Figure 2

Classification of spinal injury and treatment recommendation in the polytraumatized patient. Classification of Magerl et al. (1993) [72] based on the two column concept of Whitesides (1977)[73]. The mechanism of applied forces to the spine generates specific fractures. Pure axial compression results in type A fractures. Distraction leads to type B and rotational momentum with compression or distraction results in type C fractures. Type A1 and A2 (except for A2.3) are regarded as stable. Whereas burst fractures, especially higher rated A3.3 lacking of sufficient anterior column support, are assigned unstable. Distraction injuries in type B1 to B3 are instable. Highest instability is seen in type C fractures with rotational moment. Conservative treatment is feasible in type A1, A2 and some lower rated A3 fractures. In these patients axial alignment and log-roll are pursued during ICU stay with subsequent mobilization and ambulation under supervision of a physiotherapist. Secondary anterior vertebral replacement might be needed in A2.3 pincer fractures. Burst fractures (A3) are characterized by their incapability to withstand anterior load that assigns them instable injuries. In A3 fractures, the high rates of overseen posterior injury should lead to liberate indication for posterior instrumentation. In B type fractures the posterior ligament complex definitely is in need of posterior instrumentation. For decompression and for insufficient reduction, open approach should be preferred, since anatomical restoration of the spinal column is the prerequisite. Rotationally instable fractures type C should be assigned to open reduction, predominantly. In addition, decompression for spinal cord injury in C-type injuries should be performed from posterior to limit second hit in polytraumatized patients. Anterior surgery in C-type fractures should be carried out in a safe period following restoration of immunologic homeostasis.