Skull Traction Research Articles

Long-term outcome of adult traumatic atlantoaxial rotatory fixation: a case series

BackgroundThis case series presents five cases of adult atlantoaxial rotatory subluxation (AARS) following traumatic events, focusing on treatment strategies and long-term outcomes.Case presentationThis paper includes four Iranian male patients and one Iranian female patient with ages ranging from 25 to 46 years old. Each case involved unique presentations and management approaches. Initial conservative treatments, including skull traction and orthoses, were attempted, but surgical intervention became necessary due to inadequate response. Surgical fixation significantly improved functional status and alleviated symptoms in all patients, leading to long-term relief. Radiological assessments demonstrated successful outcomes post-surgery.ConclusionsThis study underscores the importance of considering both conservative and surgical options in managing adult atlantoaxial rotatory subluxation to achieve optimal outcomes.

Treatment of a symptomatic patient with severe progressive odontoid invagination and Cervicothoracic scoliosis: A case report.

While there is no consensus on optimal treatment management for the rare condition of odontoid invagination with cervicothoracic scoliosis, skull traction for 12 weeks followed by combined posterior and anterior spinal fusion can be a feasible option. However, surgeons should be prepared for significant intraoperative and postoperative challenges.

Surgical Treatment Outcomes of Anterior-Only Correction and Reconstruction for Severe Cervical Kyphotic Deformity with Neurofibromatosis-1: A Retrospective Study with a 5-Year Follow-Up.

Currently, anterior-only (AO), posterior-only, and combined anterior-posterior spinal fusions are common strategies for treating cervical kyphosis in patients with neurofibromatosis-1 NF-1. Nevertheless, the choice of surgical strategy remains a topic of controversy. The aim of our study is to evaluate the safety and effectiveness of anterior decompression and spinal reconstruction for the treatment of cervical kyphosis in patients with NF-1. Twelve patients with NF-1-associated cervical kyphotic deformity were reviewed retrospectively between January 2010 and April 2020. All patients underwent AO correction and reconstruction. The X-ray was followed up in all these patients to assess the preoperative and postoperative local kyphosis angle (LKA), the global kyphosis angle (GKA), the sagittal vertical axis, and the T1 slope. The visual analog scale score, Japanese Orthopedic Association (JOA) score, and neck disability index (NDI) score were used to evaluate the improvement inclinical symptoms. The results of the difference in improvement from preoperatively to the final follow-up assessment were assessed using a paired t-test or Mann-Whitney U-test. The LKA and GKA decreased from the preoperative average of 64.42 (range, 38-86) and 35.50 (range, 10-81) to an average of 16.83 (range, -2 to 46) and 4.25 (range, -22 to 39) postoperatively, respectively. The average correction rates of the LKA and GKA were 76.11% and 111.97%, respectively. All patients had achieved satisfactory relief of neurological symptoms (p < 0.01). JOA scores were improved from 10.42 (range, 8-16) preoperatively to 15.25 (range, 11-18) at final follow-up (p < 0.01). NDI scores were decreased from an average of 23.25 (range, 16-34) preoperatively to an average of 7.08 (range, 3-15) at the final follow-up (p < 0.01). Anterior-only correction and reconstruction is a safe and effective method for correcting cervical kyphosis in NF-1 patients. In fixed cervical kyphosis cases, preoperative skull traction should also be considered.

Is Anterior Cervical Discectomy and Fusion Sufficient for Neglected Unstable Hangman's Fracture? A Retrospective Case Series of Five Patients.

This study investigates the outcomes of treating neglected unstable Hangman's fractures through a single-stage Anterior Cervical Discectomy and Fusion (ACDF) procedure with tricortical iliac crest bone grafts. Five patients with neglected unstable Hangman's fractures, treated at our institution between March 2012 and March 2017, underwent C2-C3 ACDF. Functional outcomes were assessed using the Visual Analog Scale (VAS) score and Neck Disability Index (NDI), and neurological evaluation was done using the American Spinal Injury Association (ASIA) grading system. The radiological assessment included serial plain radiographs and a computed tomography scan at a 12-month follow-up. Postoperatively, C2-C3 angulation improved significantly, decreasing from 15° to 4.4°, and sagittal translation improved from 4.2 mm to 2 mm. The VAS score improved from 6.4 to 1.4 at 24 months postsurgery. Concurrently, NDI decreased from 70.4% to 14.8%. Fusion occurred in an average of 5.6 months. Neurologically, one patient improved from ASIA grade D to grade E, while the other four retained their grade E status. A single-stage ACDF with autologous iliac crest bone grafts is an effective surgical option for neglected type II/IIA Hangman's fractures, yielding satisfactory functional and radiological outcomes. This technique significantly corrects anterior translation and angulation, even in neglected cases, with the aid of intraoperative skull traction and plate reduction.

Preoperative Skull Traction, Anterior Debridement, Bone Grafting, and Internal Fixation for Cervical Tuberculosis with Severe Kyphosis.

Cervical tuberculosis (CTB) readily causes local kyphosis, and its surgical strategy remains controversial. Although some previous studies suggested that the anterior approach could effectively treat CTB, patients in these studies only suffered mild to moderate kyphosis. Therefore, little is known about whether the anterior approach can achieve satisfactory outcomes in CTB patients with severe kyphosis. This study was performed to evaluate the safety and efficacy of preoperative skull traction combined with anterior surgery for the treatment of CTB patients with a severe kyphosis angle of more than 35°. In this retrospective study, we enrolled 31 CTB patients with severe kyphosis who underwent preoperative skull traction combined with anterior surgery from April 2015 to January 2021. Patients were followed up for at least 2 years. Clinical data, such as operative time, blood loss, and postoperative hospital stay, were collected. The clinical outcomes included American Spinal Injury Association (ASIA) spinal cord injury grade, Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and related complications. The radiological outcomes included the Cobb angle of cervical kyphosis at each time point and the bony fusion state. Clinical efficacy was evaluated by paired Student's t-test, Mann-Whitney U-test, and others. Six patients had involvement of one vertebra, 21 had involvement of two vertebrae, and four had involvement of three vertebrae. The most common level of vertebral involvement was C4-5, whereas the most common apical vertebra of kyphosis was C4. The mean kyphosis angle was 46.1° ± 7.7° preoperatively, and the flexibility on dynamic extension-flexion X-rays and cervical MRI was 17.5% ± 7.8% and 43.6% ± 11.0%, respectively (p = 0.000). The kyphosis angle significantly decreased to 13.2° ± 3.2° after skull traction, and it further corrected to -6.1° ± 4.3° after surgery, which was well maintained at the final follow-up with a mean Cobb angle of -5.4° ± 3.9°. The VAS and JOA scores showed significant improvement after surgery. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels normalized at 3 months after surgery. All patients achieved solid bone fusion, and no complications related to the instrumentation or recurrence were observed. Preoperative skull traction combined with anterior debridement, autologous iliac bone grafting, and internal plate fixation can be an effective and safe surgical method for the treatment of cervical tuberculosis with severe kyphosis. Skull traction can improve the safety and success rate of subsequent anterior corrective surgery.

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.

Effect of cervical suspensory traction in the treatment of severe cervical kyphotic deformity.

This study aimed to investigate a new noninvasive traction method on the treatment of severe cervical kyphotic deformity. The clinical data of patients with severe cervical kyphosis (Cobb > 40°) treated in Peking University Third Hospital from March 2004 to March 2020 were retrospectively summarized. 46 cases were enrolled, comprising 27 males and 19 females. Fifteen patients underwent skull traction, and 31 patients underwent suspensory traction. Among them, seven used combined traction after one week of suspensory traction. Bedside lateral radiographs were taken every two or three days during traction. The cervical kyphosis angle was measured on lateral radiographs in and extended position at each point in time. The correction rate and evaluated Japanese Orthopedic Association (JOA) scoring for the function of the spinal cord were also measured. The data before and after the operation were compared with paired sample t-test or Wilcoxon signed-rank test. No neurological deterioration occurred during the skull traction and the cervical suspensory traction. There were 12 patients with normal neurological function, and the JOA score of the other 34 patients improved from 11.5 ± 2.8 to 15.4 ± 1.8 at the end of follow up (P < 0.05). The average kyphotic Cobb angle was 66.1° ± 25.2, 28.7° ± 20.1 and 17.4° ± 25.7 pre-traction, pre-operative, and at the final follow-up, respectively (P < 0.05). The average correction rate of skull traction and suspensory traction was 34.2% and 60.6% respectively. Among these, the correction rate of patients with simple suspensory traction was 69.3%. For patients with a correction rate of less than 40% by suspensory traction, combined traction was continued, and the correction rates after suspensory traction and combined traction were 30.7% and 67.1% respectively. Pre-correction by cervical suspensory traction can achieve good results for severe cervical kyphotic deformity, with no wound and an easy process. Combined traction is effective for supplemental traction after suspensory traction.

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.

Effect of C1 Single-door Laminoplasty on Symptomatic Atlas Canal Stenosis.

ObjectiveTo verify the effect of single‐door laminoplasty combined with atlantoaxial fusion in the treatment of symptomatic atlas canal stenosis.MethodsThis is a single‐center retrospective analysis. From February 2014 to January 2019, 16 patients (five were females) with an average age of 63.4 years (56–71 years) were enrolled in this study. Patients with compressive cervical myelopathy with CT scan showed an inner sagittal diameter (ISD) of C1 less than 29 mm or C1 canal space available for cord (SAC) of <12 mm were included, while isolated C1 stenosis without myelopathy or isolated C1 stenosis without atlantoaxial subluxation were excluded in this study. All patients underwent continuous heavy‐weight skull traction, atlas single‐door laminoplasty and atlantoaxial fusion. The differences in the pre‐ and post‐operative inner sagittal diameter, space available for cord, atlas‐dens interval (ADI) and compression of the spinal cord were analyzed by using CT and MRI. Functional evaluation was performed by using the Japanese Orthopaedic Association scoring system and the Neck Disability Index scoring system.ResultsSingle‐door laminoplasty provided a full decompression for the spinal cord while retaining the whole posterior arch. No complications were encountered except a superficial wound infection in one patient. At final follow‐up, The ADI was significantly reduced from 5.2 ± 1.8 mm to 1.7 ± 0.6 mm after surgery on average (P < 0.05). Average inner sagittal diameter of C1 was increased from 26.3 ± 2.6 mm to 34.9 ± 2.9 mm and the space available for cord was increased from 6 ± 1.7 mm to 17.8 ± 3.6 mm (P < 0.05). Meanwhile, the Japanese Orthopaedic Association (JOA) score of the 16 cases was improved from 11.4 ± 1.8 to 14.1 ± 1.4 on average (P < 0.05). The postoperative neck pain VAS score decreased significantly, from 2.6 ± 1.0 preoperatively to 1.3 ± 0.9 postoperatively (P < 0.05). The influence of neck pain on patient's life was improved from 17.8 ± 3.9 to 13.9 ± 3.3 after surgery (P < 0.05). At the last follow‐up, the healing of the hinge fracture and the fusion between atlas and axis were observed in all patients.ConclusionsSingle‐door laminoplasty combined with atlantoaxial fusion not only provides enough space for decompression but also offers intact arch for bone grafting, suggesting that it might provide a more feasible method for the correction of symptomatic atlas canal stenosis.

Posterior two-step distraction and reduction for basilar invagination with atlantoaxial dislocation: a novel technique for precise control of reduction degree without traction.

The pathological changes of basilar invagination (BI) and atlantoaxial dislocation (AAD) include vertical and horizontal dislocations. Current surgical techniques have difficulty in accurately controlling the degree of reduction in these two directions and often require preoperative traction, which increases patients' pain, hospital stay, and medical cost. This study aimed to introduce a novel technique for accurately reducing horizontal and vertical dislocation without preoperative traction and report the radiological and clinical outcomes. From 2010 to 2020, patients with BI and AAD underwent posterior two-step distraction and reduction (TSDR) and occipitocervical fixation. Radiological examination was used to evaluate the reduction degree (RD) and compression. Japanese Orthopedic Association (JOA) score was used to evaluate clinical outcome. A total of 55 patients with BI and AAD underwent TSDR and occipitocervical fusion. The clinical symptoms of 98.2% of them improved. JOA score increased significantly after the operation. Appropriate (50% ≤ RD < 80%) or satisfactory (RD ≥ 80%) horizontal reduction was achieved in 92.7% of patients, and 90.9% obtained appropriate or satisfactory vertical reduction. Thirty-one patients did not undergo preoperative skull traction. There was no significant difference in radiological outcomes or JOA scores between the traction and non-traction groups. However, the length of hospital stay in the traction group was longer than that in the non-traction group. TSDR enables horizontal and vertical reduction. It is a safe, simple, and effective technique for patients with BI and AAD. Despite the absence of preoperative skull traction, the degree of reduction and clinical outcomes were satisfactory.

The surgical treatment of subaxial acute cervical spine facet dislocations in adults: a systematic review and meta-analysis.

Adult cervical spine traumatic facet joint dislocations occur when excessive traumatic forces displace the vertebrae's facets, leading to loss of joint congruence. Reduction requires either cranial traction or open surgical procedures. This study aims to appraise the effects of different surgical techniques in the treatment of subaxial cervical spine acute traumatic facet blocks in adults. This study was based on a systematic literature review and meta-analysis, registered in Prospero (CRD42021279249). The PICO question was composed of adults with acute cervical spine traumatic facet dislocations submitted to anterior or posterior surgical approaches, associated or not with cranial traction for reduction. Each surgical technique was compared to the other. The primary clinical outcomes included neurological improvement or worsening and surgical success/failure rates. The anterior approach without cranial traction was efficient in reducing facet displacements. Skull traction was an efficient and immediate method to achieve spine dislocation reductions. Differences were not present among techniques regarding neurological improvement. There were no surgical failures in patients operated on via the posterior approach. The need to decompress and stabilize the cervical spine can be achieved by anterior or posterior surgical approaches, and there is no clear answer as to which initial approach is superior to the other.

An Innovative Prone Position Using a Body-Shape Plaster Bed and Skull Traction for Posterior Cervical Spine Fracture Surgeries.

BackgroundAn innovative prone cervical spine surgical position using a body-shape plaster bed with skull traction (BSPST) was compared with the traditional prone surgical position with horseshoe headrests.MethodsA total of 47 patients, undergoing posterior cervical spine surgery for cervical spine fracture, were retrospectively classified into two groups, the BSPST group (n = 24) and the traditional group (n = 23), and underwent a posterior instrumented fusion with or without decompression. Multiple indicators were used to evaluate the advantages of the BSPST compared with the traditional position.ResultsAll the operations went smoothly. The mean recovery rate was 56.30% in the BSPST group and 48.55% in the traditional group (p = 0.454), with no significant difference. The intraoperative blood loss (177.5 ml vs. 439.1 ml, p = 0.003) and the total incidence of complications (8.3 vs. 47.8%, p = 0.004) were significantly less in the BSPST group than in the traditional group. In addition, the BSPST position provided a greater comfort level for the operators and allowed convenient intraoperative radiography.ConclusionsThis is the first study to describe a combined body-shape plaster bed and skull traction as an innovative cervical spine-prone surgical position that is simple, safe, and stable, intraoperative traction direction adjustable, reproducible, and economical for posterior cervical spine fracture surgery, and potentially other cervical and upper dorsal spine surgeries in the prone position. Additionally, this position provides the surgeons with a comfortable surgical field and can be easily achieved in most orthopedic operation rooms.

Anterior C2-3 fusion surgery alone for highly displaced Hangman’s fracture with severe angulation of C2-3 of more than 30°

BackgroundHighly displaced Hangman’s fracture is a very rare and extremely unstable fracture of the C2 axis. Combined anteroposterior or posterior long-segment fusion surgery is typically performed for the treatment of highly displaced Hangman’s fracture. However, these kinds of surgeries increase the risk of complications, loss of motion, and hospital costs. ObjectiveWe sought to investigate the surgical outcomes of anterior C2-3 fusion surgery alone for highly displaced Hangman’s fractures with severe angulation of C2-3 by more than 30° and discoligamentous injury. MethodsA total of five patients (four men and one woman) were included in this study with a mean age of 40.4 years (range, 26–70 years). The mean follow-up period after surgery was 37.2 months (range, 12–96 months). The fracture characteristics, treatment methods, and outcomes were retrospectively analyzed. ResultsAll five patients had type II Hangman’s fractures (according to the Levine and Edwards classification scheme). None of the included patients had neurologic deficit or other spine injury but all patients had complete C2-3 discoligamentous injury. Before surgery, all patients successfully achieved closed reduction by skull traction, followed by C2-3 anterior decompression and fusion (ACDF) with plating. For interbody grafting, three patients received a polyetheretherketone (PEEK) cage filled with an autogenous cancellous iliac bone graft and two received autogenous tricortical iliac bone grafts. Severe angulation (39.2° vs. 3.0°, P < 0.001) and severe displacement (76.1% vs. 4.0%, P < 0.001) of C2-3 were both significantly corrected after surgery. All patients had achieved solid fusion at last follow-up. In terms of clinical outcomes, the mean neck pain visual analog scale score was significantly improved (8.6 points vs. 1.8 points, P < 0.001). The mean neck disability index value was also significantly improved (45.4 points vs. 13.0 points, P < 0.01). According to Odom’s criteria, all patients achieved satisfactory outcomes. No major complications occurred. One patient complained of dysphagia, but recovered after three months with conservative treatment. ConclusionsPreoperative closed reduction and anterior C2-3 fusion surgery alone should be considered as a less-invasive and useful surgical option for highly displaced Hangman’s fracture with severe angulation of C2-3, which is an extremely unstable fracture of the C2 axis.

Fiberoptic bronchoscopy versus video laryngoscopy guided intubation in patients with craniovertebral junction instability: A cinefluroscopic comparison.

Background: Manipulation during endotracheal intubation in patients with craniovertebral junction (CVJ) anomalies may cause neurological deterioration due to underlying instability. Fiberoptic-bronchoscopy (FOB) is better than video laryngoscope (VL) for minimizing cervical spine movement during intubation. However, evidence suggesting superiority of FOB in patients with CVJ instability is lacking. We prospectively compared dynamic movements of the upper cervical spine during intubation using FOB with VL in patients with CVJ anomalies.Methods: A prospective, randomized, and clinical trial was conducted in 62 patients of American Society of Anaesthesiologist Grade I-II aged between 12 and 65 years with CVJ anomalies. Patients were randomized for intubation under general anesthesia with either VL or FOB. The intubation process was done with application of skeletal traction and recorded cinefluroscopically. The dynamic interrelationship of bony landmarks (horizontal, vertical, and diagonal distances between fixed points on posterior C1 and C2) was analyzed to indirectly calculate alteration of the upper cervical spinal canal diameter (at CVJ). Atlanto-dental interval (ADI) was calculated wherever possible.Results: The alteration in canal diameter (using bony landmarks) at CVJ during intubation was not significant with the use of either VL or FOB (P > 0.05). In 41 patients, where ADI could be measured, ADI was reduced (increased spinal canal diameter) in a greater number of patients in VL group when compared to FOB group (P < 0.05).Conclusion: Using rigid skull traction, intubation under general anesthesia with VL offers similar advantage as FOB in terms of the spinal kinematics in patients with CVJ anomalies/instability. Nevertheless, greater number of patients intubated with VL may have an advantage of increased cervical spinal canal diameter when compared to FOB.

Cervical corpectomy in delayed presentation of irreducible cervical dislocation: experience with eight cases

Objective To describe a single-staged procedure for the management of neglected subaxial cervical spine injuries. Methods Between January 2012 and December 2014, 12 patients presented to us with healed cervical sub axial dislocations. The deformities could not be reduced using skull traction. Eight were operated with anterior cervical corpectomy. American spinal injury Association (ASIA) grade, Neck Disability index (NDI), and Visual analog scale (VAS) score were recorded throughout the patient course and CT was done at 12 months for assessment of fusion. Results Four patients improved from ASIA C to ASIA D, two patients improved from ASIA B to ASIA E, one patient improved from ASIA D to ASIA E and one patient remained static at ASIA B. All patients except one showed evidence of fusion on CT scan at 12 months. NDI improved from preoperative range (18–32, mean 25) to postoperative range (8–16 mean, 11.25), VAS from preoperative range (3–6, mean 4.25) to postoperative range (1–3, mean 1.75). Conclusions Single-stage in situ fixation does not disrupt ongoing natural healing and has good clinical and radiological outcomes.

New Classification and Its Value Evaluation for Atlantoaxial Dislocation.

ObjectiveTo introduce the TOI classification system (the Traction reduction type [T type], Operation reduction type [O type], and Irreducible type [I type] classification system) and to determine the interobserver and intraobserver reliability of the TOI classification system.MethodsBased on the characteristics of atlantoaxial dislocation (AAD), AAD was divided into Traction reduction type (T type), Operation reduction type (O type), and Irreducible type (I type). The analysis of interobserver and intraobserver agreements was done using kappa statistics. From July 2016 to January 2019, 213 AAD patients were retrospectively studied at four hospitals. Plain radiographs including extension and flexion views and three‐dimensional CT images were obtained. Twenty independent observers, including eight experienced spine specialists and 12 orthopaedic fellows from four different residency training hospitals, completed the survey.ResultsThe classification of the TOI system was based on etiology, the course of the disease, flexion–extension X‐rays, three‐dimensional CT reconstruction, and curative effects of skull traction. Flexion–extension X‐rays demonstrating a successful reduction of the dislocated atlantoaxial joint and three‐dimensional CT images showing osseous fusion of atlantoaxial facet joints and cervical traction reveal characteristics of T‐type. Furthermore, this type can be divided into two subtypes, T1 and T2, according to the etiology and course of the disease. Unsatisfactorily reduction after 1–2 weeks of strict cervical traction, no reduction shown on flexion–extension X‐rays, and no destruction or boneless fusion of atlantoaxial facet joints demonstrated in three‐dimensional CT images are characteristics of type O. Atlantoaxial facet joint showing bone fusion or failure of reduction after cervical traction or three‐dimensional CT images showing failure of surgical release are characteristics of type I. Interobserver and intraobserver reliability of the TOI classification system were moderate (κ = 0.543) and substantial (κ = 0.658), respectively. Interobserver and intraobserver reliability of the treatment choice were moderate (κ = 0.568) and substantial (κ = 0.675), respectively. There were no significant differences in the interobserver and intraobserver reliability between experienced spine specialists and fellows for all κ‐values (P > 0.05).ConclusionsThe TOI classification system had satisfactory reliability and, therefore, can be applied clinically and used by less experienced surgeons. We believe TOI can help surgeons choose appropriate treatment strategies.

An Experimental Study on the Safety and Mechanism of Reduction of Subaxial Cervical Facet Dislocation Using Z-Shape Elevating-Pulling Reduction Technique

We sought to clarify the safety and unlocking mechanism of the Z-shape elevating-pulling closed reduction (ZR) technique and to analyze the differences in facet contact force and intraspinal pressure during subaxial facet dislocation reduction using the ZR technique and traditional skull traction closed reduction (SR). In 15 human cadaveric skull-neck-thorax specimens, reproducible unilateral and bilateral facet dislocations (UFDs/BFDs) were created at the C5-C6 level and then reduced by applying the ZR and SR techniques, respectively. Tekscan FlexiForce A-201 pressure sensors were used to measure the anterior and posterior intraspinal pressure and injured facet contact force under physiological conditions and before and after reduction. The maximum pressures during the reduction process were recorded. After creation of the facet dislocation, the anterior and posterior intraspinal pressure and facet contact force were significantly increased relative to normal (P < 0.001). The UFDs and BFDs of all specimens were successfully reduced by both ZR and SR, and the intraspinal pressure and facet contact force were significantly reduced compared with before reduction (P < 0.001). Compared with SR, the maximum posterior intraspinal pressure during BFD reduction (P= 0.027) and the maximum facet contact force during UFD reduction (P < 0.001) were lower when ZR was used for closed reduction. Our findings suggest that ZR and SR can both be used to reduce subaxial facet dislocation and decompress the spinal cord. However, the ZR technique appears to safer and more effective than the SR technique for closed reduction of subaxial facet dislocations.

Surgical treatment of atlantoaxial subluxation by intraoperative skull traction and C1-C2 fixation

BackgroundAtlantoaxial subluxation (AAS) is a not rare abnormality between the atlas (C1) and axis (C2). For AAS patients with persistent neck pain and neurologic symptoms, surgical intervention is a good choice. Nevertheless, there were still few reports about the use of intraoperative skull traction and different fixation methods in treatment of AAS.MethodsFrom January 2012 to December 2018, a total of 86 cases were admitted to our hospital and diagnosed as AAS. All the patients received atlantoaxial reduction with the help of intraoperative skull traction and C1-C2 fixation. Clinical and radiological parameters were collected through chart review.ResultsThere were 86 cases included in this study. The mean operative time was 153.9 ± 73.9 min, and the mean amount of intraoperative blood loss was 219.1 ± 195.6 ml. 81 patients underwent posterior reduction, internal fixation and fusion. 5 patients underwent anterior release, followed by posterior internal fixation and fusion. 82 patients got satisfactory postoperative outcomes while complications occurred in 4 patients. Significant neurologic improvement was observed in these patients. Bone fusion was achieved on the midline sagittal reconstructed CT images at the latest follow-up in all these patients except 1 case. All the patients were followed up for 34.84 ± 15.86 months at average (range 12–60 months). The mean ADI value was 7.55 ± 1.67 mm at average preoperatively, and improved to 4.03 ± 1.21 mm postoperatively, and to 4.21 ± 0.99 mm at the latest follow-up. The mean A-A angle was 15.48 ± 9.82 degrees at average preoperatively, and improved to 21.61 ± 10.43 degrees postoperatively, and to 19.73 ± 8.13 degrees at the latest follow-up. The mean A-A height was 35.61 ± 7.66 mm at average preoperatively, and improved to 40.08 ± 8.5 mm postoperatively, and to 38.83 ± 6.97 mm at the latest follow-up. There were complications in 4 patients, including pedicle misplacement, pedicle screw fracture, infection and one death.ConclusionIntraoperative skull traction can effectively facilitate the surgical procedures for ASS caused by different etiologies. Further research will be needed to investigate the safety and effectiveness of this method in the future.

91. Can the proposed posterior ligament-bone injury classification and severity score predict the failure of anterior-only surgery for subaxial cervical facet dislocations?

BACKGROUND CONTEXT The approach selection for subaxial cervical fracture dislocations (SCFD) is controversial. While spinal surgeons increasingly prefer a single anterior approach, the complication of postoperative cervical kyphosis is worrisome. Hence, identification of suitable candidates requiring a second posterior reconstruction is necessary, thus preventing the failure of anterior-only surgery in patients with SCFD. PURPOSE To introduce a novel classification and scoring system called the posterior ligament-bone injury classification and severity (PLICS) score and verify whether this system can be generally utilized for the treatment of the SCFD to predict the failure of anterior-only surgery. STUDY DESIGN/SETTING A retrospective cohort study. PATIENT SAMPLE A total of 394 patients with SCFD who underwent anterior decompression, reduction, and fusion between January 2002 and December 2017 in one center were retrospectivelyenrolled in the study. The inclusion criteria included: 1. the preoperative magnetic resonance imaging (MRI) detected facture dislocation accompanying with an extruded disc, which deformed the dural sac beyond the line between the postero-inferior corner of cranial vertebrae and the postero-superior corner of caudal vertebrae; 2. the clinical level of neural dysfunction corresponds to the segment of reconstruction without the requirement of an extensive posterior decompression; 3. the reduction can be achieved under an attempt at the awake skull traction preoperatively or via anterior approach after the removal of herniated disc intraopertively. The exclusion criteria included: reduction can't be by preoperative skull traction, or by an anterior approach intraoperatively; the patients obtained a posterior reconstruction surgery when the intramedullary edema may extend beyond the segment of dislocation; severe traumatic cervical spondylolisthesis (over grade 3); the patients are accompanying by ankylosing spondylitis. OUTCOME MEASURES Clinical outcomes with respect to neck pain and function were recorded for each patient according to visual analog score (VAS) and the Neck Disability Index (NDI). We paired the equal number of patients between successful and unsuccessful groups to compare the difference in the clinical outcome. The American Spinal Injury Association (ASIA) impairment scale was recorded at each follow-up interval. Additionally, lateral radiography computed tomography (CT) and MRI were also recommended. METHODS Patients were divided into successful and unsuccessful groups according to whether failure of internal fixation was observed during follow-up. PLICS is based on the injury severity of the ligament-bone structure of three elements. Anatomically, the posterior column of cervical spine can be subdivided into three-column structure, including bilateral facet joints and the outside joint capsules, and posterior spinous processes and the attached ligament structures, so-called posterior ligamentous complex, including the supraspinal ligament and interspinous ligament. In this score system, a specific point value (0 - 3) is assigned to a particular variable within each element reflective of the severity of injury and its contribution to stability of posterior column of cervical spine. The preoperative PLICS score of all patients are recorded respectively. RESULTS Among 354 patients, 89.8% fulfilled the follow-up. Fifteen patients (4.2%) experienced hardware failure and progressive cervical kyphosis at the postoperative follow-up. The patients were divided into successful (15 patients) and unsuccessful (339 patients) groups. The average VAS score in the satisfactory group decreased from 6.7+0.8 to 1.3+0.6. The average VAS score in the unsatisfactory group decreased from 4.9+0.8 to 0.3+0.5. The average NDI score at the12-month follow-up was statistically low in the satisfactory group (6.2+2.1 vs 15.5+3.8, P= .028). It is worth noting that, except for only one patient with a PLICS score of 6, the PLICS score for the other 14 patients who experienced postoperative hardware failure was >7. However, the PLICS score for the other 339 patients (except for 2 cases) who obtained satisfactory radiological outcome was CONCLUSIONS When a PLICS score >7 is accompanied by severe lateral mass fracture, the risk of postoperative failure after an anterior-only reconstruction is high and supplemental posterior strengthening can be considered. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.