Fracture-dislocation Of Cervical Spine Research Articles

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.

Critical Care Management of Fracture Dislocation of Cervical Spine: A Case Report

Background: Spinal cord injuries affect nearly 1 million people every year, more than 90% of all cervical injuries require intubation, most cases also require tracheostomy, and nearly 40% are ventilator dependent. This study aimed to describe critical care management of fracture dislocation of spine. &#x0D; Case Presentation: A 27-year-old male patient complained patient came with complaints of weakness in both limbs 13 hours before admission. Initially, the patient was driving a motorbike then the patient was involved in an accident with a car after the incident, the patient also felt a bit short of breath, could not move both his leg and hand, and could not feel defecation or urination. Patient was diagnosed with Fracture dislocation of C4-C5. The patient underwent elective decompression stabilization. Patient admitted to ICU with the majority requiring assisted ventilation. After five days in the ICU, the patient was challenged to be released from the ventilator, so the patient was performed early tracheostomy&#x0D; Conclusion: Patients with cervical injuries require comprehensive care in the intensive care unit, especially in airway management and respiratory support, in addition to addressing the potentially catastrophic multisystem sequelae of nerve damage.

Complete fracture-dislocation of the cervical spine without permanent neurological sequelae: case report

Background: Cervical spine injuries occur in up to 3% of all trauma patients. Fracture-dislocation of the lower cervical spine is typically present with severe spinal cord injury in which the body of one vertebra rests fully anterior to the next body. With this kind of injury, there are very few examples where there is no permanent neurological deficit, and those that do exist are extremely rare. Case Presentation: A 19-year-old Saudi male patient was presented by ambulance to the emergency department. He was a front-seat passenger in a vehicle involved in a road accident. The patient was unconscious, Glasgow Coma Scale (GCS) (8/15), and quadriparetic. He was intubated and put on a mechanical ventilator and vasopressor support for persistent hypotension. American Spinal Injury Association impairment scale was a grade A. Initial management and resuscitation was done according to Advanced trauma life support (ATLS) guidelines: cervical collar application, logrolling, analgesic therapy, vitals normalized, and general condition stabilized. Skull traction was performed on admission. The patient underwent anterior cervical open reduction + C6/7 pedicle screw, and lateral mass screw internal fixation was performed. Conclusion: We report a rare case of complete fracture dislocation of C5/C6 listhesis with bilateral facet lock, with C7 fracture, C7/T1 listhesis, and bilateral facet lock. The patient presented with quadriparesis and was successfully treated with posterior reduction and fusion. The mechanism of injury, which was thought to be flexion and compression, was deduced by the patient&amp;apos;s history and the results of physical and neuroimaging examinations.

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.

Evaluation of Factors Related to Paralysis Improvement after Lower Cervical Spine Fracture-Dislocations

Evaluation of Factors Related to Paralysis Improvement after Lower Cervical Spine Fracture-Dislocations

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。

Advanced compressive extension injuries of the subaxial cervical spine: do we really understand the nuances of this injury?

Background ContextThe Allen and Ferguson classification of cervical spine injuries is widely used. They described compressive Extension (CE) injuries as having five progressive stages. Stage 4(CE4) and 5(CE5) have been described as having a posterior vertebral arch fracture involving two motion segments accompanied by displacement (dislocation) of the vertebral body at a single level. However, in their original work, CE4 was described only as a hypothetical stage, while CE5 was found in only three patients. Beyond this, little is understood about these injuries. PurposeTo identify characteristics of compression extension injuries with vertebral body displacement (CE4 and CE5) from a series of surgically treated subaxial cervical spine fractures. A secondary aim was to identify specific characteristics that may guide treatment or affect prognosis. DesignRetrospective case series. Patient SampleTwenty-four patients who underwent surgical stabilization of CE4 and CE5 cervical spine fracture-dislocations in non-ankylosed spines over a 14-year period. Outcome MeasuresRadiographic categorization of CE injury type, treatment rendered, postoperative spinal alignment, presence of nonunion, loss of fixation, hardware-related and neurologic complications. MethodsAfter IRB approval, patients with CE injuries were identified through billing data and radiology records at a level I trauma center between January 2005 and September 2018. Demographic data, ISS, ASA, motor score, and complications during the hospitalization were collected from the patient's EMR. CT scans were reviewed to assess fracture pattern, level, and location of the vertebral arch fracture, vertebral body displacement, spinal canal diameter and method of surgical stabilization. Injuries were classified according to the classification of Allen and Ferguson, and the AO subaxial cervical spine classification. ResultsOf 221 patients identified with CE mechanism, 24 had CE4 or CE5 injuries. High-energy mechanism occurred in 92% of the patients, with motor vehicle accidents being the most common. The average ASIA motor score was 80 preoperatively and 84 at average 398 days follow-up. All CE4 and CE5 injuries occurred at C6-C7 or C7-T1. Average anterolisthesis was 6.26 mm (SD ± 2.3 mm) for CE4 and 16.8 mm (SD ± 1.8 mm) for CE5. Average spinal canal diameter at the level of dislocation was 20 mm (SD ± 0.4 mm) for CE4 and 30.5 mm (range 29.6 – 31.4 mm) for CE5. The surgical approach was anterior in 5 patients, posterior in 12 patients, and combined in 7 patients. Four patients had single-evel fixation, all of whom had CE4 injuries, and 20 patients had fixation across two or more levels. Thirty percent of patients had complications, none of which included postoperative spinal malalignment, nonunion or hardware-related complications, or worsening of neurologic exam. Three deaths occurred in the postoperative hospitalization period (7 to 15 days). ConclusionCE4 and CE5 injuries represented 10% and 1% of all CE injuries in our series respectively occurring only at the C6-C7 and C7-T1 levels. Though by original description these are two-level injuries, in patients with milder posterior element injury, single level stabilization was used successfully. We have therefore proposed designating CE4 into less severe CE4a and more severe CE4b injuries. Because this fracture pattern typically results in widening of the spinal canal as the anterior displacement of the vertebral body occurs independent of the fractured posterior elements, spinal cord injuries are neither as severe nor as common as in fracture-dislocation from other mechanisms.

Six-year follow-up of a survivor of cervical spine fracture and dislocation with oesophageal perforation following long scarf syndrome - a case report and literature review

BackgroundAccidental strangulation due to scarf getting caught in the wheels of a vehicle or machine was called “Isadora Duncan Syndrome” or “Long Scarf Syndrome”. Survival of concomitant fracture dislocation of cervical spine and oesophageal perforation following Long Scarf Syndrome was rarely described and medium-term follow-up for this lesion has not been reported.Case presentationWe present a 39-year-old female who suffered accidental strangulation caused by the scarf around her neck getting trapped in the wheels of the a vehicle and was referred to our hospital forty days post injury. The CT examination showed a fracture dislocation at C5/6 levels with complete dissociation of the supporting structures. She developed paravertebral abscesses, cutaneous fistulas and oesophageal perforation confirmed by oesophagoscope. The patient was treated conservatively because of poor general condition and inappropriate initial treatment. Halo-vest was used to immobilize the cervical spine. The oesophagus-cutaneous fistula was managed with enteral tube feeding and repeated local care. The patient survived despite such severe injury. Nine months after the injury, the oesophageal perforation closed spontaneously and fixed malunion of the cervical spine was achieved. Six-year follow-up demonstrated that the patient survived with complete C5 tetraplegia. Literature associated with this lesion was reviewed and factors contributing to the survival were discussed.ConclusionsConcomitant fracture dislocation of cervical spine and oesophageal perforation following Long Scarf Syndrome is extremely rare with high risk of mortality. Though surgical intervention is always necessary, the optimal management for this kind of lesion should be made on an individual basis through a multidisciplinary approach.

15. Surgical treatment of lower cervical fracture dislocation with spinal cord injuries using the anterior approach: a 10-year case review with minimum five-year follow-up

BACKGROUND CONTEXT Lower cervical fracture-dislocations are often caused by flexion-stretch injuries and frequently combine with spinal cord injuries which can cause serious damage. To date, there is no clear consensus on the best treatment option for lower cervical fracture-dislocation. In recent years, anterior approach surgery with direct decompression and reduction has been widely accepted. However, a long-term follow-up study with a large sample size to assess the clinical efficacy of the anterior approach is rarely seen in the literature. PURPOSE Through this retrospective cohort study, we assessed the clinical outcomes of anterior approach surgery. STUDY DESIGN/SETTING A retrospective cohort study. PATIENT SAMPLE A total of 218 cases. OUTCOME MEASURES Odom's criteria, the Cobb angle of kyphosis, the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) scoring system. METHODS From January 2001 to January 2011, 312 patients with lower cervical spine fracture-dislocation with spinal cord injuries who were treated by the anterior approach were retrospectively analyzed. A total of 218 cases (70%) were deemed to have integrity of data and were obtained for follow-up. The average age of the 218 patients was 42.6 years (range: 21-72), and the cases included 121 males and 97 females. All patients underwent decompression, reduction, bone grafting and arthrodesis by anterior means. The clinical efficacy was evaluated using Odom's criteria and statistical analysis based on the Cobb angle of kyphosis, the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) scoring system. The neurofunctional recovery of each patient was assessed by the American Spinal Injury Association (ASIA) system. RESULTS Follow-up for patients was for 8.9±2.9 years on average, with a range from 5 to 15 years. No loss of cervical reduction and lordosis curvature, and no plate- or screw-associated complications were observed during the follow-up. The kyphosis angle and NDI and JOA scores were significantly changed from preoperative values of 10.6±8.9°, 39.7±4.3 and 7.6±2.4 to last follow-up values of -5.2±8.6°, 10.8±4.6 and 15.6±1.2, respectively (p CONCLUSIONS For lower cervical fracture-dislocation with spinal cord injuries, satisfactory clinical outcomes can be obtained by choosing the anterior surgical approach. By restoring the normal structure of the cervical spine and promoting functional recovery, the anterior approach achieved a good long-term curative effect. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Risk Factors for Poor Prognosis of Cervical Spinal Cord Injury with Subaxial Cervical Spine Fracture-Dislocation After Surgical Treatment: A CONSORT Study.

BackgroundThe objective of the study was to identify risk factors for poor prognosis of cervical spinal cord injury (SCI) with subaxial cervical fracture-dislocation after surgical treatment.Material/MethodsA total of 60 cervical SCI patients with subaxial cervical fracture-dislocation were primarily included in the study from April 2013 to April 2018. All the enrolled subjects received surgical treatment. The enrolled patients with complete follow-up record were divided into 2 groups based on the neural function prognosis: a non-functional restoration group and a functional restoration group. Multivariate regression analysis was performed to identify independent risk factors for poor prognosis of SCI after surgical treatment.ResultsFifty-five subjects were included in this study, and the follow-up time ranged from 8.5 to 44.5 months. A total of 25 subjects were categorized into the non-functional restoration group and 30 subjects into the functional restoration group. According to the results of multivariate regression analysis, time from injury to operation (more than 3.8 days), subaxial cervical injury classification (SLIC, score more than 7.5), and maximum spinal cord compression (MSCC, more than 55.8%) are independent risk factors for poor prognosis of SCI after surgical treatment (p<0.05), with AUCs of 0.95 (time from injury to operation), 0.91 (SLIC score), and 0.96 (MSCC).ConclusionsTime from injury to operation (more than 3.8 days), SLIC score (more than 7.5), and MSCC (more than 55.8%) are independent risk factors for poor prognosis of SCI with subaxial cervical fracture-dislocation after surgical treatment.

Surgical Treatment of Lower Cervical Fracture-Dislocation with Spinal Cord Injuries by Anterior Approach: 5- to 15-Year Follow-Up

Lower cervical fracture-dislocations frequently occur with spinal cord injuries. There is no clear consensus on best treatment option. Anterior approach surgery with direct decompression and reduction has become widely accepted. We assessed clinical outcomes of anterior approach surgery in a retrospective cohort study. From January 2001 to January 2011, 312 patients with lower cervical spine fracture-dislocation with spinal cord injuries who were treated by the anterior approach were retrospectively analyzed. Of 312 patients, 218 (70%; 121 men and 97 women) met inclusion criteria. Clinical efficacy was evaluated using Odom's criteria and statistical analysis based on Cobb angle of kyphosis and Neck Disability Index and Japanese Orthopedic Association scores. Neurofunctional recovery of patients was assessed by the American Spinal Injury Association system. Average follow-up was 8.9 ± 2.9 years (range, 5-15 years). Kyphosis angle and Neck Disability Index and Japanese Orthopaedic Association scores were significantly changed from preoperative values of 10.6° ± 8.9° and 39.7 ± 4.3 and 7.6 ± 2.4 to last follow-up values of-5.2° ± 8.6° and 10.8 ± 4.6 and 15.6 ± 1.2 (P < 0.05). Of patients, 197 (90.4%) had good to excellent outcomes, 14 (6.4%) had satisfactory outcomes, and 7 (3.2%) had poor outcomes. Varying degrees of neurologic function recovery were shown by 143 of the original 218 patients (65.6%) and 140 of 191 patients with incomplete paralysis (73.3%). For lower cervical fracture-dislocation with spinal cord injuries, satisfactory clinical outcomes can be obtained with an anterior approach. The anterior approach restored normal cervical spine structure and promoted functional recovery to achieve a good long-term curative effect.

One-stage anterior-posterior decompression and internal fixation for severe fracture-dislocation of lower cervical spine in "beach chair position"

Objective To explore the surgical feasibility and clinical efficacy of one-stage anterior-posterior approaches in treatment of severe fracture and dislocation of lower cervical spine in beach chair . Methods Sixteen male cases of severe fracture and dislocation of lower cervical spine and with a mean age of 49.8 years (range, 36-78 years) treated surgically from May 2012 to May 2016 were analyzed retrospectively by using case series study. The segment of injury was C4-5 in 4 cases, C5-6 in 7 and C6-7 in 5. The degree of spinal cord injury according to the American Spine injury Association (ASIA) score was Grade A in 4 cases, Grade B in 7 and Grade C in 5. Sub-axial injury classification (SLIC) score was 8 points in 9 cases and 9 points in 7. After a general anesthesia, a ring with a hole was hanged on patient's head before the operation. Then, under the protection of hole traction, the upper of operating bed was swung up slowly, so that the patient was restricted in vertical beach chair with traction on the halo in order to immobilize the head and partially reduce the kyphotic deformity. Routine cervical anterior-posterior approach was done with the exposure of damaged section of the front and rear structure. Pedicle screw system or lateral mass screw displacement was conducted. Anterior intervertebral discectomy or fracture vertebral was performed, using collaborative reset prying method before and after the road. In the front of intervertebral cage or titanium net support bone graft, rear pedicle screws or lateral mass screws fixation and bone graft fusion were implemented. The operation time and blood loss were recorded. The healing of the wound was observed. The recovery of neurological function was evaluated according to the ASIA grade. Postoperative review X-ray, CT and MRI were done to evaluate the reset and bone graft in position and fusion. Results All the surgeries were done well without aeroembolism and other related complications. The mean operative time was 153 minutes (range, 150-180 minutes), and the mean amount of blood loss was 543 ml (range, 400-800 ml). Sixteen cases were followed-up from 6 to 24 months (mean 13.7 months). All the incision were healed at I stage. Spinal cord function did not aggravate. The ASIA grade was improved with an average of one to two Grades 6 months after surgery. Postoperative X-ray and CT confirmed that graft object position was favorable and cervical sequence was recovered well. The Cobb angle decreased from (23.6±5.3)°preoperatively to (4.0±0.4)°postoperatively, and the translational displacement of vertebral body was restored into (2.7±0.4)mm (P<0.01) from (10.9±1.6)mm before operation. The cervical spinal canal was not obstructed and the cervical spinal cord was relieved, showed by MRI. Conclusions One-stage anterior-posterior approaches for severe fracture and dislocation of lower cervical spine circumferential reconstruction in beach chair is a beneficial and effective method, without the need of changing positions in a collaborative reduction and fixation. The method can reduce the interference of spinal cord, shorten the operation time and save anterior extra fixation. Key words: Cervical vertebrae; Spinal fractures; Dislocation; Beach chair position

The role of pre-reduction MRI in the management of complex cervical spine fracture-dislocations: an ongoing controversy?

BackgroundCervical spine fracture-dislocations in neurologically intact patients represent a surgical challenge due to the risk of inflicting iatrogenic spinal cord compression by closed reduction maneuvers. The use of MRI for early advanced imaging in these injuries remains controversially debated.Case presentationA 54-year old man sustained a fall over the handlebars of his racing bicycle. The helmeted patient sustained a fall on his head which resulted in a hyperflexion injury of the neck. He was neurologically intact on presentation. Initial CT imaging revealed a complex multisegmental cervical spine injury with a left-sided C6/C7 perched facet, a right sided C7/T1 fracture-dislocation, and a right-sided C6 and C7 traumatic laminotomy. The initial management consisted of temporary external Halo fixator application without closed reduction maneuver, to mitigate the risk of a delayed spinal cord injury. Subsequent advanced imaging by MRI revealed an acute traumatic C7/T1 disc herniation, with the intervertebral disc completely extruded into the spinal canal. Definitive surgical management was then accomplished by employing a three-stage anterior-posterior-anterior spinal decompression, realignment, fixation and fusion C4-T2 in one operative session. The patient recovered well and retained full neurological function. He resumed bicycle street racing within 10 months of the injury following successful spinal reconstruction.ConclusionsThe diagnostic evaluation of cervical fracture-dislocations should include advanced imaging by MRI in order to fully understand the injury pattern prior to proceeding with spinal reduction maneuvers which may impose the imminent threat of a devastating iatrogenic injury to the spinal cord. The presented staged management by initial Halo fixation without attempts for spinal reduction, followed by a surgical decompression and multilevel fusion, appears to represent a feasible and safe strategy for patients at risk of a delayed neurological injury.

One-stage surgical treatment of cervical spine fracture-dislocation in patients with ankylosing spondylitis via the combined anterior-posterior approach.

The aim of the article is to investigate the efficacy and safety of 1-stage surgical therapy via combined anterior–posterior approach on cervical spine fracture in patients with ankylosing spondylitis (AS).We retrospectively analyzed profiles of 12 AS patients with severe fracture-dislocation of cervical spine received 1-stage combined anterior–posterior surgery in our hospital from October, 2013, to October, 2015, including clinical characteristics, follow-up data, and imaging records. We compared the parameters before and after surgery on the basis of neurological function, bone fusion, Cobb angles of operation segment, Barthel index (BI) score, and incidence rate of complications.A total of 12 patients received 1-stage surgery via combined anterior–posterior approach within 3 days after injury. No severe complications and death occurred. All patients received the successfully anatomical reduction of fracture-dislocation, in which 9 achieved function restoration. The latest follow-up showed the neurological function status of patients was improved. The Cobb angles of operation segments were recovered; the rate of bone fusion was 66.7% at 3 months and 100% at 6 months post-operation. The BI score was improved, 4 cases of moderate dependence and 8 of slight dependence at the latest follow-up compared to 10 of severe dependence and 2 of moderate dependence preoperation. In no cases did severe complications from implanted instrumentation occur.It was high efficacy and safety that the surgical therapy was performed on cervical fracture-dislocation in AS patients by the 1-stage combined anterior–posterior approach. The key of the surgery is the robust stabilization and full decompression of fracture spine at early stage. In addition, if spinal anatomical reduction of fracture segments is difficult to be achieved, the functional restoration should be adopted during the surgery.

Surgical treatment for fracture-dislocation of upper cervical spine complicated with vertebral artery injury

Objective To explore the perioperative management and surgical outcomes of fracture-dislocation of the upper cervical spine complicated with vertebral artery injury. Methods We ret-rospectively analyzed the clinical data of 19 patients diagnosed with fracture-dislocation of the upper cervical spine complicated with vertebral artery injury who had been treated at our department from January 2008 through December 2012. They were 14 males and 5 females, aged from 22 to 53 years (mean, 35.2 years). All the patients had fractures of the atlas and/or axis, and disordered atlanto-axial relationship as well. According to Frankel grading system, 8 cases were Grade D and 11 Grade E. The cervical posterior fixation with pedicle screws was adopted for all and hemostasis was conducted for those with bleeding from the broken vertebral artery. Their Frankel grade, Japanese Orthopedic Association (JOA) score and visual analogue scale (VAS) score were compared between preoperation and final follow-up. Results Intraoperative hemor-rhage occurred in 2 patients from the injured vertebral artery. Hemostasis was achieved through direct tamponade with bone wax and gelatin sponge in one and through endovascular intervention after bleeding control by direct tamponade in another. Neither of them presented with symptoms of posterior circulation ischemia after operation. The mean operation time was 153.5 min, and the mean blood loss was 542.1 mL. All the patients were followed up for an average time of 28 months. Bony union was obtained in all after an average time of 13.5 weeks. Follow-ups revealed no ischemic stroke in this series. Symptoms of transient ischemic attack, like transient dizziness and blurred vision, appeared in 2 patients. At the final follow-up, all the patients were assessed as Frankel Grade E. Their mean JOA and VAS scores were significantly improved from 8.1±1.2 and 7.0±1.7 preoperatively to 12.7±1.6 and 1.3±1.2, respectively (P< 0.05). Conclusions An-giography examination is routinely indicated for the patients with fracture-dislocation of the upper cervical spine perioperatively. Preoperative evaluation of the vertebral artery and its adjacent structures and effective intra-operative hemostasis can avoid uncontrollable bleeding during operation, reduce postoperative complications, and improve surgical outcomes. Key words: Cervical; Fractures, bone; Dislocation; Vertebral artery injury

Treatment of combining anterior and posterior approach for lower cervical spine fracture and dislocation with difficult reduction at primary stage

Objective To investigate the clinical effect of the treatment of combining anterior and posterior approach for lower cervical spine fracture and dislocation with difficult reduction by fixation, decompression and bone graft fusion at primary stage. Methods From January 2012 to January 2015, 32 cases patients associated with difficult reduction of articular process interlocking of the lower cervical spine fracture dislocation were treated with primary stage combining anterior and posterior approach surgical treatment, which was anterior resection of intervertebral disc decompression and posterior facet pry dial or replacement after resection, fixed, and then anterior decompression, bone graft fusion and fixation.The operation time blood loss were recorded.Whether trachea during operation, esophagus and accessory nerve injury, dural breakage of cerebrospinal fluid leakage, whether hyponatremia, whether two spinal cord injury or illness and wound healing were observed.Whether loosening or breakage of internal fixation was observed.The fusion of bone graft and whether false joint and nonunion were recorded in the follow up observation.Frankel classification, JOA score, postoperative cervical intervertebral height and horizontal displacement of vertebral body were recorded. Results The average operation time was (3.85+ 0.66) h, average intraoperative bleeding amount was (855.00+ 3.51) ml.There were no intraoperative tracheal and esophageal injury, 2 cases were intraoperative dural breakage of cerebrospinal fluid leakage and appeared 1 case of hyponatremia after surgery 5 days, but all patients were cured.Thirty-two patients were all followed up for 12 to 26 months, with average (18.00±0.55) months.Postoperative Frankel grade, 1 case of grade A, 4 cases of grade B, 7 cases of grade C, 8 cases of grade D, 12 cases of grade E. Postoperative JOA score with average (12.35±0.80) points, improvement rate of JOA score was 55.4% when discharge, postoperative cervical intervertebral height with average (7.25 ± 1.01) mm, the postoperative intervertebral level shift with average (1.22± 0.24) mm.At last follow-up, X-ray examination prompt bone grafting position were obtained bone fusion and internal fixed position good and strong. Conclusion The treatment of combining anterior and posterior approach for lower cervical spine fracture and dislocation with difficult reduction by fixation, decompression and bone graft fusion at primary stage can make the injured segment smooth reduction, early stable, decompression fully so as to improving neural function repair foundation, and also can create the conditions for lower cervical spine fracture dislocation injury rehabilitation. Key words: Joint locking; Cervical fracture and dislocation; Anterior posterior approach; Interbody fusion