Post-traumatic cervical spondyloptosis: A rare entity with multiple management options

Non-traumatic complete cervical spine dislocation with severe fixed kyphosis: successful multidisciplinary approach to a challenging case

BACKGROUND

To our knowledge, there is no previous report in the literature of non-traumatic neglected complete cervical spine dislocation characterized by anterior spondyloptosis of C4, extreme head drop, and irreducible cervicothoracic kyphosis.

CASE PRESENTATION

We report the case of a 33-year-old Caucasian man with a 17-year history of severe immune polymyositis and regular physiotherapy who presented with severe non-reducible kyphosis of the cervicothoracic junction and progressive tetraparesia for several weeks after a physiotherapy session. Radiographs, computed tomography, and magnetic resonance imaging revealed a complete dislocation at the C4-C5 level, with C4 spondyloptosis, kyphotic angulation, spinal cord compression, and severe myelopathy. Due to recent worsening of neurological symptoms, an invasive treatment strategy was indicated. The patient's neurological status and spinal deformity greatly complicated the anesthetic and surgical management, which was planned after extensive multidisciplinary discussion and relied on close collaboration between the orthopedic surgeon and the anesthetist. Regarding anesthesia, difficult airway access was expected due to severe cervical angulation, limited mouth opening, and thyromental distance, with high risk of difficult ventilation and intubation. Patient management was further complicated by a theoretical risk of neurogenic shock, motor and sensory deterioration, instability due to position changes during surgery, and postoperative respiratory failure. Regarding surgery, a multistage approach was carefully planned. After a failed attempt at closed reduction, a three-stage surgical procedure was performed to reduce displacement and stabilize the spine, resulting in correct spinal realignment and fixation. Progressive complete neurological recovery was observed.

CONCLUSION

This case illustrates the successful management of a critical situation based on a multidisciplinary collaboration involving radiologists, anesthesiologists, and spine surgeons.

Delayed surgical treatment of asymptomatic severe traumatic C7-T1 spondylolisthesis: a rare case report from Syria

Introduction

Spondylolisthesis is described as the displacement of one vertebra over another, leading to spinal instability and potential nerve compression. When this occurs in the cervicothoracic junction, it can result in unique clinical manifestations. High-grade spondylolisthesis caused by trauma in the cervicothoracic junction of the spine usually results in acute spinal cord injury and quadriparesis. However, a few uncommon cases of the same injury reported minimal or no neurological deficits. Biomechanical evaluation of the underlying pathology can offer insights into the mechanism of injury and the preservation of neurological function.

Case presentation

This paper explains the case of a 32-year-old white male patient who suffered from a traumatic C7-T1 spondylolisthesis. Despite having radiographic evidence of grade III traumatic spondylolisthesis, cord compression, fracture in the isthmus of the C7 vertebra, and intervertebral disc traumatic change and protrusion, the patient did not exhibit any motor neurological deficits. The patient underwent posterior spine fixation via the posterior approach as the first step of the surgical management, followed by anterior spine fixation via the anterior approach after several days (360° fixation). Fortunately, after 6 months of follow-up, the patient showed good outcomes. The patient was pain-free with an intact neurological clinical examination, the radiographs showed well-maintained fusion and alignment.

Discussion

The best management approach to cervical spondylolisthesis without neurological injury is complicated and arguable due to the rarity of occurrence of such cases.

Conclusion

A combined anteroposterior surgical approach, or 360° fixation, is a valuable technique for addressing complex spinal conditions such as the condition seen in our case, offering comprehensive stabilization and improved outcomes.

Reduction of cervicothoracic spondyloptosis in an ambulatory patient: when traction fails

INTRODUCTION

Cervical spondyloptosis is a rare complication of high-energy trauma which often results in significant patient morbidity and mortality. The authors present a case of spondyloptosis of C7 over T1 with minimal radicular symptoms and otherwise complete spinal cord sparing. This case highlights the surgical challenges faced with cervical spondyloptosis and the techniques used when traction fails.

CASE PRESENTATION

A 21-year-old man with no significant past medical history presented after a high-speed motor vehicle collision with cervicothoracic pain and mild hand grip weakness in addition to numbness of the fourth and fifth digits bilaterally (American Spinal Injury Association Impairment Scale Grade D). Computed tomography imaging revealed spondyloptosis of C7 over T1, a fracture of the C2 vertebral body, and a burst fracture of C3. To relieve spinal cord compression and restore sagittal realignment, closed reduction was attempted, however this resulted in perching of the bilateral C7-T1 facets, leading to an open posterior approach. The patient underwent C7 laminectomy, bilateral C7-T1 facetectomy, and manual reduction using a Mayfield skull clamp followed by C2-T3 fixation. Postoperatively, pain was diminished, sensory disturbances were resolved and the patient was otherwise neurologically stable.

DISCUSSION

There is a role for closed traction for reduction of cervical spondyloptosis, however, its role is debated especially when the patient is predominately neurologically intact. In this setting, the spine surgeon may be required to change traction and operative strategies in order to minimize potentially harmful manipulation while restoring sagittal realignment and stabilizing the spine for preservation of neurological function.

Surgical Management of Traumatic Cervicothoracic Junction Spondyloptosis Without Neurological Injury: A Case Report and Review of the Literature

Acute traumatic cervical spondyloptosis in neurologically intact patients is uncommon and involvement of the cervicothoracic junction is rare. Herein, we report a case of traumatic C7-T1 spondyloptosis in a 56-year-old neurologically intact male patient, with radiographic findings of C7-T1 grade V traumatic listhesis associated with C7 floating segment, cord compression with myelomalacia, extensive ligamentum injury, and intervertebral disc traumatic change and protrusion. He underwent global spine fixation starting with a posterior approach. Follow-up at six months showed good outcomes. The patient was neurologically intact and pain-free; radiographs showed well-maintained fusion and alignment. Controversy surrounds the management of cervical fracture dislocation from all aspects, from "when" to "what." This is the first case reporting a 540° posterior-anterior-posterior approach with successful outcomes. The rarity of cervical spondyloptosis without neurologic injury complicates the management approaches. As few cases are reported in cervicothoracic spondyloptosis literature, it is important to report the present case.

Clinical and radiological outcomes of posterior cervical decompression and fusion for severe cervical compressive-extension injury: A case series

BACKGROUND

Although severe cervical compressive-extension (CE) injuries are usually repaired using a combined anterior-posterior approach, the repair is possible using a posterior approach alone with reliable anchors. This study aimed to present the outcomes and imaging analysis results of posterior cervical decompression and fusion (PCDF) for severe CE injuries.

METHODS

We retrospectively reviewed 16 patients who underwent PCDF surgery for severe CE injuries (>50% subluxation) between January 2012 and December 2018. All patients completed 1-year follow-up, and their mean age at the time of surgery was 63.5 years. American Spinal Injury Association Impairment Scale (AIS) grade, kyphotic angle of lower vertebra (KALV), and anterior defect area of lower vertebra (ADLV) were assessed preoperatively.

RESULTS

Of 16 patients, nine patients improved at the final follow-up, and eight patients could walk with or without assistance. All patients achieved bone union postoperatively, but four patients showed progression of correction loss of ≥10°. Therefore, patients were divided into two groups: NL group with correction loss of <10°; L group with correction loss of ≥10°. All patients in L group showed KALV of ≥15°, while 10 of 12 patients in NL group showed KALV of <15°. Furthermore, all patients in L group showed ADLV of ≥50%, whereas all patients in NL group showed ADLV of <50%.

CONCLUSIONS

PCDF is feasible and a favorable procedure for severe CE injuries that require early reduction and cervical spinal stabilization. However, in the cases of advanced destruction of the anterior vertebra, loss of correction after PCDF might occur postoperatively.

Management of Traumatic Cervical Spondyloptosis

Traumatic cervical spondyloptosis is a 3-column fracture-dislocation resulting in a highly unstable spine requiring urgent reduction, stabilization, and fixation. Since its occurrence is not that common, there are a lot of controversies concerning its management. A holistic approach has been proposed regarding the management of traumatic cervical spondyloptosis.

Two case reports of 'locked spondyloptosis': the most severe traumatic cervical spondyloptosis with locked spinous process and vertebral arch into the spinal canal

INTRODUCTION

Traumatic cervical spondyloptosis, including compressive-extension stage 5 of Allen's classification of cervical spine injuries, is commonly observed; however, cases involving locked spinous process and vertebral arch into the spinal canal are extremely rare.

CASE PRESENTATION

We present two individuals with spondyloptosis of C7 with locked spinous process of C6 and the vertebral arch into the spinal canal. Closed reduction was unable to be performed due to rigid locking of the cervical spine in the first case, whereas preoperative closed reduction was achieved with mild traction in a prone position after general anaesthesia in the second case. These two individuals underwent spinal fusion via a posterior approach after open or closed reduction. Six months after surgery, both individuals exhibited significant neurological recovery and acquired a stable gait.

DISCUSSION

To the best of our knowledge, this is the first report of traumatic 'locked spondyloptosis' of the spinous process and vertebral arch into the spinal canal. Although high-grade compressive-extension injuries are usually repaired using a combined anterior-posterior approach, repair is possible with a posterior approach alone with reliable anchors, such as pedicle screws or multiple lateral mass screws. Urgent open reduction may be required for locked spondyloptosis when closed reduction is invalid due to rigid locking of the cervical spine.

Cervical Spondyloptosis Successfully Treated with Only Posterior Short Segment Fusion Using Cervical Pedicle Screw Fixation

This paper describes two patients with cervical spondyloptosis with severe spinal cord injury treated with cervical pedicle screw (CPS) through a single-stage operation, posterior approach. A 60-year-old male patient with quadriparesis due to trauma 1 day before visited the emergency room. Cervical spine computed tomography (CT) and magnetic resonance imaging showed complete dislocation of the C7 and T1 vertebrae with severe spinal cord compression, disc injury, and disc herniation at the C7–T1 level. Cervical pedicle screw with freehand technique was done on C6 and T1 vertebrae, and bilateral distraction for a reduction was performed with a screw distractor. After reduction of the C7 vertebra on the surgical field, CPS placement on C7 body was done. After surgery, follow-up X-rays showed near complete reduction. The patient completed a rehabilitation program, and his condition improved. From the third month postoperatively, the patient could ambulate without assistance and perform nearly normal daily activities. A postoperative CT scan 1 year later showed accurate screw position and complete fusion bridges on the C6–C7–T1 vertebrae. The other patient, a 39-year-old male, also showed C7–T1 spondyloptosis with quadriparesis (grade IV). C6–T1–T2 fusion surgery was performed only through a posterior approach. The patient showed nearly normal neurology and reduction. Considering early surgery time followed by open reduction and biomechanical superiority of CPS, single posterior approach and short segment fusion appear to be a great surgical method.

Traumatic spondyloptosis of the cervical spine: A case report and discussion of worldwide treatment trends

Background:

Cervical spondyloptosis is defined as the dislocation of the spinal column most often caused by trauma. Due to compression or transection of the spinal cord, severe neurological deficits are common. Here, we review the literature and report a case of traumatic C5–6 spondyloptosis that was successfully treated using an anterior-only surgical approach.

Methods:

The patient presented with quadriplegia and absent sensation distal to the C5 dermatome following a rollover motor vehicle accident. The preoperative American Spinal Injury Association Impairment Scale was A. Computed tomography of the cervical spine revealed C5–6 spondyloptosis, lamina fractures on the right side at the C3–4 level, and widened facet joint on the right side at C6–7.

Results:

The patient underwent cervical traction and anterior cervical discectomy and fusion at the C5–6, C6–7 levels; no 360° fusion was warranted. Six months postoperatively, the patient remained quadriplegic below the C5 level.

Conclusion:

Presently, no consensus is present regarding the best treatment for spondyloptosis. Worldwide, the 360° approach is the most commonly used (45%), followed by anterior-only surgery (31%) and posterior-only surgery (25%). The surgical choice depends upon patient-specific features but markedly varies among geographical regions.