Traumatic High-Grade Cervical Dislocation: Treatment Strategies and Outcomes

Open Reduction in Traumatic Cervical Facet Dislocation Does Not Delay Time to Treatment

Background Cervical facet dislocation is a serious injury that can result in permanent neurologic damage. Current guidelines recommend immediate closed reduction of cervical dislocations, though the efficacy of this practice remains a debate. This study aims to evaluate whether immediate open reduction and fixation of cervical dislocations offer equal or better outcomes for patients and limit the need for follow-up operations. Methods This is a retrospective study including patients who presented to the emergency department of a single institution from 2008 to 2023 with cervical facet dislocation. Patients were divided into groups based on initial treatment: either open or closed reduction. Time to surgery was calculated as the time between arrival to the ED and incision time in the OR. Primary outcomes were improvement in motor and sensory deficits at six-week post-operative follow-up. Results There were 31 patients who met the inclusion criteria. Time to treatment did not differ significantly between the open versus closed reduction groups. There were no differences between groups in improvement in motor function, sensory function, or pain at the six-week follow-up. All patients treated with initial closed reduction ultimately required surgical stabilization. Conclusions Open reduction as a first-line treatment did not increase the time to treatment for patients with cervical facet dislocations. Patients had equivalent functional outcomes in both treatment groups. The findings suggest that current practice guidelines may delay definitive treatment without improving patient safety or outcomes.

Extreme dislocation of the cervical spine-case report

We present the case of rare extreme dislocation of subaxial cervical spine, which was challenging regarding type and time of surgery. A 22-year-old patient was injured in a traffic accident, from very beginning with signs of spinal shock. Severe traumatic C6/C7 dislocation with resulting transection of the spinal cord was diagnosed with MDCT imaging. The main dilemmas regarding the surgical treatment of this injury referred to the timing of surgery and the choice of surgical approach. We decided to perform posterior surgery at first stage. Postoperative her condition get worsening and on the 16th postoperative day came to the fatal outcome. Despite all the available protocols, in our case, the decision had to be made on the basis of individual multidisciplinary assessment, bearing in mind the mechanism of the injury and the clinical presentation of the injured patient.

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.

Emergency Treatment of Cervical Vertebromedullary Trauma: 10 Years of Experience and Outcome Evaluation

OBJECTIVE

The aim of the study is to identify and validate, through the recording of clinical and radiological data, the different surgical approaches and treatments valid for most subaxial cervical dislocation fractures and whether there is an advantage from using an anterior approach rather than a posterior approach and conversely..

MATERIAL AND METHODS

A retrospective study was carried out analyzing the case history of the last 10 years of vertebromedullary traumas treated at the spine surgery unit of the Policlinico Gemelli in Rome. Data on surgical timing, American Spinal Injury Association (ASIA) scores for neurological damage, and subsequent assessments on recovery, survival, and mortality were also examined.

RESULTS

A total of 80 patients were treated: 50 by the posterior approach, 24 by the anterior approach, and six by the double approach. Our average follow-up time was 4.2 years. A prevalence of surgery with the posterior approach was noted. We observed the worsening of cervical kyphosis about 15 months after the trauma in two cases treated with the posterior approach alone. A second surgical treatment was performed in these patients. One of these patients underwent an anterior fusion; the other case underwent a posterior revision because the patient had ankylosing spondylitis. Although we found no statistically significant difference in outcomes between the various surgical treatments, in this retrospective study, we analyzed the characteristics and outcomes of cervical spine injuries that required surgical treatment.

CONCLUSION

The aim of surgery in unstable cervical spine injuries should be to reduce and stabilize the damaged segment, maintain lordosis, and decompress when indicated. The optimal choice of surgical approach and treatment, or its superiority in terms of outcomes, remains a debated issue.

Anterior cervical plating combined with zero-profile anchored spacer for the treatment of cervical facet dislocation in elderly patients

OBJECTIVE

The purpose of this study was to evaluate the efficacy of anterior cervical plating combined with zero-profile (Z-P) anchored spacer for the treatment of cervical facet dislocation in elderly patients.

METHODS

This is a retrospective study. Twelve elderly patients (from 57 to 77 years old, averaged 65 years) with unilateral or bilateral facet dislocation of sub-axial cervical spine from September 2015 to September 2019 surgically treated at the authors' hospital were enrolled in this study. The patients with osteoporosis or osteopenia were all surgically treated by anterior-only procedure using cervical plating combined with zero-profile anchored spacer after closed manual reduction under general anesthesia and spinal cord monitoring. The operation times (OT), estimated blood loss (EBL), perioperative complications, were recorded. The clinical evaluation included visual analogue scales (VAS) and the American Spinal Injury Association (ASIA) scale. The radiographic evaluation included kyphotic angle (KA) and disc height (DH) and the fusion rate.

RESULTS

Anterior discectomy, interbody fusion and fixation were performed in all patients after the disloctions were reduced by manual maneuver. The average OT was 66 minutes, with a range from 45 to 110 minutes. The EBL averaged 42 ml per surgical procedure, with a range from 20 to 60 ml. The VAS, ASIA, KA were improved significantly after surgery (P<0.05). The average follow-up time was 24.2 months, with a range from 12 to 38 months. There were no statistical differences between the immediately post-op KA and KA at the last follow-up (P>0.05). No disc space subsidence was observed statistically (P<0.05) Interbody fusion was obtained in all patients. Two patient experienced slight difficulty in swallowing, which were improved 6 weeks later. There were no hardware failure, no segmental instability, no wound infection or other complications.

CONCLUSIONS

Manual reduction with spinal cord monitoring under general anesthesia is a safe and efficient option and the anterior cervical plating combined with Z-P spacer could achieve reliable fixation for the patients with cervical facet dislocation in the elderly patients with osteoporosis or osteopenia.

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.

Posterior Ligament-Bone Injury Classification and Severity Score: A Novel Approach to Predict the Failure of Anterior-only Surgery for Subaxial Cervical Facet Dislocations

STUDY DESIGN

Clinical case series.

OBJECTIVE

The aim of this study was to propose a novel posterior ligament-bone injury classification and severity (PLICS) score system that can be used to reflect the severity of subaxial cervical fracture dislocations (SCFDs) and predict the failure of anterior-only surgery; and to measure the intraobserver and interobserver reliability of this system.

SUMMARY OF BACKGROUND DATA

The approach selection for SCFDs is controversial. Although the anterior approach is familiar for most surgeons, postoperative hardware failure and/or delayed cervical deformity is a nonnegligible complication.

METHODS

Ten patients were randomly selected for intraobserver reliability evaluation on two separate occasions, one month apart. Another 30 patients were randomly selected, and the interobserver reliability was measured by comparing results of each case between each reviewer and averaging. To analyze the difference in the PLICS score, 354 patients fulfilled the follow-up were divided into stable and unstable groups according to whether radiologically stable was observed during follow-up.

RESULTS

For the intraobserver reliability, the mean intraclass correlation coefficient for the 10 reviewers was 0.931. For the interobserver reliability, the mean interobserver correlation coefficient for the three elements was 0.863. Among 16 patients with PLICS score ≥7, two patients in the stable group manifested with severe injury of the posterior ligamentous complex (PLC); extremely unstable lateral mass fractures with or without severe injury of PLC were detected in the 14 patients of the unstable group.

CONCLUSION

The proposed PLICS score system showed excellent intraobserver and interobserver reliability. When a PLICS score is >7 or 7 accompanied by extremely unstable lateral mass fractures, the risk of postoperative failure after an anterior-only reconstruction is high and supplemental posterior strengthening can be considered.Level of Evidence: 4.

Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations

Epidemiology, prevention, early management of cervical spine trauma and it's reduction are the objectives of this review paper. A PubMed and MEDLINE search between 2009 and 2019 were conducted using keywords. Case reports, experimental studies, papers other than English language and and unrelated studies were excluded. Up-to-date information on epidemiology of spine trauma, prevention, early emergency management, transportation, and closed reduction were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Global incidence of traumatic spinal injury is higher in low- and middle-income countries. The most frequent reasons are road traffic accidents and falls. The incidence from low falls in the elderly are increasing in high-income countries due to ageing populations. Prevention needs legislative, engineering, educational, and social efforts that need common efforts of all society. Emergency care of the trauma patient, transportation, and in-hospital acute management should be planned by implementing detailed protocols to prevent further damage to the spinal cord. This review summarizes the WFNS Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries.

When is the circumferential stabilization necessary for subaxial cervical fracture dislocations? The posterior ligament-bone injury classification and severity score: a novel treatment algorithm

OBJECTIVE

To propose a novel classification and scoring system called the posterior ligament-bone injury classification and severity score (PLICS) that offers a quantitative score to guide the need for posterior stabilization in addition to anterior reconstruction for subaxial cervical fracture dislocations (SCFDs).

METHODS

A total of 456 patients with SCFDs were prospectively included. Patients with PLICS ≥ 7 together with extremely unstable lateral mass fracture (EULMF) were classified as high-risk group, and the other patients were classified as low-risk group. For patients in the low-risk group, anterior-only reconstruction was performed; for patients in the high-risk group, additional posterior lateral mass fixation and fusion was performed after anterior reconstruction. Clinical outcome evaluation included using the visual analogue score (VAS), the Neck Disability Index (NDI), and the American Spinal Injury Association (ASIA) impairment scale. The change in the local sagittal alignment kyphosis Cobb angle was also recorded.

RESULTS

A total of 370 patients (81.1%) completed the minimal 12-month follow-ups, including 321 patients of low-risk group and 49 patients of high-risk group. Compared with the average VAS score preoperatively, the score at 12-month follow-up was significantly improved (from 6.1 + 0.3 to 1.1 + 0.2 in the low-risk group, P < 0.001; from 6.4 + 0.2 to 1.4 + 0.2 in the high-risk group, P < 0.001). The average NDI score at the 12-month follow-up was statistically low in the low-risk group (8.8 + 2.5 vs 13.8 + 3.4, P = 0.034). At least more than one grade improvement in the ASIA scale was observed in 80.5% of all patients. The local kyphosis Cobb angle at the injured segment averaged improved in both groups.

CONCLUSION

A PLICS score ≥ 7 together with EULMF can be the threshold for posterior stabilization in addition to anterior reconstruction for the patients with SCFDs.

Bilateral traumatic C6-C7 facet dislocation with C6 spondyloptosis and large disk sequestration in a neurologically intact patient

Traumatic cervical spondyloptosis is an uncommon and severe form of facet joint dislocation that commonly leads to severe neurological damage. Decision making regarding the reduction and fixation technique is challenging, especially when a patient is neurologically intact, since an undiagnosed prolapsed disk at the involved level may lead to severe neurological consequences during reduction. A 24-year-old male was admitted after sustaining a severe direct axial blow to his head. Computed tomographic and magnetic resonance imaging scans revealed an acute C6C7 fracture dislocation with spondyloptosis of C6 vertebra and a large disk fragment posterior to C6 vertebral body. The patient was neurologically intact, apart from mild bilateral numbness over C6 distribution. The patient underwent C6 corpectomy to avoid acute cord compression related to the large sequestered disk behind C6 vertebra. Following C6 corpectomy, we were unable to exert enough axial pull to reduce the facet dislocation through the anterior approach. Therefore, the reduction was performed through a posterior approach with C5T1 posterior fusion, followed by anterior cage placement and C5-7 anterior fusion (front-back-front approach). At postoperative follow-up of 24 months, the patient demonstrated a full and pain-free cervical range-of-motion and remained neurologically intact. Follow-up radiographs of the cervical spine demonstrated good instrumental alignment with solid fusion at 6-month follow-up.

High-dose methylprednisolone for acute traumatic spinal cord injury: A meta-analysis

OBJECTIVE

Due to the continuing debates on the utility of high-dose methylprednisolone (MP) early after acute spinal cord injury (ASCI), we aimed to evaluate the therapeutic and adverse effects of high-dose MP according to the second National Acute Spinal Cord Injury Study (NASCIS-2) dosing protocol in comparison to no steroids in patients with ASCI by performing a meta-analysis on the basis of the current available clinical trials.

METHODS

We searched PubMed and Cochrane Library (to May 22, 2018) for studies comparing neurologic recoveries, adverse events, and in-hospital costs between ASCI patients who underwent high-dose MP treatment or not. Data were synthesized with corresponding statistical models according to the degree of heterogeneity.

RESULTS

= 0.78).

CONCLUSIONS

Based on the current evidence, high-dose MP treatment, in comparison to controls, does not contribute to better neurologic recoveries but may increase the risk of adverse events in patients with ASCI. Therefore, we recommend against routine use of high-dose MP early after ASCI.

Traumatic cervical posterior spondyloptosis: report of a rare case

Traumatic spinal spondyloptosis is the extreme degree of spondylolisthesis and is not common. Traumatic cervical anterior spondyloptosis has been reported but we could not find reports of posterior traumatic cervical spondyloptosis. We present an 18-year-old female with this type of injury and cervical complete cord syndrome below C5 and explain our treatment approach.

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.

Successful surgical repair and recovery in a 2-week-old infant after birth-related cervical fracture dislocation

Cervical spine injuries are the most common spine injuries in the pediatric population. The authors present the youngest known patient who underwent cervical spine fusion to repair birth trauma-induced cervical fracture dislocation, resulting in spondyloptosis and spinal cord injury. A 2-week-old boy was found to have spondyloptosis and spinal cord injury after concerns arose from reduced movement of the extremities. The patient's birth was complicated by undiagnosed abdominal dystocia, which led to cervical distraction injury. At 15 days of age, the boy underwent successful C-5 corpectomy, with anterior C4-6 and posterior C2-7 arthrodesis, using an autologous rib graft for a C-5 fracture dislocation. MRI performed 2 weeks postoperatively revealed significant improvement in the alignment of the spinal canal. The patient was discharged from the hospital in a custom Minerva brace and underwent close follow-up in addition to occupational therapy and physical therapy. At the latest follow-up 4.5 years later, the patient was able to walk and ride a tricycle by himself. The authors describe the patient's surgery and the challenges faced in achieving successful repair and cervical spine stabilization in such a young patient. The authors suggest that significant neurological recovery after spinal cord injury in infants is possible with appropriate, timely, and interdisciplinary management.

Isolated C5 Vertebrae Dislocation with Trauma: An Extremely Rare Case of Isolated C5 Dislocation

BACKGROUND Total spondylolisthesis, or dislocation of 1 cervical vertebrae, is only caused by high-energy trauma and is usually fatal. Cervical spine fractures and dislocations often cause 3-column structural damage to the cervical spine, injury to the spinal cord, and precipitating alignment of the cervical vertebrae, as well as cervical instability, which are detrimental, show poor prognosis, and are associated with high rates of mortality rate and disability. CASE REPORT We report an extremely rare case of isolated C5 dislocation caused by falling out of a tree, with sudden tetraplegia. CONCLUSIONS Total spondylolisthesis or dislocation of 1 cervical vertebrae can be surgically treated with anterior approach because it is possible to completely remove the vertebra body, intervertebral disc, and bone fragments, to directly decompress the spinal cord with stabilization.

Circumferential Reconstruction of Subaxial Cervical and Cervicothoracic Spine by Simultaneously Combined Anterior-posterior Approaches in the Sitting Position

OBJECTIVE

To introduce and analyze the feasibility of a new surgical strategy for circumferential reconstruction of subaxial cervical and cervicothoracic spine by simultaneously combined anterior-posterior approach in the sitting position.

METHODS

A retrospective review was performed for seven patients who underwent the above surgical procedure between July 2011 and January 2015. Among the seven patients, there were six men and one woman, with an average age of 52 years (range, 36-79 years). Six patients were confirmed to have a lower subaxial cervical fracture and dislocation with a locked facet joint, and the other patient had an invasive tumor involving both anterior and posterior parts of vertebrae and lamina, detected by radiological examination. The levels involved for all patients were from C₄ to T₂ . According to American Spinal Injury Association (ASIA) classification, one case was class A, four were class B, and two were class D. The patients were restricted in the sitting position with traction and a halo in extension to immobilize the head during the operation. The simultaneously combined anterior-posterior operation for reduction, decompression or tumor resection and circumferential reconstruction was carried out.

RESULTS

Both anterior and posterior procedures were successfully completed simultaneously in the sitting position in all cases. There were no perioperative complications. The average operative time was 175 ± 32 min (range, 120-240 min), and the mean blood loss was 430 ± 85 mL (range, 200-1100 mL). The patients were followed up for 35.8 months (range, 18-60 months). The symptom of neck pain improved distinctly and no evidence of implant failure was noted in any patients. Neurological status improvement was confirmed in six patients, who had suffered incomplete paralysis. The ASIA grade improved in five patients, and two cases had no change in grade.

CONCLUSIONS

The "sitting position" simultaneously combined anterior-posterior approach is safe and is superior to the traditional prone position and supine position, and the surgical results are satisfactory.

Traumatic high-grade spondylolisthesis at C7-T1 with no neurological deficits: Case series, literature review, and biomechanical implications

Traumatic high-grade spondylolisthesis in subaxial cervical spine is frequently associated with acute spinal cord injury and quadriparesis. There have been rare cases where such pathology demonstrates minimal to no neurological deficits. Assessment of the underlying biomechanics may provide insight into the mechanism of injury and associated neurological preservation. Patient 1 is a 63-year-old female presenting after a motor vehicle collision with significant right arm pain without neurological deficits. Imaging demonstrated C7/T1 spondyloptosis, associated with a locked facet on the left at C6/7 and a locked facet on the right at C7/T1, with a fracture of the left C7 pedicle and right C7 lamina. Patient 2 is a 60-year-old male presenting after a bicycle collision with transient bilateral upper extremity paresthesias without neurological deficits. Imaging demonstrated C7/T1 spondyloptosis, with fractures of bilateral C7 pedicles, C7/T1 facets, and C7 lamina. Patient 3 is a 36-year-old male presenting after a motor vehicle collision with diffuse tingling sensation throughout all extremities. His neurological examination was nonfocal. Imaging demonstrated a grade 4 spondylolithesis at C7/T1, associated with bilateral C7/T1 locked facets. From literature, most cases were noted to be dislocations resulting from fractures of the posterior elements. A minority of cases has been found to involve facet dislocations without fractures. Further biomechanical studies are needed to understand the underlying mechanisms.

Simultaneously Combined Anterior-Posterior Approaches for Subaxial Cervical Circumferential Reconstruction in a Sitting Position

The purpose of this article is to introduce and analyze the feasibility of simultaneously combined anterior-posterior approaches for subaxial cervical circumferential reconstruction in sitting position. A retrospective case review was performed for above surgery procedure. A 79-year-old man was confirmed subaxial cervical fracture and dislocation with facet locked by radiological examination, and the involved levels were C5-6. According to American Spinal Injury Association (ASIA) classification, the impairment scale was grade B. And the Subaxial Cervical Spine Injury and Severity Score (SLIC) were 9. The patient was restricted in sitting position with traction on a halo in extension to immobilize the head during the operation. A posterior laminectomy and pedicle screws insertion to the involved cervical spine was performed firstly. And then the anterior discectomy and strut graft were accomplished through an anterior cervical approach. The final fixation was finished by clamping the strut graft with pedicle screw system. Total blood loss was 600 ml and the total operating time was 150 min. The patient was followed up for 6 months. The symptom of neck pain improved distinctly and no evidence about implant failure was noted. Neurological status improvement was confirmed and the ASIA scale was improved to grade C. We believed that the simultaneously combined anterior-posterior approach in sitting position was safe and more advantageous for appropriate cases.

Traumatic spondyloptosis at the cervico-thoracic junction without neurological deficits

Background:

There have been rare cases of traumatic cervical spondyloptosis without neurological compromise. We report another case and provide a review of the literature, with a focus on appropriate management.

Case Description:

A 60-year-old male rode his bicycle into a stationary semi-truck. He reported initial bilateral upper extremity paresthesias that resolved. Imaging demonstrated C7 on T1 spondyloptosis. Traction did not achieve reduction and a halo was applied. Subsequently, he underwent posterior decompression C6-T1, reduction via bilateral complete facetectomies at C7, and fixation from C4 to T2 fixation. Afterward, an anterior C7-T1 fixation occurred, where exposure was performed through a midline sternotomy. Postoperatively, he woke up with baseline motor and sensory examination in his extremities. He did exhibit voice hoarseness due to paralysis of the left vocal cords. He was discharged home 3 days after surgery. At 6 months follow-up, there was a progressive improvement of the left vocal cords to slight paresis; dynamic X-rays demonstrated no instability with good fusion progression.

Conclusion:

Traumatic cervical spondyloptosis without neurological compromise is a rare and challenging scenario. There is a concern for neurologic compromise with preoperative traction, but if specific posterior elements are fractured, the spinal canal may be wide enough where the concern for disc migration is minimal. For patients who have not been reduced preoperatively, a posterior approach with initial decompression to widen the canal, before reduction, appears safe. This scheme may avoid an initial anterior approach for decompression, necessitating a 3-stage procedure if circumferential stabilization is pursued.

Redislocation After a Failed Surgery to Treat C6/7 Fracture-Dislocation With Pedicular Fracture of the C6 Vertebra: Case Report of a Successful Revision Surgery, Analysis of the Causes, and Discussion of Revision Surgical Strategies

Cervical spinal fracture-dislocation with pedicular fracture of the vertebra has been little reported and the management of such a patient is difficult. Considering the little knowledge of this area, we present this special case of a successful revision surgery for the treatment of redislocation after a failed surgery to treat C6/7 fracture-dislocation with pedicular fracture of the C6 vertebra to share our experience.A 45-year-old male patient presented to our hospital with history of neck pain for 4 months. According to his medical records, he was involved in an architectural accident and diagnosed with C6/7 fracture-dislocation with pedicular fracture of the C6 vertebra (ASIA: D). A surgery of posterior lateral mass screw fixation (bilateral in C5 and C7; left side in C6) was performed in a different institution. However, 4 months after his primary surgery, he was still troubled by serious neck pain and muscle weakness in all right side limbs. The physical examination of the patient showed hypoesthesia in the right side limbs, myodynamia of the right side limbs weakened to Grade 4. Cervical X-rays, computed tomography (CT), and magnetic resonance imaging confirmed the redislocation of C6/7. A successful revision surgery of anterior cervical corpectomy and fusion (ACCF) with nanohydroxyapatite/polyamide 66 composite fulfilled with vertebral autograft plus anterior plate was performed. The 3 months postoperative X-rays and CT scan showed the good position of the implant and bony fusion. The patient's neck pain was relived and the neurological function recovered to ASIA E grade at the 3rd month follow-up.ACCF with nanohydroxyapatite/polyamide 66 composite fulfilled with vertebral autograft plus anterior plate is effective for the treatment of redislocation after a failed surgery in patients of fracture-dislocation with pedicular fracture. The best method to avoid such a failed surgery is a combined anterior-posterior approach surgery in our opinion.

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

Post-traumatic cervical spondyloptosis is a rare condition associated with high energy injuries, and to our knowledge only case reports are available. There are no universally accepted treatment paradigms for these cases and management is individualised according to the case and surgeon preference. We retrospectively analysed our management and clinical outcomes of this condition. From January 2007 to August 2014 we treated eight patients with cervical spondyloptosis at our institute. Only two patients had no neurological deficits; all the remaining patients had partial cord injury. Seven were treated surgically with preoperative traction followed by anterior cervical discectomy and fusion with fixation in three patients, and combined anterior and posterior fusion and fixation in four. Depending on the presence of anterior compression by a disc an anterior first or posterior first approach was advocated. All four combined anterior and posterior fusion and fixation patients needed to be turned more than once (540°). There was no neurological deterioration in any of the patients, as they either improved or remained stable neurologically. Post-traumatic cervical spondyloptosis is a challenging entity to manage. Surgery can be done safely with good clinical and radiological outcome and needs to be tailored to the individual patient.

Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Systematic Review and Meta-Analysis

Previous meta-analyses of methylprednisolone (MPS) for patients with acute traumatic spinal cord injuries (TSCIs) have not addressed confidence in the quality of evidence used for pooled effect estimates, and new primary studies have been recently published. We aimed to determine whether MPS improves motor recovery and is associated with increased risks for adverse events. We searched MEDLINE, EMBASE, and The Cochrane Library, and two reviewers independently screened articles, extracted data, and evaluated risk of bias. We pooled outcomes from randomized, controlled trials (RCTs) and controlled observational studies separately and used the Grades of Recommendation, Assessment, Development, and Evaluation approach to evaluate confidence. We included four RCTs and 17 observational studies. MPS was not associated with an increase in long-term motor score recovery (two RCTs: 335 participants; mean difference [MD], −1.11; 95% confidence interval [CI], −4.75 to 2.53; p = 0.55, low confidence; two observational studies: 528 participants; MD, 1.37; 95% CI, −3.08 to 5.83; p = 0.55, very low confidence) or improvement by at least one motor grade (three observational studies: 383 participants; risk ratio [RR], 0.84; 95% CI, 0.53–1.33; p = 0.46, very low confidence). Evidence from two RCTs demonstrated superior short-term motor score improvement if MPS was administered within 8 h of injury (two RCTs: 250 participants; MD, 4.46; 95% CI, 0.97–7.94; p = 0.01, low confidence), but risk of bias and imprecision limit confidence in these findings. Observational studies demonstrated a significantly increased risk for gastrointestinal bleeding (nine studies: 2857 participants; RR, 2.18; 95% CI, 1.13–4.19; p = 0.02, very low confidence), but RCTs did not. Pooled evidence does not demonstrate a significant long-term benefit for MPS in patients with acute TSCIs and suggests it may be associated with increased gastrointestinal bleeding. These findings support current guidelines against routine use, but strong recommendations are not warranted because confidence in the effect estimates is limited.