Anterior Approach Following Intraoperative Reduction for Cervical Facet Fracture and Dislocation

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Awake Cranial Traction and Isolated Anterior Cervical Discectomy and Fusion in the Treatment of Traumatic Subaxial Cervical Facet Joint Dislocations: Analysis of a Cohort of 70 Patients and Predictors of Surgical Failure

BACKGROUND

Cervical facet dislocations are among the most common traumatic spinal injuries. The management of this type of lesions is still controversial. The objective of the present study was to analyze the results of subaxial cervical facet dislocations submitted to an isolated anterior cervical discectomy and fusion (ACDF) after attempted closed reduction with cranial traction and to identify risk factors for treatment failure.

METHODS

All patients who were operated on in a tertiary trauma center during an 11-year period (2008-2018) for traumatic single-level cervical facet joint dislocation (AO C F4 injuries) were retrospectively reviewed. Age, use of cranial traction, dislocation characteristics, neurologic injury, surgical data, and follow-up records were reviewed. A minimum of 18 months follow-up was required.

RESULTS

A total of 70 patients with a mean age of 56 years (18-90) (72% men) were identified. The C6-C7 level was the most frequently affected (36/70 cases). Spinal cord injury (SCI) was present in 34% of the cases. Bilateral dislocations and rigid spines were risk factors for SCI. Cranial traction was performed in 59 cases with success in 52 cases (88%). There were 3 failures after anterior fusion, which required revision surgery with a 360° fusion, all occurring at the C7-T1 level.

CONCLUSIONS

Cranial traction of the cervical spine is an effective and fast way to achieve closed reduction of cervical facet dislocations. After successful reduction, ACDF, as a single procedure, offers an excellent surgical option. All cases of failure occurred at the C7-T1 level, suggesting that a 360° fusion may be needed at this level.

LEVEL OF EVIDENCE: 3

Tracheostomy Following Anterior Cervical Discectomy and Fusion With Plating in Trauma Patients: Is It Safe?

Objective

This study aimed to evaluate the safety and necessity of tracheostomy after anterior cervical discectomy and fusion (ACDF) with plating, despite the close proximity of the two surgical skin incisions.

Methods

Sixty-three patients with traumatic cervical fractures or spinal cord injury (SCI) who underwent single-level ACDF and plating between January 2014 and June 2019 were included in this study. The patients included 45 men and 18 women, with a mean age of 48.5 years. A retrospective analysis of the patients’ demographic data, level of injury, radiological findings, and neurological status was performed based on the American Spinal Injury Association (ASIA), open tracheostomy, and decannulation rate. Additionally, risk factors necessitating tracheostomy were statistically analyzed.

Results

Eighteen patients (28.5%) required subsequent open tracheostomy. Among them, 11 patients were successfully decannulated, four patients could not be decannulated during the follow-up period, and three patients died of unrelated complications. The median interval from ACDF with plating to open tracheostomy was 9.6 days (range, 5–23 days). On the basis of neurological status, ASIA A and B patients (p<0.001), high signal intensity on T2-weighted-magnetic resonance (MR) images (p=0.001), and major cervical fracture and dislocation were significant risk factors for tracheostomy (p=0.02). No patient showed evidence of significant soft tissue, bony infection, or nonunion during the follow-up period.

Conclusion

Independent tracheostomy did not increase the risk of infection or nonunion despite the close proximity of the two surgical skin incisions.