Reduction and fusion of fracture dislocation of the cervical spine

Reduction of Lower Cervical Facet Dislocation: A Review of All Techniques

Objective: The surgical treatment of lower cervical facet dislocation is controversial. Great advancements on reduction techniques for lower cervical facet dislocation have been made in the past decades. However, there is no article reviewing all the reduction techniques yet. The aim is to review the evolution and advancements of the reduction techniques for lower cervical facet dislocation.Methods: The application of all reduction techniques for lower cervical facet dislocation, including closed reduction, anterior-only, posterior-only, and combined approach reduction, is reviewed and discussed. Recent advancements on the novel techniques of reduction are also described. The principles of various techniques for reduction of cervical facet dislocation are described in detail.Results: All reduction techniques are useful. The anterior-only surgical approach appears to be the most popular approach. Moreover, many novel or modified reduction and fixation methods have been introduced in recent years.Conclusion: The selection of surgical approach depends on a combination of factors, including surgeon preference, patient factors, injury morphology, and inherent advantages and disadvantages of any given approach.

Anterior Approach Following Intraoperative Reduction for Cervical Facet Fracture and Dislocation

OBJECTIVE

The purpose of this study was to evaluate the efficacy of the anterior approach following intraoperative reduction under general anesthesia in patients with cervical facet fracture and dislocation.

METHODS

Twenty-three patients with single level cervical facet fracture and dislocation who were subjected to the anterior approach alone following immediate intraoperative reduction under general anesthesia from March 2013 to December 2017 were enrolled in this study. Neurological status, clinical outcome, and radiological studies were evaluated preoperatively, postoperatively, and during the follow-up period.

RESULTS

The cohort comprised 15 men and eight women with a mean age of 57 years (from 24 to 81). All patients were operated on within the first 8 hours following the injury. After gentle manual reduction or closed reduction with Gardner-Wells traction, under general anesthesia monitored by somatosensory-evoked potentials, all operations were successfully completed using the anterior approach alone except in two patients, who had a risk of over-distraction. In them, a satisfactory gentle manual reduction or closed reduction was not possible, and required open posterior reduction of the locked facets followed by anterior cervical discectomy and fusion. In one patient, screw retropulsion was observed in 1 month after surgery. There were no reduction-related complications or neurological aggravations after surgery. All patients showed evidence of stability at the instrumented level at the final follow-up (mean follow-up, 12 months).

CONCLUSION

Anterior approach following intraoperative reduction monitored by somatosensory-evoked potentials under general anesthesia for cervical dislocation and locked facets is a relatively safe and effective alternative when cervical alignment is achieved by intraoperative reduction.

Cervical Posttraumatic Unilateral Locked Facets: Clinical, Radiologic, and Surgical Remarks on a Series of 33 Patients

STUDY DESIGN

Radiographic and clinical analysis.

OBJECTIVE

Review author's experience with anterior discectomy, interbody fusion, and anterior cervical plating in 33 patients with posttraumatic unilateral cervical locked facets.

SUMMARY OF BACKGROUND DATA

Unilateral cervical locked facet syndrome is a relatively uncommon injury that often is misdiagnosed and therefore subject to a dangerous delay in surgery. Management of this trauma is controversial.

MATERIALS AND METHODS

Thirty-three patients with radiologically proven diagnosis of postraumatic unilateral cervical locked facets were treated by skull traction and surgical operation from January 2005 to December 2009. All patients preoperatively were assessed for neurological examination and underwent x-rays, magnetic resonance imaging, and computed tomography evaluation of the cervical spine.

RESULTS

The unilateral locked facet level was C4-C5 in 13 patients, C5-C6 in 10, C6-C7 in 8, and C3-C4 in 2 patients. After closed reduction attempt with Crutchfield system, the correct alignment was achieved in 30 patients, who underwent anterior discectomy with cage, interbody fusion, and anterior cervical plating. In 3 patients there was an overdistraction and therefore a closed reduction was not possible, so they were firstly operated by posterior approach with opened reduction of the facets, lateral mass screws, and posterolateral fusion. In 2 of these patients there was an anterior fragment of the disk in the canal, so was also performed an anterior approach with discectomy, cage, and plating. There were no surgery-related complications. Postoperative neurological status was unchanged in the 3 patients with tetraplegia and improved in 8 of the 10 patients with radiculopathy. Fusion was obtained in all patients, as showed in the clinical and radiologic follow-up.

CONCLUSIONS

The authors conclude that an anterior approach provides a safe and effective alternative for the treatment of patients with posttraumatic unilateral cervical locked facet, when preoperatively the cervical alignment of the dislocation is achieved with a closed reduction.

Initial closed reduction of cervical spine fracture-dislocation injuries

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines. Early closed reduction of cervical spine fracture-dislocation injuries with craniocervical traction is recommended to restore anatomic alignment of the cervical spine in awake patients. Closed reduction in patients with an additional rostral injury is not recommended. Patients with cervical spine fracture-dislocation injuries who cannot be examined during attempted closed reduction, or before open posterior reduction, should undergo magnetic resonance imaging (MRI) before attempted reduction. The presence of a significant disc herniation in this setting is a relative indication for a ventral decompression before reduction. MRI study of patients who fail attempts at closed reduction is recommended. Prereduction MRI performed in patients with cervical fracture dislocation injury will demonstrate disrupted or herniated intervertebral discs in one-third to one-half of patients with facet subluxation. These findings do not seem to significantly influence outcome after closed reduction in awake patients; therefore, the usefulness of prereduction MRI in this circumstance is uncertain.

Cervical facet dislocation: techniques for ventral reduction and stabilization

OBJECT

To demonstrate the safety and utility of one surgical approach, the authors reviewed their experience with the ventral surgical approach for decompression, reduction, and stabilization in 10 patients with either unilateral or bilateral cervical facet dislocation.

METHODS

Six patients presented with unilateral cervical facet dislocation and four patients with bilateral cervical facet dislocation. There were six male and four female patients who ranged in age from 17 to 72 years (average 37.1 years). The level of facet dislocation was C4-5 in one, C5-6 in four, and C6-7 in five patients. Three patients presented with a complete spinal cord injury (SCI), three patients with an incomplete SCI, three with radicular symptoms or myeloradiculopathy, and one patient was neurologically intact. All patients underwent plain radiography, magnetic resonance imaging, and computerized tomography evaluation of the cervical spine. All patients had sustained significant ligamentous injury with minimum or no bone disruption. All patients underwent ventral decompressive surgery, reduction of the dislocation, and stabilization of the cervical spine. Techniques for performing ventral reduction of unilateral or bilateral cervical facet dislocation are described. Decompression, reduction, and stabilization of the cervical spine via the ventral approach was accomplished in all but one patient. This patient underwent a ventral decompressive procedure and an attempt at ventral reduction and subsequent dorsal reduction and fusion in which a lateral mass screw plate fixation system was used; this was followed by ventral placement of instrumentation and fusion. There were no surgery-related complications. Postoperative neurological status was unchanged in four patients and improved in six patients. No patient experienced neurological deterioration after undergoing this surgical approach.

CONCLUSIONS

The authors conclude that a ventral surgical decompression, reduction, and stabilization procedure provides a safe and effective alternative for the treatment of patients with unilateral or bilateral cervical facet dislocation without significant bone disruption.

The interspinous method of posterior atlantoaxial arthrodesis

Thirty-six patients underwent C1-2 posterior wiring and fusion procedures over a 5-year period for unstable C-2 fractures (eight cases), unstable atlas-axis combination fractures (six cases), rheumatoid C1-2 instability (14 cases), os odontoideum (four cases), traumatic C1-2 ligamentous instability (three cases), or instability secondary to a C-2 tumor (one case). In each case, the atlantoaxial arthrodesis utilized sublaminar wire at C-1 and incorporated an iliac-crest strut-graft positioned between the posterior arches of C-1 and C-2, held in place by securing wire around the base of the spinous process of the axis. Follow-up examination was performed in all patients after a mean postoperative duration of 33.7 months. The technical aspects and clinical merits of this fusion procedure, which led to a 97% union rate (one nonunion) and minimal morbidity and mortality rates, are presented.

Technical report: method of fixation of subluxed or dislocated cervical spine below C1-C2

A method of internal fixation of adjacent vertebrae that have been dislocated or subluxed has been presented. In the author's hands and in the hands of associates this has proven to be a satisfactory method of fixation in this type of injury. It has the advantage over many other posterior techniques that only two verbebrae are fixed together.

Instrumentation for cervical wire fusion. Technical note

✓ Difficulties encountered in passing the wires for cervical fusions have been significantly diminished by new wire-passing and wire-twisting instruments and the use of very slight flexion at the atlantooccipital interspace, maintained by a threepoint headrest.