield head holder, and, after the discectomy is performed, the dislocated
facet joints are reduced manually via slight flexion and distraction. If necessary, further
distraction may be accomplished by using a Cobb elevator placed in the disc space.
16
Oral Boards Review: Management Pearls
1. Cervical fracture dislocation injuries are highly unstable. Even if closed reduc-
tion is performed successfully, either internal fixation or external immobili-
zation is necessary as there may be a high rate of recurrence and subsequent
neurologic injury.
2. Anterior or posterior approaches to internal fixation are both effective, and
the approach should be decided on a case-by-case basis, taking into account
the need for neurologic decompression.
Pivot Points
1. If, during closed reduction, the patient begins to experience new neurologic
symptoms, the last weight placed should be removed and the patient
reassessed by physical exam and fluoroscopy. More than likely, the procedure
will need to be aborted. At that point, it is recommended to proceed with
MRI and open reduction and fixation.
2. Based on the literature, prereduction MRI showing a cervical herniated disc
in conjunction with facet dislocation does not necessarily mandate discec-
tomy prior to reduction; however, this is the bias at our institution.
Aftercare
Postoperative care for cervical fusion following traumatic fracture dislocation is fairly
straightforward and entails wearing a rigid cervical collar for 8 weeks per our institution’s
protocol, followed by plain radiographs versus CT scan (depending on the extent of in-
jury) to assess for bony healing. However, because of the significant morbidity and phys-
iologic derangements associated with spinal cord injury, an intensive care unit (ICU)
level of care is necessary.
Spinal shock is commonly associated with acute spinal cord injury. Spinal shock is
characterized by a temporary loss in motor, sensory, and autonomic function below the
neurologic level that gradually returns in four phases. Areflexia in phase 1 lasts about
2 days (as seen in our case). In phase 2, some initial reflexes return during days 2–4 post-
injury, with early hyperreflexia appearing during phase 3 and lasting approximately a
month. Finally, phase 4 may last up to a year following the injury and is characterized
by hyperreflexia and spasticity. Spinal shock should not be confused with neurogenic
shock, which involves hypotension and bradycardia resulting from damage to the auto-
nomic fibers within the spinal cord, although these complications may occur together
(as in our patient).
In the ICU, blood pressure augmentation should be utilized to maintain a mean
arterial pressure (MAP) greater than 80 mm Hg for approximately 1 week. This serves
to maintain adequate systemic perfusion in the face of neurogenic shock, as well as to
provide maximal safe perfusion to the spinal cord in the hopes of facilitating potential
neurologic recovery. Anticholinergic medications such as atropine may be used in the
17
18
Spinal Neurosurgery
setting of symptomatic bradycardia. Higher level cervical injuries result in disruption

of the phrenic nerve and may lead to inadequate ventilation. These patients may re-
quire mechanical ventilation if PaO2 is less than 70 mm Hg or PaCO2 is greater than
45 mm Hg. Foley catheterization will be necessary until the patient is systemically stable,
and neurogenic bladder causes a significant problem. Autonomic dysreflexia is another
common problem facing spinal cord injury patients. Frequent patient repositioning,
range of motion exercises (to combat spasticity), and early management of pressure
ulcers is necessary. Finally, kinetic therapy via a rotorest bed may also be beneficial as a
cardiovascular and respiratory prophylactic measure.
Complications of rigid external fixation with a halo orthosis commonly include pin
loosening, pin site infection, and discomfort. Other rarer complications include skull
fracture and injury to the supratrochlear and/or supraorbital nerves. Because of the
fairly high incidence of morbidity associated with the halo vest, our center has largely
abandoned its use.
ACDF is generally a low-morbidity procedure; however, significant complications
may occur. Postoperative dysphagia is the most common complication. Efforts at
minimizing the degree of and time under retraction may reduce its incidence, but the
etiology is likely multifactorial. While largely transient, a short course of steroids may be
beneficial in severe cases.
Recurrent laryngeal nerve palsy and vocal cord paresis may result from division or
traction injuries to the nerve during exposure and/or retraction. Careful dissection,
minimizing time under retraction, deflation of the endotracheal tube cuff after the self-
retaining retractors are placed, and, as argued by some studies, a left-sided approach may
minimize its occurrence. In general, symptomatic injuries are transient, however otolar-
yngology referral may be indicated.
Postoperative wound hematoma is a potentially catastrophic complication of the
anterior approach. A large retrospective review by Fountas et al. found a 5.6% chance
of this complication with 24 of 57 affected patients requiring emergent surgical evacu-
ation. If respiratory compromise is suspected, emergent evacuation of the hematoma is
indicated.
Durotomy and cerebrospinal fluid (CSF) leak may occur in a very small percentage
of patients, and this should be treated with the prompt placement of a lumbar drain and
careful attention to a watertight wound closure. In the majority of cases, several days
of CSF diversion and head of bed elevation will resolve the leak. Durotomy is more
common in posterior cervical cases where laminectomies are performed, but because of
the wider exposure, these tears should be attempted to be closed primarily. Placement of
a dural substitute or sealant may also be beneficial.
Other rare but catastrophic complications of ACDF include vertebral artery injury
and esophageal or pharyngeal perforation. This likely occurs in less than 1% of cases.
For esophageal injuries, prompt intraoperative identification and primary repair by a
general surgeon is paramount as unidentified injuries may lead to mediastinitis and over-
whelming infection. Care should be taken during lateral dissection and when performing
foraminotomies to avoid vertebral artery injury. At our center, any vertebral artery injury
18
is treated with packing and emergent angiogram to assess the injury and potentially
sacrifice the artery. Similarly, the vertebral arteries are at risk when instrumenting the
cervical spine posteriorly. The screw should not be removed if an injury is suspected.
The wound should be packed and, at our institution, prompt referral to the endovascular
suite should be initiated.
In regards to the patient with an unstable cervical fracture and spinal cord in-
jury, simple maneuvers such as patient transfers and positioning could have serious
consequences. Strict spine precautions are necessary at all times to prevent the produc-
tion or worsening of a neurologic injury.
Oral Boards Review: Complications Pearls
1. Minimizing time under retraction and deflation of the endotracheal tube

once the self-retaining retractors are placed may minimize the risk of postop-
erative dysphonia.
2. Postoperative dysphagia is more common in three-level procedures compared
to one-or two-level procedures.
3. CSF leak encountered during ACDF should be treated with several days of
lumbar drainage and is successful in most cases.
Level 1 evidence suggests that both anterior and posterior approach surgeries are ef-
fective at treating cervical fracture dislocation injuries. One prospective randomized
controlled trial found that, compared to posterior fixation, ACDF was associated with
less postoperative pain, higher rate of fusion, better alignment, and fewer postoperative
wound infections. Numerous cohort studies have found similar results. Closed reduction
of cervical dislocations is associated with high success rates and a low rate of neurologic
complications, ranging from 1% to 4%.
References and Further Reading
Anissipour AK, Agel J, Baron M, Magnusson E, et al. Traumatic cervical unilateral and bilat-
eral facet dislocations treated with anterior cervical discectomy and fusion has a low failure
rate. Global Spine J. 2017;7(2):110–115. doi: 10.1177/2192568217694002. Epub Apr 6, 2017.
https://www.ncbi.nlm.nih.gov/pubmed/28507879
Belirgen M, Dlouhy BJ, Grossbach AJ, et al. Surgical options in the treatment of subaxial cer-
vical fractures: A retrospective cohort study. Clin Neurol Neurosurg. 2013;115(8):1420–1428.
doi: 10.1016/j.clineuro.2013.01.018. Epub Mar 5, 2013. https://www.ncbi.nlm.nih.gov/
pubmed/23481897
Casha S, Christie S. A systematic review of intensive cardiopulmonary management after spinal
cord injury. J Neurotrauma. 2011;28(8):1479–1495. doi: 10.1089/neu.2009.1156. Epub Apr 8,
2010. https://www.ncbi.nlm.nih.gov/pubmed/20030558
Ditunno JF, Little JW,Tessler A, et al. Spinal shock revisited: A four-phase model. Spinal Cord. 2004
Jul;42(7):383–395. https://www.ncbi.nlm.nih.gov/pubmed/15037862
19
20
Spinal Neurosurgery
Fisher CG, Dvorak MF, Leith J, et al. Comparison of outcomes for unstable lower cervical flexion
teardrop fractures managed with halo thoracic vest versus anterior corpectomy and plating.
Spine (Phila Pa 1976). 2002;27(2):160–166. https://www.ncbi.nlm.nih.gov/pubmed/
11805662
Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al. Anterior cervical discectomy and fusion asso-
ciated complications. Spine (Phila Pa 1976). 2007;32(21):2310–2317. https://www.ncbi.nlm.
nih.gov/pubmed/17906571
Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards for neurological
classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34(6):535–546.
doi: 10.1179/204577211X13207446293695. https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3232636/
Kwon BK, Fisher CG, Boyd MC, et al. A prospective randomized controlled trial of anterior
compared with posterior stabilization for unilateral facet injuries of the cervical spine.
J Neurosurg Spine. 2007;7(1):1–12. https://www.ncbi.nlm.nih.gov/pubmed/17633481
Lee JY, Nassr A, Eck JC, et al. Controversies in the treatment of cervical spine dislocations. Spine
J. 2009 May;9(5):418–423. doi: 10.1016/j.spinee.2009.01.005. Epub Feb 23, 2009. https://
www.ncbi.nlm.nih.gov/pubmed/19233734
Song KJ, Lee KB. Anterior versus combined anterior and posterior fixation/fusion in the treat-
ment of distraction-flexion injury in the lower cervical spine. J Clin Neurosci. 2008;15(1):
36–42. https://www.ncbi.nlm.nih.gov/pubmed/18061456
Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cer-
vical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013;60 Suppl 1:82–91.
doi: 10.1227/01.neu.0000430319.32247.7f. https://www.ncbi.nlm.nih.gov/pubmed/
23839357
20
Occipitocervical Dislocation
Alexander B. Dru and Daniel J. Hoh
Case Presentation
A 28-year-old woman presents to the emergency department after being struck by

3
a car at high speed while changing a tire on the side of a road. The patient arrives
intubated for airway protection and with a cervical collar in place. She has multiple
deep lacerations to the head and neck, an open left humerus fracture, and a distended
abdomen. She has no significant past medical or surgical history.
Upon arrival, the patient’s vital signs are blood pressure 130/71, pulse 79, respiratory
rate 14 (mechanically ventilated), and temperature 37.1°C. Neurologic examination (off
sedation) is remarkable for a Glasgow Coma Scale (GCS) of 7T (does not open eyes,
intubated, localizes right greater than left upper extremity to noxious stimuli). Cranial
nerve examination is consistent with pupils of 2 mm, equal and reactive to light, intact
corneal reflexes, and present cough and gag reflexes. On motor examination, the patient
weakly withdraws all four extremities, right greater than left.
Questions
1. What radiologic studies are indicated as part of the initial neurosurgical eval-
uation (imaging modality and anatomic area to image)?
2. What is the most appropriate management of the cervical collar?
3. In the setting of a potential spinal cord injury (SCI), what is the importance
of cardiopulmonary vital signs?
Given a history of high-energy mechanism of injury to the head and neck, the ini-
tial neurosurgical survey includes evaluation for acute intracranial pathology and spinal
column injury resulting in instability and/or spinal cord or nerve compression. The pa-
tient should be assessed for both possibilities with an emergent head computed tomog-
raphy (CT) and full spine CT. Since the patient has depressed mental status, the patient
should be maintained in a cervical collar until cervical spine CT and further clinical
assessment is made. If the patient is suspected of having a potential cervical SCI, heart
rate and blood pressure should be closely monitored for neurogenic shock. Upper cer-
vical SCI can result in impaired respiratory motor function. A secure airway should be
confirmed at time of the initial survey.
21
2
Spinal Neurosurgery
Occipitocervical dislocation (or atlanto-occipital dislocation, AOD) is a highly un-

stable injury to the cranio-cervical junction (Figure 3.1). Historically, AOD was only re-
ported in autopsy findings likely due to a high rate of mortality related to severe cervical
spine instability and concomitant upper cervical SCI. Currently, AOD is estimated to
cause up to 35% of fatalities in motor vehicle collisions and 10% of fatal cervical spine
injuries. Better management by first responders, established advanced trauma life support
protocols, and modern imaging modalities have contributed to improved survival rate
after traumatic AOD.
AOD is typically a result of high- energy deceleration forces. Distraction with
hyperextension-flexion, often with a rotational component, are necessary to cause forces
significant to disrupt the robust ligamentous attachments at the occipital-cervical junc-
tion. Mortality is likely related to dislocation at the craniocervical junction causing
upper cervical spinal cord compression and acute respiratory dysfunction and/or hemo-
dynamic instability secondary to neurogenic shock. Immediate immobilization in the
field (e.g., cervical collar) followed by prompt diagnosis and external stabilization (e.g.,
A B
C D
Figure 3.1 Radiograph (A), computed tomography (CT) sagittal (B), coronal (C), and three-dimensional
reconstruction (D) of demonstrating atlanto-occipital dislocation (AOD).
22
halo vest) may prevent or mitigate neurologic injury, with some patients presenting as
neurologically intact or with an incomplete SCI.
SCI can be a result of dislocation leading to compression, contusion, laceration, or
ischemia of the spinal cord. SCI at the cranio-cervical junction can present with a va-
riety of complete or incomplete motor and sensory deficits. Bell cruciate paralysis is an
incomplete syndrome unique to the cranio-cervical junction characterized by weak-
ness of the upper extremities with little to no involvement of lower extremity muscle
groups. The pattern of injury is secondary to midline damage to the upper pyramidal
decussation. The somatotopy of the decussation is such that the injured upper extremity
motor fibers cross more superomedially, whereas the spared lower extremity fibers are
inferolateral in the medulla.
Other associated neural and vascular injuries are often observed in the setting of
AOD. Individual cranial nerves are susceptible to injury following AOD, specifically
lower cranial nerves IX, X, XI, and XII as they traverse the jugular or hypoglossal fo-
ramen. Most commonly, cranial nerves IX, X, and XI are affected due to tethering
and traction within the jugular foramen. The hypoglossal nerve (CN XII) may be at
high risk if there is a concomitant fracture of the occipital condyle extending into the
hypoglossal canal.
Carotid and vertebral artery injuries may occur due to stretching or laceration, with
either intimal tears, dissection, or thrombosis. Pontomedullary subarachnoid blood may
be an indication of AOD with posterior circulation injury.Vertebral artery injury can re-
sult in posterior inferior cerebellar artery distribution ischemia with a lateral medullary
syndrome characterized by cerebellar dysmetria; ipsilateral cranial nerve V, IX, X, and XI
deficits; an ipsilateral Horner syndrome; and contralateral loss of pain and temperature
sensation.
1. Prompt multiplanar CT imaging is crucial to the timely and accurate diag-

nosis of AOD.
a. Displacement of the occipital condyle from C1 lateral mass by more than
2 mm (adults) or more than 4 mm (children) indicates potential AOD.
2. One should have a high index of suspicion for AOD if:
a. High cervical SCI is present without evidence of cervical fracture and/or
dislocation in the subaxial spine.
b. Bell cruciate paralysis is present with only upper extremity paralysis.
c. Isolated lower cranial nerve dysfunction (e.g., IX, X, XI, XII) is present.
d. Subarachnoid blood is present at the pontomedullary junction.
e. Significant soft-tissue swelling (e.g., retropharyngeal) is present at the
upper cervical spine.
Questions
1. Describe the utility of x-ray, CT, and magnetic resonance imaging (MRI) in
the diagnosis and management of AOD.
23
24
Spinal Neurosurgery
2. Describe image-based diagnostic criteria for AOD.

3. What are two classification systems for AOD?
Decision-Making
The diagnosis of AOD is made based on imaging studies. Historically,AOD was identified
using two-dimensional lateral plain x-ray characterizing the radiographic relationship
between structures of the skull base and upper cervical vertebrae. With the advent of
modern CT imaging technology, the current gold standard for diagnosing AOD is with
multiplanar thin-slice CT. A basic knowledge of lateral x-ray criteria for AOD, however,
may be helpful in understanding the pathophysiology of AOD and for supplementary
diagnostic evaluation in questionable cases.
The Harris method or “rule of twelves” calculates the basion-axial interval (BAI)
and basion-dental interval (BDI) (Figure 3.2A). BAI is the distance between the vertical
extension of the posterior cortex of C2 and the posterior-most tip of the basion. BDI is
the distance from the tip of the dens to the basion. In normal adults, both BAI and BDI
should be less than 12 mm.
The Powers ratio is the ratio of two distances (Figure 3.2B). The numerator is the
distance between the tip of the basion to the ventral midpoint of the posterior arch of
C1. The denominator is the distance from the tip of the opisthion to the dorsal mid-
point of the anterior arch of C1. A ratio greater than 1 suggests anterior dislocation of
the head relative to the spine.
Multiplanar CT imaging provides the highest sensitivity and specificity for diagnosing
AOD. The condyle-C1 interval (CCI) is measured by selecting four equidistant points
A B C
Figure 3.2 (A) The Harris method. In the radiograph, the basion-dental interval (BDI; white) and basion-axial
interval (BAI; yellow) are both greater than 12 mm. (B) The Powers ratio. The numerator is the distance between the
tip of the basion to the ventral midpoint of the posterior arch of C1. The denominator is the distance from the tip of
the opisthion and the dorsal midpoint of the anterior arch of C1. A ratio of greater than 1 suggests atlanto-occipital
dislocation (AOD). (C) The condyle–C1 interval (CCI). Four equidistant points along the articulating surface of the
occiput–C1 joint on sagittal CT are measured. AOD is suspected if the average of the four measurements is greater
than 2 mm in adults or greater than 4 mm in children.
24
along the articulating surface of the occiput–C1 joint on sagittal or coronal CT (Figure
3.2C). AOD is suspected if the average of the four measurements is greater than 2 mm
in adults or greater than 4 mm in children.
Additional imaging modalities may be useful in further characterizing the extent of
injury after AOD. MRI is generally not required for routine diagnosis, but it provides
superior visualization of neurologic and soft tissue structures. Particularly in the setting
of neurologic deficit, MRI may elucidate the underlying etiology, whether spinal cord
compression, contusion, ischemia, or epidural hematoma. MRI may also identify liga-
mentous disruption at the occipital-cervical articulation, as well as elsewhere in the cer-
vical spine (e.g., transverse ligament). CT angiography may identify associated vascular
injuries with potential risk of thromboembolic stroke.
There are two major classification systems for AOD. The Traynelis Classification
System characterizes the direction of head dislocation relative to the spine (Figure 3.3).
Type 1 is ventral head dislocation, type 2 is vertical displacement, and type 3 is dorsal dis-
location relative to the cervical spine.The Bellbarba system is based on imaging findings
in neutral position as well as with controlled test traction. It is designed to assess spinal
stability and facilitate management decision-making. Type 1 AOD is considered stable.
It is characterized by both BAI and BDI within 2 mm of normal and less than 2 mm
displacement with traction. Type 2 AOD is unstable. It is characterized by both BAI
and BDI within 2 mm of normal, but significant displacement with test traction. Type
3 AOD is also unstable and demonstrates BAI and BDI values of greater than 2 mm of
normal in neutral position.
Questions
1. What is the immediate management of AOD?

2. What is the risk of cervical traction in AOD?
3. What are the goals of surgical treatment?
4. What is potential loss of range of motion after surgical treatment?
Surgical Procedure
AOD is an acute, highly unstable injury with potential risk of permanent upper cer-
vical SCI. Once the diagnosis is made, the patient should be placed in immediate ex-
ternal immobilization with strict cervical spine precautions. Patients presenting with
acute trauma are usually already in a cervical collar. Halo vest immobilization generally
provides better stabilization of the cranio-cervical junction than a rigid cervical collar
alone, and securing the patient in a halo vest should be considered.
Ultimately, AOD is a result of disruption of the ligamentous attachments between
the occiput and the upper cervical spine. Therefore, external bracing alone is unlikely to
provide long-term healing and stability. Reduction of AOD and internal fixation and fu-
sion across the occipital-cervical junction is generally recommended for definitive treat-
ment. In the setting of polytrauma with cardiopulmonary compromise, it is appropriate
to maintain the patient in halo external immobilization with strict cervical precautions
until the patient is stable enough to be safely taken to the operating room.
25
26
Spinal Neurosurgery
Figure 3.3 The Traynelis classification system. Type 1 (top) is ventral head dislocation.
Type 2 (middle) is vertical displacement. Type 3 (bottom) is dorsal dislocation relative to
the cervical spine.
The role of closed reduction with traction for AOD is controversial. Due to instability
at the occipital-atlantal articulation with potential for further vertical head displacement
and neurovascular injury, one should generally avoid traction. There is a reported 10%
risk of neurologic deterioration with the use of traction in the setting of AOD.
The goals of surgical treatment are to immediately stabilize the cranio-cervical junc-
tion with internal fixation, decompress the spinal cord by reduction and/or removal
of any compressive lesions, and provide long-term maintenance of correction with ar-
throdesis.Various posterior surgical techniques for stabilization have been described with
current approaches generally involving screw fixation of the occiput and upper cer-
vical spine connected by occipital plate-rod constructs (Figure 3.4). Determining how
many cervical levels are necessary for fixation depends on individual patient anatomy,
bone integrity, and the presence of other concomitant cervical injuries. The cranio-
cervical junction can be a challenging region in which to achieve successful arthrodesis.
Various autologous (e.g., iliac crest, rib harvest), allogeneic, and synthetic graft options
supplemented by graft wiring techniques may be used to optimize fusion rate.
26
Figure 3.4 Occipital–C4 fusion for internal stabilization of atlanto-occipital

dislocation (AOD).
Surgical treatment for AOD often involves stabilization across the occiput–C2, thereby
eliminating motion across both the occipital-atlantal and atlantal-axial articulations. As
a result, patients can expect loss of 50% of head flexion/extension and 50% of right–left
rotation. Adult patients with subaxial cervical spondylosis and baseline restricted range
of motion may experience even greater overall functional impairment. This permanent
loss of range of motion should constitute an important part of the preoperative discus-
sion with patients and caregivers to appropriately align expectations after surgery.
Oral Boards Review: Management Pearls
1. AOD is a highly unstable injury and patients should be immediately placed in

a rigid external orthosis. A halo vest generally provides better immobilization
at the occipital-cervical junction than a rigid cervical collar.
2. Definitive treatment for AOD generally involves reduction with surgical
decompression (if needed) and stabilization across the occipital–cervical
junction.
a. Current surgical stabilization techniques include screw fixation of the
occiput and the cervical spine with a connecting occipital plate-rod
construct.
b. Determining adequate points of fixation in the cervical spine depends on
the patient’s individual anatomy and bone integrity.
27
28
Spinal Neurosurgery
3. Perioperative intensive care management may be necessary to treat cardiopul-

monary issues related to neurogenic shock and upper cervical SCI leading to
diaphragm paralysis.
a. Neurogenic shock is best treated with dopamine and phenylephrine. The
presence of bradycardia and hypotension that fail to respond to intrave-
nous fluids suggest neurogenic rather than hypovolemic shock.
Aftercare
Early postoperative care after surgical treatment for AOD is generally determined by the
extent of neurologic deficits and other associated injuries. Patients with cardiopulmo-
nary compromise from cervical SCI should be managed in an intensive care unit until
hemodynamic and respiratory issues are stabilized. Hypotension and bradycardia in the
setting of acute cervical SCI should alert for potential neurogenic shock. Management
consists of intravenous sympathomimetic agents and fluid resuscitation. Patients with
upper cervical SCI with diaphragmatic paralysis and who fail ventilator weaning should
be expeditiously transitioned from an endotracheal tube to a tracheostomy. Aggressive
pulmonary toilet and respiratory rehabilitation should be implemented to reduce risk of
pneumonia. Additional SCI management should be directed toward preventing venous
thromboembolic, urinary tract, and pressure ulcer complications.
Patients with adequate surgical reduction and internal fixation generally do not re-
quire supplementary external bracing. Continued postoperative use of a rigid cervical
collar or halo vest may lead to skin breakdown or halo pin site complications and can
impede rehabilitation. Patients with poor bone mineral density or with high risk of
instrumentation failure, however, may benefit from additional postoperative external
orthosis, and may be considered in select individuals. Serial routine follow-up should
be performed at regular intervals up to generally 12 months postoperative to assess for
neurologic function and for eventual successful fusion. Maintenance of correction, stable
instrumentation, and the presence of bridging bone across the occipital-cervical junc-
tion indicate bony healing.
Surgical complications after occipital-cervical fusion include those that may be encountered
after any posterior spine fusion including surgical site infection, blood loss, cerebrospinal
fluid leak, pseudarthrosis, and instrumentation failure. New postoperative neurologic
deficits after surgery are uncommon. Given the relatively favorable spinal canal-to-spinal
cord ratio at the craniocervical junction, direct injury to the spinal cord during surgery
is rare. Placing patients prone with AOD, however, can potentially cause new neurologic
deficits given the highly unstable injury and risk of further dislocation during positioning.
Positioning patients in a halo vest with pre-and postpositioning electrophysiologic spinal
cord monitoring and intraoperative fluoroscopy are measures that may reduce this risk.
The course of the vertebral artery as it traverses the cranio-cervical junction can
be variable, and preoperative assessment of its anatomy is recommended prior to screw
placement, specifically at C1 and C2. Bilateral vertebral artery injuries are generally fatal,
28
and therefore, careful evaluation for any vertebral artery anomalies (e.g., unilateral dom-
inant, torturous) or associated traumatic occlusion (e.g., dissection) should be made. In
situations of an incompetent unilateral vertebral artery, careful consideration should be
made to avoid screw placement that may put the contralateral artery at risk.
The occipital-cervical junction is a region that can be challenging to achieve successful
arthrodesis. Instrumentation failure with screw loosening or rod fracture on routine post-
operative x-ray indicate likely pseudarthrosis. Late postoperative new onset or worsening
pain may be an early sign of failed fusion. Further investigation of suspected pseudarthrosis
includes fine-cut CT imaging to assess for the presence or absence of bridging bone across
the occipital–cervical junction. Asymptomatic pseudarthrosis with intact instrumentation
may be treated conservatively. Instrumentation failure, progressive deformity, worsening pain,
or new neurologic deficits in the setting of failed fusion may be indications for revision
surgery.
Oral Boards Review: Complication Pearls
1. AOD is a highly unstable injury and therefore maintaining strict immobiliza-

tion is critical.
a. Neurologic deterioration may occur with any excessive motion, and
therefore cervical traction should generally be avoided.
b. Special care should be made in positioning patients prone for surgery, with
pre-and postpositioning fluoroscopy and electrophysiologic spinal cord
monitoring.
2. The vertebral artery may be at risk during surgical fixation at the occipital-
cervical junction due to preexisting anatomic anomalies or secondary to trau-
matic injury.
a. Careful preoperative assessment of both vertebral arteries should be made
to avoid potential risk of bilateral vertebral artery compromise.
3. The occipital–cervical junction is susceptible to pseudarthrosis, which may
present with late-onset pain, neurologic worsening, progressive deformity, or
instrumentation failure.
a. Evaluation includes multiplanar thin-cut CT imaging to assess for
bridging bone.
b. Symptomatic pseudarthrosis should be treated with revision fusion.
AOD is relatively uncommon compared to other traumatic cervical spine injuries,

which may in part be secondary to a high mortality risk immediately at the time of
injury. Existing literature, therefore, regarding treatment, prognosis, and outcomes
is limited. Modern advances in care by first responders, emergency trauma serv-
ices, diagnostic imaging, and spine surgery have likely contributed to better survival.
Long-term outcome after AOD is most likely related to neurologic function at time
of initial presentation, including both SCI and any potential concomitant traumatic
brain injury. Complete upper cervical SCI portends a worse prognosis than incom-
plete and lower cervical injuries. Recent literature suggests that early decompression
29
30
Spinal Neurosurgery
and stabilization of cervical spine injuries may enhance potential for neurologic re-
covery. Additionally, better medical management with aggressive rehabilitation and
chronic preventative care for SCI-related complications have improved overall life
expectancy post-SCI.
References and Further Reading
Fisher CG, Sun JC, Dvorak M. Recognition and management of atlanto- occipital disloca-
tion: Improving survival from an often fatal condition. Can J Surg. 2001;44(6):412–420.
Horn EM, Feiz-erfan I, Lekovic GP, Dickman CA, Sonntag VK, Theodore N. Survivors of
occipitoatlantal dislocation injuries: Imaging and clinical correlates. J Neurosurg Spine.
2007;6(2):113–120.
Kleweno CP, Zampini JM,White AP, Kasper EM, Mcguire KJ. Survival after concurrent traumatic
dislocation of the atlanto-occipital and atlanto-axial joints: A case report and review of the
literature. Spine. 2008;33(18):E659–E662.
Pang D, Nemzek WR, Zovickian J. Atlanto-occipital dislocation—part 1: Normal occipital
condyle-C1 interval in 89 children. Neurosurgery. 2007;61(3):514–521.
Pang D, Nemzek WR, Zovickian J. Atlanto-occipital dislocation—part 2: The clinical use of
(occipital) condyle-C1 interval, comparison with other diagnostic methods, and the mani-
festation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery.
2007;61(5):995–1015.
30
Another random document with
no related content on Scribd:
CHAPTER I.
HISTORY AND LITERATURE.
The commencement of the history of Ichthyology

Aristotle. coincides with that of Zoology generally. Aristotle
(384–322 b.c.) had a perfect knowledge of the
general structure of fishes, which he clearly discriminates from the
Aquatic animals with lungs and mammæ, i.e. Cetaceans, and from
the various groups of Aquatic Invertebrates. He says that “the
special characteristics of the true fishes consist in the branchiæ and
fins, the majority having four fins, but those of an elongate form, as
the eels, having two only. Some, as the Muræna, lack the fins
altogether. The Rays swim with their whole body, which is spread
out. The branchiæ are sometimes furnished with an opercle,
sometimes without one, as is the case in the cartilaginous fishes....
No fish has hairs or feathers; most are covered with scales, but
some have a rough or smooth skin. The tongue is hard, often
toothed; and sometimes so much adherent that it seems to be
wanting. The eyes have no lids; nor are any ears or nostrils visible,
for what takes the place of nostrils is a blind cavity. Nevertheless
they have the senses of tasting, smelling, and hearing. All have
blood. All scaly fishes are oviparous, but the cartilaginous fishes
(with the exception of the Sea-devil, which Aristotle places along with
them) are viviparous. All have a heart, liver, and gall-bladder; but
kidneys and urinary bladder are absent. They vary much in the
structure of their intestines: for whilst the mullet has a fleshy stomach
like a bird, others have no stomachic dilatation. Pyloric coeca are
close to the stomach, variable in number; there are even some, like
the majority of the cartilaginous fishes, which have none whatever.
Two bodies are situated along the spine, which have the function of
testicles, and open towards the vent, and which are much enlarged
in the spawning season. The scales become harder with age. Not
being provided with lungs, they have no voice, but several can emit
grunting sounds. They sleep like other animals. In the majority the
females exceed the males in size; and in the Rays and Sharks the
male is distinguished by an appendage on each side of the vent.”
Aristotle’s information on the habits of fishes, their migrations,
mode and time of propagation, utility, is, as far as it has been tested,
surprisingly correct. Unfortunately, only too often we lack the means
of recognising the species of which he gives a description. His ideas
of specific distinction were as vague as those of the fishermen
whose nomenclature he adopted; it never occurred to him that such
popular names are subject to change, or may be entirely lost with
time, and the difficulty of deciphering his species is further increased
by the circumstance that popular names are often applied by him to
the same fish, or that different stages of growth are designated by
distinct names. The number of fishes known to Aristotle seems to
have been about 115, all of which are inhabitants of the Ægean Sea.
That one man should have discovered so many truths, and
formed so sure a base for Zoology, is less surprising than the fact
that for about eighteen centuries a science which seemed to offer
particular attractions to men gifted with power of observation, was no
farther advanced. Yet this is the case. Aristotle’s disciples, as well as
his successors, remained satisfied to be his copiers or
commentators, and to collect fabulous stories or vague notions. With
very few exceptions (such as Ausonius, who wrote a small poem, in
which he describes from his own observations the fishes of the
Mosel) authors entirely abandoned original research. And it was not
until about the middle of the sixteenth century that Ichthyology made
a new step in advance by the appearance of Belon, Rondelet, and
Salviani, who almost simultaneously published their grand works, by
which the idea of species was established definitely and for all times.
P. Belon travelled in the countries bordering on

Belon. the eastern part of the Mediterranean, in the years
1547–50; he collected rich stores of positive
knowledge, which he deposited in several works. The one most
important for the progress of Ichthyology is that entitled “De
aquatilibus libri duo” (Paris 1553; small 4to.) Belon knows about 110
fishes, of which he gives rude, but generally recognisable, figures. In
his descriptions he pays regard to the classical as well as vernacular
nomenclature, and states the outward characteristics, sometimes
even the number of fin-rays, frequently also the most conspicuous
anatomical peculiarities.
Although Belon but rarely gives definitions of the terms used by
him, it is generally not very difficult to ascertain the limits which he
intended to assign to each division of aquatic animals. He very
properly divides them into such as are provided with blood, and into
those without it: two divisions, called in modern language Vertebrate
and Invertebrate aquatic animals. The former are classified by him
according to sizes, the further subdivisions being based on the
structure of the skeleton, mode of propagation, number of limbs,
form of the body, and on the physical character of the localities
inhabited by fishes. This classification is as follows:—
I.The larger fishes or Cetaceans.
A. Viviparous Cetaceans with bony skeletons (= Cetacea).
B. Viviparous Amphibians.
1. “With four limbs: Seals, Hippopotamus, Beaver, Otter, and other
aquatic Mammalia.
2. With two limbs: Mermaids, etc.
C. Oviparous Amphibians (= Reptiles and Frogs).
D. Viviparous Cartilaginous fishes.
1. Of an oblong form (= Sharks).
2. Of a flat form (= Rays and Lophius).
E. Oviparous Cartilaginous fishes (= Sturgeons and Silurus).
F. Oviparous Cetaceans, with spines instead of bones (= large marine
fishes, like the Thunny, Sword-fish, Sciænoids, Bass, Gadoids,
Trachypterus).
II.Spinous Oviparous fishes of a flat form (= Pleuronectidæ).
III.Fishes of a high form, like Zeus.
IV.Fishes of a snake like form (= Eels, Belone, Sphyræna).
V.Small Oviparous, spinous, scaly, marine fishes.
1. Pelagic kinds.
2. Littoral kinds.
3. Kinds inhabiting rocky localities.
VI.Fluviatile and Lacustrine fishes.
The work of the Roman ichthyologist, H. Salviani
Salviani. (1514–72), is characteristic of the high social
position which the author held as the physician of
three popes. Its title is “Aquatilium animalium historia” (Rom. 1554–
57, fol.) It treats exclusively of the fishes of Italy. Ninety-two species
are figured on seventy-six plates which, as regards artistic execution,
are masterpieces of that period, although those specific
characteristics which nowadays constitute the value of a zoological
drawing, were entirely overlooked by the author or artist. No attempt
is made at a natural classification, but the allied forms generally are
placed in close proximity. The descriptions are quite equal to those
given by Belon, entering much into the details of the economy and
usefulness of the several species, and were evidently composed
with the view of collecting in a readable form all that might prove of
interest to the class of society in which the author moved. Salviani’s
work is of a high standard, most remarkable for the age in which he
lived. It could not fail to convey valuable instruction, and to render
Ichthyology popular in the country to the fauna of which it was
devoted, but it would not have advanced Ichthyology as science
generally; and in this respect Salviani is not to be compared with
Rondelet or Belon.
G. Rondelet (1507–1557) had the great advantage

Rondelet. over Belon in having received a medical education at
Paris, and more especially in having gone through a
complete course of instruction in anatomy as a pupil of Guentherus
of Andernach. This is conspicuous throughout his works—“Libri de
Piscibus marinis” (Lugd. 1554, fol.); and “Universæ aquatilium
historiæ pars altera” (Lugd. 1555, fol.) Nevertheless they cannot be
regarded as more than considerably enlarged editions of Belon’s
work. For although he worked independently of the latter, and differs
from him in numerous details, the system adopted by him is
characterised by the same absence of the true principles of
classification. Rondelet had a much more extensive knowledge of
details. His work is almost entirely limited to European, and chiefly
Mediterranean, forms, and comprises not less than 197 marine and
47 freshwater fishes. His descriptions are more complete and his
figures much more accurate than those of Belon; and the specific
account is preceded by introductory chapters in which he treats in a
general manner on the distinctions, the external and internal parts,
and on the economy of fishes. Like Belon, he had no conception of
the various categories of classification—for instance, confounding
throughout his work the terms “genus” and “species;” but he had
intuitively a notion of what his successors called a “species,” and his
principal object was to collect and give as much information as
possible of such species.
For nearly a century the works of Belon and Rondelet remained
the standard works of Ichthyology; but this science did not remain
stationary during this period. The attention of naturalists was now
directed to the products of foreign countries, especially the Spanish
and Dutch possessions in the New World; and in Europe the
establishment of anatomical schools and academies led to the
careful investigation of the internal anatomy of the most remarkable
European forms. Limited as these efforts were as to their scope,
being directed either only to the fauna of some district, or to the
dissection of a single species, they were sufficiently numerous to
enlarge the views of naturalists, and to destroy that fatal dependency
on preceding authorities which had continued to keep in bonds the
minds of even such men as Rondelet and Belon.
The most noteworthy of those who were active in
W. Piso. G. tropical countries are W. Piso and G. Margrav.
Margrav. They accompanied as physicians the Dutch
Governor, Prince Moritz of Nassau, to Brazil (1637–
44). Margrav especially studied the fauna of the country, and
although he died before his return to Europe, his observations were
published by his colleague, and embodied in a work “Historia
naturalis Braziliæ” (Lugd. 1648, fol.), in which the fourth book treats
of the fishes. He describes about 100 species, all of which had been
previously unknown, in a manner far superior to that of his
predecessors. The accompanying figures are not good, but nearly
always recognisable, and giving a fair idea of the form of the fish.
Margrav himself, with the aid of an artist, had made a most valuable
collection of coloured drawings of the objects observed and
described by him, but many years were allowed to pass before it was
scientifically utilised by Bloch and others.
Of the men who left records of their anatomical
Anatomists, researches, we may mention Borelli (1608–79),
1600–1700. who wrote a work “De motu animalium” (Rom. 1680,
4to), in which he explained the mechanism of
swimming, and the function of the air-bladder; M. Malpighi (1628–
94), who examined the optic nerve of the sword-fish; the celebrated
J. Swammerdam (1637–80), who described the intestines of
numerous fishes; and J. Duverney (1648–1730), who entered into
detailed researches of the organs of respiration.
A new era in the history of Ichthyology commences with Ray,

Willughby, and Artedi, who were the first to recognise the true
principles by which the natural affinities of animals should be
determined. Their labours stand in so intimate a connection with
each other that they represent only one stride in the progress of this
science.
J. Ray (born 1628 in Essex, died 1705), was the

Ray and friend and guide of F. Willughby (1635–72). They
Willughby had recognised that a thorough reform of the
treatment of the vegetable and animal kingdoms had
become necessary; that the only way of bringing order into the
existing chaos was that of arranging the various forms with regard to
their structure; that they must cease to be burdened with inapplicable
passages and quotations of the ancient writers, and to perpetuate
the erroneous or vague notions of their predecessors. They
abandoned speculation, and adhered to facts only. One of the first
results, and perhaps the most important, of their method was, that
having recognised the “species” as such, they defined this term, and
fixed it as the base, from which all sound zoological knowledge has
to start.
Although they had divided their work thus that Ray attended to
the plants principally, and Willughby to the animals, the “Historia
piscium” (Oxford, 1686, fol.), which bears Willughby’s name on the
titlepage, and was edited by Ray, is clearly their joint production. A
great part of the observations contained in it were collected during
their common journeys in Great Britain and on the Continent, and it
is no exaggeration to say that at that time these two Englishmen
knew the fishes of the Continent, especially those of Germany, better
than any other Continental zoologist.
By the definition of fishes as animals with blood, breathing by
gills, provided with a single ventricle of the heart, covered with scales
or naked; the Cetaceans are excluded. Yet, at a later period Ray
appears to have been afraid of so great an innovation as the
separation of whales from fishes, and, therefore, he invented a
definition of fish which comprises both. The fishes proper are then
arranged in the first place according to the cartilaginous or osseous
nature of the skeleton; further subdivisions being formed with regard
to the general form of the body, the presence or absence of ventral
fins, the soft or spinous structure of the dorsal rays, the number of
dorsal fins, etc. Not less than 420 species are thus arranged and
described, of which about 180 were known to the authors from
autopsy: a comparatively small proportion, descriptions and figures
still forming at that time in a great measure a substitute for
collections and museums. With the increasing accumulation of forms
the want of a fixed nomenclature is now more and more felt.
Peter Artedi would have been a great ichthyologist

P. Artedi. if Ray or Willughby had never preceded him. But he
was fully conscious of the fact that both had
prepared the way for him, and therefore he derived all possible
advantages from their works. Born in 1705 in Sweden, he studied
with Linnæus at Upsala; from an early period he devoted himself
entirely to the study of fishes, and was engaged in the arrangement
and description of the ichthyological collection of Seba, a wealthy
Dutchman who had formed the then perhaps richest museum, when
he was accidentally drowned in one of the canals of Amsterdam in
the year 1734, at an age of twenty-nine years. His manuscripts were
fortunately rescued by an Englishman, Cliffort, and edited by his
early friend Linnæus.
The work is divided into the following parts:—
1. In the “Bibliotheca Ichthyologica” Artedi gives a very complete
list of all preceding authors who have written on fishes, with a critical
analysis of their works.
2. The “Philosophia Ichthyologica” is devoted to a description of
the external and internal parts of fishes; Artedi fixes a precise
terminology of all the various modifications of the organs,
distinguishes between those characters which determine a genus
and such as indicate a species or merely a variety; in fact he
establishes the method and principles which subsequently have
guided every systematic ichthyologist.
3. The “Genera Piscium” contains well-defined diagnoses of forty-
five genera, for which he fixes an unchangeable nomenclature.
4. In the “Species Piscium” descriptions of seventy-two species,
examined by himself, are given; descriptions which even now are
models of exactitude and method.
5. Finally, in the “Synonymia Piscium” references to all previous
authors are arranged for every species, very much in the same
manner which is adopted in the systematic works of the present day.
Artedi has been justly called the Father of
Linnæus. Ichthyology. So perfect was his treatment of the
subject, that even Linnæus could no more improve
it, only modify and add to it; and as far as Ichthyology is concerned,
Linnæus has scarcely done anything beyond applying binominal
terms to the species properly described and classified by Artedi.
Artedi had divided the fishes proper into four orders, viz.
Malacopterygii, Acanthopterygii, Branchiostegi, and Chondropterygii,
of which the third only, according to our present knowledge, appears
to be singularly heterogeneous, as it comprises Balistes, Ostracion,
Cyclopterus, and Lophius. Linnæus, besides separating the
Cetaceans entirely from the class of fishes (at least since the 10th
edition of the “Systema Naturæ”) abandoned Artedi’s order of
Branchiostegi, but substituted a scarcely more natural combination
by joining it with Artedi’s Chondropterygians, under the name of
“Amphibia nantes.”
His classification of the genera appears in the 12th edition of the
“Systema,” thus—
Amphibia Nantes.
Spiraculis compositis.
Petromyzon.
Raia.
Squalus.
Chimæra.
Spiraculis solitariis.
Lophius.
Acipenser.
Cyclopterus.
Balistes.
Ostracion.
Tetrodon.
Diodon.
Centriscus.
Syngnathus.
Pegasus.
Pisces Apodes.
Muræna.
Gymnotus.
Trichiurus.
Anarhichas.
Ammodytes.
Ophidium.
Stromateus.
Xiphias.
Pisces Jugulares.
Callionymus.
Uranoscopus.
Trachinus.
Gadus.
Blennius.
Pisces Thoracici.
Cepola.
Echeneis.
Coryphæna.
Gobius.
Cottus.
Scorpæna.
Zeus.
Pleuronectes.
Chæetodon.
Sparus.
Labrus.
Sciæna.
Perca.
Gasterosteus.
Scomber.
Mullus.
Trigla.
Pisces Abdominales.
Cobitis.
Amia.
Silurus.
Teuthis.
Loricaria.
Salmo.
Fistularia.
Esox.
Elops.
Argentina.
Atherina.
Mugil.
Mormyrus.
Exocœtus.
Polynemus.
Clupea.
Cyprinus.
Two contemporaries of Linnæus attempted a

Gronow and systematic arrangement of fishes; both had
Klein. considerable opportunities for their study, especially
in possessing extensive collections; but neither
exercised any influence on the progress of Ichthyology. The one, L.
T. Gronow, a German who resided in Holland, closely followed the
arrangements proposed by Artedi and Linnæus, and increased the
number of genera and species from the contents of his own
museum. He published two works, “Museum Ichthyologicum” (Lugd.
1754–6, fol.), and “Zoophylacium” (Lugd. 1763–81, fol.); a
posthumous work, containing numerous excellent descriptions of
new forms was published by J. E. Gray in 1854 under the title of
“Systema Ichthyologicum.” To Gronow also is due the invention of
preparing flat skins of fishes in a dry state, and preserving them in
the manner of a herbarium. The specimens thus prepared by him
belong to the oldest which have been preserved down to our time.
Much less important are the ichthyological labours of J. T. Klein
(1685–1759). They are embodied in five parts (Missus) of a work
entitled “Historia naturalis piscium” (Sedæ, 1740–9, 4to.) He
regarded a system merely as the means of recognising the various
forms of animals, not as the expression of their natural affinities; and
that method seemed to him to be the most perfect by which an
animal could be most readily determined. He eschewed all reference
to minute or anatomical characters. Hence his system is a series of
the most unnatural combinations, and we cannot be surprised that
Linnæus passed in silence over Klein’s labours.
The works of Artedi and Linnæus excited fresh

Pupils and activity, more especially in Scandinavia, Holland,
Successors of Germany, and England, such as has not been
Linnæus equalled in the history of biological science either
before or after. Whilst some of the pupils and
followers of Linnæus devoted themselves to an examination and
study of the fauna of their native countries, others proceeded on
voyages of discovery to foreign and distant countries. Of these latter
the following may be specially mentioned:—O. Fabricius worked out
the Fauna of Greenland, Kalm collected in North America,
Hasselquist in Egypt and Palestine, Brünnich in the Mediterranean,
Osbeck in Java and China, Thurnberg in Japan; Forskål examined
and described the fishes of the Red Sea; Steller, Pallas, S. T.
Gmelin, and Güldenstedt traversed nearly the whole of the Russian
Empire in Europe and Asia. Others attached themselves as
naturalists to the celebrated circumnavigators of the last century, like
the two Forsters (father and son), and Solander, who accompanied
Cook; Commerson, who travelled with Bougainville; and Sonnerat.
Numerous new and startling forms were discovered by those men,
and the foundation was laid of the knowledge of the geographical
distribution of animals.
Of those who studied the fishes of their native country the most
celebrated are Pennant (Great Britain), O. F. Müller (Denmark),
Duhamel (France), Meidinger (Austria), Cornide (Spain), Parra
(Cuba).
The materials brought together by those and other zoologists
were so numerous that, not long after the death of Linnæus, the
necessity was felt of collecting them in a compendious form. Several
compilators undertook this task; they embodied the recent
discoveries in new editions of Artedi’s and Linné’s classical works,
but not possessing either a knowledge of the subject or any critical
discernment, they only succeeded in covering those noble
monuments under a mass of confused rubbish. For Ichthyology it
was fortunate that two men at least, Bloch and Lacépède, made it a
subject of long and original research.
Mark Eliezer Bloch, born in the year 1723 at

M. E. Bloch. Anspach in Germany, practised as a physician in
Berlin; he had reached an age of fifty-six years when
he commenced to write on ichthyological subjects. To commence at
his age a work in which he intended not only to give full descriptions
of the species known to him from specimens or drawings, but also to
illustrate every species in a style truly magnificent for his time, was
an undertaking of the execution of which an ordinary man would
have despaired. Yet he accomplished not only this task, but even
more, as we shall see hereafter.
His work consists of two divisions:—
1. “Oeconomische Naturgeschichte der Fische Deutschlands”
(Berl. 1782–4, 4to. Plates in fol.)
2. “Naturgeschichte der auslændischen Fische” (Berl. 1785–95,
4to. Plates in fol.)
Bloch’s work is unique, and probably will for ever remain so.
Although Cuvier fifty years later undertook a similar general work on
fishes, the subject had then become too extensive to allow of an
attempt of giving illustrations of all the species, or illustrations of a
similar size and costliness.
The first division of the work, which is devoted to a description of
the fishes of Germany, is entirely original, and based upon Bloch’s
own observations. His descriptions as well as figures were made
from nature, and are, with but few exceptions, still serviceable; many
continue to be the best existing in literature.
Bloch was less fortunate and is much less reliable in his natural
history of foreign fishes. For many of the species he had to rely on
more or less incorrect drawings and descriptions of travellers;
frequently, also, he was deceived as to the origin of specimens
which he acquired by purchase. Hence his accounts contain
numerous confusing errors which it would have been difficult to
correct, if not nearly the whole of the materials on which his work is
based had been preserved in the collections at Berlin.
After the completion of his Ichthyology Bloch occupied himself
with systematic work. He prepared a general system of fishes, in
which he arranged not only those described in his great work, but
also those with which he had become acquainted afterwards from
the descriptions of others. The work was ably edited and published
after Bloch’s death by a philologist, J. G. Schneider, under the title
“M. E. Blochii Systema ichthyologiæ iconibus ex. illustratum” (Berl.
1801, 8vo.) The number of species enumerated in it amounts to
1519. The system is based upon the number of the fins, the various
orders being termed Hendecapterygii, Decapterygii, etc. We need
not add that an artificial method like this led to the most unnatural
combinations or severances.
Bloch’s Ichthyology remained for many years the
Lacépède. standard work, and, by the great number of excellent
illustrations, proved a most useful guide to the
student. But as regards originality of thought, Bloch was far
surpassed by his contemporary, B. G. E. de Lacépède, born at
Agen, in France, in 1756, a man of great and general erudition, who
died as Professor of the Museum of Natural History of Paris in 1826.
Lacépède had to contend with great difficulties in the preparation
of his “Histoire des Poissons” (Paris, 1798–1803, 4to, in 5 vols.),
which was written during the most disturbed period of the French
Revolution. A great part of it was composed whilst the author was
separated from collections and books, and had to rely on his notes
and manuscripts only. Even the works of Bloch and other
contemporaneous authors remained unknown, or at least
inaccessible, to him for a long time. Therefore we cannot be
surprised that his work abounds in all those errors to which a
compiler is subject. The same species not only appears under two
and more distinct specific names, but it sometimes happens that the
author understands so little the source from which he derives his
information that the description is referred to one genus and the
accompanying figure to another. The names of genera are unduly
multiplied; and the figures with which the work is illustrated are far
inferior to those of Bloch. Thus the influence of Lacépède on the
progress of Ichthyology was infinitely less than that of his fellow-
labourer; and the labour caused to his successors by correcting the
numerous errors into which he has fallen, probably outweighs the
assistance which they derived from his work.
The work of the principal cultivators of Ichthyology in
Anatomists. the period between Ray and Lacépède was chiefly
systematic and descriptive, but also the internal
organisation of fishes received attention from more than one great
anatomist. Haller, Camper, and Hunter, examined the nervous
system and organs of sense; and more especially Alexander Monro
(the son) published a classical work, “The Structure and Physiology
of Fishes explained and compared with those of Man and other
Animals” (Edinb. 1785, fol.) The electric organs of fishes (Torpedo
and Gymnotus) were examined by Réaumur, Allamand, Bancroft,
Walsh, and still more exactly by J. Hunter. The mystery of the
propagation of the Eel called forth a large number of essays, and
even the artificial propagation of Salmonidæ was known and
practised by Gleditsch (1764).
Bloch and Lacépède’s works were almost
Faunists. immediately succeeded by the labours of Cuvier, but
his early publications were of necessity tentative,
preliminary, and fragmentary, so that a short period elapsed before
the spirit infused by this great anatomist into Ichthyology could
exercise its influence on all workers in this field. Several of such
antecuvierian works must be mentioned on account of their
importance to our knowledge of certain Faunas: the “Descriptions
and Figures of Two Hundred Fishes collected at Vizagapatam on the
coast of Coromandel” (Lond. 1803; 2 vols. in fol.), by Patrick Russel;
and “An Account of the Fishes found in the River Ganges and its
branches” (Edinb. 1822; 2 vols. in 4to), by F. Hamilton (formerly
Buchanan)—works distinguished by a greater accuracy of their
drawings (especially in the latter), than was ever attained before. A
“Natural History of British Fishes” was published by E. Donovan
(Lond. 8vo, 1802–8); and the Mediterranean Fauna formed the study
of the lifetime of A. Risso (“Ichthyologie de Nice.” Paris, 1810, 8vo;
and “Histoire naturelle de l’Europe Meridionale.” Paris, 1827, 8vo). A
slight beginning in the description of the fishes of the United States
was made by S. L. Mitchell, who published, besides various papers,
a “Memoir on the Ichthyology of New York,” in 1815.[2]
G. Cuvier did not occupy himself with the study of

G. Cuvier. fishes merely because this class formed part of the
“Règne animal,” but he devoted himself to it with
particular predilection. The investigation of their anatomy, and
especially of their skeleton, was taken up by him at an early period,
and continued until he had succeeded in completing so perfect a
framework of the system of the whole class that his immediate
successors could content themselves with filling up those details for
which their master had no leisure. Indefatigable in examining all the
external and internal characters of the fishes of a rich collection, he
ascertained the natural affinities of the infinite variety of fishes, and
accurately defined the divisions, orders, families, and genera of the
class, as they appear in the various editions of the “Règne animal.”
His industry equalled his genius: he opened connections with almost
every accessible part of the globe; not only French travellers and
naturalists, but also Germans, Englishmen, Americans, rivalled one
another to assist him with collections; and for many years the
Muséum of the Jardin des Plantes was the centre where all
ichthyological treasures were deposited. Thus Cuvier brought
together a collection the like of which had never been seen before,
and which, as it contains all the materials on which his labours were
based, must still be considered to be the most important. Soon after
the year 1820, Cuvier, assisted by one of his pupils, A.
Valenciennes, commenced his great work on fishes, “Histoire
naturelles des Poissons,” of which the first volume appeared in 1828.
The earlier volumes, in which Cuvier himself took his share, bear
evidence of the freshness and love with which both authors devoted
themselves to their task. After Cuvier’s death in 1832 the work was
left entirely in the hands of Valenciennes, whose energy and interest
gradually slackened, to rise to the old standard in some parts only,
as, for instance, in the treatise on the Herring. He left the work
unfinished with the twenty-second volume (1848), which treats of the
Salmonoids. Yet, incomplete as it is, it is indispensable to the
student.
There exist several editions of the work, which, however, have
the same text. One, printed in 8vo, with coloured or plain figures, is
the one in common use among ichthyologists. A more luxurious
edition in 4to has a different pagination, and therefore is most
inconvenient to use.
As mentioned above, the various parts of the work are very
unequally worked out. Many of the species are described in so
masterly a manner that a greater excellency of method can hardly be
conceived. The history of the literature of these species is entered
into with minuteness and critical discernment; but in the later
volumes, numerous species are introduced into the system without
any description, or with a few words only, comparing a species with
one or more of its congeners. Cuvier himself, at a late period of his
life, seems to have grown indifferent as to the exact definition of his
species: a failing commonly observed among Zoologists when
attention to descriptive details becomes to them a tedious task. What
is more surprising is, that a man of his anatomical and physiological
knowledge should have overlooked the fact that secondary sexual
characters are developed in fishes as in any other class of animals,
and that fishes undergo great changes during growth; and,
consequently, that he described almost all such sexual forms and
different stages of growth under distinct specific and even generic
names.
The system finally adopted by Cuvier is the following:—
A. Poissons Osseux.
I.—a branchies en peignes ou en lames.
1. a mâchoire supérieure libre.
a. Acanthoptérygiens.
Percoïdes.
Polynèmes.
Mulles.
Joues cuirassées.
Scienoïdes.
Sparoïdes.
Chétodonoïdes.
Scomberoïdes.
Muges.
Branchies labyrinthiques.
Lophioïdes.
Gobioïdes.
Labroïdes.
b. Malacoptérygiens.
Abdominaux.
Cyprinoïdes.
Siluroïdes.
Salmonoïdes.
Clupeoïdes.
Lucioïdes.
Subbrachiens.
Sparoïdes.
Pleuronectes.
Discoboles.
Apodes.
Murenoïdes.
2. a mâchoire supérieure fixée.

Sclérodermes.
Gymnodontes.
II. a branchies en forme de houppes.

Lophobranches.
B. Cartilagineux ou Chondroptérygiens.
Sturioniens.
Plagiostomes.
Cyclostomes.
We have to compare this system with that of Linnæus if we wish

to measure the gigantic stride Ichthyology has made during the
intervening period of seventy years. The various characters
employed for classification have been examined throughout the
whole class, and their relative importance has been duly weighed
and understood. Though Linnæus had formed a category of
“Amphibia nantes” for fishes with a cartilaginous skeleton, which
should coincide with Cuvier’s “Poissons Cartilagineux,” he had failed
to understand the very nature of cartilage, apparently comprising by
this term any skeletal framework of less firmity than ordinary bone.
Hence he considered Lophius, Cyclopterus, Syngnathus to be
cartilaginous fishes. Adopting the position and development of the
ventral fins as a highly important character, he was obliged to
associate fishes with rudimentary and inconspicuous ventral fins, like
Trichiurus, Xiphias, etc., with the true Eels. The important category of
a “family” appears now in Cuvier’s system fully established as that
intermediate between genus and order. Important changes in
Cuvier’s system have been made and proposed by his successors,
but in the main it is still that of the present day.
Cuvier had extended his researches beyond the living forms, into
the field of palæontology; he was the first to observe the close
resemblance of the scales of the fossil Palæoniscus to those of the
living Polypterus and Lepidosteus, the prolongation and identity of
structure of the upper caudal lobe in Palæoniscus and the
Sturgeons, the presence of peculiar “fulcra” on the anterior margin of
the dorsal fin in Palæoniscus and Lepidosteus: inferring from these
facts that that fossil genus was allied either to the Sturgeons or to
Lepidosteus. But it did not occur to him that there was a close
relationship between those recent fishes. Lepidosteus and, with it,
the fossil genus remained in his system a member of the order of
Malacopterygii abdominales.
It was left to L. Agassiz (born 1807, died 1873) to point out the
importance of the character of the structure of the scales, and to
open a path towards the knowledge of a whole new sub-class of
fishes, the Ganoidei.
Impressed with the fact that the peculiar scales of Polypterus and
Lepidosteus are common to all fossil osseous fishes down to the
chalk, he takes the structure of the scales generally as the base for
an ichthyological system, and distinguishes four orders:—
1. Placoids.—Without scales proper, but with scales of enamel,
sometimes large, sometimes small and reduced to mere points
(Rays, Sharks, and Cyclostomi, with the fossil Hybodontes).
2. Ganoids.—With angular bony scales, covered with a thick
stratum of enamel: to this order belong the fossil Lepidoides,
Sauroides, Pycnodontes, and Coelacanthi; the recent Polypterus,
Lepidosteus, Sclerodermi, Gymnodontes, Lophobranches, and
Siluroides; also the Sturgeons.
3. Ctenoids.—With rough scales, which have their free margins
denticulated: Chætodontidæ, Pleuronectidæ, Percidæ, Polyacanthi,
Sciænidæ, Sparidæ, Scorpænidæ, Aulostomi.
4. Cycloids.—With smooth scales, the hind margin of which lacks
denticulation: Labridæ, Mugilidæ, Scombridæ, Gadoidei, Gobiidæ,
Murænidæ, Lucioidei, Salmonidæ, Clupeidæ, Cyprinidæ.
We have no hesitation in affirming that if Agassiz had had an
opportunity of acquiring a more extensive and intimate knowledge of

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Benjamin D. Elder, MD, PhD James S. Harrop, MD, FACS

James Kalyvas, MD Evan Lewis, MD

Michael Karsy, MD, PhD Jason Liounakos, MD

Rani Nasser, MD Christopher I. Shaffrey, MD

Khoi D. Than, MD Anand Veeravagu, MD

Nicholas Theodore, MD Todd D. Vogel, MD

Daniel Tarazona and Alexander R. Vaccaro

A 79-​year-​old woman presents to the emergency department after falling at a nursing

1. What is the likely diagnosis?

Assessment and Planning

Oral Boards Review: Diagnostic Pearls

Initial radiographic evaluation of the cervical spine includes anteroposterior (AP),

Anderson and D’Alonzo

Figure 1.1 Anderson and D’Alonzo.

Figure 1.2 Grauer classification.

1. What are risk factors for nonunion?

Positioning and Preparation

A midline longitudinal incision is utilized. Intraoperative radiographs should be taken to

Fluoroscopy is initially used to confirm adequate position of C1 relative to C2. Next,

Oral Boards: Management Pearls

1. Evaluation of vertebral artery anatomy with preoperative imaging,

1. If an aberrant vertebral artery is present, then an alternative operative tech-

It is recommended that patients undergoing fixation of type II odontoid type fractures

Complications and Management

Neurovascular injuries are the most concerning intraoperative complications. With a

Following a posterior cervical approach, occipital neuralgia is a common complaint.

Oral Boards Review: Complications Pearls

1. If there is an inadvertent injury to the vertebral artery, bleeding should be

Evidence and Outcomes

References and Further Readings

Jason Liounakos, G. Damian Brusko, and Michael Y. Wang

1. What is the most likely diagnosis?

Assessment and Planning

Figure 2.1 Computed tomography (CT) scan demonstrating cervical fracture

referred to as being “perched.” Unilateral facet dislocation often results in a grade 1

Oral Boards Review: Diagnostic Pearls

1. The physical examination is the most important component in the initial

5. Much controversy surrounds whether prereduction MRI should be

Oral Boards Review: Management Pearls

setting of symptomatic bradycardia. Higher level cervical injuries result in disruption

Complications and Management

Oral Boards Review: Complications Pearls

1. Minimizing time under retraction and deflation of the endotracheal tube

Evidence and Outcomes

References and Further Reading

Alexander B. Dru and Daniel J. Hoh

A 28-​year-​old woman presents to the emergency department after being struck by

Assessment and Planning

Occipitocervical dislocation (or atlanto-​occipital dislocation, AOD) is a highly un-

Library of Congress Cataloging-in-Publication Data

A 79-year-old woman presents to the emergency department after falling at a nursing

A 28-year-old woman presents to the emergency department after being struck by

Occipitocervical dislocation (or atlanto-occipital dislocation, AOD) is a highly un-

2. Describe image-based diagnostic criteria for AOD.

Figure 3.4 Occipital–C4 fusion for internal stabilization of atlanto-occipital