Posterior Open Reduction Research Articles

Effectiveness analysis of three-dimensional printing assisted surgery for unstable pelvic fracture

To evaluate the effectiveness of three-dimensional (3D) printing assisted internal fixation for unstable pelvic fractures. The clinical data of 28 patients with unstable pelvic fractures admitted between March 2015 and December 2017 were retrospectively analyzed. The patients were divided into two groups according to different surgical methods. Eighteen cases in the control group were treated with traditional anterior and posterior open reduction and internal fixation with plate; 10 cases in the observation group were treated with 3D printing technology to make pelvic models and assist in shaping the subcutaneous steel plates of the anterior ring. Sacroiliac screw navigation template was designed and printed to assist posterior ring sacroiliac screw fixation. There was no significant difference between the two groups in gender composition, age, cause of injury, fracture type, and time interval from injury to surgery ( P>0.05). The operation time, intraoperative blood loss, intraoperative fluoroscopy times, incision length, waiting time for weight-bearing exercise, and fracture healing time were recorded and compared between the two groups. Majeed score was used to evaluate the function at last follow-up. At immediate after operation, the reduction was evaluated according to Matta imaging scoring criteria, and the success of sacroiliac joint screw implantation in the observation group was evaluated. The deviation of screw entry point and direction between postoperative screws and preoperative simulated screws were compared in the observation group. All the operation was successfully completed, and all patients were followed up 6-18 months (mean, 14.4 months). In the control group, 1 case had wound infection and 2 cases had deep vein thrombosis. No serious complication such as important blood vessels, and nerve injury and pulmonary embolism occurred in other patients in the two groups. No screw pulling out or steel plate breaking occurred. The operation time, intraoperative blood loss, fluoroscopy times, incision length, and waiting time for weight-bearing exercise of the control group were significantly more than those of the observation group ( P<0.05); there was no significant difference in fracture healing time between the two groups ( t=0.12, P=0.90). There was no significant difference in reduction quality between the two groups at immediate after operation ( Z=-1.05, P=0.30); Majeed score of the observation group was significantly better than that of the control group at last follow-up ( Z=-2.42, P=0.02). The success rate of sacroiliac joint screw implantation in the observation group reached category Ⅰ. In the observation group, the deviation angle of the direction of the screw path between the postoperative screw and the preoperative simulated screw implant was (0.09±0.22)°, and the deviation values of the entry points on the X, Y, and Z axes were (0.13±0.63), (0.14±0.58), (0.15±0.53) mm, respectively. There was no significant difference when compared with those before the operation (all values were 0) ( P>0.05). Computer design combined with 3D printing technology to make personalized pelvic model and navigation template applied to unstable pelvic fractures, is helpful to accurately place sacroiliac screw, reduce the operation time, intraoperative blood loss, and the fluoroscopy times, has good waiting time for weight-bearing exercise and function, and it is an optional surgical treatment for unstable fractures.

Surgical Treatment of Lower Cervical Locked Facet. An Experience in 20 Cases

Background: Cervical spine injuries are common as a result of a growing number of high energy accidents. The subaxial Injury Classification System and Severity Score (SLICS) suggest that a unilateral or bilateral facet dislocation must be managed surgically, even in the absence of SCI (Level of Evidence III). The surgical approaches could be anterior, posterior or combined anterior and posterior approaches. Methods: 20 patients, 12 males and 8 females, with age ranged from 20 to 45 years with lower cervical spine locked facet treated operatively by anterior or posterior spinal instrumentation after trial of closed reduction by skull traction. Results: In this series, satisfactory closed reduction was achieved in 15 patients with percentage 75% and fixed anteriorly, but 5 patients with percentage 25% needed posterior approach for reduction. Regarding ASIA score all of the patients improved at least one level after surgery except 2 cases with preoperative score A: they didn’t improve. Mean preoperative pain score VAS was 7.7 (range from 5 to 9) and postoperative mean of VAS was 0.75 with range from 0 to 3 until final follow up. Conclusion: Anterior approach with discectomy and fusion is necessary; however, if the closed reduction failed, posterior open reduction is indicated with lateral mass fixation, combined approaches can be indicated in specific cases such as increase of the kyphotic angle post anterior approach or when an osteotomy may be required to restore cervical alignment and neural decompression.

Posterior open reduction and internal fixation of C1 fractures: the C-clamp technique.

The treatment of isolated atlas (C1) fractures is still controversial. The surgical management usually involves an arthrodesis of the atlanto-axial (C1-C2) joint with or without occipital fixation. We reviewed the senior author's series of posterior only open reduction and internal fixation (ORIF) of isolated C1 fractures. Retrospective analysis of consecutive patients with isolated C1 fractures, treated in one institution by posterior only ORIF between 2005 and 2017. All fractures of C1 with concomitant C2 or occipital condyle fractures were excluded. The C1 arch was reduced with C1 lateral mass screws, connected with a transverse rod in a C-clamp fashion. We analyzed neck pain on the visual analog scale (VAS) and imaging signs of instability on follow-up. We identified eight patients, six males, and two females with a mean age of 37.9years (range 20-71years). All were neurologically intact before surgery, none had a documented transverse ligament disruption, and the mean gap between the fractured pieces was 5.3mm. Five patients were treated < 72h of injury, two patients had failed halo vest for 8-10weeks, and one patient was operated after 6months because of painful pseudarthrosis despite wearing a hard collar. One patient developed a transient neurological deficit due to vertebral artery dissection that had resolved completely at time of follow-up. The mean follow-up after surgery was 12.6months (range 1-49months) and mean preoperative neck pain (VAS 5.1) was significantly decreased (VAS 0.8; p < 0.001). On follow-up radiological evaluation, no instability was noted in any patient. Posterior ORIF of C1 fractures may be an option for patients who fail or do not wish to pursue conservative management. The particular advantage of this technique over C1-C2 arthrodesis is the preserved range of rotational motion. Mono-axial screws seem to provide better reduction capacity.

The application of multifunctional inflatable pelvis and hip-joint fixator (MIPHF) in damage control in patients with pelvic fracture

Objective To discuss the safety and the application of the self-designed multifunctional inflatable pelvis and hip-joint fixator (MIPHF) in damage control in pelvic fracture patients. Methods The MIPHF was subjected to pressure test and quality inspection. From September 2016 to June 2017, 61 pelvic-fracture patients were treated with our self-designed MIPHF as pre-hospital first-aid care according to the concept of damage control orthopedics (DCO) (MIPHF group). The control group consisted of 69 pelvic-fracture patients who had not received pre-hospital first-aid care with the self-designed MIPHF from December 2015 to August 2016. There were no statistically significant differences between the two groups in gender, age, types of pelvic fracture, and preoperative injure severity score (ISS). The study compared the two groups for the case fatality rate, volume of blood transfused during surgeries, early complication rates, fracture reduction (Matta standards), and long-term efficacy (Cole scores). Results The pressure test showed that the MIPHF had a good fixation effect on the pelvis. And the quality inspection showed that the material used for the MIPHF was in line with national standards and the safety was guaranteed. The MIPHF group had 1 death (1.6%) and the control group had 8 deaths (11.6%), which was a significant difference (χ2=4.979, P=0.026). All survival patients in both groups were followed up. The MIPHF group (61 cases) received 3.0 to 18.0 months follow-up, with an average of 9.0 months. And the control group (69 cases) had 18.0 to 30.0 months follow-up, with an average of 21.9 months. In the MIPHF group, 23 cases were treated conservatively, and 37 cases were treated with surgery. Among them, 3 cases were fixed with external fixator, 20 cases with anterior open reduction and internal fixation, 9 cases with posterior open reduction and internal fixation, and 5 cases with combined anterior and posterior fixation. The timing of surgery was 1 to 20 days after injury, with an average of 4.1 days. The volume of blood transfused in the MIPHF group during surgery was 200 to 1500 ml, with an average of 628.6 ml. In the control group, 27 patients were treated conservatively, and 42 patients were treated with surgery. Among them, 2 cases were fixed with external fixator, 24 cases with anterior open reduction and internal fixation, 10 cases with posterior open reduction and internal fixation, and 6 cases with combined anterior and posterior fixation. The timing of surgery was 1 to 15 days after injury, with an average of 3.1 days. The volume of blood transfused in the control group during surgery was 200 to 4000 ml, with an average of 1 707.1 ml. There was a significant difference between the two groups in intraoperative blood transfusion(Z=-2.330, P=0.020). The MIPHF group had 10 (16.4%) cases of early serious complications and the control group had 22 (31.9%) cases, which had a significant difference (χ2=4.187, P=0.041). According to the criteria proposed by Matta et al., the good rate of results for treating fractures was 82.0% in the MIPHF group and 60.9% in the control group, which got a significant difference (χ2=6.967, P=0.008). The MIPHF group and the control group also differed significantly in their mean long-term Cole scores (27.2±4.0 versus 25.1±5.6, t=2.457, P=0.015). Conclusion MIPHF, which reflects the DCO concept, may be recommended as pre-hospital first-aid care for patients with pelvic fracture because it can lessen bleeding and prevent secondary pelvic injury, thus reduce case fatality rate and the incidence of complications. It can also improve the success rate of treating pelvic fracture, which will positively affect long-term outcomes. Key words: Pelvis; Fractures, bone; External fixators; First aid

Hemostasis following local versus intravenous tranexamic acid in patients undergoing posterior open reduction and internal fixation of thoracolumbar fractures: study protocol for a parallel-group, randomized controlled trial

Hemostasis following local versus intravenous tranexamic acid in patients undergoing posterior open reduction and internal fixation of thoracolumbar fractures: study protocol for a parallel-group, randomized controlled trial

Homeopathic closed leverage anatomical plate with compression bolt for treatment of displaced intra-articular calcaneal fractures

Objective To compare the treatment of displaced intra-articular calcaneal fractures by homeopathic closed leverage anatomical plate with compression bolt through small posterior lateral approach vs. traditional open reduction and internal fixation. Methods A retrospective case control study was made on 98 cases of displaced intra-articular calcaneal fractures admitted from September 2012 to May 2015. According to the random number table, the subjects were assigned to homeopathic closed leverage anatomical plating with compression bolt through small posterior lateral approach (experiment group, 58 cases, 66 sides) and open reduction and internal fixation through L-shape approach (control group, 40 cases, 45 sides). Experiment group consisted of 50 male and eight females cases aging from 27-56 years (mean, 41.9 years), and the Sanders classification was 40 cases of type Ⅱ, 24 type Ⅲ and two type Ⅳ. Control group consisted of 36 male and four female cases aging from 25-58 years (mean, 43.7 years), and the Sanders classification was 25 cases of type Ⅱ, 18 type Ⅲ and two type Ⅳ. Operation time, bone reduction, postoperative Bohler's angle, width of the calcaneum, and incision healing were recorded. Functional outcomes were evaluated with Maryland hindfoot scoring system at last follow-up. Results Operation time was (52.6±11.2)min in experiment group, significantly shorter than that in control group [(86.4±14.1)min] ( P 0.05). Postoperative Bohler's angle was (28.0±6.2)° in experiment group, and (26.8±7.0)° in control group (P>0.05). Width of the calcaneum was (31.3±3.6)mm in experiment group and (34.9±4.0)mm in control group (P 0.05). Conclusion Homeopathic percutaneous leverage and anatomical plate with compression bolt through small posterior lateral approach is an effective method for treatment of displaced intra-articular calcaneal fractures, for it has advantages of minimal invasion, less operation time, good reduction and function, and less wound complications. Key words: Calcaneus; Intra-aticular fractures; Percutaneous leverage

Surgical strategies for cervical spine fracture combined with ankylosing spondylitis and cervicothoracic junction kyphosis

Objective To discuss the operative strategies for cervical spine fracture combined with ankylosing spondylitis and the deformity of cervicothoracic kyphosis. Methods Retrospectively analyzed 21 cases of cervical spine fracture combined with ankylosing spondylitis and the deformity of cervicothoracic kyphosis, who underwent surgeries from January, 2007 to August, 2014. Twenty males and 1 female were included. Mean age was (48.6±7.5) years (range, 36-65 years). The preoperative American Spine Injury Association (ASIA) classification distribution: 2 cases of Grade A, 6 cases of Grade B, 7 cases of Grade C, 5 cases of Grade D, and 1 case of of Grade E. The investigative surgical methods including posterior cervical open reduction, internal fixation and bone graft fusion; posterior cervical open reduction/decompression, internal fixation and bone graft fusion; or combined posterior and anterior cervical decompression, bone graft fusion and instrumentation. The operative time and blood loss were recorded, the clinical therapeutic effect was evaluated by visual analogue scale (VAS) score, ASIA grade improvement, cervical curvature (the angle between a line drawn parallel to the inferior endplate of C2 and a line drawn parallel to the inferior endplate of C7 in the lateral plane of an X-ray image) and radiological assessment (including bone graft fusion condition and internal fixation position). Results One case died from severe pulmonary infection and respiratory failure at the 45th day after operation. All the other 20 patients obtained complete follow-up with a mean time of (39.4±8.76) months (range, 25-59 months). 7 cases received posterior cervical open reduction, internal fixation and bone graft fusion, average operative time was (92.1±5.4) minutes and average blood loss was (96.1+23.7) ml. 9 cases received the posterior cervical open reduction and decompression, internal fixation and bone graft fusion, mean operation time was (121.4±14.0) minutes and blood loss was (250.0±38.9) ml. 3 cases experienced combined posterior and anterior cervical decompression, bone graft fusion and fixation, average operative time was (222.4±14.9) minutes and average blood loss was (354.3+46.7) ml. Mean of VAS scores at the 3th month postoperatively was 2.76±0.46, significantly lower than the preoperatively VAS scores (8.95±0.36). Mean of VAS scores at the 24th month postoperatively was 1.77±0.39, significantly lower than those at the 3th month postoperatively. The neurological function of spinal cord achieved significant improvement after operations and continued recovered gradually in the subsequent follow up. ASIA Classification distribution at the 24th month postoperatively was: 0 case of Grade A, 0 case of Grade B, 3 cases of Grade C, 8 cases of Grade D, 9 case of Grade E. Mean of the cervical curvature after operation was -7.1°±1.9°, significantly higher than preoperatively(-13.4°±3.3°) and did not have any loss of Cobb's angles at 24th month after operation. All the surviving cases achieved solid bone graft fusion. Mean bone graft fusion time was 5.8 months (range, 4-9 months). There was no internal fixation loose, fracture and dislocation occurred during follow up. Conclusion All procedures can significantly relieve the painful symptoms, effectively restore the normal cervical alignment and stability, and remarkably improve the neural function of the patients suffering cervical spine fracture combined with ankylosing spondylitis and the deformity of cervicothoracic junction kyphosis. Key words: Spondylitis, ankylosing; Cervical vertebrae; Spinal fractures; Thoracic vertebrae; Kyphosis

Gartland Type 3 Supracondylar Humeral Fractures in Children: Which Open Reduction Approach Should Be Used After Failed Closed Reduction?

For displaced supracondylar humeral fractures in children, in the event of closed reduction failure, anatomic reduction is achieved via open reduction techniques; however, there are no confirmative reports among the published open reduction approaches that deliver the best functional and cosmetic results. Here, we compared long-term functional and cosmetic results of different surgical approaches. Retrospective cohort study. Ankara Education and Research Hospital/Turkey. Secondary care hospital and trauma center. We evaluated 70 surgically treated Gartland type 3 supracondylar humeral fractures. Patients, with detailed history record, were divided into 5 groups with respect to surgery methods. All patients were treated surgically using closed reduction and percutaneous pinning or 4 different open reduction approaches and percutaneous pinning. Flynn cosmetic and functional score results were compared between surgical groups. Posterior open reduction and triceps transection groups showed worst results, whereas medial and lateral open reduction groups showed good to excellent results similar to closed reduction group. Medial and lateral approaches demonstrated better functional results than posterior and triceps transection approaches. Posterior approaches lead to restrictions in extension and poor functional results. In the posterior approach, transecting triceps from olecranon does not benefit from fracture reduction but results in loss of triceps strength and should be avoided. In failed closed reduction, medial and lateral open reduction approaches lead to similar cosmetic outcomes and functional results that are only slightly worse compared with those in closed reduction. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

New bone fixation plate for the repair of avulsion fracture of the tibial attachment of the posterior cruciate ligament: study protocol for a prospective, open-label, self-controlled, clinical trial

Background: Avulsion fractures of the tibial attachment of the posterior cruciate ligament have been repaired using open reduction and rivet fixation, hollow screw fixation, or arthroscopic reconstruction of the posterior cruciate ligament. These methods ignore the importance of early tension reconstruction of the posterior cruciate ligament, so their efficacies are uncertain. Determining the optimal fixation method and how best to restore knee stability remain controversial. Methods/Design: We will conduct a prospective, single-center, self-controlled, clinical trial at the Cangzhou Central Hospital, Hebei Province, China. Fracture fragments and the injured posterior cruciate ligament will be exposed in twenty patients with avulsion fracture of the tibial attachment of the posterior cruciate ligament through a posterior approach and open reduction. The posterior cruciate ligament will be reconstructed with a new type of bone plate. All patients will be followed for 3 and 12 months. Primary outcome: The Hospital for Special Surgery knee score will be used to evaluate knee function preoperatively and 3 and 12 months postoperatively. Secondary outcomes: Lysholm Knee Scoring Scale, X-ray, computed tomography, and magnetic resonance imaging will be used to assess knee morphology preoperatively and 3 and 12 months postoperatively. Patient satisfaction will also be assessed at 3 and 12 months postoperatively. Discussion: This trial will evaluate a newly-designed plate fixation device for early tension reconstruction of the posterior cruciate ligament to repair avulsion fractures of the tibial attachment of the posterior cruciate ligament and restore knee stability. This trial will verify the plate's efficacy, provide an experimental basis for treating avulsion fractures of the tibial attachment of the posterior cruciate ligament, and provide a method of maximizing knee stability. Trial registration: ClinicalTrials.gov identifier: NCT03059368. Ethics: The study protocol has been approved by the Ethics Committee of Cangzhou Central Hospital of China. All protocols will be in accordance with Helsinki Declaration, formulated by the World Medical Association. Informed consent: Written informed consent will be provided by participants.

The Effects of Positioning the Operative Limb on Tibial and Fibular Nerve Somatosensory Responses during Acetabulum Fracture Repair: A Report of Two Unusual Cases

ABSTRACTOur institution uses lower extremity somatosensory evoked potentials from the fibular (peroneal) and tibial nerves during posterior open reduction and internal fixation of the acetabulum to monitor the functional integrity of the sciatic nerve. This allows identification of compromised function caused by operative maneuvers. However, nonsurgical factors can also significantly affect the responses. In this article, we present one case where positioning of the leg and foot apparently caused diminished responses and was resolved by changing the manner of wrapping and securing the leg and foot. The second case is unusual because positioning improved the responses from being absent to identifiable and stable. Investigation of changes in peripheral responses should include examination of the position of the affected leg for ischemia and edema, and particularly the stimulation site for possible compromise

Posterior Open Reduction and Interlaminae Compression Fusion for Os Odontoideum with Atlantoaxial Dislocation

To evaluate the outcome of posterior open reduction and interlaminae compression fusion using a screw-rod system combined with a structural iliac bone graft in the treatment of atlantoaxial dislocation (AAD) secondary to os odontoideum. A retrospective study was performed on 24 patients with AAD secondary to os odontoideum. All cases were with partial reduction after skeletal traction. Intraoperative open reduction and fixation were performed with a posterior screw-rod system, followed by interlaminae compression of an autologous iliac bone graft for fusion. The modified atlanto-dental interval (MADI) was measured to assess the degree of dislocation before traction, after traction, and postoperatively. Japanese Orthopaedic Association (JOA) score, Nurick scale score, visual analog scale score for neck pain (VASSNP), Neck Disability Index (NDI) score, and neck stiffness were used to evaluate functional outcomes. The mean duration of follow-up was 43.0±24.0 months. All patients achieved relief of symptoms and solid bone fusion. There were no complications associated with instrumentation and operation. At the final follow-up, the average MADI was reduced to 2.0 ± 0.8 mm (pretraction: 9.2 ± 1.1 mm; post-traction: 6.6 ± 0.7 mm; P<0.001). The neck stiffness was significantly relieved (P< 0.001), and function of the spinal cord manifested by the JOA score and Nurick scale score significantly improved (all P < 0.001). The NDI score and VASSNP markedly decreased (all P < 0.001). Intraoperative open reduction and interlaminae compression fusion using a posterior screw-rod system combined with a structural iliac bone graft is a safe and effective procedure for AAD secondary to os odontoideum.

Preoperative digital plan and 3D rapid prototyping technique in treatment of complete fracture-dislocation of thoracic and lumbar spine fracture

Objective To apply the preoperative digital plan and 3D rapid prototyping technique in supervising the surgical manipulation and restoring spinal stability of thoracic and lumbar spinal fracture accompanied by complete dislocation and investigate the clinical feasibility and effecacy. Methods From January 2009 to January 2014, 32 cases (19 males and 13 females) of thoracic and lumbar spinal fracture accompanied by complete dislocation were admitted. Age ranged from 17 to 56 years[(30.1±7.6)years]. Fifteen cases admitted before October 2010 received open posterior reduction, pedicle screw fixation and bone grafting (conventional group). Prior to the posterior open reduction and internal fixation, 17 cases admitted after October 2010 were aided using the new technique (computer-assisted group). 3D reconstruction of the CT scanned spine was performed so as to get the dislocation patterns and degree of pedicle rupture, 3D templates were fabricated using the rapid prototyping technique, and preoperative plan included the decompression area, fusion segments, and insertion point and angle. Operation time, blood loss, drainage, visual analogue scale (VAS), Frankel score and fusion rate were compared between the two groups. Results All cases were followed up at least 1 year[(3.6±0.5) years]. Operation time and bleeding in conventional group were (194.0±38.5)min and (502.0±114.5)ml, significantly lowered compared to(168.8±23.8)min and (420.0±94.6)ml in computer-assisted group (P 0.05], but there was significant difference at the final follow-up [(1.87±0.27) vs. (1.67±0.22)points, P 0.05). Frankel score used for assessment of nerve function did not differ significantly between the two groups (P>0.05). Conclusions Preoperative digital plan and 3D rapid prototyping technique enable the understanding of fracture patterns and pedicle integrity and then help guide decompression and screw insertion. The benefits included shorter operation time, improved reduction and decreased risks of implant failure. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Dislocations; 3D-printing

Complications in Minimally Invasive Percutaneous Fixation of Thoracic and Lumbar Spine Fractures

Minimally invasive stabilization of thoracic and lumbar fractures without neurologic involvement is becoming a more frequent alternative to open fusion and conservative treatment. The authors analyzed the complication rate and limits of this technique in a consecutive series of 99 patients (127 thoracolumbar vertebral fractures) who underwent this technique between May 2005 and November 2009. Eighty-three patients had only spine injuries, whereas 16 had polytrauma injuries (mean Injury Severity Score, 25.2). In these 16 patients, percutaneous fixation was performed as a damage control procedure. The most frequent construct was monosegmental: 1 level above and 1 level below the fractured vertebra. In the remaining 21 patients, multilevel construction was performed for multiple injuries. Complications were analyzed according to the period of onset (intra- and postoperative) and the severity (major and minor). Twelve (12%) complications were recorded: 4 (4%) were intraoperative, 6 (6%) were early postoperative, and 2 (2%) were late postoperative; 4 (4%) were minor and 8 (8%) were major. Mean follow-up was 52 months (range; 36-90 months). All patients except 1 were considered healed after 6-month follow-up. The failed patient had an initial kyphosis greater than 20°, and a posterior open reduction and fusion would have been more appropriate. Minimally invasive stabilization of selected spine injuries is a safe technique with a low complication rate. The main goal of this approach is a fast recovery time, so any complication leading to an extended length of stay should be considered severe. An adequate learning curve is important to minimize complications.

Management of Hangman's Fractures and a Subaxial Compression Fracture in Two Children With Osteogenesis Imperfecta

Cervical spine fractures in osteogenesis imperfecta are rare. The purpose of this article is to describe the successful outcomes of the nonoperative and operative treatment of C2 pars fracture and operative treatment of C7 compression fracture in two children with osteogenesis imperfecta. Patient 1, a 22-month-old female, had a C2 pars fracture managed nonoperatively with a cervical orthosis. Patient 2, a 15-year-old male, had concurrent C2 pars and C7 compression fractures; the C2 pars fractures were treated operatively via a posterior approach and open reduction and internal fixation, and the C7 compression fracture was treated via a C7 corpectomy, iliac crest strut autograft, and anterior plating from C6 to T1. Patient 1 had delayed union but complete healing at latest follow-up (31 months postpresentation). At latest follow-up, patient 2 remained asymptomatic.

Operative treatment of subaxial cervical dislocation without spinal cord injury

Objective To discuss the selection and clinical efficacy of operative methods for subaxial cervical dislocation without spinal cord injury. Methods A retrospective study was performed on 11 patients with subaxial cervical dislocation without spinal cord injury treated from January 2004 to June 2009. According to Allen' s classification, all patients suffered from retracted flexion injuries, including seven patients with Ⅰ degree dislocation, one with Ⅱ degree dislocation and three with Ⅲ degree dislocation. There were eighth patients with old dislocation and three with fresh dislocation, both of which were simple cervical trauma without other organ injuries. Open reduction, internal fixation and iliac bone graft spinal fusion were performed in seven patients and combined posterior and anterior open reduction,internal fixation and iliac bone graft spinal fusion in four. All the patients were followed up for observation of clinical effect. Results All operations were completed successfully. There were 11 patients at Frankel grade E preoperatively and 11 at grade E postoperatively. X-ray photographs showed that the sequence and curvature of the cervical spine recovered to normal after operation. All patients were followed up for 3-31 months postoperatively, which showed no redislocation or symptoms of spinal cord injury.Conclusion For lower cervical dislocation combined with locked facet, one-stage combined anterior and posterior reduction and internal fixation should be performed. While for those without locked facet, simple anterior reduction and bone graft spinal fusion is needed. Open reduction, internal fixation and bone graft spinal fusion are effective method for treatment of subaxial cervical dislocation without spinal cord injury. Key words: Spinal injuries; Cervical vertebrae; Dislocations; Surgical procedures, operative

Posterior approach for cervical fracture-dislocations with traumatic disc herniation.

In the treatment algorithm for cervical spine fracture-dislocations, the recommended approach for treatment if there is a disc fragment in the canal is the anterior approach. The posterior approach is not common because of the disadvantage of potential neurological deterioration during reduction in traumatic cervical herniation patients. However, reports about the frequency of this deterioration and the behavior of disc fragments after reduction are scarce. Forty patients with traumatic disc herniation were observed. They represented 29.2% of 137 consecutive patients with subaxial cervical spine fracture-dislocations. Surgical planning was performed according to our two-stage algorithm. In the first stage, they were treated with posterior open reduction and posterior spine arthrodesis. In the second stage, anterior surgery was added for cases where neurological deterioration attributed to non-reduced disc fragments on postoperative magnetic resonance imaging (MRI). Neurological deterioration after posterior open reduction was not observed. Furthermore, 25% of total cases and 75% of incomplete paralysis cases improved postoperatively by ≥ 1 grade in the American Spinal Injury Association impairment scale. Reduction or reversal of disc herniation was observed in all cases undergoing postoperative MRI. For local sagittal alignment, preoperative 9.4° kyphosis was corrected to 6.9° lordosis postoperatively. The disc height ratio was 72.4% preoperatively and 106.3% postoperatively. The second stage of our plan was not required after the posterior approach in this series. The incidence of neurological deterioration after posterior open reduction was zero, even in cases with traumatic cervical disc herniation. Favorable clinical and radiological outcomes could be obtained by the first stage alone. Although preparations for prompt anterior surgery should always be made to cover any contingency, the need for them is minimal.

Lateral C1–C2 dislocation complicating a type II odontoid fracture

We describe a unique C1–C2 lateral dislocation complicating a displaced type II odontoid fracture. We report a 63-year-old female pedestrian involved in a motor vehicle accident who required posterior open reduction and segmental C1–C2 instrumentation and fusion. Radiological examination of the cervical spine demonstrated a lateral dislocation of the atlantoaxial joint with a displaced type II fracture of the odontoid, fracture of the right lateral mass of C1 and left superior articular facet of C2. Neurological examination revealed the patient to be myelopathic and closed halo traction failed to achieve reduction. Due to the irreducible nature of the dislocation, posterior open reduction and segmental C1–C2 instrumentation and fusion was performed. The dislocated C1–C2 articulation was successfully reduced surgically with subsequent bony fusion and resolution of all neurological symptoms and signs at final follow-up. To our knowledge, this the first report of this type of injury. We also review the related literature on this unique injury pattern.

Treatment choices for unilateral cervical facet locking

Objective To explore different treatment choices for unilateral cervical facet locking. Methods The study involved 32 patients with cervical unilateral facet locking. Successful reduction by the skull traction was done in eight patients, of whom three were fixated by the head and neck chest plas-ter after a month of traction. Five patients were treated with anterior decompression and internal fusion fixation. The other 23 patients resulted in failure of traction and then were treated with anterior reduction, discectomy and internal fusion fixation in 14 patients, subtotal vertebral decompression and bone graft fix-ation in three, posterior open reduction and anterior bone graft fixation in one, posterior reduction, fixation and internal fusion fixation in three and posterior reduction and decompression plus anterior discectomy decompression and bone graft fixation in two. Due to misdiagnosis, one patient was treated with anterior decompression and fusion eight months after injury. Results A follow-up for average 18 months showed cervical instability in two patients who were treated with only traction, without fusion. The patients treated with anterior cervical fusion obtained bone union after 12 weeks, with satisfactory cervical physiological curvature and vertebral height. There were no internal fixation complications or neurological complications. Conclusions The treatment of lower cervical unilateral facet locking needs a compre-hensive considerations on whether there associates with disc injury, posterior column fractures or spinal cord injuries. As for patients with lower cervical unilateral facet locking combined with traumatic cervical disc herniation, the anterior reduction and decompression is the choice of treatment. While for those with-out disc herniation, traction or posterior open reduction and fixation can be carried out directly. Key words: Spinal injuries; Cervical vertebrae; Fracture fixation, internal; Bone fusion

Comparison study between Wiltse paraspinal approach and conventional approach for thoracolumbar vertebral fracture.

Objective To determine the difference of paraspinal muscle injury between Wiltse paraspinal approach and conventional approach for the thoracolumbar vertebral fracture with open reduction and internal fixation. Methods A total of 47 patients with thoracolumbar vertebral fracture(ASIA E) under-went posterior open reduction and internal fixation from June 2004 to December 2006. Randomly, 22 pa-tients adopted Wiltse paraspinal approach, including 16 males and 6 females with the mean age of 37.6 years; 25 patients adopted traditional approach, 18 males and 7 females with the mean age of 40.1 years. The operative duration, blood loss and changes of postoperative serum level of Creatinine Kinase were com-pared. Total 47 patients were followed up with VAS scores 1 day preoperatively, 1 and 6 months postopera-tively. And EMG were adopted for long-term evaluation. Results There was no obvious difference in surgi-cal time, but less blood loss, lower index of serum level of Creatinine Kinase in Wihse paraspinal approach group. The VAS score in Wihse paraspinal approach was significantlt less than that in conventional approach group 1 and 6 months postoperatively. And in conventional approach group EMGs demonstrated fibrillation potentials, but they were normal in Wihse approach group. Conclusion The Wihse paraspinal approach is an easy way for treating of thoracolumbar vertebral fracture, minimize the soft tissue injury in operation and creates less complications after operation. Key words: Thoracic vertebrae; Lumbar vertebrae; Spinal fractures; Fracture fixation, internal

Complete Hyperextension Fracture-Dislocation of the Lower Cervical Spine without Spinal Cord Deficit: A Case Report

An unusual case of complete hyperextension fracture-dislocation of C 6 on C 7 with no spinal cord deficit in a 50-year-old man is reported. Dissociation between the fractured posterior arch, remaining in good alignment, and the anteriorly displaced vertebral body, with anterior-posterior widening of the spinal canal, prevented spinal cord damage. Posterior open reduction and internal fixation with plates screwed to the articular masses resulted in anatomic and stable reposition of the displacements. One year after the injury, the patient was symptom-free, with almost full neck mobility and neurologically normal and CT scans showed a normal spinal canal.