Subaxial Cervical Spine Fractures Research Articles

Predictors of early mortality following surgical or nonsurgical treatment of subaxial cervical spine fractures: a retrospective nationwide registry study

BACKGROUNDTraumatic subaxial cervical spine fractures are a significant public health concern due to their association with spinal cord injuries (SCI). Despite being mostly caused by low-energy trauma, these fractures significantly contribute to morbidity and mortality. Currently, research regarding early mortality based on the choice of treatment following these fractures is limited. Identifying predictors of early mortality may aid in postoperative patient monitoring and improve outcomes. PURPOSEThis study aimed to identify predictors of 30-days, 90-days, and 1-year mortality in adults treated for subaxial fractures. STUDY DESIGNA retrospective review of the nationwide Swedish Fracture Register (SFR). PATIENT SAMPLEAll adult patients in the SFR who underwent treatment for a subaxial cervical fracture (n = 1,963). OUTCOME MEASURESAnalyzed variables included age, sex, injury mechanism, neurological function, fracture characteristics, and treatment type. The primary endpoints were 30-days, 90-days, and 1-year mortality. METHODSAbout 1,963 patients in the SFR, treated for subaxial cervical fractures between 2013 and 2021, were analyzed. Surgical procedures included anterior, posterior, or anteroposterior approaches. Nonsurgical treatment included collar treatment or medical examinations without intervention. Stepwise regression and Cox regression analysis were used to determine predictors. Model performance was tested using the area under the receiver operating characteristic curve (AUC). RESULTSA total of 620 patients underwent surgery and 1,343 received nonsurgical treatment. Surgical cases had primarily translation fractures, with 323 (52%) displaying no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 22/620 (3.5%), 35/620 (5.6%), and 53/620 (8.5%), respectively. Age and SCI were predictors of mortality. Nonsurgically treated patients mostly had compression fracture, with 1,214 (90%) experiencing no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 41/1,343 (3.1%), 71/1,343 (5.3%), and 118/1,343 (8.7%). Age, male sex, SCI and fractures occurring at the C3 or C6 levels were predictors of mortality. An intact neurological function was a positive predictor of survival among nonsurgically treated patients (AUC >0.78). CONCLUSIONSAge and SCI emerged as significant predictors of early mortality in both surgically and nonsurgically treated patients. An intact neurological function served as a protective factor against early mortality in nonsurgically treated patients. Fractures at C3 or C6 vertebrae may impact mortality.

Treatment of Ankylosing Spondylitis Patients with Cervical Spinal Injury with Anterior Single-Stage Fixation with Bone Cement Augmentation.

Background/Objectives: Cervical spine fractures in ankylosing spondylitis (AS) are characterized as highly unstable fractures posing an elevated risk of neurological deficit and a significantly elevated mortality rate. This study assesses the efficacy and safety of single-stage plate stabilization with ventral cement augmentation in treating subaxial cervical spine fractures in patients with AS. Methods: Over 86 months, 38 patients diagnosed with AS received ventral plate stabilization with cement augmentation after suffering unstable subaxial cervical fractures. No additional dorsal stabilization was used in any of these surgeries. Results: There were no complications as a result of cement leakage. During the follow-up period, screw loosening and implant displacement were documented in two out of 38 cases. At the time of data analysis, 17 patients who had undergone treatment had died, representing 44.7% of the total cases. Seven patients died within 1 month, two patients died within 6 months, four patients died within 1 year, and four patients died after 1 year. Conclusions: Our study shows that a single-stage anterior screw and plate fixation of the cervical spine with cement augmentation could be a feasible and effective method to treat cervical spine fractures in patients with AS.

Predictors of failure after primary anterior cervical discectomy and fusion for subaxial traumatic spine injuries

IntroductionTraumatic subaxial fractures account for more than half of all cervical spine injuries. The optimal surgical approach is a matter of debate and may include anterior, posterior or a combined anteroposterior (360º) approach. Analyzing a cohort of patients initially treated with anterior cervical discectomy and fusion (ACDF) for traumatic subaxial injuries, the study aimed to identify predictors for treatment failure and the subsequent need for supplementary posterior fusion (PF).MethodsA retrospective, single center, consecutive cohort study of all adult patients undergoing primary ACDF for traumatic subaxial cervical spine fractures between 2006 and 2018 was undertaken and 341 patients were included. Baseline clinical and radiological data for all included patients were analyzed and 11 cases of supplementary posterior fixation were identified.ResultsPatients were operated at a median of 2.0 days from the trauma, undergoing 1-level (78%), 2-levels (16%) and ≥ 3-levels (6.2%) ACDF. A delayed supplementary PF was performed in 11 cases, due to ACDF failure. On univariable regression analysis, older age (p = 0.017), shorter stature (p = 0.031), posterior longitudinal ligament (PLL) injury (p = 0.004), injury to ligamentum flavum (p = 0.005), bilateral facet joint dislocation (p < 0.001) and traumatic cervical spondylolisthesis (p = 0.003) predicted ACDF failure. On the multivariable regression model, older age (p = 0.015), PLL injury (p = 0.048), and bilateral facet joint dislocation (p = 0.010) remained as independent predictors of ACDF failure.ConclusionsACDF is safe and effective for the treatment of subaxial cervical spine fractures. High age, bilateral facet joint dislocation and traumatic PLL disruption are independent predictors of failure. We suggest increased vigilance regarding these cases.

Subaxial cervical spine fractures

Subaxial cervical spine fractures pose significant challenges for spine surgeons due to their varied nature and potential for neurological compromise. Despite C2 being the most frequently fractured level, subaxial fractures, especially at C7, constitute a substantial portion of cervical spine injuries. Incidence rates are rising, with up to 40 % involving multiple levels. Various classification systems, including AO Spine, SLIC, and CSISS, aid in treatment decisions, with SLIC showing high reliability among experienced surgeons. Surgical intervention is warranted for fractures causing persistent neurological deficits or instability. Treatment goals encompass neurologic preservation, biomechanical stability, and deformity correction, with considerations for prior surgery, degenerative stenosis, and osteoporosis. Fracture types, such as vertebral body, facet, flexion-distraction, and extension-distraction injuries, demand tailored surgical approaches. Special considerations, including comorbidities, pre-existing conditions, and vascular injuries, influence treatment strategies. A methodical approach considering neurology, stability, deformity, and patient-specific factors guides surgical planning. Despite the absence of a universal algorithm, a comprehensive understanding and individualized approach are essential for optimal management of subaxial cervical spine fractures.

Timing of Surgery and Pre-operative Physiological Parameters as Clinical Predictors of Surgical Outcomes in Traumatic Subaxial Cervical Spine Fractures and Dislocations.

Objective To evaluate the risk factors and outcomes in patients surgically treated for subaxial cervical spine injuries with respect of the timing of surgery and preoperative physiological parameters of the patient. Methods 26 patients with sub-axial cervical spine fractures and dislocations were enrolled. Demographic data of patients, appropriate radiological investigation, and physiological parameters like respiratory rate, blood pressure, heart rate, PaO2 and ASIA impairment scale were documented. They were divided pre-operatively into 2 groups. Group U with patients having abnormal physiological parameters and Group S including patients having physiological parameters within normal range. They were further subdivided into early and late groups according to the timing of surgery as U early , U late, S early and S late . All the patients were called for follow-up at 1, 6 and 12 months. Results 56 percent of patients in Group S had neurological improvement by one ASIA grade and a good outcome irrespective of the timing of surgery. Patients in Group U having unstable physiological parameters and undergoing early surgical intervention had poor outcomes. Conclusion This study concludes that early surgical intervention in physiologically unstable patients had a strong association as a risk factor in the final outcome of the patients in terms of mortality and morbidity. Also, no positive association of improvement in physiologically stable patients with respect to the timing of surgery could be established.

Evolution of patient-reported outcome measures, 1, 2, and 5 years after surgery for subaxial cervical spine fractures, a nation-wide registry study

BACKGROUND CONTEXTA longer duration of patient follow up arguably provides more reliable data on the long-term effects of a treatment. However, the collection of long-term follow up data is resource demanding and often complicated by missing data and patients being lost to follow up. In surgical fixation for cervical spine fractures, data are lacking on the evolution of patient reported outcome measures (PROMs) beyond 1-year of follow up. We hypothesized that the PROMs would remain stable beyond the 1-year postoperative follow up mark, regardless of the surgical approach. PURPOSETo assess the trends in the evolution of patient-reported outcome measures (PROMs) at 1, 2-, and 5-years following surgery in patients with traumatic cervical spine injuries. STUDY DESIGNNation-wide observational study on prospectively collected data. PATIENT SAMPLEIndividuals treated for subaxial cervical spine fractures with anterior, posterior, or combined anteroposterior approaches, between 2006 and 2016 were identified in the Swedish Spine Registry (Swespine). OUTCOME MEASURESPROMs consisting of EQ-5D-3Lindex and the Neck Disability Index (NDI) were considered. METHODSPROMs data were available for 292 patients at 1 and 2 years postoperatively. Five-years PROMs data were available for 142 of these patients. A simultaneous within-group (longitudinal) and between group (approach-dependent) analysis was performed using mixed ANOVA. The predictive ability of 1-year PROMs was subsequently assessed using linear regression. RESULTSMixed ANOVA revealed that PROMs remained stable from 1- to 2-years as well as from 2- to 5-years postoperatively and were not significantly affected by the surgical approach (p<0.05). A strong correlation was found between 1-year and both 2- and 5-years PROMs (R>0.7; p<0.001). Linear regression confirmed the accuracy of 1-year PROMs in predicting both 2- and 5-years PROMs (p<0.001). CONCLUSIONPROMs remained stable beyond 1-year of follow up in patients treated with anterior, posterior, or combined anteroposterior surgeries for subaxial cervical spine fractures. The 1-year PROMs were strong predictors of PROMs measured at 2, and 5 years. The 1-year PROMs were sufficient to assess the outcomes of subaxial cervical fixation irrespective of the surgical approach.

Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System.

Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty. A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants' management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine. In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001). The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.

Overview of Subaxial Cervical Spine Fractures and Dislocations

Injuries of the subaxial cervical spine are among the most common and potentially most devastating injuries involving the axial skeleton. The lower cervical spine can suffer minor bony or ligamentous injury that nevertheless results in severe neurologic injury. Plain radiography, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans are all part of the standard imaging regimen. The delayed timing of dislocation reduction and cost-effectiveness are two issues with routine use of MRI in the diagnosis of cervical facet dislocations. Serval treatment options and approaches can be used. However Orthopedic treatment can be used to reduce the fracture or dislocation returns the vertebral canal to its normal shape and dimensions and decompresses the spinal cord. Immediate treatment should be started if there are signs of spinal cord injury or any factor that could lead to such injuries. In this review we will be looking at epidemiology, causes, evaluation and treatment of such cases.

Accuracy and reliability of the AO Spine subaxial cervical spine classification system grading subaxial cervical facet injury morphology.

A classification system was recently developed by the international association AO Spine for assessing subaxial cervical spine fractures. Significant variability exists between users of the facet component, which consists of four morphological types (F1-F4). The primary aims of this study were to assess the diagnostic accuracy and reliability of this new system's facet injury morphological classifications. A survey consisting of 16 computed tomography (CT) scans of patients with cervical facet fractures was distributed to spine surgeon members of AO Spine Latin America. To provide a gold standard diagnosis for comparison, all 16 injuries had been classified previously by six co-authors and only were included after total consensus was achieved. Demographic and surgical practice characteristics of all respondents were analyzed, and diagnostic accuracy calculated. Inter- and intra-observer agreement rates were calculated across two survey rounds, conducted one month apart. A total of 135 surgeons completed both surveys, among whom the mean age was 41.6years (range 26-71), 130 (96.3%) were men, and 83 (61.5%) were orthopedic surgeons. The mean time in practice as a spine surgeon was 9.7years (1-30). The overall diagnostic accuracy of all responses was 65.4%. Inter-observer and intra-observer agreement rates for F1/F2/F3/F4 were 55.4%/47.6%/64.0%/94.7% and 60.0%/49.1%/58.0%/93.0%, respectively. This study evaluates the AO Spine Classification System specifically for facet injuries involving the subaxial cervical spine in a large sample of spine surgeons. There was significant variability in diagnostic accuracy for F1 through F3-type fractures, whereas almost universal agreement was achieved for F4-type injuries.

Does Dynamic Anterior Plate Fixation Provide Adequate Stability for Traumatic Subaxial Cervical Spine Fractures at Mid-Term Follow-Up?

Background: It remains questionable if the treatment of cervical fractures with dynamic plates in trauma surgery provides adequate stability for unstable fractures with disco-ligamentous injuries. The primary goal of this study was to assess the radiological and mid-term patient-reported outcome of traumatic subaxial cervical fractures treated with different plate systems. Patients and Methods: Patients, treated with anterior cervical discectomy and fusion (ACDF) between 2001 and 2015, using either a dynamic plate (DP: Mambo™, Ulrich, Germany) or a rigid locking plate (RP: CSLP™, Depuy Synthes, USA), were identified. For radiological evaluation, the sagittal alignment, the sagittal anterior translation and the bony consolidation were evaluated. After at least two years, the patient-reported outcome measures (PROM) were evaluated using the German Short-Form 36 (SF-36), Neck Disability Index (NDI) and the EuroQol in 5 Dimensions (EQ-5D) scores. Results: 33 patients met the inclusion criteria (DP: 13; RP:20). Twenty-six patients suffered from AO Type B or C fractures. Both the sagittal alignment and the sagittal translation could be sufficiently improved in both groups (p ≥ 0.05). No significant loss of reduction could be observed at the follow-up in both groups (p ≥ 0.05). Bony consolidation could be observed in 30 patients (DP: 12/13 (92%); RP: 18/20 (90%); (p ≥ 0.05)). In 20 patients, PROMs could be evaluated (follow-up: 71.2 ± 25.5 months). The whole cohort showed satisfactory PROM results (EQ-5D: 72.0 ± 4.9; SF-36 PCS: 41.9 ± 16.2, MCS: 45.4 ± 14.9; NDI: 11.0 ± 9.1). without significant differences between the DP and RP group (p ≥ 0.05) Conclusion: The dynamic plate concept provides enough stability without a difference in fusion rates in comparison to rigid locking plates in a population that mostly suffered fragile fractures.

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.

Management of subaxial cervical spine trauma: Clinical results of early surgical decompression

Traumatic injuries of the subaxial cervical spine (C3-7); considered among the most common and most damaging injuries to the axial skeleton. Decompression of the spine is standard approach after cervical spinal cord injury.In this study, 72 patients who underwent early decompression with the decision of surgery according to the classification system with the Subaxial Injury Classification and Severity Scale (SLICS) among 212 patients who developed spine fractures as a result of acute traumatic subaxial cervical trauma were examined.ASIA scoring system was used for neurological examination evaluation.Patients were included in the rehabilitation program, which lasted at least six months after the operation.Neurological recovery results were evaluated with ASIA scores obtained after the rehabilitation program.It has been shown that early surgery for subaxial cervical spine fractures contributes significantly to the patient's neurological recovery.

Incidence and Outcome Analysis of Vertebral Artery Injury in Posttraumatic Cervical Spine.

Objective:Vertebral artery injury (VAI) after cervical spine trauma often remains undiagnosed. Despite various clinical studies suggesting simultaneous occurrence of VAI with cervical spine trauma, guidelines regarding screening and management of posttraumatic VAI are yet to be formulated. The primary objective of the current study was to formulate a low-cost screening protocol for posttraumatic VAI, thereby reducing the incidence of missed VAI in developing countries.Materials and Methods:This was a single-center prospective study performed on 61 patients using plain magnetic resonance imaging (MRI) as a screening tool to assess the frequency of VAI and routine X-ray to detect morphological fracture patterns associated with the VAI in posttraumatic cervical spine cases. If the MRI study showed any evidence of vascular disruption, then further investigation in the form of computed tomography angiography was done to confirm the diagnosis.Results:This study showed the incidence of VAI was 14.75% (9/61). Of 61 patients, 16 had supraaxial, and 45 patients sustained subaxial cervical spine fractures. In the cohort of nine cases of VAI, eight patients had subaxial cervical spine injuries, of which seven were due to flexion-distraction injury. C5–C6 flexion-distraction injury was most commonly associated with VAI (4 cases). Of the nine cases, five succumbed to injury (mortality 55.55%), and 19 patients from the non-VAI group succumbed to injury (mortality 36.53%). From surviving four cases with VAI, two had improvement in the American Spinal Injury Association scale by Grade 1.Conclusion:VAI in cervical spine trauma is an underrecognized phenomenon. Plain MRI axial imaging sequence can be an instrumental low-cost screening tool in resource-deficient parts of the world. VAI has tendency to occur with high-velocity trauma like bi-facetal dislocation, which has a high mortality and poor neurological recovery.

Effect of Magnetic Resonance Imaging on Surgical Approach and Outcomes in the Management of Subaxial Cervical Fractures

In the initial evaluation of suspected cervical fracture, computed tomography (CT) is the gold standard for assessing bony anatomy and fracture morphology with high sensitivity and specificity. However, CT is relatively insensitive to ligamentous, discogenic, and myelopathic injury, leading to supplementary use of MRI, which is more sensitive and specific to these diseases. Here, we assess whether preoperative cervical spine magnetic resonance imaging (MRI) affects surgical management of subaxial cervical fractures. The National (Nationwide) Inpatient Sample (NIS) was queried for MRI use, surgical approach, rate of operative intervention, all-cause mortality, days from admission to surgery, discharge disposition, length of hospital stay, and total hospital charges among those with closed subaxial cervical spine fractures from 2012 to 2015. The effect of MRI on these End points was evaluated, controlling for significant baseline differences in demographics, comorbidities, and presentation. A total of 820 patients met inclusion and exclusion criteria; 255 (31.1%) were assessed with MRI and CT, 565 (68.9%) were evaluated with CT alone. After 1:1 propensity score matching based on severity of presentation, preoperative MRI was not significantly associated with surgical approach, in-hospital mortality, discharge disposition, length of stay, or total hospital charges. Segregating patients by functional status group shows MRI use among patients presenting with moderate loss of function associated with a shorter length of time between admission and surgery (1.50 vs. 2.59 days; P= 0.027). The addition of MRI to CT in the evaluation of subaxial cervical spine fractures does not seem to affect surgical management.

Treatment of Cervical Spine Fractures and Subluxations without the Use of Intraoperative Fluoroscopy in Resource-Limited Settings.

Background Surgical management of subaxial cervical spine injuries remains challenging. Although intraoperative fluoroscopy is usually used for intraoperative spinal level localization (SLL), it is unavailable in most developing countries. The surgeon therefore has to rely on anatomic landmarks. In our setting, in the absence of intraoperative fluoroscopy, we used the carotid tubercle for SLL. Herein we evaluate the accuracy and reliability of the carotid tubercle as a landmark during surgery for traumatic cervical spine injury. Methods This was a retrospective cohort study on 34 patients undergoing anterior cervical surgery for subaxial cervical spine fractures and/or subluxation between January 2005 and February 2011. From their medical records, the patients’ sociodemographic, clinical, radiological, and operative data were retrieved and analyzed. Results Thirty-four patients were included in the study. The mean age was 36.2 years. Thirty patients were males. The mean duration between the trauma and surgical intervention was 9.6 days. Six patients were completely tetraplegic. Fourteen patients had fractures and 20 patients had subluxation. The carotid tubercle was palpable in all the 34 cases. Twenty-two (68.8%) patients had partial or complete neurologic recovery. Complete anatomic reduction was achieved in 30 cases. One case of slight malalignment of the plate was observed. No case of significant deviation nor penetration of the screw into the vertebral canal was found. One patient died. Conclusions Carotid tubercle, a palpable intrinsic marker, is an attractive anatomic landmark for SLL during surgeries for traumatic spine injuries in resource-limited settings.

Contiguous Sub-Axial Cervical Spine Fractures with Spinal Canal Obliteration Due to C5 Posterior Dislocation. "Traumatic Ectopic Vertebrae": A Case Report

Contiguous Sub-Axial Cervical Spine Fractures with Spinal Canal Obliteration Due to C5 Posterior Dislocation. "Traumatic Ectopic Vertebrae": A Case Report

Cervical spine injuries in the elderly patient

Studies have shown that the numbers of injuries of the cervical spine increase in elderly patients. An early clinical examination and adequate diagnostics are necessary to initiate the appropriate treatment. Acomputed tomography (CT) scan is recommended to exclude injuries of the cervical spine. Dynamic fluoroscopy and magnetic resonance imaging (MRI) can additionally be helpful to detect instabilities. The treatment of the injury depends on the extent of the fracture and includes conservative treatment options with soft or rigid ortheses for cervical spine immobilization, retention with a halo fixator or open/closed reduction and fixation. In the selection of treatment it should be taken into consideration that the use of rigid immobilization or a halo fixator is associated with a significant reduction of the quality of life. In the region of the upper cervical spine only unstable fractures of the atlas and of the axis should be operatively treated. In the region of the subaxial cervical spine fractures are prone to be unstable due to the lack of flexibility of the cervical spine in elderly patients. Therefore, fractures of typesB andC according to AO Spine, for which operative treatment is recommended, are regularely seen. In addition, apre-existing stenosis of the spinal cord may lead to neurological symptoms which negatively influence the clinical outcome.

P154. Outcome of surgical intervention in neglected cervical spine fractures: a case series of 41 patients

BACKGROUND CONTEXT Neglected and delayed presentations of cervical spine fractures to hospitals are rare, but it is a pretty common scenario in developing and third world countries. At present, there are no guidelines about surgical management in these late presenting patients. Lack of awareness, expertise and finances as well as the well-equipped tertiary centers appears to be the main reason for delayed presentations of these cases. The 'neglected' word was used where no primary management of spine injury was done other than a cervical collar. The ‘delayed’ word was used when any definitive intervention was used at least after 3 weeks of injury. PURPOSE The objective of this study was to assess the clinical outcome of the surgical interventions, in cervical spine fractures presenting after at least 3 weeks of injury. STUDY DESIGN/SETTING It was a case series study where retrospective and prospective, clinical and radiological data were collected. PATIENT SAMPLE A total of 41 patients of neglected and delayed sub-axial cervical spine fractures were included in the study. They were operated over a period of 3 years, in a tertiary care center, equipped with all the facilities. OUTCOME MEASURES All cervical spine fractures with neurological deficits were evaluated with ASIA score, Frankel grade's, VAS, NDI and WISCI-2 scores preoperatively and postoperatively. They were also assessed radiologically with X-rays, CT scans and MRI preoperatively and x-ray's postoperatively. The statistics were done using multivariate/univariate analysis and paired t-test,on SPSS v22 software. METHODS Initial head traction was used through Gardner- Wells Tongs for 24 hours. All patients were operated after clinical and radiological evaluation, using combined either Post-Ant-Post or Ant-post-Ant. approaches. Anterior fixation was done using plate and cage/interbody graft construct; and posterior fixation was done with lateral mass screws. Postoperatively, all patients were assessed clinically and radiologically. The data collection was done at 3, 6 and 12 months. The minimal follow-up was one year post-surgery. RESULTS There were 26 males and 15 females in this study. The mean age was 35.58 (+/-11.7) years with a variation from 19 to 58 years. The mean duration between injury and surgery was 8.17 (+/-5.09) weeks, with a minimum of 3 weeks and maximum of 15 weeks. Preoperatively, 14 patients had Frankel's grade of A and 27 had grade B on neurological examination. Postoperatively it improved to grade B in 9, grade C in 28 and grade E in 4 patients over a period of one year. The preoperative VAS score mean was 8.90 (+/-0.70), which improved to 1.23 (SD +- 0.48,p CONCLUSIONS Delayed and neglected cervical spine fractures pose a unique problem. Though they are confined to developing countries, there are no standard guidelines about the surgical management of these injuries. Deciding about exact approach of surgery is also a difficult task, as patients require usually a combined anterior and posterior approaches. Our study showed there was significant improvement (p FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Two-Nation Comparison of Classification and Treatment of Subaxial Cervical Spine Fractures: An Internet-Based Multicenter Study Among Spine Surgeons

To date, no evidence-based treatment algorithm is available for fractures of the subaxial spine. The aim of the present study was to assess and compare the management strategy for traumatic subaxial fractures among German and Dutch spine surgeons. In our web-based multicenter study, German and Dutch spine surgeons evaluated the computed tomography data of traumatic subaxial fractures (C3-C7). Supplementary case-specific information was provided. The fractures were classified using the AO spine classification. Next, 9 questions concerning the treatment algorithm were evaluated. Data were analyzed using SPSS. Statistical significance was defined as P < 0.05. Ten surgeons (5/country) evaluated 31 cases (310 votes). The fractures were classified as AO type A in 37% (114 votes), type B in 50% (155 votes), and type C in 13% (41 votes). German spine surgeons had a lower threshold concerning the indication for surgical treatment (German, 94.2% vs. Netherlands, 58.1%; P < 0.05). A consensus was present for operative stabilization for type B and C injuries, but a discrepancy was found in the therapeutic algorithm for type A fractures. The most significant difference was seen in the treatment of type A2 and A3 fractures (surgery for type A2/A3 fracture: German, 92.9% vs. Netherlands, 5.3%; P < 0.05). We found a consensus for the stabilization of AO type B and C fractures but country-specific differences in the treatment of type A fractures, especially for A2 and A3 fractures. Further evidence is necessary to ensure more consistent international treatment strategies.

Outcomes of Unstable Subaxial Cervical Spine Fractures Managed by Posteroanterior Stabilization and Fusion

Study DesignRetrospective study.PurposeTo evaluate clinical and radiological outcomes of unstable subaxial cervical spine injuries managed by both posterior tension band column stabilization and anterior decompression, stabilization, and fusion.Overview of LiteratureUnstable subaxial cervical spine injuries often involve disruption of the anterior column and posterior tension band osteoligamentous complex. Such injuries need immediate surgical intervention. Different methods of reduction and surgical approaches have been published in the literature, with lack of consensus on a uniform or standardized method. Controversy still exists regarding stabilization of unstable cervical fractures by anterior or posterior approach alone or combined approaches.MethodsWe retrospectively evaluated 24 patients with post-traumatic unstable subaxial cervical spine injuries with their preoperative clinical details, X-ray, computed tomography, and magnetic resonance imaging of the cervical spine for fracture classification based on the mechanism of injury with status of disc herniation and posterior tension band disruption. All patients were managed by immediate reduction, posterior and anterior stabilization, and fusion in a single session of anesthesia. Data of all patients were analyzed with respect to pre- and postoperative neurological status based on American Spinal Injury Association grading, Visual Analog Scale score, the observation of bony fusion, and implant failure at 1, 3, 6, and 12 months. Data were analyzed using paired t-test.ResultsAll patients had solid fusion at the desired level with considerable neurological improvement at the 1-year follow-up.ConclusionsIn unstable cervical injuries, stabilization of disrupted posterior tension band increases the stability of anterior plating and fusion. This method of immediate reduction and circumferential stabilization is rapid, safe, and effective and has a low rate of complications.