Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds

Delayed presentation of lower cervical facet dislocations: What to learn from past reports?

Delayed presentation of lower cervical facet dislocations is uncommon, and there is no standardized way to approach these neglected injuries. The literature on neglected lower cervical facet dislocations is limited to case reports and few retrospective studies. This justifies the need for a comprehensive review of this condition. Our purpose was to elaborate a review on the epidemiology, clinical and radiological presentation, and treatment techniques and approach to these neglected injuries. Middle-aged adults from 30 to 50 represent 73.8% of reported cases, and most of them are males (72.0%). The most affected level is C5-C6 (43.0%). While most delays are due to missed injuries (52.1%) and ineffective non-operative treatment (36.2%), the other reason for delay is negligence in seeking medical care (11.7%). Patients present with variable degrees of neurological deficit, persistent neck pain, and neck stiffness. Reported approaches and techniques to reduce and stabilize these injuries are highly variable and depend on the surgeon's judgment, experience, and preference. Fibrotic tissues and bony fusion around the dislocated facet joint contribute to the reduction challenge, and 77.0% of closed reduction attempts fail. Anterior and posterior approaches to the cervical spine are used selectively or in combination for surgical release, reduction, and stabilization. Despite the lack of standardized treatment guidelines and different approaches, most of the authors reported improvement in pain, balance, and neurology post-surgery. Starting with the posterior surgical approach aims to achieve reduction compared to the anterior approach which largely aims at spinal decompression. Given the existing controversies, the need for quality prospective studies to determine the best treatment approach for lower cervical facet dislocations presenting with delay is evident.

Immediate Closed Reduction Technique for Cervical Spine Dislocations

STUDY DESIGN

Retrospective study.

PURPOSE

This research aimed to assess the clinical outcomes of patients with traumatic cervical spine dislocation who underwent closed reduction employing our approach.

OVERVIEW OF LITERATURE

Bedside closed reduction is the quickest procedure for repairing traumatic cervical spine dislocations; nevertheless, it also possesses the risk of neurological deterioration.

METHODS

For closed reduction, the patient's head was elevated on a motorized bed, the cervical spine was placed at the midline, traction of 10 kg was applied, the motorized bed was gradually returned to a flat position, the head was lifted off the bed, and the cervical spine was slowly adjusted to a flexed position. The weight of traction was elevated by 5-kg increments until the positional shift was attained. Subsequently, the bed was gradually tilted while traction was applied again to return the cervical spine to the midline position.

RESULTS

Of the 43 cases of cervical spine dislocation, closed reduction was carried out in 40 cases, of which 36 were successful. During repositioning, three patients experienced a temporary worsening of their neck pain and neurological symptoms that enhanced when the cervical spine was flexed. Closed reduction was conducted while the patient was awake; nevertheless, sedation was needed in three cases. Among the 24 patients whose pretreatment paralysis had been characterized by American Spinal Injury Association Impairment Scale (AIS) grades A-C, seven patients (29.2%) demonstrated an enhancement of two or more AIS grades at the last observation.

CONCLUSIONS

Our closed reduction approach safely repaired traumatic cervical spine dislocations.

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.

The impact of helicopter emergency medical services and craniocervical traction on the early reduction of cervical spine dislocation in a rural area of Japan

BACKGROUND

Several studies have shown an association between achieving decompression of the spinal cord within a few hours and neurological recovery, even in patients with complete paralysis due to cervical spine dislocation. This study aimed to clarify the impact of helicopter emergency medical services (HEMSs) and craniocervical traction on the rapid reduction of lower cervical spine dislocation in rural Japan.

METHODS

The success rate of and factors inhibiting closed reduction, the time from injury to reduction and the functional prognosis of lower cervical spine dislocations treated between July 2012 and February 2020 were retrospectively analysed.

RESULTS

Fourteen patients were transported by HEMS (group H), seven by ambulance (group A) and two by themselves. Although the average traveled distance and injury severity score were significantly higher in group H (64.5 km, 28.0) than in group A (24.7 km, 18.6), there was no significant difference in the average time to admission or the time to initiation of craniocervical traction after admission between groups H (159.4 min, 52.2 min) and A (163.6 min, 53.2 min). The success rate of closed reduction was 95%, and neurological deterioration was not observed in any cases. The average traction time and weight for reduction were 30.3 min and 16.3 kg, respectively. Body size and fracture-dislocation type did not significantly affect the traction time or weight. The rate of reduction within 4 h after injury was higher in group H (79%) than in group A (33%). Inner fixations were treated an average of 5.7 days after admission. After treatment, three of nine AIS A patients recovered the ability to walk, and all three patients underwent successful closed reduction within 4 h after injury.

CONCLUSION

HEMS and highly successful closed reduction contributed to the early reduction of cervical spine dislocation and can potentially improve complete paralysis.

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.

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.

Sub-Axial Cervical Facet Dislocation: A Review of Current Concepts

Cervical facet dislocation is a serious injury that carries risks of short- and long-term morbidity. The optimal management of these injuries remains controversial with the ongoing debate regarding indications and requirements for closed reduction, timing, type of surgical approach and method of fixation. This review gives an update on the relevant anatomy, classification systems for sub-axial cervical facet dislocation and an overview of the current concepts regarding their management, including surgical approaches and the choice of implants.

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.

An Experimental Study on the Safety and Mechanism of Reduction of Subaxial Cervical Facet Dislocation Using Z-Shape Elevating-Pulling Reduction Technique

OBJECTIVE

We sought to clarify the safety and unlocking mechanism of the Z-shape elevating-pulling closed reduction (ZR) technique and to analyze the differences in facet contact force and intraspinal pressure during subaxial facet dislocation reduction using the ZR technique and traditional skull traction closed reduction (SR).

METHODS

In 15 human cadaveric skull-neck-thorax specimens, reproducible unilateral and bilateral facet dislocations (UFDs/BFDs) were created at the C5-C6 level and then reduced by applying the ZR and SR techniques, respectively. Tekscan FlexiForce A-201 pressure sensors were used to measure the anterior and posterior intraspinal pressure and injured facet contact force under physiological conditions and before and after reduction. The maximum pressures during the reduction process were recorded.

RESULTS

After creation of the facet dislocation, the anterior and posterior intraspinal pressure and facet contact force were significantly increased relative to normal (P < 0.001). The UFDs and BFDs of all specimens were successfully reduced by both ZR and SR, and the intraspinal pressure and facet contact force were significantly reduced compared with before reduction (P < 0.001). Compared with SR, the maximum posterior intraspinal pressure during BFD reduction (P = 0.027) and the maximum facet contact force during UFD reduction (P < 0.001) were lower when ZR was used for closed reduction.

CONCLUSIONS

Our findings suggest that ZR and SR can both be used to reduce subaxial facet dislocation and decompress the spinal cord. However, the ZR technique appears to safer and more effective than the SR technique for closed reduction of subaxial facet dislocations.

Complete Traumatic Spinal Cord Injury: Current Insights Regarding Timing of Surgery and Level of Injury

STUDY DESIGN

A narrative literature review.

OBJECTIVES

To review the neurological recovery patterns in traumatic spinal cord injury (tSCI) patients with a complete lack of motor and sensory function below the level of injury (ie, ASIA A [American Spinal Injury Association scale]), as well as the impact of level of injury and timing of surgical intervention.

RESULTS

Spontaneous neurological recovery in patients with complete tSCI differs per level of injury: patients with cervical and thoracolumbar tSCI recover ≥1 ASIA grade in 17.3% to 34.0% 1 year after injury, compared with 10.7% to 18.6% in thoracic tSCI. Surgical decompression within 24 hours has a beneficial effect on neurological recovery in patients with complete cervical tSCI, whereas this effect is less clear for thoracic and thoracolumbar tSCI. A 1- or 2-grade improvement in the ASIA scale does not necessarily result in functional recovery.

CONCLUSION

In complete tSCI, the level of injury as well as surgical timing affect neurological recovery. There appears to be a beneficial effect of early surgical decompression in patients with complete cervical tSCI, more so than for thoracic and thoracolumbar tSCI. Frequently, the effect of surgical intervention is evaluated by an improvement in ASIA grade, but it is unclear whether this scale is sensitive enough to evaluate meaningful effectiveness of the intervention and desired outcome for patients with tSCI.

Neurological recovery after traumatic spinal cord injury: what is meaningful? A patients' and physicians' perspective

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

Most studies on neurological recovery after traumatic spinal cord injury (tSCI) assess treatment effects using the American Spinal Injury Association Impairment Scale (AIS grade) or motor points recovery. To what extent neurological recovery is considered clinically meaningful is unknown. This study investigated the perceived clinical benefit of various degrees of neurological recovery one year after C5 AIS-A tSCI.

SETTING

The Netherlands.

METHODS

By means of a web-based survey SCI patients and physicians evaluated the benefit of various scenarios of neurological recovery on a scale from 0 to 100% (0% no benefit to 100% major benefit). Recovery to AIS-C and D, was split into C/C+ and D/D+, which was defined by the lower and upper limit of recovery for each grade.

RESULTS

A total of 79 patients and 77 physicians participated in the survey. Each AIS grade improvement from AIS-A was considered significant benefit (all p < 0.05), ranging from 47.8% (SD 26.1) for AIS-B to 86.8% (SD 24.3) for AIS-D+. Motor level lowering was also considered significant benefit (p < 0.05), ranging from 66.1% (SD 22.3) for C6 to 81.7% (SD 26.0) for C8.

CONCLUSIONS

Meaningful recovery can be achieved without improving in AIS grade, since the recovery of functional motor levels appears to be as important as improving in AIS grade by both patients and physicians. Moreover, minor neurological improvements within AIS-C and D are also considered clinically meaningful. Future studies should incorporate more detailed neurological outcomes to prevent potential underestimation of neurological recovery by only using the AIS grade.

Traction load, tong position, and head support significantly influence cervical spine loading during traction

Some cervical dislocation injuries may be acutely treated with traction via Gardner-Wells tongs, which are attached to the skull via two pins. While a variety of techniques have been proposed and utilized in the literature and clinical practice to use the tongs, these techniques have not been methodically studied to confirm how they transmit loads to the cervical spine. The current study investigated the mechanical effect of different traction techniques in a laboratory setting. A 50th male Hybrid anthropomorphic test device was used as a human surrogate to represent an average male in height and weight was modified to represent a patient with a unilateral facet dislocation injury. Electronic sensors at the atlanto-occipital joint recorded the loading delivered to the superior cervical spine by traction loading. Combinations of the following variables were evaluated as traction loads were progressively increased to one-third of body weight: tong pin position in the skull (anterior-posterior and superior-inferior to the recommended neutral position), traction cable angle in the sagittal plane (elevated, horizontal, declined), and presence or absence of an occipital support. Analysis of the cervical axial traction loads showed that the only significant predictor of cervical tension was the magnitude of the traction load. Anterior-posterior changes in the pin positions in the skull significantly influenced the cervical flexion-extension moment and anterior-posterior (AP) shear. The data show that a combined cervical tension, flexion moment, and anterior shear force can be achieved with posteriorly biased pins and a bolster behind the head. Increasing the angle of traction cable increased the cervical flexion moment and anterior shear force. The following variables should be carefully considered when applying cervical traction since they significantly affect cervical loading: magnitude of the hanging traction load, anterior-posterior pin position, use of an occipital bolster, and traction load angle.

Immediate anterior open reduction and plate fixation in the management of lower cervical dislocation with facet interlocking

Lower cervical dislocation with facet interlocking is one of the most drastic injuries to the cervical spine. The early reduction is thought critical in preventing progressive secondary spinal cord injury. The authors report a new surgical procedure in the management of lower cervical dislocation with facet interlocking. A total of twenty-one cases received immediate single-staged anterior open reduction, realignment and plate fixation under general anesthesia. After the procedures, most cases exhibited improved neurological function. All patients showed stable fusion at 1-year follow-up. Loss of spinal alignment or kyphotic deformity was not found in any case. Hardware failure including screw loosening or penetrating was not observed. In conclusion, the immediate anterior open reduction and plate fixation is a safe and effective procedure in the management of lower cervical dislocation with facet interlocking.

Neurologic Status on Presentation as Predictive Measurement in Success of Closed Reduction in Traumatic Cervical Facet Fractures

BACKGROUND

Dislocations to cervical facets resulting from traumatic injury often lead to neurologic impairment and can be treated both surgically and in a closed manner.

OBJECTIVE

We sought to evaluate the utilization of closed reduction in the initial management of bilateral facet dislocations over the past 10 years at our institution.

METHODS

We retrospectively reviewed the charts of patients who experienced subaxial cervical facet injury within the Penn Health System between 1 June 2006 and 1 June 2016 to identify patients with bilateral jumped/perched facets. The neurologic injury was identified on the basis of the American Spinal Injury Association (ASIA) spinal cord injury score. Analysis of variance and 2-sample t-tests were used to compare continuous distributions, and chi-square tests were used to compare categorical distributions.

RESULTS

We focused our analyses on patients who presented with bilateral jumped/perched facets with (ASIA A and B) or without (ASIA C, D, E) complete voluntary motor deficit and underwent attempted closed reduction. We found that the rate of successful closed reduction was significantly higher in incomplete motor deficits (5/5, P = 0.04, chi-square test) as compared with complete motor deficits (n = 2/11).

CONCLUSION

Our results demonstrate a significant difference in the success rate of closed reduction in patients with good neurologic status on presentation (ASIA A or B), compared with those with poor neurologic status (ASIA C, D, and E). These results suggest that closed reduction should be attempted in patients with good motor examinations on presentation, whereas those with significant deficits may benefit from earlier surgical intervention.

Efficacy and complications of the use of Gardner-Wells Tongs: a systematic review

We conducted a thorough review of the literature to examine the risks and complications associated with the use of Gardner-Wells Tongs (GWT). Twenty-three articles were included in this review for final analysis. One article reported a 37.5% (6/16) incidence rate of minor complications with the usage of GWTs, which included pin loosening, asymmetrical pin positioning, and superficial infections. Various cases reported more serious yet rare complications, including perforation of the skull, brain abscesses, and neurovascular damage. Overall, the complication rate is low, and often associated with only minor and transient complications, which can be easily managed. Therefore, we conclude that GWT are safe and effective, with only rare, more serious complications reported in the literature.

Effects of Treatment of Cervical Spinal Cord Injury without Fracture and Dislocation in A Medium-to Long-Term Follow-Up Study

OBJECTIVES

The purpose of this study is to evaluate the clinical effects of cervical spinal cord injury without fracture and dislocation (CSCIWFD) treatment in a medium-to long-term follow-up study. The clinical treatment of CSCIWFD is also discussed.

METHODS

A consecutive series of 42 CSCIWFD patients with complete follow-up data were retrospectively analyzed. Among these patients, 9 received conservative treatment and 33 underwent surgical treatment from June 2009 to March 2013. Neurologic functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the Frankel grade on admission, during hospital discharge, and at final follow-up. The average follow-up time was 49.6 months (range, 36-68 months).

RESULTS

The 33 cases with surgical treatment showed significantly higher JOA scores at the final follow-up than those with conservative treatment. In addition, statistically significant differences were found in all of the follow-up visits between patients whose operations were performed within 7 days after injury and those performed after 7 days (P < 0.05). Early surgery promoted spinal cord recovery. However, JOA scores at 49.6 months postsurgery were not significantly different between patients treated via the anterior approach and those treated via the posterior approach (P > 0.05). On the basis of Frankel functional classification, differences were also significant between surgical treatment and conservative treatment at all of the follow-up visits.

CONCLUSIONS

Early surgical treatment for CSCIWFD can directly relieve spinal cord compression. The medium-to long-term follow-up revealed that surgery clearly promotes decompression.

Modified anterior-only reduction and fixation for traumatic cervical facet dislocation (AO type C injuries)

PURPOSE

Surgical reduction of uni and bi-facetal dislocations of the cervical spine (AO type C injuries) can be performed by posterior, anterior or combined approaches. Ease of access, low infection rates and less risks of neurological worsening has popularized anterior approach. However, the reduction of locked cervical facets can be intricate through anterior approach. We analyzed the safety, efficacy and outcomes at a minimum 1 year, of a novel anterior reduction technique for consecutively treated cervical facet dislocations.

MATERIALS AND METHODS

Patients with single level traumatic sub-axial cervical dislocation (n = 39) treated by this modified anterior technique were studied. The technique involved standard Smith-Robinson approach, discectomy beyond PLL, use of inter-laminar distracter to distract while Caspar pins were used as "joysticks" (either flexion-extension or lateral rotation moments are provided), to reduce the sub-luxed facets. Among 51 patients with cervical type C injury treated during the study period, 4 patients who had spontaneous reduction and 8 treated by planned global fusion were excluded.

RESULTS

39 patients of mean age 49.9 years were studied. The levels of injury included (C3-4 = 2, C4-5 = 5, C5-6 = 20, C6-7 = 12). 18 were bi-facetal and 21 were uni-facetal dislocation. One facet was fractured in 17 and both in 5 patients. 30% (n = 13) had a concomitant disc prolapse. The neurological status was as follows: 9 ASIA A, 9 ASIA C, 13 ASIA D and 8 ASIA E. All the patients were successfully reduced by this technique and fixed with anterior locking cervical locking plates. No supplemental posterior surgery was performed. 22 patients with incomplete deficit showed recovery. The mean follow-up was 14.3 months and there was no implant failure except one patient who had partial loss of the reduction.

CONCLUSION

Patients with traumatic sub-axial cervical dislocation (AO type C injuries) can be safely and effectively reduced by this technique. Other advantages include minimal blood loss, less risks of infection, shorted fusion zone, good fusion rate and neurological recovery.

Pedicolaminar Fracture-Dislocation

A 28-year-old man presented to a level 1 trauma center with significant cervical spine pain after sliding into third base during a softball game. He struck his head on the thigh of the defensive player and had immediate pain in his neck and arm. He reported no loss of consciousness, no transient tetraplegia/paraplegia, and no loss of bowel and bladder control. After initial imaging, enhanced computed tomography scans were obtained.

Anatomic Study of Anterior Transdiscal Axial Screw Fixation for Subaxial Cervical Spine Injuries

Anterior transdiscal axial screw (ATAS) fixation is an alternative or supplement to the plate and screw constructs for the upper cervical spine injury. However, no existing literatures clarified the anatomic feasibility of this technique for subaxial cervical spine. Therefore, the objective of this study was to evaluate the anatomical feasibility and to establish guidelines for the use of the ATAS fixation for the subaxial cervical spine injury.Fifty normal cervical spines had radiographs to determine the proposed screw trajectory (the screw length and insertion angle) and the interbody graft-related parameters (the disc height and depth, and the distance between anterior vertebral margin and the screw) for all levels of the subaxial cervical spine. Following screw insertion in 8 preserved human cadaver specimens, surgical simulation and dissection verified the feasibility and safety of the ATAS fixation.Radiographic measurements showed the mean axial screw length and cephalic incline angle of all levels were 41.2 mm and 25.2°, respectively. The suitable depth of the interbody graft was >11.7 mm (the distance between anterior vertebral margin and the screw), but <17.1 mm (disc depth). Except the axial screw length, increase in all the measurements was seen with level up to C5-C6 segment. Simulated procedure in the preserved specimens demonstrated that ATAS fixation could be successfully performed at C2-C3, C3-C4, C4-C5, and C5-C6 levels, but impossible at C6-C7 due to the obstacle of the sternum. All screws were placed accurately. None of the screws penetrated into the spinal canal and caused fractures determined by dissecting the specimens.The anterior transdiscal axial screw fixation, as an alternative or supplementary instrumentation for subaxial cervical spine injuries, is feasible and safe with meticulous surgical planning.

Early versus delayed decompression in acute subaxial cervical spinal cord injury: A prospective outcome study at a Level I trauma center from India

Aims:

This study was done with the aim to compare the clinical outcome and patients’ quality of life between early versus delayed surgically treated patients of acute subaxial cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute subaxial cervical spinal cord trauma is safe and is associated with improved outcome as compared to delayed surgical decompression.

Materials and Methods:

A total of 69 patients were recruited and divided into early decompression surgery Group A (operated within 48 h of trauma; n = 23) and late/delayed decompression surgery Group B (operated between 48 h and 7 days of trauma; n = 46). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion.

Results:

The early surgery group spent lesser days in the intensive care unit and hospital (Group A 28.6 vs. Group B 35 days) had lesser postoperative complications (Group A 43% vs. Group B 61%) and a reduced mortality (Group A 30% vs. Group B 45%). In Group A, 38% patients had 1 American Spinal Injury Association (ASIA) grade improvement while 31% experienced >2 ASIA grade improvement. In Group B, the neurological improvement was 27% and 32%, respectively (P = 0.7). There was a significant improvement in the postoperative quality of life scores in both groups.

Conclusion:

Early surgery in patients with acute subaxial cervical spine injury should be considered strongly in view of the lesser complications, early discharge, and reduced mortality.

Management of delayed posttraumatic cervical kyphosis

We describe three patients with misdiagnosed unstable fractures of the cervical spine, who were treated conservatively and developed kyphotic deformity, myelopathy, and radiculopathy. All three patients were then managed with closed reductions by crown halo traction, followed by instrumented fusions. Their neurologic function was regained without permanent disability in any patient. Unstable fractures of the cervical spine will progress to catastrophic neurologic injuries without surgical fixation. Posttraumatic kyphosis and the delayed reduction of partially healed fracture dislocations by preoperative traction are not well characterized in the subaxial cervical spine. The complete evaluation of any subaxial cervical spine fracture requires CT scanning to assess for bony fractures, and MRI to assess for ligamentous injury. This allows for assessment of the degree of instability and appropriate management. In patients with delayed posttraumatic cervical kyphosis, preoperative closed reduction provided adequate realignment, facilitating subsequent operative stabilization.

Surgical options in the treatment of subaxial cervical fractures: a retrospective cohort study

OBJECTIVE

To compare clinical and radiographic parameters and outcomes in patients undergoing anterior vs. posterior surgery in unstable cervical subaxial spine fractures.

METHODS

We analyzed a group of 33 patients with reducible cervical subaxial fractures. Patients underwent anterior or posterior cervical instrumentation. Inpatient and outpatient records were retrospectively reviewed, and the multiple pre-operative and post-operative clinical and radiographic factors were recorded and analyzed.

RESULTS

Posterior cervical fixation was performed in 15 patients, and anterior cervical fixation in 18 patients. Operative time, blood loss, and number of levels instrumented were all significantly less in the anterior than the posterior cervical group. There was no difference in patient age, surgical complications, follow-up ASIA score, Rand SF-36 evaluation, or cost analysis between the two groups. Mean follow-up time was 11.8±7 months. All patients achieved bony fusion and good alignment at follow-up.

CONCLUSIONS

In patients with reducible cervical subaxial dislocations, posterior cervical fixation entails a larger number of fused segments. Anterior surgery is associated with shorter operative times and less blood loss. Anterior instrumentation with interbody grafting can be the initial choice of treatment for stabilization for this subgroup of patients. Posterior surgery is indicated if radiographs after anterior instrumentation show failure.

Surgical treatment for acute spinal cord injury study pilot study #2: evaluation of protocol for decompressive surgery within 8 hours of injury

Acute spinal cord injury (SCI) is a major public health problem for which there is still only limited treatment available. The National Acute Spinal Cord Injury Study-2 (NASCIS-2) and -3 clinical trials demonstrated that the use of acute pharmacotherapy with methylprednisolone can attenuate the secondary injury cascade if administered within 8 hours of acute SCI. However, no trial has been performed to examine whether acute surgical decompressive procedures within this critical 8-hour time window can improve patients' neurological outcome. The purpose of the current prospective Surgical Treatment for Acute Spinal Cord Injury Study (STASCIS) pilot study was to determine the feasibility of obtaining a radiological diagnosis of spinal canal compromise of 25% or more and to perform spinal cord (C3-T1) decompressive procedures by 8 hours postinjury. One of the following three decompressive methods was used: 1) traction alone; 2) traction and surgery; or 3) surgery alone. Twenty-six patients from eight North American centers were entered into the study between 1996 and 1997. Significant difficulties were encountered in many centers in performing immediate magnetic resonance imaging examination in patients with acute SCI. Fewer than 10% of acute cervical SCI patients could be enrolled into this protocol mainly because the combination of the required time for rescue, resuscitation, transport, imaging study, and surgical preparation exceeded the 8-hour injury-to-decompressive surgery window. Eleven patients underwent decompressive procedures initially by being placed in traction at a mean time of 10.9 hours postinjury. Those patients not undergoing this procedure underwent decompressive surgery at a mean time of 40.1 hours. However, the surgical decompressive procedure was completed within 12 hours in seven patients. As a result of these findings, several major changes have been made to the STASCIS protocol for early decompressive therapy.

Controversies in the surgical management of spinal cord injuries

Traumatic spinal cord injury (SCI) affects over 200,000 people in the USA and is a major source of morbidity, mortality, and societal cost. Management of SCI includes several components. Acute management includes medical agents and surgical treatment that usually includes either all or a combination of reduction, decompression, and stabilization. Physical therapy and rehabilitation and late onset SCI problems also play a role. A review of the literature in regard to surgical management of SCI patients in the acute setting was undertaken. The controversy surrounding whether reduction is safe, or not, and whether prereduction magnetic resonance (MR) imaging to rule out traumatic disc herniation is essential is discussed. The controversial role of timing of surgical intervention and the choice of surgical approach in acute, incomplete, and acute traumatic SCI patients are reviewed. Surgical treatment is an essential tool in management of SCI patients and the controversy surrounding the timing of surgery remains unresolved. Presurgical reduction is considered safe and essential in the management of SCI with loss of alignment, at least as an initial step in the overall care of a SCI patient. Future prospective collection of outcome data that would suffice as evidence-based is recommended and necessary.

Magnetic resonance imaging in cervical facet dislocation: a third world perspective

Study Design

Retrospective case series.

Purpose

The objective of our study was to determine the change in management brought about by magnetic resonance imaging (MRI) of the cervical spine in alert and awake patients with facet dislocation and spinal cord injury presenting within 4 hours after injury.

Overview of Literature

Spinal cord injury is a common clinical entity. The role of MRI is well established in evaluating spinal trauma. However, the time at which MRI should be used is still controversial.

Methods

Retrospective data from 2002-2010 was evaluated. All of the alert and awake patients with spinal cord injury, based on clinical examination with facet dislocation diagnosed on lateral cervical spine X-rays, were included. A questionnaire was also conducted, the data of which consisted of demographic details including age and sex, the mechanism of injury, clinical examination, X-ray findings, MRI findings, whether or not surgery was performed and the time elapsed since injury. Data was analyzed using SPSS ver. 17.0. Continuous variables such as age were expressed in terms of mean ± standard deviation. Categorical variables such as change in management, X-ray/MRI findings and neurological motor level were assessed in terms of percentage.

Results

Fifty patients participated in our study. All these patients had spinal cord injury with defined motor levels. The mean age was 35.5 ± 8.95 years (range, 20 to 52 years). Fifty percent showed a motor level at C6 level. None of the patients required any change in management based on the MRI.

Conclusions

MRI of the spine in awake patients within 4 hours after injury does not change the management of patients. However, we can hypothesize that such patients can proceed to traction without waiting for the MRI.

Neurophysiological changes in deformity correction of adolescent idiopathic scoliosis with intraoperative skull-femoral traction

STUDY DESIGN

Retrospective review of 36 consecutive patients undergoing coronal plane deformity correction with intraoperative skull-femoral traction between 2005 and 2008 with motor evoked potential (MEP)/somatosensory evoked potential monitoring.

OBJECTIVE

To determine the prevalence and significance of neurophysiological changes with intraoperative skull-femoral traction in adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Intraoperative skeletal traction can be associated with spinal cord stretching and ischemia with resultant electrophysiological changes. The prevalence and risks of such changes and their clinical significance is unknown.

METHODS

Thirty-seven procedures involving 36 patients (27 females and 9 males) with a mean age of 14.8 (12-18) years were divided into two groups on the basis of the presence (group 1, n = 18 procedures) or absence (group 2, n = 19) of significant MEP changes with surgery. They were compared with patients undergoing correction without traction (group 3).

RESULTS

Significant differences among the groups were observed in mean preoperative Cobb angle (86° vs. 70° vs. 59°), mean intraoperative posttraction Cobb angle (50.0° vs. 34.6°), traction index (0.41 vs. 0.50), flexibility index (0.14 vs. 0.27 vs. 0.25), and presence of primary lumbar curves (0% vs. 32% vs. 14%). Initial onset of MEP amplitude loss (group 1) occurred at a mean of 94 (1-257) minutes from the onset of surgery, was bilateral in 13 procedures, and improved at a mean of 5.5 (1-29) minutes after decreasing or removing the traction. At closure, complete bilateral recovery to baseline was observed in 10 procedures, recovery to >50% baseline in five, and recovery to <50% baseline in three procedures. There were no neurologic deficits in this series.

CONCLUSION

Intraoperative traction is associated with frequent changes in MEP monitoring. The thoracic location of the major curve, increasing Cobb angle, and rigidity of major curve are significant risk factors for changes in MEP with traction. The presence of any MEP recordings irrespective of its amplitude at closure was associated with normal neurological function. Somatosensory evoked potential monitoring did not correlate with the traction induced MEP amplitude changes.

Sub-axial cervical spine injuries: Modified Stellerman's algorithm

BACKGROUND

Global fusion is recommended in sub-axial cervical spine injuries with retrolisthesis, translation rotation injuries associated with end plate or tear drop fractures. We propose a modification of Stellerman's algorithm which we have used where in patients are primarily treated via anterior decompression and fixation. Global fusion was done only in cases where post-decompression traction does not achieve reduction in cases with locked facets.

MATERIALS AND METHODS

Two hundred and thirty consecutive patients with sub-axial cervical spine injuries were studied in a prospective trial over a 7 year period. Seven cases with posterior compression alone were not subjected to our protocol. Of the other 223 cases, 191 cases who on radiological evaluation needed surgery were initially approached anteriorly. Decompression was effected through a corpectomy in 14 cases and a single or multiple level disc excisions were performed in the others. Cases with cervical listhesis (n=36) where on table reduction could not be achieved following decompression were subjected to progressive skeletal traction for 48 h. Posterior facetectomy and global fixation was done for patients in whom reduction could not be achieved despite post-decompression traction (n=11).

RESULTS

Of the 223 cases, 20 cases were managed conservatively, 12 cases expired pre-operatively, and the remaining 191 cases needed surgical intervention. Out of the 154 cases of distraction/rotation/translation injuries on table reduction could be achieved in 118 cases (76.6%). Thirty-six patients had locked facets (23 cases were bifacetal, 13 cases unifacetal) and of these 36 cases reduction could be achieved with post-anterior decompression traction in 25 patients (16.2%); however, only 11 cases (7.1%)-8 bifacetal and 3 unifacetal dislocations-needed posterior facetectomy and global fusion. One hundred and forty-three patients were followed up for a minimum period of 6 months. One hundred and twenty-six patients showed evidence of complete fusion (88.1%) while the remaining 17 (11.8) showed evidence of partial fusion. There were no signs of instability on clinical and radiological evaluation in any of the cases. Reduction of graft height was noted in 18 patients (12.5%). There were eight cases of immediate postoperative mortality and two cases of delayed mortality in our series of cases.

CONCLUSION

We feel that on table decompression and reduction followed by anterior stabilization can be used as the initial surgical approach to manage most types of cervical injuries. In rotation/translational cases where reduction cannot be achieved, monitored cervical traction on the decompressed spine can safely achieve reduction and hence avoid the need for a posterior facetectomy in a large percentage of cases.

Controversies in the treatment of cervical spine dislocations

BACKGROUND CONTEXT

Cervical spine dislocations represent an area of great controversy among spine surgeons.

PURPOSE

The purpose of this review is to present the specific areas of controversy and to provide a review of the literature.

STUDY DESIGN

A case of cervical spine dislocation is presented to illustrate the major controversies related to the treatment of cervical spine dislocations.

METHODS

A review of the literature is presented regarding the major controversial aspects of the treatment of cervical spine dislocations.

RESULTS

The major areas of controversy include the choice of imaging, closed versus open reduction and surgical approach.

CONCLUSIONS

Guidelines for the management of cervical spine dislocations are presented based on evidence-based medicine.

Anterior cervical discectomy and fusion with a locked plate and wedged graft effectively stabilizes flexion-distraction stage-3 injury in the lower cervical spine: a biomechanical study

STUDY DESIGN

An in vitro three-dimensional (3D) flexibility test of human C3-C7 cervical spine specimens.

OBJECTIVE

To test the hypothesis that anterior cervical fusion with a wedged graft and a locked plate can effectively stabilize the cervical spine after complete anterior and posterior segmental ligamentous release.

SUMMARY OF BACKGROUND DATA

Distraction-flexion Stage 3 injuries of the lower cervical spine (bilateral facet dislocations) are usually reduced under awake cranial traction. When the magnetic resonance imaging reveals a traumatic disc prolapse, anterior cervical discectomy and fusion (ACDF) is usually recommended. Most authors advise combining ACDF with posterior instrumentation to address the insufficiency of the posterior elements. However, there is clinical evidence that ACDF with a locked plate alone suffices for the treatment of these injuries, especially in young patients. Still, there are no biomechanical studies on the effect of a locked plate on the complete anterior and posterior ligamentous-deficient young cervical spine under physiologic preload.

METHODS

Eight fresh frozen human lower cervical spines (C3-C7) from young donors (age, 44.5 years; range, 21-63 years) were used. A 3D flexibility test was conducted using a moment of 0.8 Nm without preload. Flexion-extension was additionally tested using a moment of 1.5 Nm under 0 and 150 N follower preload. Spines were tested first intact, then after complete C5-C6 discectomy with posterior longitudinal ligament resection and ACDF with a wedged bone graft and a rigid locked plate, and finally after complete release of the supraspinous, interspinous, and intertransverse ligaments; the facet capsules; and ligamentum flavum. RESULTS.: When tested under 0.8 Nm moment without preload, complete posterior and anterior ligamentous release did not significantly increase the ROM of the ACDF construct in flexion-extension (P > 0.025), lateral bending (P > 0.025), and axial rotation (P > 0.025). When tested under 1.5 Nm moment with or without a compressive preload, the complete posterior and anterior ligamentous release did not significantly affect the ROM of the ACDF construct (P > 0.01). The application of preload significantly reduced the motion at the C5-C6 ACDF construct with ligamentous disruption in comparison with the motion in the absence of a preload (P < 0.01).

CONCLUSION

Anterior cervical fusion with a wedged graft and a rigid constrained (locked) plate can effectively stabilize the nonosteoporotic cervical spine after complete posterior element injury when excessive ROM is prevented (for example, by the use of postoperative external immobilization). Even when the construct is subjected to higher moments, adequate stability can be achieved when physiologic preload is present. Osteoporosis and lack of sufficient preload due to poor neuromuscular control may affect long-term screw stability, and additional external immobilization may be needed until fusion matures.

Cervical spine trauma

Cervical spine trauma is a common problem with a wide range of severity from minor ligamentous injury to frank osteo-ligamentous instability with spinal cord injury. The emergent evaluation of patients at risk relies on standardized clinical and radiographic protocols to identify injuries; elucidate associated pathology; classify injuries; and predict instability, treatment and outcomes. The unique anatomy of each region of the cervical spine demands a review of each segment individually. This article examines both upper cervical spine injuries, as well as subaxial spine trauma. The purpose of this article is to provide a review of the broad topic of cervical spine trauma with reference to the classic literature, as well as to summarize all recently available literature on each topic. IDENTIFICATION OF REFERENCES FOR INCLUSION: A Pubmed and Ovid search was performed for each topic in the review to identify recently published articles relevant to the review. In addition prior reviews and classic references were evaluated individually for inclusion of classic papers, classifications and previously unidentified references.

[Reduction of traumatic dislocations and facet fracture-dislocations in the lower cervical spine]

BACKGROUND

Traumatic facet dislocations and facet-fracture dislocations in the lower cervical spine (C2/C3 to C7/T1) are frequently associated with devastating neurological symptoms. A good outcome can only be achieved if the operator has wide and sound knowledge of reduction techniques and the best possible strategy is devised for the subsequent treatment of these severe lesions.

PATIENTS AND METHODS

Between 1973 and 1997 a total of 117 of our patients met at least one of the following inclusion criteria: unilateral locked facet dislocation (48%), bilateral locked facet dislocations (23%), unilateral "perched" facet subluxation (14%), bilateral perched facet subluxation (12%), uni- or bilateral dislocation/perched subluxation with facet fractures (3%).

RESULTS

Most of the lesions were located at the levels of C5/C6 and C6/7 (n=46 for each). Associated neurological deficits were present initially in 65% of patients: 35% had complete or incomplete spinal cord injuries (tetraplegia), 2% were paraplegic, and 28% had cervical radiculopathies.

CONCLUSIONS

Closed reduction (e.g. with the aid of a halo ring) should be carried out as soon as possible after lower cervical spine dislocation or facet-fracture dislocation, as both the success rate of reduction and the potential for recovery from neurological deficits are clearly higher when reduction is achieved within the first 4 h after the initial injury.

Physical rehabilitation as an agent for recovery after spinal cord injury

The initial level of injury and severity of volitional motor and clinically detectable sensory impairment has been considered the most reliable for predicting neurologic recovery of function after spinal cord injury (SCI). This consensus implies a limited expectation for physical rehabilitation interventions as important in the facilitation of recovery of function. The development of pharmacologic and surgical interventions has always been pursued with the intent of altering the expected trajectory of recovery after SCI, but only recently physical rehabilitation strategies have been considered to improve recovery beyond the initial prognosis. This article reviews the recent literature reporting emerging activity-based therapies that target recovery of standing and walking based on activity-dependent neuroplasticity. A classification scheme for physical rehabilitation interventions is also discussed to aid clinical decision making.

Neurological outcome following early versus delayed lower cervical spine surgery

PURPOSE

To determine whether the timing of surgery affects neurological outcome in patients with lower cervical spine trauma.

METHODS

29 patients with a fracture and 38 with a fracture-dislocation of C3 to C7 cervical vertebrae were treated operatively during the inclusive period January 1987 to December 2000. Surgery was performed as soon as the patient's medical condition allowed, within 72 hours in 31 and more than 72 hours after the injury in 36.

RESULTS

Only patients with incomplete spinal cord injury had neurological improvement after surgery. There was no statistically significant difference in final neurological outcomes in patients having early as opposed to delayed surgery.

CONCLUSION

Surgical intervention for cervical injuries is safe, as no postoperative neurological deterioration was recorded. Timing of surgery does not affect neurological outcome.

Delayed presentation of cervical ligamentous instability without radiologic evidence

STUDY DESIGN

A case of delayed presentation of unstable cervical ligamentous injury without radiologic evidence is presented.

OBJECTIVES

To report a rare case of delayed presentation of cervical ligamentous injury without radiologic evidence, and to discuss diagnosis, initial management, and techniques of operative stabilization.

SUMMARY OF BACKGROUND DATA

The literature is reviewed.

METHODS

A 48-year-old man who sustained a nondisplaced unilateral C6 pillar fracture with no radiologic evidence of ligamentous injury returned for follow-up with radicular pain and bilateral perched facets at C5-C6.

RESULTS

Closed reduction of the cervical subluxation was performed via cervical traction, and subsequent surgical stabilization was undertaken with anterior cervical discectomy and instrumented arthrodesis of C5-C6 with structural interbody autograft. The patient wore a cervical brace for 6 weeks after surgery, and progressed to a stable fusion with pain resolution and no neurologic sequelae.

CONCLUSIONS

This is a rare reported case of delayed presentation of an unstable ligamentous injury in a nondisplaced cervical pillar fracture without initial radiologic evidence of instability. If any reason to suspect ligamentous injury exists, workup with upright cervical lateral radiographs, flexion/extension radiographs, or magnetic resonance imaging should be obtained. Awake, closed reduction with cervical traction followed by surgical stabilization with an anterior discectomy and instrumented arthrodesis with structural autograft achieved stable fixation.

A pilot study of magnetic resonance imaging-guided closed reduction of cervical spine fractures

STUDY DESIGN

We report on a prospective selective case series of 17 patients with cervical fracture-dislocations treated with closed reduction under MRI guidance.

OBJECTIVE

To demonstrate the safe and effective use of in-line axial traction in the reduction of cervical fracture-dislocations using MRI guidance.

SUMMARY OF BACKGROUND DATA

Closed reduction of the cervical spine for acute fracture-dislocations has been a traditional technique used for restoring vertebral alignment and providing neural element decompression. The safety of this technique has been questioned, with concerns of disc migration and overdistraction causing neurologic worsening cited as reasons to choose operative reduction and decompression as a safer option in some circumstances.

METHODS

Seventeen patients with fracture-dislocations of the subaxial cervical spine were given a trial of traction under MRI guidance between 1999 and 2003. The incidence of posteriorly herniated disc material was noted, and the diameter of the spinal canal at the injured level was recorded before and after traction.

RESULTS

All patients tolerated traction without neurologic worsening. Pretraction disc disruption was found in 15 of 17 (88.2%) of patients, with posterior herniation in 4 of 17 (23.5\%). Traction caused a return of herniated disc material toward the disc space in all cases. Canal dimensions improved in 11 of 17 patients, with canal diameter increasing by a factor of 1.1 to 3.0, with a mean improvement of 1.73. The process of reduction was observed to be a gradual one, with progressive, significant improvement in canal dimensions occurring before anatomic realignment. As distracting force was increased, sequential MRIs showed that canal dimensions did not diminish at any time in any patient.

CONCLUSIONS

MRI monitoring in closed cervical reduction is a useful research tool for this technique. Closed reduction appears to be safe as used in this preliminary study and is effective in achieving immediate spinal cord decompression.

The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence

STUDY DESIGN

Evidence-based literature review.

OBJECTIVE

To provide updated evidence-based recommendations regarding spinal cord decompression in patients with acute spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

It is controversial whether early decompression following SCI conveys a benefit in neurologic outcome.

METHODS

MEDLINE search of experimental and clinical studies showing the effect of decompression on neurologic outcome following SCI. We focused on articles published within the last 10 years, with a particular emphasis on research conducted within the past 5 years.

RESULTS

A total of 66 articles were retrieved. Animal studies consistently show that neurologic recovery is enhanced by early decompression. There was 1 randomized controlled trial that showed no benefit to early (<72 hours) decompression. Several recent prospective series suggest that early decompression (<72 hours) can be performed safely and may improve neurologic outcomes. A recent systematic review showed that early decompression (<24 hours) resulted in statistically better outcomes compared to both delayed decompression and conservative treatment.

CONCLUSIONS

There are currently no standards regarding the role and timing of decompression in acute SCI. We recommend urgent decompression of bilateral locked facets in a patient with incomplete tetraplegia or in a patient with SCI with neurologic deterioration. Urgent decompression in acute cervical SCI remains a reasonable practice option and can be performed safely. There is emerging evidence that surgery within 24 hours may reduce length of intensive care unit stay and reduce post-injury medical complications.

Subaxial cervical spine trauma

Subaxial cervical spine injuries are common, ranging in severity from minor ligamentous strain or spinous process fracture to complete fracture-dislocation with bone and ligament failure, resulting in severe spinal cord injury. Understanding the epidemiology, anatomy, biomechanics, and classification of subaxial cervical spine injuries is important. Emergent management of such injuries is based on obtaining an accurate clinical history, careful physical examination, and organized radiographic evaluation. Attaining a unified approach to the wide spectrum of subaxial cervical injuries is difficult. In addition, controversy exists regarding the safety of closed reduction in certain injury patterns and the administration of methylprednisolone for acute spinal cord injury. Definitive management (surgical or nonsurgical) is based on the assessment of the mechanical instability of the injury, the presence or absence of neurologic impairment, and various patient factors that may influence outcome. Several complications, including the deterioration of neurologic status, may occur with either surgical or nonsurgical management, but the most frequent mistake made is missing the injury on initial evaluation.

Traumatic fracture-dislocation of C5 on C6 through a previously solid multilevel anterior cervical discectomy and fusion: a case report and review of the literature

BACKGROUND CONTEXT

Due to the underlying pathology and altered biomechanics, traumatic cervical fractures have been reported in patients with ankylosing spondylitis (AS), diffuse idiopathic skeletal hyperostosis (DISH), ossification of the posterior longitudinal ligament (OPLL), and combination of DISH and OPLL. However, incidence of a fracture-dislocation through a solid multilevel anterior cervical discectomy and fusion (ACDF) construct with no associated underlying pathology of AS, DISH, or OPLL but severe osteopenia has not, to the best knowledge of the authors, been reported in the medical literature.

PURPOSE

To report the development of an unstable cervical spine fracture that occurred through a previous multilevel anterior cervical fusion and the challenges associated with the diagnosis and surgical management of these uncommon lesions.

STUDY DESIGN/SETTING

A case report and review of the literature.

METHODS

A case report entailing the clinical history, operative management, and postoperative course of a 72-year-old male patient with no known AS, DISH, or OPLL who suffered a cervical spine fracture-dislocation, secondary to a motor vehicle accident, through a previous solid three-level ACDF that was performed 20 years earlier.

RESULTS

The patient underwent emergent reduction and realignment of the cervical fracture-dislocation, eventual posterior spinal fusion and stabilization with rigid segmental internal fixation, and application of external halo immobilization. At recent follow-up, he has radiographic evidence of fusion and maintenance of sagittal alignment without loss of reduction.

CONCLUSIONS

Multilevel cervical fusion constructs are susceptible to traumatic injuries. Many of the same challenges in the management of the previously fused ACDF patient, who sustains a fracture-dislocation, are similar to those found in the patient with mass-inflammatory conditions or metabolic disorders, such as AS, DISH, or OPLL. In many cases, this includes severe osteopenia, long unstable fusion segments, and difficulties associated with prolonged halo vest immobilization. As a result, preoperative surgical planning should take into consideration the difficulties in achieving fracture reduction, decompression, and proper stabilization.

Initial radiographic evaluation of the spine after trauma: when, what, where, and how to image the acutely traumatized spine

BACKGROUND

Radiographic evaluation of the spine after an acute traumatic event is an integral part of the initial assessment of the patient. Despite this, an imaging protocol that includes detailed recommendations of the views, modalities, and techniques of radiographic work-up is lacking in the peer-reviewed literature.

STUDY PURPOSE

The goal of the current review was to suggest a uniform protocol for initial imaging in the traumatized patient and provide a rationale and guidelines to assist in deciding which studies are indicated and at what time they are best obtained.

METHODS

The authors' reviewed the available modern, published, English literature, including both peer-reviewed articles and commonly used textbooks, for recommendations concerning which imaging studies are most effective and cost-efficient in detecting spinal injuries in the acute trauma setting. A list of radiologic studies was compiled. A panel of spine surgeon members of the Spine Trauma Study Group, all of whom were highly experienced in trauma management, evaluated the utility and necessity of these imaging studies.

CONCLUSIONS

Surgeons agreed that the mainstay of initial radiographic evaluation of the spine after acute trauma remains plain radiographs. CT scanning remains the best mode of delineating the bony details of a spinal injury and should be used to characterize all bony injuries identified on plain radiographs. As CT technology continues to improve, it is likely to play an even greater role as an initial screening tool. The role for MRI continues to expand, particularly in detecting the soft tissue components of injuries.

Acute quadriplegia following closed traction reduction of a cervical facet dislocation in the setting of ossification of the posterior longitudinal ligament: case report

STUDY DESIGN

A case report of acute quadriplegia resulting from closed traction reduction of traumatic bilateral cervical facet dislocation in a 54-year-old male with concomitant ossification of the posterior longitudinal ligament (OPLL).

OBJECTIVES

To report an unusual presentation of a spinal cord injury, examine the approach to reversal of the injury, and review the treatment and management controversies of acute cervical facet dislocations in specific patient subgroups.

SUMMARY OF BACKGROUND DATA

The treatment of acute cervical facet dislocations is an area of ongoing controversy, especially regarding the question of the necessity of advanced imaging studies before closed traction reduction of the dislocated cervical spine. The safety of an immediate closed, traction reduction of the cervical spine in awake, alert, cooperative, and appropriately select patients has been reported in several studies. To date, there have been no permanent neurologic deficits resulting from awake, closed reduction reported in the literature. A case of temporary, acute quadriplegia with complete neurologic recovery following successful closed traction reduction of a bilateral cervical facet dislocation in the setting of OPLL is presented.

METHODS

The clinical neurologic examination, radiographic, and advanced imaging studies before and after closed, traction reduction of a cervical facet dislocation are evaluated and discussed. A review of the literature regarding the treatment of acute cervical facet dislocations is presented.

RESULTS

Radiographs showed approximately 50% subluxation of the fifth on the sixth cervical vertebrae, along with computerized tomography revealing extensive discontinuous OPLL. The cervical facet dislocation was successfully reduced with an awake, closed traction reduction, before magnetic resonance imaging (MRI) evaluation. The patient subsequently had acute quadriplegia develop, with the ensuing MRI study illustrating severe spinal stenosis at the C5, C6 level as a result of OPLL or a large extruded disc herniation. Following an immediate anterior decompression and a posterior stabilization procedure, the patient regained full motor and sensory function.

CONCLUSIONS

This case report highlights the advantages and shows some safety concerns regarding immediate, closed traction reduction of cervical facet dislocation with real-time neural monitoring in an awake, alert, oriented, and appropriately select patient before MRI studies in the setting of preexisting central stenosis from OPLL.

The role and timing of early decompression for cervical spinal cord injury: update with a review of recent clinical evidence

It remains controversial whether early decompression following spinal cord injury conveys a benefit in neurological outcome. The goal of this paper is to provide evidence-based recommendations regarding spinal cord decompression in patients with acute spinal cord injury. We performed a Medline search of experimental and clinical studies reporting on the effect of decompression on neurological outcome following spinal cord injury. Animal studies consistently show that neurological recovery is enhanced by early decompression. One randomized controlled trial showed no benefit to early (<72 h) decompression, however, several recent prospective series suggest that early decompression (<12 h) can be performed safely and may improve neurological outcomes. A recent meta-analysis showed that early decompression (<24 h) resulted in statistically better outcomes compared to both delayed decompression and conservative management. Currently, there are no standards regarding the role and timing of decompression in acute spinal cord injury. We recommend urgent decompression of bilateral locked facets in patients with incomplete tetraplegia or in patients with spinal cord injury experiencing neurological deterioration. Urgent decompression in acute cervical spinal cord injury remains a reasonable practice option and can be performed safely.

Unilateral cervical facet dislocation: biomechanics of fixation

STUDY DESIGN

Unilateral facet dislocation was created in human cadaveric cervical spines. Specimens were sequentially instrumented with posterior or anterior screws and plates, and studied biomechanically.

OBJECTIVE

To determine the biomechanical differences between anterior and posterior fixation for stabilization of a reduced unilateral cervical facet dislocation.

SUMMARY OF BACKGROUND DATA

Although previous studies have compared anterior to posterior instrumentation, no data exist on the biomechanics of either type of stabilization after this particular injury.

METHODS

In 6 human cadaveric cervical spine segments, a reproducible unilateral facet dislocation was created and then unlocked (reduced). Nondestructive torques were applied to specimens that were intact, injured-reduced, fixated using posterior nonlocking lateral mass plates, and fixated using a bone graft plus an anterior nonlocking plate. Flexion, extension, lateral bending, and axial rotation were measured stereophotogrammetrically.

RESULTS

Lateral mass plating was more effective than anterior plating in limiting motion after reduction of a unilateral facet dislocation. Averaged, over all loading directions, lateral mass plates reduced the range of motion to 17% of normal; anterior plates reduced range of motion to 89% of normal. In all loading directions, lateral mass plates performed significantly better than anterior plates (P < 0.05, paired Student t-tests).

CONCLUSIONS

Anterior and posterior plating effectively stabilized a reduced unilateral facet dislocation. Lateral mass fixation provided better immobilization than anterior graft and plate.