Neurological and functional outcome after unstable cervicothoracic junction injury treated by posterior reduction and synthesis

Abstract

Background context Unstable lesions of the cervicothoracic junction present a severe clinical problem for diagnosis, treatment, and prognosis. Purpose The objective of the present study was to evaluate the neurological and functional outcomes following surgical treatments which combine in all cases posterior reduction and stabilization. Study design Retrospective clinical and radiological study. Patient samples Between September 1996 and September 2003, 30 patients underwent surgery for unstable fracture at the cervicothoracic junction. This group included 23 patients who sustained a motor vehicle accident, 5 who had fallen from a height, 1 case of ballistic trauma, and 1 person injured by diving in shallow water. There were 22 male and 8 female patients aged between 18 and 80, with an average age of 49. In 18 cases the lesion level was vertebra C7, in 5 cases vertebra T1, in 2 cases vertebra T2, and in 5 cases vertebra T3. Neurologically, on initial clinical examination 16 patients were classified Frankel A, 6 Frankel B, 2 Frankel C, and 6 Frankel D. Surgically, all the patients underwent posterior reduction and synthesis. Posterior stabilization was performed using rods and screws 3 times, plate-screw fixation 25 times, and rods and screws at the thoracic level linked to plate-screw at the cervical level 2 times. Spinal cord compression of more than two levels was associated with 25 cases. In these 25 cases, spinal cord decompression was associated with reduction and stabilization. Outcome measures Clinical outcome using neurological scale of Frankel, radiological outcomes using computed tomographic (CT) scans and plain X-ray evaluations. Methods Follow-up periods ranged from 11 to 48 months, with an average of 18 months. Seven patients died as a result of cardiopulmonary insufficiency within 4 months postoperative. Twenty-eight CT scans with sagittal and frontal slides were examined to evaluate postoperative reduction and to control screw placement. Results The observed reductions were satisfactory in 27 cases. In one case, reduction was satisfactory in the sagittal plane but lateral translation persisted in the frontal plane. Two mechanical failures with delayed mobilization of implants occurred. Bony fusion was recorded in all cases on CT scan evaluation. Complete or partial neurological recovery was observed in only 10 of 14 patients. The initial neurological status of these 14 patients was Frankel B, C, or D. Conclusion The surgical procedure was chosen according to the particularity of the anatomical region and the possibility of associated medullar decompression. Insertion of pedicle screws in the upper thoracic portion in T1, T2, and T3 requires a careful technique and knowledge of the posterior projection points of the pedicles and their orientation in space. The high rate of fusion observed in these patients justified posterior reduction and stabilization. The high death rate and the low rate of neurological recovery in this group of patients emphasizes the severe prognosis of unstable injuries of the cervicothoracic junction. Considering the few mechanical failures observed at the last examination, the choice of the posterior approach was appropriate as the one stage procedure. Plate synthesis is preferable in fractures that do not require extension of synthesis beyond T2, whereas screws and rods systems are more appropriate for superior thoracic injuries. Despite early diagnosis and surgical treatment, the presence of neurological or pulmonary lesions resulted in increased mortality of the operated patients.