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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.
Assessment and Planning
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
12
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
Cervical Fracture Dislocation
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
14
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.
Oral Boards Review: Diagnostic Pearls
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
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cut off at the battle of the Metaurus, been brutally cast over the
palisades into his own camp in Southern Italy, the first warning that
he had of his brothers having crossed the Alps. And little Mago, who
had been with Hasdrubal up in the fig-tree, where was he now? But
recently dead, also killed like Hasdrubal by the Romans. And he,
Hannibal, what was his own position? That of a disgraced man,
disgraced by the Romans. Oh! how he hated them, how well he
remembered his vow of hatred made with his father in the temple of
Melcareth, of which he could espy the roof yonder. He yearned that
for every Roman he had slain he might have slain ten, ay, might yet
slay ten. And yet he was, he knew it, but here himself in Carthage
solely on the sufferance of the Roman General Scipio, a young man
who had vanquished him in war, and yet one who loved his daughter.
Vainly now did Hannibal wish that he had allowed Elissa to pursue
her voyage to Syracuse after the sea-fight at Locri, and fulfil her
engagement to espouse this Scipio. For he well saw how much
better it would have been for his country. He vainly wished also that
he had not been so severe with Scipio during the interview before
the battle of Zama. But how could he foretell that all the elephants
were going to stampede, or that the Carthaginian levies would prove
such arrant cowards? He cursed the Carthaginians in his heart even
more than the Romans when he thought of it all; but even while
despising his fellow-countrymen he did not despise his native
country, but loved it as much as ever.
Ay! as he looked out and saw the olive groves, the pomegranate
trees, the waving cornfields, the orange trees, the houses, the
marble temples, and the green dancing sea beyond, he felt, indeed,
that he loved his country as much as ever. But never could he have
dreamed that the hour of his return could have been so bitter as the
hour of anguish through which he was then passing. The mighty
warrior thought of his father and the past, the long past of years and
years ago. Then he laid his head upon the cold marble of the
balustrade and wept—wept bitter tears at that very spot where, when
a little boy, his father Hamilcar had bade him look well around and
impress every land-mark, every headland, on his memory. For to this
spot had he not returned—disgraced!
The following morning Hannibal was informed that the Roman
General Scipio wished to see him. He was obliged to repair to the
palace in the suburbs which Scipio occupied. The latter strove to
receive him in a manner not to hurt his dignity, for whatever he might
feel for the other Carthaginian generals, for Hannibal himself he had
the most unbounded respect. A long conference took place between
Hannibal and Scipio in private upon the terms of the treaty about to
be concluded, and Scipio made to him a suggestion, which was
absolutely for his ears alone. It was to the following effect: Although,
so he said, it was now utterly impossible for him, the Roman
General, to modify the general terms of the treaty, which were, he
owned, excessively severe—as, owing to the various acts of
treachery on the part of the Carthaginians, they deserved to be—on
one very important clause Scipio proposed a modification, but upon
one condition only. This clause was that the Roman General and the
Roman army should remain in Carthage at the expense of the
Carthaginians until the whole of the war indemnity should be paid.
This implied a Roman occupation of the country for at least twenty
years to come, for so enormous was the indemnity required it could
not be paid sooner. And after twenty years would they ever go? This
clause Scipio expressed to Hannibal his willingness to forego should
the Carthaginian General give him even now his daughter in
marriage. Under such circumstances Scipio pledged himself to
evacuate Carthage with all his army, and sail for Sicily at once,
leaving the care of protecting Roman interests to his ally Massinissa.
And he vowed, by all the gods of Rome, that, should he once set foot
on Sicilian soil in company with Hannibal’s daughter, not only would
he never again himself set foot upon Carthaginian soil, but that he
would, to the utmost, discourage all future attempts upon Carthage
from any Roman sources.
Hannibal was too astute to allow to appear upon his countenance
the joy that he felt at this proposal. On the contrary, he made
difficulties, talked of Elissa having changed her mind since the battle
of Zama, and being, he now feared, thoroughly averse to Scipio. So
well did he manage matters that Scipio was quite pleased when,
almost as a favour, Hannibal consented in the end to consider the
matter, and promised to speak to Elissa about it. The next morning,
without acquainting Elissa or Maharbal with the subject of his
conversation with Scipio, he requested them both to accompany him
to the temple of the great god Melcareth, there to offer a solemn
sacrifice at the same altar at which he had participated in the
sacrifice with his father Hamilcar.
To the temple of Melcareth the three accordingly proceeded, and
with the most serious and awful rites, offered up, under the
instructions and guidance of an ancient priest, named Himilco, a
most solemn and terrible sacrifice. This old man, Himilco, was the
same who had been a priest in the temple in the time of Hannibal’s
youth, and had known him from a boy. He was now an old man
eighty years of age, with a white beard that reached down to his
knees. His sanctity was most renowned, and he was looked upon,
with reason, as a prophet by all the people. Under his guidance, for
he had doubtless been somewhat, if only partly, prompted in his part
by Hannibal, Maharbal and Elissa each made a most terrible vow,
invoking, in case of failure to observe it, the most awful penalties of
all the gods, to sacrifice themselves to the very last for the good of
their country. The priest now caused them to plunge their arms up to
the elbow in the blood of the sacrifice, and to vow solemnly to be
guided, without question, by Hannibal alone as to what was to be
considered for the good of their country; for the old man told them
that the great god Melcareth was even at that very moment there
present, and pervading all the space in the temple, and that the god
had informed him that Hannibal alone was at this moment the arbiter
of his country’s fate. To disobey him would therefore be death here
and awful damnation hereafter.
While the old man was impressively dictating to the pair the terms
of the prescribed oath, the temple became dark. Sounds of rolling
thunder were heard, and sudden flames flew from the altar to the
roof, to be as suddenly extinguished. There could now be no doubt
about the presence of the mighty god among them. They all fell upon
their faces during his manifestation. At length Hannibal arose, and
most solemnly declared that he had had a vision. That vision was
that he had seen Elissa being joined in marriage to Scipio by the
very high priest now before them. He further said that it had been
revealed to him by the god in his vision that by that means alone
could salvation come to unhappy Carthage, for upon Scipio being
united to Elissa in marriage he would leave Carthage with all his
army, and, he added, that it would be sufficient for Scipio to be
accompanied by Elissa as far as the island of Sicily for the god to lay
a spell upon him under which he would never return to Libyan soil.
Vainly did Maharbal declare to the high priest and to Hannibal that
Elissa was his wife, and his alone.
“Where are thy witnesses?” replied the high priest. “ ’Tis true the
gods did allow a semblance of a marriage between ye, yet had not
the priest my license. And, in token of their displeasure, that priest is
already dead. A marriage without two witnesses is no legal marriage.
Thou sayest that Hannibal was thy witness. One witness is not
enough, oh Maharbal, in Carthage, whatever it may be in Spain or
Italy. Moreover, think of thine awful oath. And is not the great god
Melcareth speaking through Hannibal, whom ye have bound
yourselves to obey?”
Now it was Elissa’s turn to protest. With tears in her eyes she
declared that she was indeed Maharbal’s wife in very sooth, and
could not now possibly give herself to any other man with honour.
“Think of thine oath!” firmly replied the aged priest, “and fear the
anger of the immortal gods. ’Tis thou, Elissa, alone who canst save
thy country; ’tis thou alone who canst withdraw the invader hence.
Land with him but in Sicily and thou shalt be free; but dare thou but
to breathe to him one word, and such an awful curse shall fall, not
only upon thee and Maharbal, but upon thy country and thy father
Hannibal, through thee, that ye had all better have died a thousand
deaths on Zama’s battle-field. Thou must be wed to Scipio by me.
That is thy fate, for I, too, have had a vision. Ah! the terrible gods are
now angry. Submit thyself, proud woman, to their immortal will.”
At this moment the rolling thunder recommenced louder than
before, while the lightning flashes from the altar were more frequent
and more vivid. The scene in the temple was most awful and
impressive, and all, including the aged priest, fell upon their faces.
Elissa hesitated no longer.
“It is the will of the gods!” she muttered. “I must obey.”
“And thou?” inquired the high priest, turning to Maharbal.
“If it be the will of the gods,” he replied, “how can I resist? But I
would that the gods were men that I might fight this matter out with
them at the point of my sword. I could soon show them who was in
the right.”
But, upon Maharbal uttering this awful blasphemy, such a peal of
thunder shook the sacred fane that it seemed as though it would fall.
He now fell upon his face, repentant, for he realised that he was
failing in his vow, and it was indeed evident that the gods were
angry.
Before they all left the temple in fear and trembling, both Maharbal
and Elissa had humbly asked forgiveness of the gods for trying,
against their immortal wishes, to set up their own weak wills, and
had once more vowed, in order to appease them, to consider their
country, and their country only. To confirm this feeling in both their
hearts, the old priest informed them that it would be impious on their
parts to consider themselves any longer as husband and wife, and
that they must separate as such from that moment. For, whether she
would or no, the salvation of her country depended upon Elissa
marrying Scipio. Therefore, with sadness, these twain became once
more strangers to each other at the temple door.
Ten days afterwards the marriage of Elissa with Scipio was
solemnised in that very temple, when the Roman General declared
that he recognised in the high priest him whom he had seen in his
vision. He reminded his bride, with a happy smile, of what he had
written to her; but Elissa’s face wore in return no corresponding glow
of happiness. For so terribly complex were her feelings that she
knew she had no right to be happy, and, had it not been for her vow,
would doubtless have taken her own life. Hannibal had, however,
reminded her that in no wise could she benefit her country by so
doing, and that her duty to Carthage lay in taking Scipio and his
army away from its shores and completely beyond the seas. Once
she had landed there her life was in her own hands. She would
meanwhile have the satisfaction of having obeyed the mandates of
the gods by sacrificing herself upon this occasion.
There were indeed reasons why she should not have married
Scipio, the man whom she really loved, and yet her terrible oath
prevented her from revealing them to him. And Elissa felt it all the
more deeply because she was at heart the very soul of honour.
Upon the same afternoon that the marriage took place did Scipio
and all his army embark for Sicily. He himself and his pale but
beautiful bride were accommodated upon a most luxurious and
stately hexireme. Upon the voyage, which lasted two days, Scipio
could not in any way account for the apparent state of alternate
gaiety and despondency of his bride. She scarcely seemed to know
what she was doing, and despite all the caresses that he showered
upon her, ever seemed to shudder and draw back if inadvertently
she had herself returned but one of them.
Upon landing at Libybæum in Sicily, no sooner had she
disembarked, than, falling on her knees before him, Elissa presented
Scipio with the hilt of a dagger, and, with many bitter tears, told him
all, absolutely without reserve, beseeching him to slay her on the
spot.
At first his fury was so great that he was even about to do so, but
then he mastered himself completely, and his wonted nobility and
greatness of character did not desert him even in this awful crisis.
Scipio dashed the dagger to the ground violently.
“Nay!” he exclaimed, “I will not slay thee, Elissa, for thou art but
like myself, the victim of a cruel, a pitiless fate, and not thyself to
blame. May the gods protect thee in the future as in the past, and
guide thee to do that which is right. As for me, I do forgive thee, for
now I know the truth indeed, which is that thou dost love me most.
But to mine enemy Maharbal do I owe my life thrice over. To him,
therefore, will I return two lives—thine and that of his unborn child.
Farewell, Elissa!—farewell for ever, beloved!”
He kissed her tenderly on the forehead, and thus they parted, to
meet no more in this world, for Scipio sent her back to Carthage that
same day.
But Elissa never held up her head again; she pined, and grew
paler day by day. And when at the expiration of the half-year her son
was born, she died in giving him birth.
Thus perished in all the bloom of her beauty one who was ever a
martyr to duty and to her country’s cause, Elissa, Hannibal’s
daughter.
THE END.
TRANSCRIBER’S NOTES
The available copies of the source text have the following two
defects (illegible words).
(p. 376) “…that Elissa returned when she fir[***] rejoined her father
in his camp…” Use first.
(p. 377) “…that the siege was raised by Scipio [***]r a naval battle
in which the Romans were defeated.” Use after.
If you have access to an intact copy of the text and can confirm
that either of these changes are wrong please contact Project
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Minor spelling inconsistencies (e.g. earrings/ear-rings, hunting
party/hunting-party/, praetor/pretors/prætors, etc.) have been
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Alterations to the text:

Add title and author’s name to cover image.
Punctuation: sentences missing periods, quotation mark pairings,
etc.
[Part I/Chapter III]
Change “they more than equalled in valour and dermination” to
determination.
“Greeks who had fled to Carthage from Lilybœum to escape” to
Lilybæum.
“Could Lutatius Catulus have conquered Lilybœum even had” to
Lilybæum.
“for their long continued neglect of him and all the best” to long-
continued.
[Part II/Chapter II]
“remember, writing now, Oh! Elissa, as a father” to oh.
[Part II/Chapter V]
“He unmasked his battery without futher delay” to further.
“my men will, storm the palace, and, unless they find me” delete
first comma.
[Part III/Chapter IV]
“the heavy armed cavalry men being in the former, two men” to
heavy-armed.
[Part III/Chapter XII]
“shyly responding to the advances of the the Prince Massinissa”
delete one the.
[Part IV/Chapter VI]
“To him then was the Princess Cœcilla offered as his wife” to
Cœcilia.
[Part V/Chapter I]
“after various sieges and conflicts wiih each power in turn” to with.
[Part V/Chapter II]
“magnificent camp, of which the the tents were made of purple”
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[End of text]
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Spinal Neurosurgery 1St Edition James Harrop Editor Full Download Chapter

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Spinal Neurosurgery 1st Edition James

Volume 1: Peripheral Nerve Surgery, Wilson and Yang

James S. Harrop, MD, FACS

Christopher M. Maulucci, MD, FACS

Published in the United States of America by Oxford University Press

© Oxford University Press 2019

All rights reserved. No part of this publication may be reproduced, stored in

You must not circulate this work in any other form

Library of Congress Cataloging-​in-​Publication Data

Series Editor’s Preface vii

1. Odontoid Fracture Type II 1

15. Spinal Cord Tumor: Intramedullary 141

I am delighted to introduce this volume of Neurosurgery by Example: Key Cases and

Bizhan Aarabi, MD, FRCSC, FACS Domagoj Coric, MD

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

Alterations to the text:

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