Cervical Fracture-dislocation Research Articles

Traumatic Cervical Facet Fractures and Dislocations.

Cervical facet injuries, though less common than other spinal injuries, represent a subset of subaxial cervical spine injuries and can present significant challenges in terms of diagnosis, management, and outcomes. A major concern with cervical facet fracture is identifying instability patterns that may necessitate surgical stabilization. Particularly in cases of cervical facet fracture dislocations, there remains controversy regarding requirements for closed reduction, timing, surgical approach, need for preoperative MRI, and method of fixation. This review article aims to provide a thorough understanding of the etiology, clinical presentation, diagnostic techniques, treatment options, and prognostic factors associated with cervical facet fractures.

Hounsfield units in assessing bone mineral density in ankylosing spondylitis patients with cervical fracture-dislocation.

Cervical spine fracture-dislocations in patients with ankylosing spondylitis (AS) are mostly unstable and require surgery. However, osteoporosis, one of the comorbidities for AS, could lead to detrimental prognoses. There are few accurate assessments of bone mineral density in AS patients. To analyze Hounsfield units (HUs) for assessing bone mineral density in AS patients with cervical fracture-dislocation. The HUs from C2 to C7 of 51 patients obtained from computed tomography (CT) scans and three-dimensional reconstruction of the cervical spine were independently assessed by two trained spinal surgeons and statistically analyzed. Inter-reader reliability and agreement were assessed by interclass correlation coefficient. The HUs decreased gradually from C2 to C7. The mean values of the left and right levels were significantly higher than those in the middle. Among the 51 patients, 25 patients (49.02%) may be diagnosed with osteoporosis, and 16 patients (31.37%) may be diagnosed with osteopenia. The HUs obtained by cervical spine CT are feasible for assessing bone mineral density with excellent agreement in AS patients with cervical fracture-dislocation.

Effects of early surgery for cervical fracture dislocation on 30-day mortality using the Japanese Diagnosis Procedure Combination database.

Retrospective study of data abstracted from the Diagnosis Procedure Combination (DPC) database. This study aimed to investigate the effects of surgery in the early phase. The optimal timing of surgery for cervical fracture dislocation (CFD) remains unclear because only a few clinical studies with approximately 100 patients have been published. This study included 4,653 adult patients with a definitive diagnosis of CFD from the DPC database. The database contains nationwide inpatient data collected from >1,000 acute care hospitals in Japan. The DPC database contains information regarding hospitalization, such as diagnosis, treatment, medical history, complications, and hospitalization outcomes. This study identified 460 pairs of patients after one-to-one propensity-score matching (PSM). Treatment outcomes were compared between patients who underwent surgery for CFD within 72 hours (early group) and later (delayed group) after admission. The main outcomes included 30-day mortality, inhospital death, and major complications. The secondary outcomes were improvement in the Barthel index, length of hospital stay, and discharged home rate. After adjusting for PSM, the early group had a significantly higher 30-day mortality rates than the delayed group (3.0% vs. 0.4%, p=0.006). In the multivariate logistic regression analysis after PSM, the early group was associated with an increased risk of 30-day mortality (odds ratio, 8.05; 95% confidence interval, 2.15-5.26; p=0.007). This study indicated that early surgery for CFD resulted in increased 30-day mortality.

Blunt Traumatic Vertebral Artery Injury After Cervical Fracture Dislocation: A Systematic Review of the Literature.

Certain high-energy blunt forces may produce unstable cervical fractures with or without dislocation. In rare cases where the superior facets are dislocated, however showing a significant increase within the last decade, these types of injuries may include vertebral artery entrapment at the involvement level leading to artery dissection or occlusion. This phenomenon is usually seen at the C4-C5 and C5-C6 levels of injury. A systematic review of the literature was performed by examining online databases such as PubMed - NCBI, Web of Science, Cochrane Library, Scopus, and Embase to identify relevant scientific articles. Keywords (MeSH terms) used in the search included cervical spine injuries, cervical spine dislocation, cerebrovascular injury, vertebral artery injury, vertebral artery injury management, and incidence of vertebral artery injury. Initially, 1516 studies were identified as a primary search for screening. After excluding papers that did not fulfill the inclusion criteria, 34 studies were included in this review. Vertebral artery injury consists of a severe complication that could compromise a surgical intervention since the patient's clinical image may be unrevealing at first. Early diagnosis and correct timing constitute the golden standard for adequate treatment. This systematic review aims to summarize the current evidence for the diagnosis, management, and treatment of blunt traumatic vertebral artery injuries.

Fracture-dislocations of the subaxial cervical spine

Fracture-dislocations of the subaxial cervical spine are rare yet potentially devastating injuries often associated with high-energy trauma. These inherently unstable injuries frequently lead to neurologic compromise, necessitating urgent operative intervention. This review provides a comprehensive overview of subaxial cervical spine fracture-dislocations, addressing their epidemiology, anatomy, and classification systems. Classification schemes including Allen and Ferguson, Cervical Spine Injury Severity Score (CSISS), Subaxial Cervical Spine Injury Classification System (SLIC), and AO Spine Subaxial Cervical Spine Injury Classification System are discussed. Prompt recognition and management of these injuries is critical in optimizing long-term functional and neurologic outcomes. Rates of neurologic injury can exceed 50 %, with distractive flexion injuries and bilateral facet injuries often presenting with higher ASIA grades and lower neurologic recovery potential. Minimizing time to reduction is the most important factor in optimizing neurologic outcomes in these injury patterns. We discuss both closed and open reduction methods, timing considerations, technical pearls, and potential complications associated with each strategy. We also discuss the diagnosis and management of concurrent acute disk herniations, the role of advanced imaging, and the debated utility of pre-reduction MRI. Many subaxial cervical fracture-dislocations necessitate surgical intervention, which can be approached from an anterior, posterior, or combined approach. Although no standard surgical treatment algorithm exists, we discuss surgical options and situations where a preferred approach may exist. Selection of the approach depends on injury characteristics and surgeon preference, and there are no clearly defined surgical recommendations based on injury pattern.

Vertebral Artery Injury in Cervical Spine Fracture Dislocation: An Observational Study in a Tertiary Care Center.

The incidence of traumatic vertebral artery injury (VAI) associated with cervical spine trauma varies widely in published trauma series. The primary aim of this study was to determine the incidence of traumatic VAIin patients who suffered cervical spine injuries by means of routine magnetic resonance imaging, and the secondary objective was to identify any associations with injury mechanism, level ofinjury, and neurologic injury severity. Materials and methods: A retrospective review was conducted on 96 patients who suffered cervical spine fracture dislocation with or without an associated spinal cord injury (SCI) in Indian Spinal Injuries Center (ISIC), New Delhi, Indiafrom January 2013 to April 2023. Cervical magnetic resonance imaging (MRI) was used to diagnose VAI. Patient's age, sex, cervical injury level, mechanism of injury, neurologic level of injury, association with foraminal fracture, facet dislocation,and clinical sequelae of vertebral artery injury were analyzed. In this study, of 96 patients who met the inclusion criteria, 18 patients (18.75%) had VAI on the MRI study. Thirteen (72.22%) of the eighteen patients had right-sided injuries, four (22.22%) had left-sided injuries, and one (5.55%) had bilateral injuries. There was an associated SCI in every VAI patient. VAI was significantly more common in patients who had ASIA A (61%, n = 11) and ASIA B (22%, n = 4)injuries, and no VAI was noted in neurologically intact patients (p<0.001). The incidence of VAI was higher in the flexion distraction type of injury (n = 12, 66%).The most commonly involved cervical spine injury level was C5-C6 (27%, n = 5), followed by 22% (n = 4) at C4-C5 and C6-C7 levels. About 27.8% (n = 5) of VAI was associated with foraminal fractures, and 72% (n = 13) of VAI was associated with facet dislocations, of which 44% (n = 8) were bifacetal and 28% (n = 5) were unifacetal dislocations. On clinical symptoms, only one (5.56%) patient had a headache, and 17 (94.4%) had no clinical features due to VAI. The incidence of traumatic vertebral artery disease is not very uncommon and requires careful and meticulous screening and management. Otherwise, complications like pseudoaneurysm, neurologic deficit, late-onset hemorrhage, infarction, and death can happen. Mostly, it is associated with high-velocity injuries and neurological injuries. MRI can be used as a good screening tool, which can be aided by a CT angiogram or digital subtraction angiographyfor confirmation. Proper pre-operative evaluation of vascular injury in cervical spine fracture dislocation is very important for patient counseling, patient management, and surgical planning.

Comparison of Anterior Cervical Discectomy Fusion Combined with Lateral Mass Screw and with Cervical Pedicle Screw Fixation Surgery under O-Arm Navigation for Single-Stage Management of Severe Lower Cervical Fracture Dislocation.

The incidence of severe lower cervical fractures and dislocations due to trauma has increased significantly, and the optimal treatment remains controversial. This study compares the safety and efficacy of anterior cervical discectomy fusion (ACDF) combined with lateral mass screw (LMS) and with cervical pedicle screw (CPS) fixation surgery under O-arm navigation as single-stage treatments of severe lower cervical fracture dislocations. Data from 48 patients who underwent ACDF + CPS (Group A) or ACDF + LMS (Group B) for severe lower cervical fracture dislocation between January 2016 and September 2020 were retrospectively reviewed. Groups A and B comprised 25 and 23 cases, respectively. Clinical parameters, such as operative time, intraoperative blood loss, number of fixed segments, posterior incision length, operative complications, and hospitalization days were recorded. Preoperatively and postoperatively, the sub-axial injury classification (SLIC) score, the American Spinal Injury Association (ASIA) impairment scale, and the Japanese Orthopaedic Association (JOA) score were recorded and analyzed using Student's t-test. The SLIC scores were 7.1 ± 1.2 and 7.5 ± 1.1, ASIA were 1.5 ± 0.6 and 1.2 ± 0.6, JOA score improvements were 3.2 ± 2.4 and 3.0 ± 2.1, operative times were 282.1 ± 91.7 and 266.5 ± 88.2 min, intraoperative blood losses were 437.8 ± 118.5 and 418.7 ± 104.2 mL, fixed segments were 2.8 ± 0.7 and 4.8 ± 1.1, and lengths of posterior incisions were 12.7 ± 2.8 and 13.8 ± 3.2 cm in Groups A and B, respectively. There was no significant difference between the two groups in the operative time, intraoperative blood loss, incision length, and postoperative recovery; however, group A had more fixed segments. At the final follow-up, no intraoperative or postoperative complications directly caused by the implant were present. Throughout the follow-up, all cases showed recovery and progressive improvement. Both ACDF + LMS and ACDF + CPS under O-arm navigation can safely and effectively restore cervical vertebral sequence, fully release spinal canal compression, and promote patients' neurological recovery. Thus, both are effective treatments for severe lower cervical fracture dislocations. However, compared to LMS, CPS under O-arm navigation has shorter fixed segments and induces less trauma.

Comparative study of halo-vest reduction and skull traction reduction in the treatment of cervical fracture dislocation in patients with ankylosing spondylitis.

This study aimed to investigate the safety and efficacy of the halo-vest in the treatment of cervical fracture in patients with ankylosing spondylitis (AS) and kyphosis. From May 2017 to May 2021, 36 patients with cervical fractures with AS and thoracic kyphosis were included in this study. The patients with cervical spine fractures with AS underwent preoperative reduction by halo-vest or skull tractions. Instrumentation internal fixation and fusion surgery were then performed. The level of cervical fractures, the operative duration, blood loss, and treatment outcomes were investigated preoperatively and postoperatively. A total of 25 cases were included in the halo-vest group and 11 cases were included in the skull tractions group. The intraoperative blood loss and the surgery duration were significantly less in the halo-vest group than in the skull traction group. A comparison of American Spinal Injury Association scores at admission and final follow-up showed that the neurological function of patients improved in both groups. All patients had reached solid bony fusion during the follow-up. This study presented a unique approach to use halo-vest treatment fixation of unstable cervical fracture in patients with AS. The patient should also have early surgical stabilization with a halo-vest to correct spinal deformity and avoid worsening of neurological status.

An Innovative Technique for Anterior Cervical Surgery in Sub-axial Cervical Fracture Dislocation with incomplete spinal cord injury: A Paradigm Shift in Surgical Approach

An Innovative Technique for Anterior Cervical Surgery in Sub-axial Cervical Fracture Dislocation with incomplete spinal cord injury: A Paradigm Shift in Surgical Approach

Perioperative Complications of Open Spine Surgery in Older Adults over 90 Years of Age.

Despite perioperative risks in nonagenarian patients who undergo open spine surgery for degeneration disorder or spinal trauma being of great interest, the prevalence of complications in this group remains unclear. This study aims to examine the perioperative complications of open spine surgery in the elderly over 90 years of age. Preoperative and intraoperative characteristics including the American Society of Anesthesiologists Physical Status (ASA-PS) class, type of surgery, and complications within 30 postoperative days were retrospectively collected from the medical records of nonagenarians who underwent open spine surgery between April 2004 and July 2019 at our spine centers. A total of 48 patients met the inclusion criteria of this study. All belong to ASA-PS class 2 (69%) or 3. Preoperative American Spinal Injury Association Impairment Scale grades in trauma group were grade A in 4 cases, B in 1 case, C in 5 cases, D in 11 cases, and E in 1 case. Major complications (deep surgical site infection, cardiac event, respiratory disorder, gastrointestinal hemorrhage, and renal failure) occurred in 13 cases, and the rate of overall perioperative complications was 45.8%. One patient who underwent cervical stabilization for cervical fracture dislocation died at postoperative 13 days due to respiratory disorder. The rates of major complications and overall perioperative complications were 3.6% and 14.3% in the degenerative group and 45.5% and 81.8% in the trauma group, respectively. Especially in the trauma group, respiratory disorder occurred in 7 cases, delirium in 11 cases, and urinary tract infection in 5 cases. Although the perioperative complication rate reached 81.8% in spinal trauma cases, the complication rate in degenerative disorders was relatively low as 14.3%. Open spine surgery for degenerative disorders can be relatively safe even in nonagenarians, whereas the risks of perioperative complications, including respiratory disorder and delirium, were high in spinal trauma cases.

PREOPERATIVE CLOSE REDUCTION OF CERVICAL FRACTURE DISLOCATIONS

Study design: Retrospective study. Purpose: To determine Reduction rate of cervical fracture dislocations using preoperative gradual in hospital skull traction. Overview of literature: Cervical spine fracture dislocations are unstable injuries and require surgical intervention and stabilization. The approach may be anterior, posterior or combined. Majority of the surgeons prefer anterior approach after initial close reduction of cervical fracture dislocation. If close reduction preoperatively fails, then posterior direct reduction is needed followed by anterior surgery.In this study we intend to determine the rate of success (reduction) using preoperative gradual traction. Method: This retrospective study was conducted at Spine Unit Hayatabad Medical Complex and Aman hospital Peshawar. All patients with cervical fracture dislocations presented between Jan 2015 &amp; Jan 2019, who underwent cervical traction prior to surgical interventions were included in the study. The demographics, types of dislocation, preoperative traction, duration and neurology of all patients were recorded. The success of reduction using closed in hospital gradual traction was assessed using lateral cervical spine x-rays. Data was assessed using SPSS version 20. Results: A total of 52 patients were included in the study with a mean age of 30.06 years (SD± 8.03). In 35(67.3%) patients the dislocation was bifacetal while in 17(32.7%) it was unifacetal. Successful reduction using gradual in hospital awake traction was achieved in 39(75%) patients while in 13(25%) patients reduction was not achieved. Mean duration of preoperative traction was 3.6 (SD±1.1) days with minimum 2 days and maximum 7 days. Conclusion: Gradual in hospital traction in awake patients is an effective mean of reducing cervical fracture dislocations.

O-Arm Navigated Cervical Pedicle Screw Fixation in the Treatment of Lower Cervical Fracture-Dislocation.

ObjectiveTo evaluate the safety and efficacy of cervical pedicle screw (CPS) placement with O‐arm navigation in the treatment of lower cervical fracture‐dislocation.MethodsA retrospective clinical study was performed involving 42 consecutive patients with lower cervical spine fracture‐dislocation who underwent CPS fixation surgery with O‐arm navigation (CPS group) or received conventional lateral mass screw (LMS) fixation surgery (LMS group) between August 2015 and August 2019. Accuracy of CPS position was evaluated by postoperative CT. The clinical parameters including preoperative and final follow‐up Japanese Orthopaedic Association (JOA) score and American Spinal Injury Association (ASIA) Impairment Scale, preoperative Sub‐axial Injury Classification (SLIC) score, number of fixation segments, operation time, intraoperative blood loss, injury mechanism, injury location, surgical complications were also assessed between the two groups.ResultsIn LMS group, the preoperative SLIC score was 7.5 ± 0.9, ASIA score improvement was 0.8 ± 0.5, JOA score improvement was 3.0 ± 1.8, mean operation time was 204 ± 89 min, intraoperative blood loss was 311 ± 127 ml. In CPS group, the preoperative SLIC score was 7.3 ± 1.2, ASIA score improvement was 0.9 ± 0.5, JOA score improvement was 3.2 ± 2.4, mean operation time is 241 ± 85 min, intraoperative blood loss is about 327 ± 120 ml. There was no significant difference in terms of above clinical parameters between the two groups (P > 0.05), the fixation segments in CPS group (3.5 ± 1.1) were less than that in LMS group (4.2 ± 0.7) (P = 0.037). The accuracy of CPS insertion was evaluated based on postoperative CT. Of all the 118 CPSs, 83 (70.3%) were defined as Grade 0; 27 (22.9%) as Grade 1; eight (6.8%) as Grade 2; and none as Grade 3. CPS malposition rate in this study was 6.8%. In this study, there was no direct intraoperative or postoperative complication caused by CPS or LMS insertion. All the operations were successfully completed in two groups. One of the patients in LMS group presented cerebrospinal fluid leak caused by bone fragment broken of the dural sac, which led to delayed incision healing. CPS group and LMS group both had two patients who suffered pulmonary infection after surgery. A total of 78.6% of the patients showed evidence of neurologic recovery. Satisfactory reduction was achieved in all cases and maintained throughout the follow‐up duration.ConclusionIn the treatment of lower cervical spine fracture‐dislocation, cervical pedicle screw insertion with O‐arm navigation is a safe and effective method for posterior fixation.

Posttraumatic Retropharyngeal Pseudomeningocele—A Case Report

AbstractA retropharyngeal pseudomeningocele after cervical vertebral fracture dislocation is an extremely rare complication and often associated with hydrocephalus. It usually presents with respiratory difficulty and dysphagia, sometimes as an incidental finding in radiological study. We reported a case of 45-year-old female patient who had posttraumatic lower cervical prevertebral retropharyngeal pseudomeningocele, found as an incidental finding in a routine radiological workup. Patient underwent ACDF but expired 2 weeks postoperatively due to respiratory failure. Although the prognosis of retropharyngeal pseudomeningocele depends upon the severity of initial trauma, early recognition and management can prevent enlargement of cyst and development of respiratory difficulty and dysphagia.

Cervical spine fracture-dislocation in patients with ankylosing spondylitis and severe thoracic kyphosis: Application of halo vest before and during surgical management

Cervical spine fracture-dislocation in patients with ankylosing spondylitis (AS) and severe thoracic kyphosis is extremely unstable. This study was performed to investigate the efficacy and safety of halo vest application before and during surgery for these patients. We retrospectively analyzed the case histories, operations, neurologic outcomes, follow-up data, and imaging records of 25 patients with AS and severe thoracic kyphosis who underwent surgical treatment of cervical fracture-dislocation in our department from 2008 to 2019. A halo vest was used to reduce and immobilize the fractured spinal column ends before and during surgery. The neurologic injury was evaluated using the American Spinal Injury Association (ASIA) impairment scale score, visual analog scale (VAS) score, and Japanese Orthopaedic Association (JOA) score before and after the operation. Twenty-two patients achieved closed anatomical reduction; two achieved successful reduction and one underwent failed reduction after halo vest application. No fracture site displacement occurred after movement into the prone position. No patients developed secondary neurological deterioration. The mean Cobb angle of thoracic kyphosis was 69.0° ± 12.3°. All patients underwent posterior or combined anterior-posterior surgery. The ASIA grade improved significantly (P < 0.01). The mean VAS and JOA scores also increased significantly after the operation (14.6 ± 3.0 vs. 10.4 ± 4.3 and 0.5 ± 0.6 vs. 4.6 ± 1.9, respectively; P < 0.01). One patient died 3 weeks after the operation. No other severe complications occurred. All patients had reached solid bony fusion by the 12-month follow-up. Use of a halo vest before and during the operation is safe and effective in patients with AS and severe thoracic kyphosis who develop cervical fracture-dislocation. This technique makes positioning, awake nasoendotracheal intubation, nursing, and the operation more convenient. It can also provide satisfactory reduction and rigid immobilization and prevent secondary neurologic deterioration.

Letter to the Editor Regarding “Bilateral Vertebral Artery Occlusion After Cervical Spine Fracture Dislocation”

Letter to the Editor Regarding “Bilateral Vertebral Artery Occlusion After Cervical Spine Fracture Dislocation”

頸髄損傷に対して緊急手術を施行し再生医療のために転院した1例(A case of emergency surgery for cervical spinal cord injury and transferred for regenerative medicine)

要旨再生医療は，脊髄損傷の有望な治療法として浮上してきている。本邦では2019年2月に自己骨髄間葉系細胞投与に保険が適応された。今回，頸髄損傷の患者に対して早期の固定術と早期からのmechanical insufflation–exsufflation（MI–E）の使用と再生医療を実施した症例を経験したため報告する。14歳の女児。遊具からの転落により後頸部を強打して受傷30分後に来院した。精査の結果，麻痺を伴う第5，6頸椎脱臼骨折を認めたため，同日に非観血的整復術を施行したが困難であり観血的整復術を施行した。第3病日に抜管したが咳嗽力が低下していたため第4病日からMI–Eを用いてリハビリを開始した。その後，再生医療を受けるため第14病日に北海道へ転院した。入院期間中にはステロイドは一切使用しなかった。急性期頸髄損傷に対する治療方針は変わり大量ステロイドの有用性は乏しく，急性期手術と早期リハビリが合併症を減少させている。新たな治療として再生医療も行われている。救急医としてはこれらを認識して初期治療を行うことが重要である。

Adherence to a standard operating procedure for patients with acute cervical spine dislocations: review of a tertiary, referral, academic hospital in South Africa

ABSTRACT BACKGROUND: To analyse the impact that the adoption of our institutional standard operating procedure (SOP) for cervical spine dislocations had on the timing of closed reduction at our hospital METHODS: The study was a retrospective review of patients who presented to our institution with cervical dislocation injuries and who were managed with closed reduction. The patient records of acute cervical spine dislocations from 2015 to 2018, data from the Acute Spinal Cord Injury database along with patient's demographic information were gathered and compared. Participants within the study time frame were diagnosed with a cervical facet dislocation based on clinical examination findings and radiological confirmation. Patients who had reduction performed at other referring hospitals were excluded from the study. RESULTS: The practice within all tertiary hospitals in the Western Cape is to perform closed reduction of cervical fracture dislocations as soon as possible after injury. In this study the time between injury and closed reduction before introducing the SOP was 13 h 13 min and after introducing the SOP, the time increased to an average of 14 h 28 min. The main cause of delay was the transfer time from the site of injury to the emergency ward. Other reasons for the delay include missed diagnosis, orthopaedic registrar unavailability and incomplete reduction bed CONCLUSION: This study found that the time taken for orthopaedic management of cervical dislocations increased by an hour after introduction of the SOP. Additionally, the overall time to reduction also increased. This was due to delays in transfer to the emergency ward and referral to Orthopaedics. We recommend that, in our setting, reduction could be initiated within an hour of patient arrival, if emergency ward doctors rapidly identified the problem and commenced cervical traction when the orthopaedic team was not immediately available. Our impression was that there was poor adherence to the new SOP guidelines on time management by the trauma team, and possibly transport delays prior to hospital admission. A further study to investigate the bottlenecks of the referral system is advisable Level of evidence: Level 4 Keywords: acute outcomes, cervical spine, dislocation injuries

Imaging Features of Cervical Spinal Motion Segment Lesions before and after Surgery: A Case Report

Spinal injuries remain a serious modern health problem that leads to a high level of disability and prehospital mortality. This clinical case of cervical fracture-dislocation demonstrates the diagnostic signs and the surgical approach.

Posterior Ligament-Bone Injury Classification and Severity Score: A Novel Approach to Predict the Failure of Anterior-only Surgery for Subaxial Cervical Facet Dislocations.

Clinical case series. 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. 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. 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. 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. 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.

When is the circumferential stabilization necessary for subaxial cervical fracture dislocations? The posterior ligament-bone injury classification and severity score: a novel treatment algorithm.

To propose a novel classification and scoring system called the posterior ligament-bone injury classification and severity score (PLICS) that offers a quantitative score to guide the need for posterior stabilization in addition to anterior reconstruction for subaxial cervical fracture dislocations (SCFDs). A total of 456 patients with SCFDs were prospectively included. Patients with PLICS ≥ 7 together with extremely unstable lateral mass fracture (EULMF) were classified as high-risk group, and the other patients were classified as low-risk group. For patients in the low-risk group, anterior-only reconstruction was performed; for patients in the high-risk group, additional posterior lateral mass fixation and fusion was performed after anterior reconstruction. Clinical outcome evaluation included using the visual analogue score (VAS), the Neck Disability Index (NDI), and the American Spinal Injury Association (ASIA) impairment scale. The change in the local sagittal alignment kyphosis Cobb angle was also recorded. A total of 370 patients (81.1%) completed the minimal 12-month follow-ups, including 321 patients of low-risk group and 49 patients of high-risk group. Compared with the average VAS score preoperatively, the score at 12-month follow-up was significantly improved (from 6.1 + 0.3 to 1.1 + 0.2 in the low-risk group, P < 0.001; from 6.4 + 0.2 to 1.4 + 0.2 in the high-risk group, P < 0.001). The average NDI score at the 12-month follow-up was statistically low in the low-risk group (8.8 + 2.5 vs 13.8 + 3.4, P = 0.034). At least more than one grade improvement in the ASIA scale was observed in 80.5% of all patients. The local kyphosis Cobb angle at the injured segment averaged improved in both groups. A PLICS score ≥ 7 together with EULMF can be the threshold for posterior stabilization in addition to anterior reconstruction for the patients with SCFDs.