TRAUMA

Controversies in Spinal Trauma and Evolution

James S. Harrop, MD
George N. Rymarczuk, MD
Alexander R. Vaccaro, MD,
PhD
Michael P. Steinmetz, MD
Lindsay A. Tetreault, HBSc||
Michael G. Fehlings, MD, PhD||
of Care
Management of spinal trauma is a complex and rapidly evolving field. To optimize patient
treatment algorithms, an understanding of and appreciation for current controversies and
advancing technologies in the field of spinal trauma is necessary. Therefore, members
of the AOSpine Knowledge Forum Trauma initiative used a modified Delphi method to
compile a list of controversial issues and emerging technologies in the field of spinal
trauma, and a list of the 14 most relevant topics was generated. A total of 45 440
manuscripts covering the breadth of spine and spinal trauma were initially identified.
This broad search was then refined using the 14 categories felt to be most relevant to

Department of Neurological Sur-
gery, Thomas Jefferson University,
Philadelphia, Pennsylvania; Division
of Neurosurgery, Walter Reed
National Military Medical Center,
Bethesda, Maryland; Department of
Orthopaedic Surgery, Thomas Jefferson
University and The Rothman Institute,
Philadelphia, Pennsylvania; Department
of Neurological Surgery, Cleveland Clinic
Lerner College of Medicine, Cleveland
Clinic, Cleveland, Ohio; || Division of
Neurosurgery and Spine Program,
University of Toronto and Toronto
Western Hospital, Toronto, Canada
Correspondence:
James S. Harrop, MD,
Departments of Neurological and
the current field of spinal trauma. The results were further pared down using inclusion
criteria to select for the most relevant topics. The 8 remaining topics were classification
schemes, treatment of vertebral compression fractures, treatment of burst fractures, timing
of surgery in spinal trauma, hypothermia, the importance of global sagittal balance, lumbar
subarachnoid drainage, and diffusion magnetic resonance imaging. These 8 topics were
felt to be the most relevant, controversial, rapidly evolving, and most deserving of inclusion
in this summary. In summary, despite recent advances, the field of spinal trauma has many
ongoing points of controversy. We must continue to refine our ability to care for this patient
population through education, research, and development. It is anticipated that the new
AOSpine fracture classification system will assist with prospective research efforts.
KEY WORDS: Spine, Future, Imaging, Classification, Timing of surgery, Trauma
Neurosurgery 80:S23S32, 2017 DOI:10.1093/neuros/nyw076 www.neurosurgery-online.com

Orthopedic Surgery,
Division of Spine and Peripheral Nerve
Surgery,
Thomas Jefferson University,
909 Walnut Streetthird floor,
Philadelphia, PA 19107.
E-mail: james.harrop@jefferson.edu
Received, August 15, 2016.
Accepted, January 30, 2017.
Copyright 
C 2016 by the
Congress of Neurological Surgeons.
M
anagement of spine trauma patients,
including spinal cord injuries, has
evolved rapidly over the last several
decades. This is variously attributed to a
greater understanding of the pathophysio-
logic processes affecting spine trauma patients,
a more thorough comprehension of spinal
biomechanics, improved instrumentation and
surgical techniques, and improved patient triage
and medical management strategies. However,
this rapid expansion of information has led
to an exuberant amount of literature to be
digested and incorporated into existing patient
ABBREVIATIONS: AIS, ASIA impairment score;
ASIA, American Spinal Injury Association; CT,
computed tomography; CSF, cerebrospinal fluid;
DTI, diffusion tensor imaging; NFL, National
football league; MIS, minimally invasive surgery;
MRI, magnetic resonance imaging; SCI, spinal cord
injury; TLICS, thoracolumbar injury classification
and severity; VCF, vertebral compression fracture
management algorithms. This glut of infor-
mation can contribute to the confusion regarding
the optimal management of victims of spinal
trauma with and without spinal cord injury. This
paper was developed to provide an overall review
of the current body of spine trauma literature,
identify the most rapidly evolving fields, and
concisely highlight the major points suggested
by the literature to have benefit for the patient.
METHODS
The AOSpine Foundation is an international
nonprofit organization dedicated to the concept of
improving the care of patients with musculoskeletal
injuries and other spinal pathologies by fostering
education and knowledge through research and devel-
opment. AOSpine North America identified 14
spine surgeons based on their significant knowledge
and expertise in the field of spinal trauma. A list
of relevant and current topics in spinal trauma
was dispersed to these individuals. The list was
edited and refined through multiple e-mails, personal

NEUROSURGERY VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement | S23

HARROP ET AL
communications, and direct telephone conference calls. At the
conclusion of this process, the initial list had been distilled to the 14
topics considered most relevant and controversial by the panel of experts.
These topics are:
1. corticosteroid therapy in acute spinal trauma,
2. odontoid fractures,
3. timing of surgery in central cord syndrome,
4. thoracolumbar burst fracture treatment,
5. thoracolumbar vertebral compression fractures (VCFs),
6. timing of surgery in spinal trauma,
7. blood pressure management goal,
8. timing of magnetic resonance imaging (MRI) in spinal trauma,
9. hypothermia in spinal trauma,
10. effect of global sagittal balance on clinical outcomes,
11. lumbar subarachnoid drainage,
12. minimally invasive surgery (MIS) strategies for thoracolumbar
trauma,
13. diffusion MRI,
14. classification schemes in spinal trauma.
Numerous concepts of management of spine trauma patients are
longstanding and have been consistently reiterated throughout the liter-
ature. In order to attempt to define and elucidate the most relevant and
rapidly evolving topics within the field of spinal trauma, a repeat liter-
ature search limited to articles published in the last 5 years was performed.
The percentage of new literature (ie, which was published within the
last 5 years) was compared to all existing literature for a particular topic
within the field of spinal trauma, spanning the period from 1966 to
present. The percentage of the literature that was published within the
last 5 years was then calculated using the following formula:
number of manuscripts published within the past 5 years
100
total number of manuscripts on the topic
Using this method, the proportion of up-to-date literature for each
particular topic was determined. Inclusion criteria were set such that a
particular topic was considered relevant and/or rapidly evolving if (1) at
least 10 manuscripts were published on the topic within the last 5 years,
and (2) at least 25% of the material published on the topic occurred
within the last 5 years. The topics which met the inclusion criteria were
individually reviewed, and key articles were summarized on each relevant
topic.
RESULTS
In total, 14 subtopics within the field of spine trauma were
entered into the PubMed search engine on August 5, 2016. This
query included all documents returned from 1966 to present.
This initial search identified 45 440 manuscripts. A further
refinement of this literature search was performed by limiting the
original search algorithm to include the 14 subtopic terms listed
in Table. As previously stated, the 14 subtopics were determined
by the results of the Delphi method performed by the expert spine
surgeons identified by AO North America.
To determine the proportion of the literature for each of
the 14 topics which are relevant in terms of rapidly changing
or evolving literature, the percentage of manuscripts for each
S24 | VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement
topic that were published within the last 5 years was calcu-
lated. The percentage of manuscripts published within the past
5 years are as follows: 21.9% of manuscripts on corticosteroid
usage in spine trauma (227/1032), 19.4% of manuscripts on
odontoid fractures (207/1062), 38% of manuscripts on the
timing of decompression of central cord injuries (8/21), 28%
of manuscripts on management of thoracolumbar burst fractures
(300/1070), 25.7% of manuscripts on the management of VCFs
(916/3559), 54.9% of manuscripts on the timing of surgery
in spinal trauma (138/251), 18.7% of manuscripts on blood
pressure management goals (315/1683), 29.9% of manuscripts
on MRI in the setting of spinal trauma (1592/6643), 32.3%
of manuscripts on hypothermia in the setting of spinal trauma
(33/102), 50% of manuscripts on the importance of global
sagittal balance in the setting of spinal trauma (47/94), 29.2% of
manuscripts on lumbar subarachnoid drainage (57/195), 100%
of manuscripts on MIS treatment of thoracolumbar trauma (3/3),
41.1% of manuscripts on diffusion MRI (109/265) in the setting
of spinal trauma, and 31.0% of manuscripts on classification
systems of spinal trauma (640/2123; Table).
Based on the inclusion and exclusion criteria set a priori, 6
topics were excluded from further analysis. The following topics
were excluded due to fewer than 10 manuscripts being published
in the past 5 years: timing of surgery in central cord syndrome
and MIS strategies for thoracolumbar trauma. The following
topics were excluded because fewer than 25% of manuscripts
were published within the past 5 years: corticosteroid therapy,
odontoid fractures, blood pressure management, and magnetic
resonance imaging. Eight of the original 14 topics met inclusion
criteria and are discussed below. These results are also depicted in
Table.
DISCUSSION
The treatment of the polytrauma patient can be challenging.
These patients often have concurrent injuries to multiple organ
systems which can result in medical instability. The multiple
injuries must be prioritized, and therapies aimed at 1 organ system
must be reconciled with potential deleterious effects on another.
An altered sensorium can preclude a comprehensive neurological
examination, which can affect management of the patients neuro-
logical injury. In spine trauma, the issue is further complicated
due to the heterogeneity of spinal fractures, dislocations, and
discoligamentous injuries. In addition to the enormous variability
of patient-specific factors and concurrent injuries, other aspects
unique to the spinal trauma patient that must be fully appreciated
include bone quality, age, and baseline health and medical comor-
bidities. Thus, each spinal injury must be evaluated individually,
with respect to its unique identity and complexity.
Despite the complexity of spinal trauma, there have been
numerous advances in diagnosis and management, particularly
over the last several decades. In order to attempt to quantify the
relative relevance of recent contributions to the field of spinal
www.neurosurgery-online.com
 CONTROVERSIES IN SPINAL TRAUMA AND EVOLUTION OF CARE

TABLE. Total Number of Manuscripts per Topic, The Percentage Published within the Past 5 Years, and if the Topic was Excluded vs Included
Based on the Relevancy Analysis

Search Terms Manuscripts Manuscripts Manuscripts Included vs

Topic (Spine Trauma + .) (total) (within 5 years) (% within 5 years) excluded

Corticosteroids Corticosteroids, steroids 1032 227 21.9 Excluded

Odontoid fractures Odontoid fracture 1062 207 19.4 Excluded
Central cord syndrome Central cord injury, Central cord 21 8 38 Excluded
syndrome
Burst fractures Burst fracture, traumatic fracture 1070 300 28 Included
Vertebral compression fractures Vertebral compression fracture, VCF 3559 916 25.7 Included
Timing of surgery Timing of surgery, time 251 138 54.9 Included
Blood pressure management blood pressure management 1683 315 18.7 Excluded
Magnetic resonance imaging Magnetic resonance imaging, MRI 6643 1,592 29.9 Excluded
Hypothermia Hypothermia 102 33 32.3 Included
Sagittal balance Sagittal balance, global sagittal 94 47 50 Included
balance
Lumbar drainage Lumbar drainage, lumbar catheter 195 57 29.2 Included
MIS for thoracolumbar trauma Minimally invasive surgery, 3 3 100 Excluded
thoracolumbar trauma, MIS
Diffusion MRI Diffusion MRI, Diffusion imaging 265 109 41.1 Included
Classification schemes Classification, Classification 2123 640 31 Included
schemes

trauma, a list of controversial topics was compiled by recognized
spine trauma experts. This list was discussed, modified, refined,
and finalized to 14 individual topics that are particularly contro-
versial and noteworthy in the recent literature. These topics were
considered to be the most current and appropriate for further
discussion. By limiting the material to relevant manuscripts
published within the last 5 years (ie, by requiring a particular topic
to have greater than 10 articles and more than 25% of its total
volume of literature published in last 5 years), only 8 topics met
the inclusion criteria.
These 8 subtopics can be further categorized as (1) ascer-
taining structural integrity of the spine, or (2) identification
and treatment of the underlying pathophysiology of spine and
spinal cord injury. These 2 categories can each serve as overar-
ching themes for the discussion that ensues in this manuscript.
Each theme contains 4 of the 8 individual subcategories that
are included in this discussion. The spine structural integrity
group consists of classification schemes, management of thora-
columbar burst fractures, management of VCFs, and appreciation
of global sagittal balance. The second group, treatments targeting
the pathophysiology of spinal injuries, encompasses timing of
surgery in spinal trauma, hypothermia, lumbar drainage, and
diffusion MRI.
Classification Schemes and Thoracolumbar Burst
Fractures
The classification of traumatic spine injuries has always been
complex and fraught with difficulty. Multiple competing and
overlapping schema exist. Improvements in classification and
categorization of spinal fractures have been affected by advances
in our collective understanding of spinal biomechanics, as well as
improvement of spinal imaging technologies (computed tomog-
raphy [CT] and MRI). In addition, for a classification scheme to
be uniformly accepted and applied clinically, the scheme needs to
be useable by all treating surgeons and physicians. Spine trauma
classification schemes should be comprehensive, reproducible,
have low inter- and intraobserver variability, and facilitate the
treatment and outcome of spine trauma patients.
Historically, spine classification systems were centered on the
thoracolumbar region due to the high incidence of fractures
in this area, and the relative uncertainty regarding definitive
management. In 1938, Watson-Jones proposed a 3-category
system for describing thoracolumbar vertebral body fractures
based on an analysis of 252 radiographs.1 In this early
but comprehensive manuscript, Watson-Jones classified thora-
columbar vertebral body fractures as simple wedge fractures,
comminuted fractures, or fracture dislocations. The author also
proposed mechanisms of injury, options for reduction and
fixation, outcome, pitfalls to therapy, and special cases such as
jumped facets. Next, in 1949, the concept of spinal stability
emerged in a key publication by Nicoll,2 who established stable
vs unstable fractures based on the integrity of the posterior
ligamentous complex. As a greater understanding of anatomic
and morphological principles accumulated, focus shifted to the
multiple columns of support provided by the spine. Classifi-
cation schemes began to further evolve under this premise. In the
1960s, many authors considered the spine to consist of 2 columns
of support: an anterior column, which resisted compression, and
posterior elements, which resisted tensile stress.3 In 1980, the
advent of CT provided consistent visualization of the osseous

NEUROSURGERY VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement | S25

HARROP ET AL
elements of the vertebra and posterior arch. During this decade,
multiple authors refined the 2-column model of support into
a more functional 3-column model.4,5 Importantly, in 1983,
Denis underscored the importance of the middle osteoliga-
mentous complex as part of the 3-column system he proposed in a
retrospective review of 412 thoracolumbar injuries. Denis corre-
lated the 3-column system with overall spinal stability and indica-
tions for intervention.5 In 1994, Magerl et al6 presented the
AO classification based on a review of 1445 consecutive thora-
columbar traumas. While complex, this system represents a signif-
icant jump in the amount of information that can be conveyed
regarding individual fracture patterns and moreover, one was able
to classify any fracture seen. Magerl et al6 discerned fractures into
3 main morphologies based on different mechanisms of injury:
compression, distraction, and rotation. Numerous subcategories
that reflect progressive damage further subclassify the injuries
based on instability and propensity for neurological deficit.
Despite their strengths, these classification systems have
weaknesses. They can be confusing, unwieldy at the bedside, and
difficult to interpret, lack inter- and intraobserver agreement,
and perhaps most importantly, lack prognostic value. Oner et al7
confirmed these findings in a review of 53 thoracolumbar trauma
patients with both CT and MRI available for review. The authors
showed that the AO classification system had a low interobserver
variability and a greater ability to describe all types of injury;
however, this comes at the cost of more a cumbersome scheme.
Conversely, the Denis classification,5 while simpler and easier to
apply clinically, leads to information loss.7
Recently, there has been increased interest and discussion on
classification systems. This review found that 31% of the publi-
cations on spinal trauma classification schemes were published
in the last 5 years. The Spine Trauma Study Group, consisting
of multiple spine physicians and both orthopedic spine surgeons
and neurosurgeons, devised the Thoracolumbar Injury Classi-
fication and Severity (TLICS) Scale in 2005.8-17 This system
has successfully merged the positive attributes and merits of
prior classification systems, and functionally categorizes fracture
patterns based on morphology of the injury, the patients neuro-
logical status, and the integrity of the posterior ligamentous
complex. The concepts of this system were subsequently success-
fully expanded to encompass injuries of the subaxial cervical
spine through the Subaxial Cervical Spine Injury Classification
System.18
In 2013, in another multicenter group collaboration, the
AOSpine Knowledge Forum on Spinal Cord Injury and Trauma,
under the guidance of Vaccaro, devised the AOSpine Thora-
columbar Spine Injury Classification System (Figure 1).19 This
classification system combines the merits of Magerls AO classi-
fication of 1994 with the TLICS classification system. The
result is a scheme that combines the morphological classifi-
cation of the fracture (compression, tension band disruption,
or translational injuries due to failure to all elements) with
the patients neurological status, as well as patient-specific
modifiers that may be important in individualizing management
S26 | VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement
plans. In 2016, Vaccaro et al20 expanded the classification of
subaxial cervical spine injuries in much the same manner, with
the publication of the AOSpine subaxial cervical classification
scheme.
Classification systems for thoracolumbar fractures were
originally devised to guide therapy in an algorithmic and
reproducible fashion, in order to standardize the way fractures
were cared for. Still, the optimal treatment of the thoracolumbar
burst fracture is controversial, especially in the patient that is
neurologically intact, or with fracture morphology that is of
low or intermediate severity. This controversy is illustrated by
the fact that 28% of the literature on this topic was produced
in the last 5 years, with no strong consensus. Recently, this
matter has been addressed by 3 prospective randomized studies.
In 2 studies, the authors concluded that surgery for thora-
columbar burst fractures in the neurologically intact patient
offered no advantage to more conservative measures, while a third
author recommended that short-segment fixation be used over
nonoperative management in type A3 injuries (the incomplete
burst fracturea fracture involving a single endplate and the
posterior vertebral wall) to reduce local and regional kyphosis and
improve functional outcome scores at a mean follow-up of 4.3
years.19,21-23
The controversies have only increased with the recent intro-
duction of MIS techniques. There has been some suggestion
that less invasive procedures for thoracolumbar burst fractures
may improve outcome. By limiting soft-tissue disruption and
avoiding the risks of conventional open approaches such as thora-
cotomy and thoracoabdominal exposures, they may require less
analgesia and permit a shorter recovery period.24 However, in
2010, Fourney et al25 noted in a small review series of degen-
erative spine disorders that, other than perhaps lower volumes
of blood loss, there was no difference in rate of complications
of MIS vs open surgical treatment, and there was no evidence
to assess the effectiveness of strategies that reduce the risk of
MIS-related complications. Furthermore, in 2015 Oh et al26
reported their results of a MEDLINE literature review of the
use of MIS for treatment of thoracolumbar burst fractures. The
authors noted that, while MIS is being used increasingly in degen-
erative deformity surgery, the level of evidence supporting the
use of MIS in the trauma population is low.26 Another treatment
option for thoracolumbar burst fractures that is even less invasive
than MIS is immobilization through bracing. There has been
recent resurgence of interest in the benefit and usefulness of
bracing for these fractures. Bailey et al27 performed a prospective
study of 69 patients with thoracolumbar burst fractures of the
AO type A3 morphology. It should be noted that the authors
excluded patients with radiographic findings of spinal insta-
bility, eg, involvement of the tension band, or translational
injuries. To be included in the analysis, patients were specified
to be neurologically intact, skeletally mature individuals less
than 60 years of age, with fractures occurring between T11 and
L3, and less than 35 degrees of focal kyphosis at the index
level. The authors found equivalency between orthosis and no
www.neurosurgery-online.com
 CONTROVERSIES IN SPINAL TRAUMA AND EVOLUTION OF CARE

FIGURE 1. This diagram illustrates the pathway to classify thoracolumbar fractures according to the AO Thoracolumbar
Classification scheme. A review of the fracture morphology through images will assess the severity of the injuries. If there is
displacement or dislocation of the fracture, then it is categorized as a type C injury. When there is failure of the posterior
tension band or failure in extension, the fracture is classified as a type B, with subclassifications noted. The least traumatic
fractures are vertebral body fractures (type A) with their listed subclassification. Copyright by AO Foundation, Switzerland.

orthosis at interim analysis, and concluded that thoracolumbar without bracing is the preferred means of treating this clinical
burst fractures without injury to the posterior ligamentous entity, as it lowers cost, avoids patient deconditioning, and is
complex are stable injuries.27 In a follow-up study published associated with fewer complications related to prolonged bed
in 2014, Bailey et al28 further concluded that early ambulation rest and brace availability. Thus, these studies do not support

NEUROSURGERY VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement | S27

HARROP ET AL
bracing in stable thoracolumbar fractures in neurologically intact
patients.
Vertebral Compression Fractures
The population is aging, and the relative proportion of elderly
individuals continues to increase. There has been a corresponding
increase in osteoporotic VCFs. Numerous retrospective studies
with small sample sizes have noted a benefit to vertebral augmen-
tation (kyphoplasty and vertebroplasty) for the treatment of VCF.
Several authors have variously noted significant reductions in
visual analog pain scores and Oswestry disability indices, signif-
icant restoration of vertebral height in acute and, to a lesser
extent, chronic compression fractures, and decreased narcotic
usage in patients treated with these therapies.29-31 This topic
has the greatest evidence base with 7 randomized trials.32-38 The
results of these studies are conflicting, however, the majority of
authors report improved outcomes with vertebral augmentation
compared to maximal medical therapy, similar to the aforemen-
tioned retrospective studies. The dissenting views on vertebral
augmentation are 2 studies published in the New England Journal
of Medicine in 2009,32,34 both of which used a sham procedure
as a control, as opposed to best medial management. With these
studies, there are significant methodology flaws, and the conclu-
sions drawn must be interpreted with care. In the study by
Kallmes et al,34 there was a trend toward clinically meaningful
improvement with vertebral augmentation (65% vs 48%, P =
.06), and there was a significantly greater rate of crossover in
the control group by 3 months time (51% vs 13%, P < .001).
Buchbinder et al32 also reported no efficacy of vertebral augmen-
tation when compared with simulated procedure. It should be
noted that median duration of preprocedural symptoms in the
augmentation group was 9.0 weeks, and 9.5 weeks in the placebo
group. Less than one-third of participants had a duration of
symptoms of less than 6 weeks.32 The natural history of VCF
is a decrease in axial pain with time, and it is known that
vertebral augmentation is more efficacious for acute fractures
than chronic. It is possible the authors treated a population of
patients with chronic fractures that were too remote from the
ictus to elucidate a difference. In properly designed studies, it
therefore appears that surgical treatment of VCF with augmen-
tation is effective and beneficial, but candidates must be chosen
carefully.
Global Sagittal Balance
The importance of spinal global sagittal alignment and
overall global spinopelvic balance for patient outcomes has
been well established in spine deformity surgery population.39,40
The deformity literature, and our ability to understand overall
spinopelvic alignment, has improved greatly. This has led to
significant advancements in patient care and surgical outcomes.
These principles are being used not only in deformity surgery,
but are now pervasive in spinal degenerative diseases, spinal
reconstruction, and spinal trauma.41-43 The importance of this
principle is noted in that 50% of the papers on this topic
S28 | VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement
were published within the last 5 years. While there are no large
series available, the importance of optimal spinopelvic alignment
and global sagittal balance is self-evident. In the spine trauma
population, optimal spinal alignment is required to place the body
in an appropriate, upright biomechanical position in order to
reduce pain and maximize use and rehabilitation of any preserved
neurological function. These concepts may be of greater impor-
tance in those with neurological deficit, and is presently being
studied. Koller et al43 have proposed that a patients ability
to compensate for severely angulated kyphotic deformities is
dictated by the interplay of spinopelvic balance and the fixed
orientation of the pelvis. Eventually, the patient may reach the
limit of their compensatory mechanisms, much as in the degen-
erative deformity population. These factors affecting long-term
outcome should be kept in mind when evaluating the acute
spinal trauma patient. Bailey et al,27,28 in their evaluation of
efficacy of bracing, selected AO type A3 fractures for evaluation,
intentionally excluding individuals with more severe injuries, and
radiographic surrogates for instability (eg, local kyphosis greater
than 35 degrees, loss of height more than 50 degrees, etc). The
long-term natural history is not known with certainty, and longer
follow-up is needed. The surgeon should always keep in mind
the effect of overall global sagittal balance and spinopelvic balance
when evaluating the trauma patient.
In addition to the advances in our comprehension and
management of structural components of spine trauma, there
has been further advance in understanding and treatment of
traumatic spinal cord injuries. Some of these topics are also
discussed in the chapter on spinal cord injury. However, due
to their importance and rapid advancement in spine trauma,
a brief review of the following topics is warranted in this
manuscript: hypothermia in spinal trauma, timing of surgery,
lumbar subarachnoid drain placement, and use of diffusion
MRI.
Timing of Surgery for Spinal Canal Compression
There is ample evidence of the benefit of early surgical decom-
pression in animal spinal cord injuries models; however, there
has been a relative lack of literature illustrating a benefit in the
human population.44-47 In 2013, Batchelor et al47 performed a
meta-analysis of the preclinical literature to examine the effect of
urgent decompression on spinal cord injury in animal models.
The authors noted that as compressive pressure and duration
increased, greater neurobehavioral deficits were noted in the
subjects after decompression. In a large and systematic review of
manuscripts covering the treatment of human spinal cord injury,
Furlan et al46 illustrated that early surgical intervention was not
only safe, but was associated with improved patient outcomes,
reduced rates of complications, reduced length of stay, and overall
reduced cost to the healthcare system. What constitutes early
intervention, however, is not clearly defined. The term early
has varied over the years; it has variously been ascribed to time
periods ranging from 5 days to less than 24 h. Furlan et al46
www.neurosurgery-online.com

recommend that decompression be considered between 8 and
24 h from injury. Over the last 2 decades, there has been a
general consensus that earlier surgical intervention most likely
carries greater clinical benefit if it can be accomplished safely.
This principle was illustrated in the meta-analysis by La Rosa et
al,48 in which the timing of surgical intervention was analyzed
in 1687 eligible spinal cord injury patients. Early intervention
was defined as less than 24 h to decompression. In their analysis of
neurological recovery in both the complete and incomplete spinal
cord injured patients, the authors noted a clear benefit of early
decompression when compared to either late decompression or
conservative management.
The largest and most comprehensive assessment on neuro-
logical recovery and the timing of surgical intervention was
performed by Fehlings et al.49 The authors defined early
treatment as spinal cord decompression occurring less than 24
h after the pathology was confirmed with imaging. A total of
313 patients were enrolled, with 182 patients in the early
cohort (mean time to decompression: 14.2 h) and 131 patients
in the late cohort (mean time to decompression: 48.3 h). Final
analysis at 6 months postinjury revealed a significant advantage
to early surgery, which the authors defined as at least a 2-grade
improvement in ASIA impairment score (AIS). The authors also
concluded that early surgery can be safely performed.
Hypothermia
In addition to early surgical decompression of the injured spinal
cord patient, several other strategies have recently been employed
in order to improve neurological outcome. One recent treatment
strategy has been the use of hypothermia after spinal cord injury.
This treatment was publicized after an incident in 2007 involving
a professional football player that unfortunately experienced a
cervical spinal cord injury during an National football league
(NFL) game.50 At the time of that incident, there was little
evidence to conclusively support local or systemic hypothermia
in the management of traumatic spinal cord injury.
The use of mild hypothermia to improve neurological outcome
has been shown to result in improved neurological recovery after
cardiac arrest.51 Some literature supports the use of hypothermia
in the treatment of traumatic head injury as a means of lowering
refractory intracranial pressure, although the overall effect on
outcome is controversial and beyond the scope of this text. In
the care of traumatic spinal cord injury, there have been several
case cohort studies reviewing potential benefit in a retrospective
manner. In 2014, Hansebout and Hansebout52 reviewed the long-
term outcome of 20 patients with American Spinal Injury Associ-
ation (ASIA) A spinal cord injuries treated with surgical decom-
pression, glucocorticoid administration, and hypothermia. Of
these 20 patients, 80% experienced some improvement of their
neurological exam, with 30% improving to ASIA B, and 25%
improving to ASIA C. The mean improvement in neurological
level of injury is 1.05; however, despite their success, further
NEUROSURGERY
CONTROVERSIES IN SPINAL TRAUMA AND EVOLUTION OF CARE
review of the data reveals that there was only a minimal motor-
level (1.7) and sensory-level (2.8) improvement.
In a 2013 case-controlled study, Dididze et al53 reported that
35% of patients with spinal injuries and initial ASIA grade
of A demonstrated functional improvement with hypothermia
therapy, which the authors suggested was favorable when
compared to historical controls. It should be pointed out
that concurrent changes in tenants of medical management
of spinal cord injury, such as earlier surgical decompression
and more aggressive medical and pharmacological therapy, may
serve as confounding variables. One may have concluded that
hypothermia, along with the evolution of earlier surgical inter-
vention, may have allowed these patients to have an improved
neurological outcome. Although still controversial, hypothermia
treatment may represent an additional tool which could be
implemented concurrently with other modalities with a limited
morbidity profile.
Lumbar Subarachnoid Drainage
Optimizing spinal cord perfusion as a means to minimize
neurological injury and enhance neurological recovery has been
a well-known and established treatment. Specifically, in the
2013 version of the Guidelines for the Management of Acute
Cervical Spine and Spinal Cord Injuries,54 the authors note at
a level III recommendation that maintenance of mean arterial
blood pressure between 85 and 90 mm Hg for the first 7 days
following an acute spinal cord injury is beneficial. It should
be noted that long-term pharmacologic maintenance of mean
arterial pressure can lead to pulmonary complications, including
acute respiratory distress syndrome. Aside from increasing mean
arterial blood pressure, another potential technique to improved
spinal cord perfusion is to decrease transmural pressure. Kwon
et al55 evaluated 22 patients within 48 h of traumatic spinal
cord injury, and in a prospective and randomized manner,
lumbar subarachnoid drains were inserted. No adverse events were
encountered in the study. The authors noted that restoration of
cerebrospinal fluid (CSF) flow through surgical decompression
resulted in increased intrathecal pressure measured caudal to the
site of injury, and throughout the postoperative period. Fluctu-
ations in intrathecal pressure can potentially impair spinal cord
perfusion, which would have otherwise gone undetected without
real-time transduction of the intrathecal pressure. The authors
concluded that lumbar subarachnoid catheters may be useful to
document adequate perfusion pressure and decompression by
gauging restoration of normal CSF flow in the thecal sac caudal
to the injury, and measuring the perfusion pressure in much the
same way that cerebral perfusion pressure is calculated.55 One
additional advantage of this technique is the ability to sample CSF
in order to evaluate for cytokines or other potential biomarkers of
spinal cord injury severity.56 The authors demonstrated elevations
in a number of inflammatory cytokines, potentially representing
further areas for research into the biochemical pathophysiology of
spinal cord injury in humans. Lumbar subarachnoid drainage at
VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement | S29
HARROP ET AL

present it not widely used, and knowledge of its effect is still in its
infancy. Further investigation in this area is needed.

Microstructural MRI Techniques

Treatment of traumatic neurological injuries have benefited
greatly from advances in radiological technology. In particular,
the use of CT and subsequently MRI has been invaluable in our
understanding of fracture patterns and morphology, discoliga-
mentous integrity, and more recently, damage to the parenchyma
of the spinal cord itself. Standard magnetic resonance sequences
demonstrate edema and hemorrhage within cord parenchyma,
blurring the graywhite junction, and although the site of injury is
grossly apparent, no further conclusion can be drawn. Diffusion
tensor imaging (DTI) has revolutionized the study of eloquent
tracts within the brain, but not only recently has this application
lent itself to the spinal cord. Spatial resolution has proven to
be a significant problem in the spinal cord, and distinguishing
gray matter from white matter is more difficult than in tracts of FIGURE 2. MRI diffusion techniques. Fractional anisotropy maps in healthy
the brain. In 2006, Ellingson et al57 described a technique using control spinal cord (A) with corresponding axial fractional anisotropy maps at
newly developed anisotropy indices that resulted in larger contrast the high and mid cervical level. Second patient has severe acute spinal cord injury
between gray and white matter than could be obtained with (SCI) with sagittal and axial images B.
fractional anisotropy. The authors report this technique to permit
significantly improved resolution of gray matter and white matter
tracts.57 Ellingson et al58,59 expounded upon this technique to
obtain sharper contrast between spinal gray and white matter in 2 which patients will improve. Loy et al,67 in a similar study, noted
follow-up manuscripts in 2007. The authors describe the complex that graded injury severity can be detected using DTI-derived
mathematical model used to enhance tissue contrast based on new sequences. This may represent a method to ascertain the severity
anisotropy indices. Other authors have used this technology to of injury that a patient has sustained. At present, the utility that
study evolving spinal cord injuries in animal models.60,61 In 2008, DTI has in guiding therapy spinal cord injury patients is still in its
Ellingson et al62 used DTI to study 13 individuals and used the infancy (Figure 2). It has shown in animal studies and early human
data to characterize the normal human spinal cord. The authors controls that it has great possibility for providing prognosis, but
noted that this could provide a useful control comparison for more studies are needed.
future work on patients with spinal cord injuries.62 More recently,
several authors have used this technology to evaluate human CONCLUSION
spinal cord injury. Ellingson et al63-65 studied 10 individuals with
chronic spinal cord injuries, and noted that the areas of chronic In summary, one can envision that with the numerous and
spinal cord injury the fractional anisotropy was low, suggesting concurrent improvements in our understanding of structural
this can be a means to measure the extent of injured tissue. The injury to the spine and spinal cord, as well as the biochemical
authors also noted that diffusion magnitude was elevated at the pathophysiologic processes that underlie spinal cord injuries, the
locus of injury, but was reduced in areas that are removed from patients can hope for significant improvements in neurological
the site of injury. This may indicate that spinal cord injury is a outcome in the future. The most important concept to appreciate
more diffuse and systemic process.63-65 In 2010, Kim et al66 were is that each modality listed above is not independent, but rather
able to use DTI for prognostication in a murine model. In this synergistic.
study, the authors assessed axial diffusivity of ventrolateral white
matter in subjects with spinal cord injury. Histological analysis Disclosure
was performed on half of the subjects once the imaging was The authors of this article have no personal, financial, or institutional interest
complete, and in the other half at 14 days. The authors noted in any of the drugs, materials, or devices described in this article.
a strong inverse correlation between neurological recovery and
the amount of ventrolateral white matter spared by the insult.
REFERENCES
The authors noted that standard T2 sequences show extensive
edema but lead to blurring or even loss of the ability to discern the 1. Watson-Jones R. The results of postural reduction of fractures of the spine. J Bone
Joint Surg Am. 1938;20(3):567-586.
graywhite junction acutely. They conclude that the proportion 2. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br.
of tissue injury on axial diffusivity may be a means to predict 1949;31B(3):376-394.

S30 | VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement www.neurosurgery-online.com


3. Kelly RP, Whitesides, TE. Treatment of lumbodorsal fracture-dislocations. Ann
Surg. 1968;167(5):705-717.
4. McAfee PC, Yuan HA, Fredrickson BE, et al. The value of computed tomography
in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new
classification. J Bone Joint Surg Am. 1983;65(4):461-473.
5. Denis F. The three column spine and its significance in the classification of acute
thoracolumbar spinal injuries. Spine. 1983;8(8):817-831.
6. Magerl F, Aebi M, Gertzbein SD, et al. A comprehensive classification of thoracic
and lumbar injuries. Eur Spine J. 1994;3(4):184-201.
7. Oner FC, Ramos LMP, Simmermacher RKJ, et al. Classification of thoracic and
lumbar spine fractures: problems of reproducibility. A study of 53 patients using
CT and MRI. Eur Spine J. 2002;11(3):235-245.
8. Vaccaro Alexander R, Lehman Ronald A, Hurlbert R J, et al. A new classi-
fication of thoracolumbar injuries: the importance of injury morphology, the
integrity of the posterior ligamentous complex, and neurologic status. Spine.
2005;30(20):2325-2333.
9. Vaccaro Alexander R, Lee Joon Y, Schweitzer Karl M, et al. Assessment of injury
to the posterior ligamentous complex in thoracolumbar spine trauma. Spine J.
2006;6(5):524-528.
10. Vaccaro Alexander R, Baron Eli M, Sanfilippo J, et al. Reliability of a novel
classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity
Score. Spine. 2006;31(11 suppl):S62-S69; discussion S104.
11. Vaccaro Alexander R, Lim Moe R, Hurlbert R J, et al. Surgical decision making
for unstable thoracolumbar spine injuries: results of a consensus panel review by
the Spine Trauma Study Group. J Spinal Disord Tech. 2006;19(1):1-10.
12. Vaccaro Alexander R, Zeiller Steven C, Hulbert R J, et al. The thora-
columbar injury severity score: a proposed treatment algorithm. J Spinal Disord
Tech. 2005;18(3):209-215.
13. Harrop James S, Vaccaro Alexander R, Hurlbert R J, et al. Intrarater and interrater
reliability and validity in the assessment of the mechanism of injury and integrity
of the posterior ligamentous complex: a novel injury severity scoring system for
thoracolumbar injuries. Invited submission from the Joint Section Meeting On
Disorders of the Spine and Peripheral Nerves, March 2005. J Neurosurg Spine.
2006;4(2):118-122.
14. Ratliff J, Anand N, Vaccaro Alexander R, et al. Regional variability in use of a
novel assessment of thoracolumbar spine fractures: United States versus interna-
tional surgeons. World J Emerg Surg. 2007;2:24.
15. Patel Alpesh A, Vaccaro Alexander R, Albert Todd J, et al. The adoption of a new
classification system: time-dependent variation in interobserver reliability of the
thoracolumbar injury severity score classification system. Spine. 2007;32(3):E105-
E110.
16. Raja Rampersaud Y, Fisher C, Wilsey J, et al. Agreement between ortho-
pedic surgeons and neurosurgeons regarding a new algorithm for the treatment
of thoracolumbar injuries: a multicenter reliability study. J Spinal Disord Tech.
2006;19(7):477-482.
17. Lee Joon Y, Vaccaro Alexander R, Schweitzer Karl M, et al. Assessment of injury
to the thoracolumbar posterior ligamentous complex in the setting of normal-
appearing plain radiography. Spine J. 2007;7(4):422-427.
18. Vaccaro Alexander R, Hulbert R J, Patel Alpesh A, et al. The subaxial cervical
spine injury classification system: a novel approach to recognize the importance
of morphology, neurology, and integrity of the disco-ligamentous complex. Spine.
2007;32(21):2365-2374.
19. Vaccaro Alexander R, Oner C, Kepler Christopher K, et al. AOSpine thora-
columbar spine injury classification system: fracture description, neurological
status, and key modifiers. Spine. 2013;38(23):2028-2037.
20. Vaccaro Alexander R, Koerner John D, Radcliff Kris E, et al. AOSpine subaxial
cervical spine injury classification system. Eur Spine J. 2016;25(7):2173-2184.
21. Wood K, Buttermann G, Butterman G, et al. Operative compared with nonop-
erative treatment of a thoracolumbar burst fracture without neurological deficit. A
prospective, randomized study. J Bone Joint Surg Am. 2003;85-A(5):773-781.
22. Siebenga J, Leferink Vincent JM, Segers Michiel JM, et al. Treatment of traumatic
thoracolumbar spine fractures: a multicenter prospective randomized study of
operative versus nonsurgical treatment. Spine. 2006;31(25):2881-2890.
23. Wang ST, Ma HL, Liu CL, et al. Is fusion necessary for surgically treated burst
fractures of the thoracolumbar and lumbar spine?: a prospective, randomized study.
Spine. 2006;31(23):2646-2652; discussion 2653.
24. Wood Kirkham B, W Li, Lebl Darren R, et al. Management of thoracolumbar
spine fractures. Spine J. 2014;14(1):145-164.
NEUROSURGERY
CONTROVERSIES IN SPINAL TRAUMA AND EVOLUTION OF CARE
25. Fourney Daryl R, Dettori Joseph R, Norvell Daniel C, et al. Does
minimal access tubular assisted spine surgery increase or decrease compli-
cations in spinal decompression or fusion? Spine. 2010;35(9 suppl):
S57-S65.
26. Oh T, Scheer Justin K, Fakurnejad S, et al. Minimally invasive spinal surgery
for the treatment of traumatic thoracolumbar burst fractures. J Clin Neurosci.
2015;22(1):42-47.
27. Bailey Christopher S, Dvorak Marcel F, Thomas Kenneth C, et al. Comparison
of thoracolumbosacral orthosis and no orthosis for the treatment of thoracolumbar
burst fractures: interim analysis of a multicenter randomized clinical equivalence
trial. J Neurosurg Spine. 2009;11(3):295-303.
28. Bailey Christopher S, Urquhart Jennifer C, Dvorak Marcel F, et al. Orthosis
versus no orthosis for the treatment of thoracolumbar burst fractures without
neurologic injury: a multicenter prospective randomized equivalence trial. Spine
J. 2014;14(11):2557-2564.
29. Phillips Frank M, Ho E, Campbell-Hupp M, et al. Early radiographic
and clinical results of balloon kyphoplasty for the treatment of osteoporotic
vertebral compression fractures. Spine. 2003;28(19):2260-2265; discussion 2265-
2267.
30. Rhyne A, Banit D, Laxer E, et al. Kyphoplasty: report of eighty-two
thoracolumbar osteoporotic vertebral fractures. J Orthop Trauma. 2004;18(5):
294-299.
31. Crandall D, Slaughter D, Hankins PJ, et al. Acute versus chronic
vertebral compression fractures treated with kyphoplasty: early results. Spine J.
2004;4(4):418-424.
32. Buchbinder R, Osborne Richard H, Ebeling Peter R, et al. A randomized
trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med.
2009;361(6):557-568.
33. Wardlaw D, Cummings Steven R, Van Meirhaeghe J, et al. Efficacy and safety of
balloon kyphoplasty compared with non-surgical care for vertebral compression
fracture (FREE): a randomised controlled trial. Lancet. 2009;373(9668):1016-
1024.
34. Kallmes David F, Comstock Bryan A, Heagerty Patrick J, et al. A randomized trial
of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361(6):569-
579.
35. Rousing R, Hansen Karina L, Andersen Mikkel O, et al. Twelve-months follow-up
in forty-nine patients with acute/semiacute osteoporotic vertebral fractures treated
conservatively or with percutaneous vertebroplasty: a clinical randomized study.
Spine. 2010;35(5):478-482.
36. Klazen Caroline AH, Lohle Paul NM, de Vries J, et al. Vertebro-
plasty versus conservative treatment in acute osteoporotic vertebral compression
fractures (Vertos II): an open-label randomised trial. Lancet. 2010;376(9746):
1085-1092.
37. Farrokhi Majid R, Alibai E, Maghami, Z. Randomized controlled trial of percuta-
neous vertebroplasty versus optimal medical management for the relief of pain and
disability in acute osteoporotic vertebral compression fractures. J Neurosurg Spine.
2011;14(5):561-569.
38. Evans Avery J, Kip Kevin E, Brinjikji W, et al. Randomized controlled trial
of vertebroplasty versus kyphoplasty in the treatment of vertebral compression
fractures. J Neurointerv Surg. 2016;8(7):756-763.
39. Schwab Frank J, Blondel B, Bess S, et al. Radiographical spinopelvic parameters
and disability in the setting of adult spinal deformity: a prospective multicenter
analysis. Spine. 2013;38(13):E803-E812.
40. Schwab F, Patel A, Ungar B, et al. Adult spinal deformity-postoperative standing
imbalance: how much can you tolerate? An overview of key parameters in assessing
alignment and planning corrective surgery. Spine. 2010;35(25):2224-2231.
41. Le Huec JC, Faundez A, Dominguez D, et al. Evidence showing the relationship
between sagittal balance and clinical outcomes in surgical treatment of degenerative
spinal diseases: a literature review. Int Orthop. 2015;39(1):87-95.
42. Le Huec JC, Demezon H, Aunoble S. Sagittal parameters of global cervical
balance using EOS imaging: normative values from a prospective cohort of asymp-
tomatic volunteers. Eur Spine J. 2015;24(1):63-71.
43. Koller H, Acosta F, Hempfing A, et al. Long-term investigation of nonsurgical
treatment for thoracolumbar and lumbar burst fractures: an outcome analysis in
sight of spinopelvic balance. Eur Spine J. 2008;17(8):1073-1095.
44. Tarlov IM, Klinger H, Vitale, S. Spinal cord compression studies. I. Experimental
techniques to produce acute and gradual compression. AMA Arch Neurol Psychiatry.
1953;70(6):813-819.
VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement | S31
HARROP ET AL
45. Tarlov IM, Klinger H. Spinal cord compression studies. II. Time limits for
recovery after acute compression in dogs. AMA Arch Neurol Psychiatry. 1954;71(3):
271-290.
46. Furlan Julio C, Noonan V, Cadotte David W, et al. Timing of decom-
pressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based
examination of pre-clinical and clinical studies. J Neurotrauma. 2011;28(8):1371-
1399.
47. Batchelor Peter E, Wills Taryn E, Skeers P, et al. Meta-analysis of pre-clinical
studies of early decompression in acute spinal cord injury: a battle of time and
pressure. PLoS One. 2013;8(8):e72659.
48. La Rosa G, Conti A, Cardali S, et al. Does early decompression improve neuro-
logical outcome of spinal cord injured patients? Appraisal of the literature using a
meta-analytical approach. Spinal Cord. 2004;42(9):503-512.
49. Fehlings Michael G, Vaccaro A, Wilson Jefferson R, et al. Early versus
delayed decompression for traumatic cervical spinal cord injury: results of the
Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One.
2012;7(2):e32037.
50. Cappuccino A, Bisson Leslie J, Carpenter B, et al. The use of systemic
hypothermia for the treatment of an acute cervical spinal cord injury in a profes-
sional football player. Spine. 2010;35(2):E57-E62.
51. Bernard Stephen A, Gray Timothy W, Buist Michael D, et al. Treatment of
comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.
N Engl J Med. 2002;346(8):557-563.
52. Hansebout, RR, Hansebout, CR. Local cooling for traumatic spinal cord
injury: outcomes in 20 patients and review of the literature. J Neurosurg Spine.
2014;20(5):550-561.
53. Dididze M, Green BA, Dietrich, WD, et al. Systemic hypothermia in acute
cervical spinal cord injury: a case-controlled study. Spinal Cord. 2013;51(5):395-
400.
54. Ryken Timothy C, Hurlbert R J, Hadley Mark N, et al. The acute cardiopul-
monary management of patients with cervical spinal cord injuries. Neurosurgery.
2013;72(suppl 2):84-92.
55. Kwon Brian K, Curt A, Belanger Lise M, et al. Intrathecal pressure monitoring and
cerebrospinal fluid drainage in acute spinal cord injury: a prospective randomized
trial. J Neurosurg Spine. 2009;10(3):181-93.
S32 | VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement
56. Kwon Brian K, Stammers Anthea MT, Belanger Lise M, et al. Cerebrospinal fluid
inflammatory cytokines and biomarkers of injury severity in acute human spinal
cord injury. J Neurotrauma. 2010;27(4):669-682.
57. Ellingson Benjamin M, Ulmer John L, Schmit Brian D. A new technique for
imaging the human spinal cord in vivo. Biomed Sci Instrum. 2006;42(2005):255-
260.
58. Ellingson Benjamin M, Ulmer John L, Schmit Brian D. Gray and white matter
delineation in the human spinal cord using diffusion tensor imaging and fuzzy
logic. Acad Radiol. 2007;14(7):847-858.
59. Ellingson Benjamin M, Ulmer John L, Schmit Brian D. Optimal diffusion
tensor indices for imaging the human spinal cord. Biomed Sci Instrum. 2007;43:
128-133.
60. Brennan Faith H, Cowin Gary J, Kurniawan Nyoman D, et al. Longitu-
dinal assessment of white matter pathology in the injured mouse spinal cord
through ultra-high field (16.4 T) in vivo diffusion tensor imaging. Neuroimage.
2013;82:574-585.
61. Kim Joong H, Loy David N, Liang HF, et al. Noninvasive diffusion tensor
imaging of evolving white matter pathology in a mouse model of acute spinal cord
injury. Magn Reson Med. 2007;58(2):253-260.
62. Ellingson BM, Ulmer JL, Kurpad SN, et al. Diffusion tensor MR imaging
of the neurologically intact human spinal cord. AJNR Am J Neuroradiol.
2008;29(7):1279-1284.
63. Ellingson Benjamin M, Ulmer John L, Prost Robert W, et al. Morphology and
morphometry in chronic spinal cord injury assessed using diffusion tensor imaging
and fuzzy logic. Conf Proc IEEE Eng Med Biol Soc. 2006;1:1885-1888.
64. Ellingson Benjamin M, Ulmer John L, Schmit Brian D. Morphology and
morphometry of human chronic spinal cord injury using diffusion tensor imaging
and fuzzy logic. Ann Biomed Eng. 2008;36(2):224-236.
65. Ellingson BM, Ulmer JL, Kurpad SN, et al. Diffusion tensor MR imaging in
chronic spinal cord injury. AJNR Am J Neuroradiol. 2008;29(10):1976-1982.
66. Kim Joong H, Loy David N, Wang Qing, et al. Diffusion tensor imaging at
3 hours after traumatic spinal cord injury predicts long-term locomotor recovery.
J Neurotrauma. 2010;27(3):587-598.
67. Loy David N, Kim Joong H, Xie M, et al. Diffusion tensor imaging predicts
hyperacute spinal cord injury severity. J Neurotrauma. 2007;24(6):979-990.
www.neurosurgery-online.com