The indications for anterior surgery are well defined in the upper and lower cervical spine if one accepts the importance of early restoration of stability for improved patient rehabilitation. Cannulated screw fixation of Type II fractures of the odontoid peg is a highly specialized procedure that requires technical expertise still only available at a limited number of orthopaedic centers. The engineering improvements in internal fixation for the anterior cervical spine, allied with an increasing expertise in instrumentation, have increased the tendency toward anterior stabilization for all unstable lower cervical fractures, except irreducible dislocations, irrespective of the mechanism of injury. Most thoracolumbar fractures with less than 50% to 60% canal compromise can be adequately dealt with by posterior surgery, largely because of the powerful correction inherent in the short segment, pedicle crew systems available. Anterior surgery continues to have a role in the correction of severe disruption, late deformity, and chronic anterior cord compression. No ideal anterior internal fixation system exists, but the Kaneda device is undoubtedly the strongest. The timing and indications for intervention for acute cord compression remain controversial in the absence of neurologic deterioration, although the route is undisputedly anterior in view of the usual site of compression.
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