Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

Predictors of early mortality following surgical or nonsurgical treatment of subaxial cervical spine fractures: a retrospective nationwide registry study

BACKGROUND

Traumatic subaxial cervical spine fractures are a significant public health concern due to their association with spinal cord injuries (SCI). Despite being mostly caused by low-energy trauma, these fractures significantly contribute to morbidity and mortality. Currently, research regarding early mortality based on the choice of treatment following these fractures is limited. Identifying predictors of early mortality may aid in postoperative patient monitoring and improve outcomes.

PURPOSE

This study aimed to identify predictors of 30-days, 90-days, and 1-year mortality in adults treated for subaxial fractures.

STUDY DESIGN

A retrospective review of the nationwide Swedish Fracture Register (SFR).

PATIENT SAMPLE

All adult patients in the SFR who underwent treatment for a subaxial cervical fracture (n = 1,963).

OUTCOME MEASURES

Analyzed variables included age, sex, injury mechanism, neurological function, fracture characteristics, and treatment type. The primary endpoints were 30-days, 90-days, and 1-year mortality.

METHODS

About 1,963 patients in the SFR, treated for subaxial cervical fractures between 2013 and 2021, were analyzed. Surgical procedures included anterior, posterior, or anteroposterior approaches. Nonsurgical treatment included collar treatment or medical examinations without intervention. Stepwise regression and Cox regression analysis were used to determine predictors. Model performance was tested using the area under the receiver operating characteristic curve (AUC).

RESULTS

620 patients underwent surgery and 1,343 received nonsurgical treatment. Surgical cases had primarily translation fractures, with 323 (52%) displaying no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 22/620 (3.5%), 35/620 (5.6%), and 53/620 (8.5%), respectively. Age and SCI were predictors of mortality. Nonsurgically treated patients mostly had compression fracture, with 1,214 (90%) experiencing no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 41/1,343 (3.1%), 71/1,343 (5.3%), and 118/1,343 (8.7%). Age, male sex, SCI and fractures occurring at the C3 or C6 levels were predictors of mortality. An intact neurological function was a positive predictor of survival among nonsurgically treated patients (AUC >0.78).

CONCLUSIONS

Age and SCI emerged as significant predictors of early mortality in both surgically and nonsurgically treated patients. An intact neurological function served as a protective factor against early mortality in nonsurgically treated patients. Fractures at C3 or C6 vertebrae may impact mortality.

Predictors of failure after primary anterior cervical discectomy and fusion for subaxial traumatic spine injuries

INTRODUCTION

Traumatic subaxial fractures account for more than half of all cervical spine injuries. The optimal surgical approach is a matter of debate and may include anterior, posterior or a combined anteroposterior (360º) approach. Analyzing a cohort of patients initially treated with anterior cervical discectomy and fusion (ACDF) for traumatic subaxial injuries, the study aimed to identify predictors for treatment failure and the subsequent need for supplementary posterior fusion (PF).

METHODS

A retrospective, single center, consecutive cohort study of all adult patients undergoing primary ACDF for traumatic subaxial cervical spine fractures between 2006 and 2018 was undertaken and 341 patients were included. Baseline clinical and radiological data for all included patients were analyzed and 11 cases of supplementary posterior fixation were identified.

RESULTS

Patients were operated at a median of 2.0 days from the trauma, undergoing 1-level (78%), 2-levels (16%) and ≥ 3-levels (6.2%) ACDF. A delayed supplementary PF was performed in 11 cases, due to ACDF failure. On univariable regression analysis, older age (p = 0.017), shorter stature (p = 0.031), posterior longitudinal ligament (PLL) injury (p = 0.004), injury to ligamentum flavum (p = 0.005), bilateral facet joint dislocation (p < 0.001) and traumatic cervical spondylolisthesis (p = 0.003) predicted ACDF failure. On the multivariable regression model, older age (p = 0.015), PLL injury (p = 0.048), and bilateral facet joint dislocation (p = 0.010) remained as independent predictors of ACDF failure.

CONCLUSIONS

ACDF is safe and effective for the treatment of subaxial cervical spine fractures. High age, bilateral facet joint dislocation and traumatic PLL disruption are independent predictors of failure. We suggest increased vigilance regarding these cases.

Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors

PURPOSE

To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors.

METHODS

Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant.

RESULTS

Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions.

CONCLUSION

sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.

Outcome and complications of operatively treated subaxial cervical spine injuries: A population-based retrospective cohort study

Objective

The aim was to study the outcome and complications of operative treatment for subaxial cervical spine injuries with respect to injury morphology and surgical strategy.

Methods

A population-based cohort of 271 consecutive patients treated at Kuopio University Hospital from 2003 to 2018 was retrospectively reviewed.

Results

The mean age was 52.4 (range 12-90) years and 78.6% were male. The AOSpine morphological classification was C in 56.5%, B in 24.7% and A in 17.0% of cases. The surgical approach was anterior in 70.8%, posterior in 20.3% and combined in 8.9% of patients. Fixation alignment was maintained in 96.9% of patients. Instrumentation failures were observed only in patients operated anteriorly but no statistical difference was found between the surgical approaches. The American Spinal Injury Association Impairment Scale (AIS) grade improved in 22.1% of patients. Patients with preoperative AIS grade C had significant potential for neurological improvement (OR 10.44; 95% CI 1.77-61.56; p = 0.010). Postoperative, mostly mild, complications manifested in 22.5% of patients. The posterior approach was associated with fewer postoperative complications (OR 0.18; 95% CI 0.06-0.51; p = 0.001). Preoperative AIS grade A was a significant predisposing factor for complications (OR = 4.90; 95% CI = 1.49-16.10; p = 0.009). The perioperative (90-day) mortality rate was 3.3%. The mean follow-up period was 64.7 ± 25.9 (radiological)/136.7 ± 174.8 (clinical) days.

Conclusions

Operative treatment is safe and effective but the surgical approach should be patient- and injury-specific. The prognosis for neurological recovery from spinal cord injury is superior in patients with partially preserved motor function.

Secondary Dislocations in Type B and C Injuries of the Subaxial Cervical Spine: Risk Factors and Treatment

INTRODUCTION

This study analyzed the incidence of secondary dislocations (sDLs) after surgical stabilization of AO Spine type B and C injuries of the subaxial cervical spine (sCS).

MATERIALS AND METHODS

Patients treated for injuries of the sCS from 2010 to 2020 were retrospectively analyzed for the incidence of sDL within 60 days after first surgery. A univariate analysis of variables potentially influencing the risk of sDL was performed. Patients with solitary anterior stabilization underwent subgroup analysis. The treatment of sDLs was described.

RESULTS

A total of 275 patients were included. sDLs occurred in 4.0% of patients (n = 11) in the total sample, most frequently after solitary anterior stabilization with 8.0% (n = 10, p = 0.010). Only one sDL occurred after combined stabilization and no sDLs after posterior stabilization. In the total sample and the anterior subgroup, variables significantly associated with sDL were older age (p = 0.001) and concomitant unstable facet joint injury (p = 0.020). No neurological deterioration occurred due to sDL and most patients were treated with added posterior stabilization. sDL is frequent after solitary anterior stabilization and rare after posterior or combined stabilization.

DISCUSSION

Patients of higher age and with unstable facet joint injuries should be followed up diligently to detect sDLs in time. Neurological deterioration does not regularly occur due to sDL, and most patients can be treated with added posterior stabilization.

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.

Clinical and radiological outcomes of one-level cervical corpectomy with an expandable cage for three-column uncomplicated subaxial type «B» injures: a multicenter retrospective study

PURPOSE

To evaluate the clinical and radiological results of the operative management of three-column uncomplicated type «B» subaxial injures treated with a one-level cervical corpectomy with an expandable cage.

METHODS

This study included 72 patients with a three-column uncomplicated type «B» subaxial injures who met the inclusion criteria, underwent a one-level cervical corpectomy with an expandable cage at one of three neurosurgical departments between 2005 and 2020, and were followed up for clinical and radiological outcomes at a minimum 3-yr follow-up.

RESULTS

There was a decrease in the VAS pain score from an average of 80 mm to 7 mm (p = 0.03); a decrease in the average NDI score from 62 to 14% (p = 0.01); excellent and good outcomes according to Macnab's scale were 93% (n = 67/72). There was an average change in the cervical lordosis (Cobb method) from -9.10 to -15.40 (p = 0.007), without significant loss of lordosis (p = 0.27). There was no significant degeneration of the adjacent levels by 3 years post-op. The fusion rate, using the Cervical Spine Research Society criteria, was poor: it was 62.5% (n = 45/72), and using the CT criteria, it was 65.3% (n = 47/72). 15.4% patients (n = 11/72) suffered complications. Statistical difference between the fusion and pseudoarthrosis (according to X-ray criteria) subgroups showed that there were no statistically significant differences in the smoking status, diabetes, chronic steroid use, cervical injury level, subtypes of AO type B subaxial injuries and types of expandable cage systems.

CONCLUSIONS

One-level cervical corpectomy with an expandable cage, despite a poor fusion rate, can be considered a feasible and relatively safe method for treating three-column uncomplicated subaxial type «B» injures, with the benefit of immediate stability, anatomical reduction, and direct decompression of the spinal cord. While no one in our series had any catastrophic complications, we did note a high complication rate.

Anterior cervical discectomy and fusion with plate versus posterior screw fixation after traumatic subaxial fractures in octogenarians: complications and outcomes with a 2-year follow-up

INTRODUCTION

Surgical intervention for management of spinal instability after traumatic subaxial fractures in octogenarians requires a clear consensus on optimal treatments. This study aimed to provide a guide for more efficient management through comparison and assessment of clinical outcomes and complications of anterior cervical discectomy and fusion with plate (pACDF) and posterior decompression fusion (PDF) instrumentation alone in patients aged 80 years.

METHODS

A single institution retrospective review of electronic medical records was undertaken between September 2005 and December 2021. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Logistic regression was used to identify potential risk factors for ACDF complications.

RESULTS

The rate of comorbidities were similarly high between the pACDF (n=13) and PDF (n=15) groups (pACDF: 8.7 ± 2.4 points vs. 8.5 ± 2.3 points; p=0.555). Patients in the PDF group had significantly longer surgical duration (235 ± 58.4 min vs. 182.5 ± 32.1 min; p<0.001) and significantly higher volumes of intraoperative blood loss (661.5 ± 100.1 mL vs. 487.5 ± 92.1 mL; p<0.001). The in-hospital mortality was 7.7% for the pACDF group and 6.7% for the PDF group. On day 90, the mortality rate increased in both groups from baseline (pACDF: 15.4% vs. PDF: 13.3; p>0.05). Motor scores (MS) improved significantly after surgery in both groups (pACDF: preOP MS: 75.3 ± 11.1 vs. postOP MS: 82.4 ± 10.1; p<0.05; PDF: preOP MS: 80.7 ± 16.7 vs. postOP MS: 89.5 ± 12.1; p<0.05). Statistically significant predictors for postoperative complications included longer operative times (odds ratio 1.2, 95% confidence interval 1.1-2.1; p=0.005) and larger volume of blood loss (odds ratio 1.5, 95% confidence interval 1.2-2.2; p=0.003).

CONCLUSIONS

Both pACDF and PDF can be considered safe treatment strategies for octogenarians with a poor baseline profile and subaxial fractures as they lead to patients substantial neurological improvements, and they are accompanied with low morbidity and mortality rates. Operation duration and intraoperative blood loss should be minimized to increase the degree of neurological recovery in octogenarian patients.

CT Scan in Subaxial Cervical Facet Injury: Is It Enough for Decision-Making?

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

Assessment of subaxial cervical facet injuries using the AO Spine Subaxial Cervical Spine Injury Classification System is based on CT scan findings. However, additional radiological evaluations are not directly considered. The aim of this study is to determine situations in which spine surgeons request additional radiological exams after a facet fracture.

METHODS

A survey was sent to AO Spine members from Latin America. The evaluation considered demographic variables, routine use of the Classification, as well as the timepoint at which surgeons requested a cervical MRI, a vascular study, and/ or dynamic radiographs before treatment of facet fractures.

RESULTS

There was 229 participants, mean age 42.9 ± 10.2 years; 93.4% were men. Orthopedic surgeons 57.6% with 10.7 ± 8.7 years of experience in spine surgery. A total of 86% used the Classification in daily practice. An additional study (MRI/vascular study/and dynamic radiographs) was requested in 53.3%/9.6%/43.7% in F1 facet injuries; 76.0%/20.1%/50.2% in F2; 89.1%/65.1%/28.4% in F3; and 94.8%/66.4%/16.6% in F4. An additional study was frequently required: F1 72.5%, F2 86.9%, F3 94.7%, and F4 96.1%.

CONCLUSIONS

Spine surgeons generally requested additional radiological evaluations in facet injuries, and MRI was the most common. Dynamic radiographs had a higher prevalence for F1/F2 fractures; vascular studies were more common for F3/F4 especially among surgeons with fewer years of experience. Private hospitals had a lower spine trauma cases/year and requested more MRI and more dynamic radiographs in F1/F2. Neurosurgeons had more vascular studies and dynamic radiographs than orthopedic surgeons in all facet fractures.

Unilateral Cervical Facet Fractures: Relevance of Acute Disc Injury in Conservative Treatment Failure

STUDY DESIGN

Case-control study.

PURPOSE

Analyze association between imaging factors related to the failure of conservative treatment in isolated subaxial cervical facet fractures.

OVERVIEW OF LITERATURE

Facet fracture (F1, F2, and F3 AOSpine) may be stable or unstable depending on clinical and imaging variables, which are not well established. As a result, differences in fracture management lead to differences in surgical or conservative indications, and there is no evidence to predict conservative treatment failure.

METHODS

Patients were categorized into two groups: six patients (16.2%) with conservative treatment failure (defined as the appearance of neurological symptoms, listhesis >3.5 mm, kyphotic deformation >11°, and/or non-union), and 31 patients (83.7%) with successful conservative management (defined as complete consolidation confirmed by computed tomography [CT] at the 6-month followup). All participants were fitted with rigid collars of the Miami type, and standardized follow-up was performed until consolidation or failure. CT and magnetic resonance imaging (MRI) was used to examine imaging characteristics. Sagittal balance parameters were assessed using CT, and signs of acute disc injury, prevertebral edema, facet synovitis, and interspinous hyperintense signal were assessed using MRI.

RESULTS

Thirty-seven patients were diagnosed with unilateral cervical facet fractures between 2009 and 2020. In this sample, acute disc injury had a significative association to failure of conservative treatment in F2 and F3 AOSpine facet fractures, 100% of the failure group presented with traumatic disc injury compared to 9.7% of the successful group, for the other variables: prevertebral edema, 83.7% vs. 41.9%; facet synovitis, 100% vs. 77.4%; and interspinous hyperintensity, 71.4% vs. 38.7%, respectively. With conservative management, all F1 fractures healed successfully. Conservative treatment failed in 20% of F2 fractures and 50% of F3 fractures, respectively. In terms of cervical sagittal balance parameters, there were no significant differences between groups.

CONCLUSIONS

Conservative management was successful in all F1 fractures. In F2 and F3 types, there was a significant association between acute disc injury and conservative treatment failure.

Secondary damage management of acute traumatic spinal cord injury in low and middle-income countries: A survey on a global scale (Part III)

•In LMICs, several factor may affect the applicability of guidelines for secondary damage control of spinal cord injury.•In LMICs, the use of steroids for spinal cord injury is heterogeneous and admissions to an intensive care units are limited.•The delays for surgical decompression of spinal cord injury can be significan and vary across income and geographic region.•Transfer times seem to be the most common reason for surgical delay in all income and geographic regions.•Costs for surgery for spinal trauma may be a significant barrier to guideline adherence, especially in low-resource settings.

The Subaxial Cervical AO Spine Injury Score

STUDY DESIGN

Global cross-sectional survey.

OBJECTIVE

To develop an injury score for the AO Spine Subaxial Cervical Spine Injury Classification System.

METHODS

Respondents numerically graded each variable within the classification system for severity. Based on the results, and with input from the AO Spine Trauma Knowledge Forum, the Subaxial Cervical AO Spine Injury Score was developed.

RESULTS

An A0 injury was assigned an injury score of 0, A1 a score of 1, and A2 a score of 2. Given the significant increase in severity, A3 was given a score of 4. Based on equal severity assessment, A4 and B1 were both assigned a score of 5. B2 and B3 injuries were assigned a score of 6. Unstable C-type injuries were given a score of 7. Stable F1 injuries were assigned a score of 2, with a 2-point increase for F2 injuries. Likewise, F3 injuries received a score of 5, whereas more unstable F4 injuries a score of 7. Neurologic status severity rating scores increased stepwise, with scores of 0 for N0, 1 for N1, and 2 for N2. Consistent with the Thoracolumbar AO Spine Injury Score, N3 (incomplete) and N4 (complete) injuries were given a score of 4. Finally, case-specific modifiers M1 (PLC injury) received a score of 1, while M2 (critical disc herniation) and M3 (spine stiffening disease) received a score of 4.

CONCLUSIONS

The Subaxial Cervical AO Spine Injury Score is an easy-to-use metric that can help develop a surgical algorithm to supplement the AO Spine Subaxial Cervical Spine Injury Classification System.

Impact of 2 different posterior screw fixation techniques on primary stability in a cervical translational injury model: A biomechanical evaluation

BACKGROUND

In case of injuries to the subaxial cervical spine, especially in osteoporotic bone, the question of the most stable operative technique arises. There are several techniques of screw fixation available regarding dorsal stabilization. This study investigates 2 techniques (lateral mass screws (LMS) vs cervical pedicle screws (CPS)) in the subaxial cervical spine regarding primary stability in a biomechanical testing using a translational injury model.

METHODS

A total of 10 human formalin fixed and 10 human fresh-frozen specimens (C 4 - T 1) were investigated. Specimens were randomized in 2 groups. Fracture generation of a luxation injury between C 5 and C 6 was created by a transection of all ligamentous structures as well as the intervertebral disc and a resection of the facet joints.Dorsal stabilization of C 4/C 5 to C 6/C 7 was performed in group A by lateral mass screws, in group B by pedicle screws. In the biomechanical testing, the specimens were loaded at 2 N/s in translation direction until implant failure.

RESULTS

Formalin fixed specimen: Mean load failure was 513.8 (±86.74) Newton (N) for group A (LMS) and 570.4 (±156.5) N for group B (CPS). There was no significant difference (P = .6905).Fresh frozen specimen: Mean load failure was 402.3 (±96.4) N for group A (LMS) and 500.7 (±190.3) N for group B (CPS). There was no significant difference (P = .4206).

CONCLUSION

In our loading model respecting the translational injury pattern and a flexion movement we could not verify statistically significant differences between lateral mass screws and cervical pedicle screws. Mean loading failure was slightly higher in the CPS group though.

Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System

OBJECTIVE

Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty.

METHODS

A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants' management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine.

RESULTS

In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001).

CONCLUSIONS

The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.

Subaxial spine trauma: radiological approach and practical implications

The cervical spine is part of the axial skeleton and is responsible for protecting vital structures, such as the spinal cord and the vertebral arteries and veins. Traumatic injury to the cervical spine occurs in approximately 3% of blunt trauma injuries, and approximately 80% are below the level of C2. The AO Spine society divides the spine into four segments: the upper cervical spine (C0-C2), subaxial spine (C3-C7), thoracolumbar spine, and sacral spine. Various classifications have been proposed for the subaxial segment since that of Allen and Ferguson in 1982; however, none is universally accepted, and treatment remains controversial. The complex anatomy and biomechanics of the subaxial spine and the lack of a widely accepted classification system make these injuries difficult to evaluate on imaging. The Subaxial Injury Classification System (SLIC) uses fracture morphology, the integrity of discoligamentous complex, and neurological status to score the patient and determine between operative and non-operative management; however, other factors may influence management, such as time for immobilisation, osteoporosis, surgeon's experience, and hospital circumstances. SLIC classifies fracture morphology in a crescent order of severity based on Allen and Ferguson's classification. Compression fractures are the simpler ones, while both distraction injuries and translation/rotation are severe injuries, which are always associated with some degree of discoligamentous complex (DLC) injury. This article will review the indications for imaging, the basis of the SLIC classification, the different types of fracture morphology, evaluation of the DLC, and other features important in decision making in subaxial spine trauma.

Cervical spine injury after virtual reality gaming: a case report

Background

We report a patient who fractured the seventh cervical vertebra while playing a virtual reality (VR) game, without any other trauma.

This case report aims to describe the spinal trauma incurred during the use of a VR headset in a video game.

Case presentation

The Caucasian patient presented with pain and swelling in the lower cervical spine at our clinic after playing a video game involving a combination of shoulder, arm and head movements while wearing a VR headset. Preexisting comorbidities were not present in the 31-year-old male. No history of regular medication use or drug abuse was recorded. After performing a clinical examination and radiological diagnostics, we found a dislocated traumatic fracture of the spinous process of the seventh cervical vertebra. After a soft tissue defect was excluded through magnetic resonance imaging (MRI) diagnostics, a conservative therapy regimen with pain therapy and immobilization was started.

After hospitalization, outpatient controls were conducted at 4, 6 and 12 weeks. At 6 weeks after hospitalization, the patient had recovered from the injury without complications.

Conclusions

Rapid movements during VR gaming can lead to injuries of the cervical spine. In addition to rapid movements, the additional weight of the VR headset as well as the decoupling of audiovisual stimuli from the perceived proprioceptive information should be considered. Determining whether this is an isolated incident induced by unknown preexisting factors or whether the trauma mechanism alone can lead to severe spinal trauma needs to be studied further with additional cases.

Accuracy and reliability of the AO Spine subaxial cervical spine classification system grading subaxial cervical facet injury morphology

PURPOSE

A classification system was recently developed by the international association AO Spine for assessing subaxial cervical spine fractures. Significant variability exists between users of the facet component, which consists of four morphological types (F1-F4). The primary aims of this study were to assess the diagnostic accuracy and reliability of this new system's facet injury morphological classifications.

METHODS

A survey consisting of 16 computed tomography (CT) scans of patients with cervical facet fractures was distributed to spine surgeon members of AO Spine Latin America. To provide a gold standard diagnosis for comparison, all 16 injuries had been classified previously by six co-authors and only were included after total consensus was achieved. Demographic and surgical practice characteristics of all respondents were analyzed, and diagnostic accuracy calculated. Inter- and intra-observer agreement rates were calculated across two survey rounds, conducted one month apart.

RESULTS

A total of 135 surgeons completed both surveys, among whom the mean age was 41.6 years (range 26-71), 130 (96.3%) were men, and 83 (61.5%) were orthopedic surgeons. The mean time in practice as a spine surgeon was 9.7 years (1-30). The overall diagnostic accuracy of all responses was 65.4%. Inter-observer and intra-observer agreement rates for F1/F2/F3/F4 were 55.4%/47.6%/64.0%/94.7% and 60.0%/49.1%/58.0%/93.0%, respectively.

CONCLUSION

This study evaluates the AO Spine Classification System specifically for facet injuries involving the subaxial cervical spine in a large sample of spine surgeons. There was significant variability in diagnostic accuracy for F1 through F3-type fractures, whereas almost universal agreement was achieved for F4-type injuries.

Does Dynamic Anterior Plate Fixation Provide Adequate Stability for Traumatic Subaxial Cervical Spine Fractures at Mid-Term Follow-Up?

Background: It remains questionable if the treatment of cervical fractures with dynamic plates in trauma surgery provides adequate stability for unstable fractures with disco-ligamentous injuries. The primary goal of this study was to assess the radiological and mid-term patient-reported outcome of traumatic subaxial cervical fractures treated with different plate systems. Patients and Methods: Patients, treated with anterior cervical discectomy and fusion (ACDF) between 2001 and 2015, using either a dynamic plate (DP: Mambo™, Ulrich, Germany) or a rigid locking plate (RP: CSLP™, Depuy Synthes, USA), were identified. For radiological evaluation, the sagittal alignment, the sagittal anterior translation and the bony consolidation were evaluated. After at least two years, the patient-reported outcome measures (PROM) were evaluated using the German Short-Form 36 (SF-36), Neck Disability Index (NDI) and the EuroQol in 5 Dimensions (EQ-5D) scores. Results: 33 patients met the inclusion criteria (DP: 13; RP:20). Twenty-six patients suffered from AO Type B or C fractures. Both the sagittal alignment and the sagittal translation could be sufficiently improved in both groups (p ≥ 0.05). No significant loss of reduction could be observed at the follow-up in both groups (p ≥ 0.05). Bony consolidation could be observed in 30 patients (DP: 12/13 (92%); RP: 18/20 (90%); (p ≥ 0.05)). In 20 patients, PROMs could be evaluated (follow-up: 71.2 ± 25.5 months). The whole cohort showed satisfactory PROM results (EQ-5D: 72.0 ± 4.9; SF-36 PCS: 41.9 ± 16.2, MCS: 45.4 ± 14.9; NDI: 11.0 ± 9.1). without significant differences between the DP and RP group (p ≥ 0.05) Conclusion: The dynamic plate concept provides enough stability without a difference in fusion rates in comparison to rigid locking plates in a population that mostly suffered fragile fractures.

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.

[Guideline-conform diagnostics for injuries of the subaxial cervical spine]

Injuries to the subaxial cervical spine are increasing and have a high risk for neurological injury in comparison to the thoracic and lumbar spine. The current treatment recommendations according to the recommendations of the section spine of the German Society for Orthopaedics and Trauma (DGOU) and the S1 guidelines of the German Society for Trauma Surgery are summarized in this article. High-energy as well as low-energy trauma can cause a significant injury to the cervical spine. If there is a suspicion of a cervical spine injury, a tomographic imaging modality (CT/MRI) is the procedure of choice. Injuries should be classified according to the AOSpine classification for subaxial injuries. Based on this classification, a decision on a conservative or operative treatment regimen as well as individual details of the treatment can be made.

Cervical spine clearance after blunt trauma: current state of the art

No definite consensus exists for the clearance of the cervical spine (C-spine) after blunt trauma, despite many validated algorithms, recommendations and guidelines. We intend to answer the most relevant questions with which physicians are confronted when clearing C-spines after blunt trauma in emergency departments (EDs). To exclude significant C-spine injuries we designed an algorithm to be compatible with clinical practice, to simplify patient management and avoid unrewarding evaluation.

We conducted an exploratory PubMed search including articles published from January 2000 to October 2018. Keywords used were “cervical spine”, “injury”, “clearance”, “Canadian C-spine Rule”, “CCR” and “national emergency x-radiography utilization study”. Clinical and experimental studies were included in a detailed review.

We based our literature review on 33 articles. While answering fundamental triage questions from daily clinical practice, the current literature is discussed in detail. We designed an algorithm for the C-spine clearance suitable for any trauma centre with a high-quality multiplanar reconstruction computerized tomography (CT) scan continuously available.

The high sensitivity of the Canadian C-spine Rule (CCR) prevents missing C-spine injuries while limiting the amount of unnecessary radiologic examinations. Plain radiographs were fully abandoned for C-spine clearance. A negative CT scan is sufficient to clear the majority of C-spine injuries and allows for collar removal. In case of motor symptoms or radio-clinical discrepancy, the advice of a specialized spine surgeon must be requested. Magnetic resonance imaging must not be routinely used. Neck pain despite negative imaging is not a reason to delay removal of stiff cervical collars.

Cite this article: EFORT Open Rev 2020;5:253-259. DOI: 10.1302/2058-5241.5.190047

Transpedicular lag screw placement in traumatic cervical spondylolisthesis: Case report and systematic review of the literature

Traumatic spondylolisthesis of C2-C3 is an unstable fracture. Posterior fixation techniques can be employed with intraoperative navigation, however this tool is not available to all spine surgeons. Furthermore, the evidence for posterior surgical stabilization of C2, while adhering to motion preservation principles is currently unknown. The authors describe a patient who had fractures of the pedicle and vertebral body of C2 and C3, which was successfully stabilized with freehand placement of C2 pedicle lag screws and subsequent C2-C5 fixation. Subsequently, a systematic review was performed to evaluate studies that utilized C2 lag screw placement in patients with traumatic spondylolisthesis of the axis (TSA). Eight retrospective case series were identified (N = 63 patients). Five studies evaluated an open posterior cervical approach and 3 investigated a percutaneous approach. Follow-up time ranged from 2 to 48 months and fusion was successful in most cases. No intra-operative complications were reported. On final follow-up, 2 patients had unintentional C2-C3 fusion, and 3 had C2-C3 instability. Three minor complications (urinary tract infection, surgical site hematoma, respiratory infection) were also reported, that resolved with medical management. Freehand placement of C2 pedicle lag screws may be a viable option in select cases. While posterior C2 lag-screw fixation demonstrated successful fusion in most patients with TSA, the supporting evidence is limited to level IV studies.

Retropharyngeal Granulation: Delayed Complication of Anterior Cervical Diskectomy and Fusion in C2-3

BACKGROUND

A 26-year-old man presented with acute quadriparesis owing to a traffic accident. A computed tomography scan revealed a hangman fracture and locking of the left facet joint at C2-3. Magnetic resonance imaging showed a high signal change of the spinal cord on T2-weighted image and hemorrhage in the C2-3 level.

CASE DESCRIPTION

An emergency closed reduction after anterior cervical diskectomy and fusion were performed for spinal stability and decompression of the dural sac. Five months postoperatively, C1-2-3 posterior wiring using an iliac bone graft with the Brook method was performed due to nonunion of C2-3. After using the posterior cervical approach, the patient began complaining about the difficulty in swallowing. A 5 × 2 × 1-cm-sized posterior pharyngeal wall mass was detected on an endoscopic examination. Despite conservative management, the retropharyngeal mass progressed and dysphagia worsened, so the retropharyngeal wall granulation mass was resected by a laryngologist. Despite removal of the granulation mass, dysphagia and throat discomfort persisted for about 2 years. The plate and screws were removed considering their possible correlation with the granulation tissue. One month after plate removal, the retropharyngeal granulation tissue resolved almost spontaneously. At the last follow-up, the radiologic examination showed well-fused C1-2-3 with good alignment. The patient had no residual neurologic deficits or dysphagia.

CONCLUSIONS

Retropharyngeal granulation can occur as a late complication associated with plate fixation after anterior cervical diskectomy and fusion. Recurrent retropharyngeal wall granulation caused by plate irritation might only be resolved after plate and screw removal.