Subaxial Spine Injury Research Articles

Long-term outcomes after surgery for subaxial cervical spine injuries in octogenarians, a matched population-based cohort study

PurposeWe aimed to investigate surgical outcomes in octogenarians with subaxial cervical spine injuries and determine the predictors of complications and mortality.MethodsEligible for inclusion were all patients surgically treated between 2006 and 2018, with either anterior or posterior fixation for subaxial spine injuries. A cohort of octogenarians was identified and matched 1:1 to a corresponding cohort of younger adults. Primary outcomes were perioperative complications and mortality.ResultsFifty-four patients were included in each of the octogenarian and younger groups (median age: 84.0 vs. 38.5). While the risks for surgical complications, including dural tears and wound infections, were similar between groups, the risks of postoperative medical complications, including respiratory or urinary tract infections, were significantly higher among the elderly (p < 0.05). Additionally, there were no differences in operative time (p = 0.625) or estimated blood loss (p = 0.403) between groups. The 30 and 90-day mortality rates were significantly higher among the elderly (p = 0.004 and p < 0.001). These differences were due to comorbidities in the octogenarian cohort as they were revoked when propensity score matching was performed to account for the differences in American Society of Anesthesiology (ASA) grade. Multivariable logistic regression revealed age and ASA score to be independent predictors of complications and the 90-day mortality, respectively.ConclusionsOctogenarians with comorbidities were more susceptible to postoperative complications, explaining the increased short-term mortality in this group. However, octogenarians without comorbidities had similar outcomes compared to the younger patients, indicating that overall health, including comorbidities, rather than chronological age should be considered in surgical decision-making.

The Effect of Concomitant Spinal Cord Injury on Postoperative Health-related Quality of Life After Traumatic Subaxial Cervical Spine Injuries: A Nationwide Registry Study

ObjectiveTo evaluate the effect of spinal cord injury (SCI) on the health-related quality of life (HRQoL) in patients surgically treated for traumatic subaxial cervical spine injuries and investigate the agreement between objective neurologic outcomes and patient reported outcome measures (PROMs) in that context. Study DesignObservational study on prospectively collected multi-institutional registry data. SettingSweden. ParticipantsPatients with traumatic subaxial spine injuries identified in the Swedish Spine Registry (Swespine) between 2006 and 2016. InterventionsAnterior, posterior, or anteroposterior cervical fixation surgery. Main OutcomesPatient-reported outcome measures (PROMs) consisting of EQ-5D-3Lindex and Neck Disability Index (NDI). ResultsAmong the 418 identified patients, 93 (22%) had a concomitant SCI. In this group, 30 (32%) had a complete SCI (Frankel A), and the remainder had incomplete SCIs (17%) Frankel B; 25 (27%) Frankel C; 22 (24%) Frankel D. PROMs significantly correlated with the Frankel grade (P<.001). However, post hoc analysis revealed that the differences between adjacent Frankel grades failed to reach both statistical and clinical significance. On univariable linear regression, the Frankel grade was a significant predictor of a specific index derived from the EQ-5D-3L questionnaire (EQ-5D-3Lindex) at 1, 2, and 5 years postoperatively as well as the NDI at 1 and 2 years postoperatively (P<.001). Changes of PROMs over time from 1, to 2, and 5 years postoperatively did not reach statistical significance, regardless of the presence and degree of SCI (P>.05). ConclusionOverall, the Frankel grade significantly correlated with the EQ-5D-3Lindex and NDI and was a significant predictor of PROMs at 1, 2, and 5 years. PROMs were stable beyond 1 year postoperatively regardless of the severity of the SCI.

Development of Online Technique for International Validation of the AO Spine Subaxial Injury Classification System.

Global cross-sectional survey. To develop and refine the techniques for web-based international validation of fracture classification systems. A live webinar was organized in 2018 for validation of the AO Spine Subaxial Injury Classification System, consisting of 35 unique computed tomography (CT) scans and key images with subaxial spine injuries. Interobserver reliability and intraobserver reproducibility was calculated for injury morphology, subtype, and facet injury according to the classification system. Based on the experiences from this webinar and incorporating rater feedback, adjustments were made in the organization and techniques used and in 2020 a repeat validation webinar was performed, evaluating images of 41 unique subaxial spine injuries. In the 2018 session, the AO Spine Subaxial Injury Classification System demonstrated fair interobserver reliability for fracture subtype (κ = 0.35) and moderate reliability for fracture morphology and facet injury (κ=0.45, 0.43, respectively). However, in 2020, the interobserver reliability for fracture morphology (κ = 0.87) and fracture subtype (κ = 0.80) was excellent, while facet injury was substantial (κ = 0.74). Intraobserver reproducibility for injury morphology (κ =0.49) and injury subtype/facet injury were moderate (κ = 0.42) in 2018. In 2020, fracture morphology and subtype reproducibility were excellent (κ =0.85, 0.88, respectively) while reproducibility for facet injuries was substantial (κ = 0.76). With optimized webinar-based validation techniques, the AO Spine Subaxial Injury Classification System demonstrated vast improvements in intraobserver reproducibility and interobserver reliability. Stringent fracture classification methodology is integral in obtaining accurate classification results.

Vertebral artery dissection in acute cervical spine trauma.

Objective:The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST).Methods:A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD.Results:Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified.Conclusion:There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour.

"Floating Cervical Spine Injuries": Craniocervical Dissociation with Associated, Noncontiguous, Unstable Cervical or Cervicothoracic Spine Fracture.

Advances in prehospital life support of patients who have sustained high-energy trauma have resulted in an increase in the number of patients with craniocervical dissociations (CCDs) surviving. With better imaging and more severely injured patients surviving, we are now seeing other associated injuries. CCDs in association with unstable, noncontiguous, subaxial spine injuries have not been described. The objective of this study was to (1) describe this injury pattern and its characteristics, including the mechanism of injury, injury levels, and neurological deficits, and (2) understand prognosis and outcome. After institutional review board approval, a retrospective study of patients who sustained CCD in association with an unstable, circumferential, subaxial, or cervicothroacic spine injury (C3-T2) between January 1, 2003, and August 31, 2018, was done. Review of imaging was performed to identify spine injury localization and type. Demographic data, mechanism of injury, neurological status, type of treatment, and patient outcomes were obtained from the electronic medical records. One hundred seventeen patients with CCD were identified, of which 105 had full spine radiographs. Thirteen (8 male and 5 female) had an associated, noncontiguous, unstable cervical, or cervicothoracic injury. Mean age was 45.4 ± 19 years. No exam could be obtained in 6; in the other 7, 1 was American Spinal Injury Association (ASIA) E, 1 ASIA D, and 5 ASIA A. Operative management of both injuries was planned for all 13 patients; however, 2 died before surgery. At discharge, there were 9 survivors with mean follow up of 2 years; 4 patients were independent (3 ASIA D, 1 ASIA E), and 5 were dependent (1 ASIA C, 4 ASIA A). Approximately 12% of patients with CCD have a floating cervical spine injury. Floating cervical spine injuries have an unfavorable prognosis with 69% surviving to hospital discharge but only 31% functioning independently (ASIA D or E). 4. Floating cervical spine injuries need to be recognized to optimize prognosis, yet even in the best of circumstances, prognosis is guarded.

Minimally displaced unilateral facet fracture of cervical spine can lead to spinal cord injury: a report of two cases

BackgroundAccording to most of the commonly used classification systems for subaxial spine injuries, unilateral and minimally displaced facet fractures without any sign of a spinal cord injury would be directed to non-operative management. However, the failure rate of non-operative treatment varies from 20 to 80%, and no consensus exists with regard to predictors of failure after non-operative management.Case presentationCase 1 is a patient with a unilateral facet fracture. The patient had only numbness in the right C6 dermatome but failed non-operative treatment, which resulted in severe spinal cord injury. Case 2 is a patient who had a similar injury pattern as case 1 but presented with immediate instability and underwent fusion surgery. Both patients had a minimally displaced unilateral facet fracture accompanied by disc injury and blunt vertebral artery injury, which are possible signs indicating significant instability.ConclusionsThis is the first report of an isolated unilateral facet fracture that resulted in catastrophic spinal cord injury. These two cases illustrate that an isolated minimally displaced unilateral facet fracture with disc injury and vertebral artery injury were associated with significant instability that can lead to spinal cord injury.

A prospective study of subaxial spine injuries: An armed forces experience

Introduction: Cervical spine injuries account for 3% of all polytrauma patients and can lead to quadriplegia, significant functional loss, and permanent disability. A large spectrum of such cases requires surgical decompression and reconstruction with variable neurological outcomes. Aims and Objectives: The aim of the study was to critically review the subaxial cervical spine injury cases managed surgically with different types of implants at a tertiary level armed forces hospital and analyze their postoperative outcomes. Methods: A prospective analysis of patients (n = 85) of subaxial cervical spine injury was carried out between October 2014 and December 2017. The last patient of our study on July 17 was followed for 5 months. Surgical decompression and stabilization were done in 71 patients whereas 14 patients were managed conservatively. Pre- and post-operative neurological outcome was assessed by the American Spinal Injury Association (ASIA) score. Results: There were 81 men and 04 women whose mean age was 39 years (range 16–78 years). The most common cause of injury was road traffic accidents (45%, n = 38). C5-C6 was the most common site of injury 46% (n = 39). ASIA Grade C (n = 27, 32%) was the most common presentation. Seventy-one cases were treated surgically; 95% (n = 68) of through the anterior approach, 2 by the posterior approach and one by a combined approach. Of the 44 patients operated within 24 h of injury, 19 (43%) had a two-grade improvement in their ASIA scores, 5 (11%) had a one-grade improvement and the remaining 20 showed no change. Only one patient out of 27 patients operated 24 h after the injury showed improvement in ASIA grade. Conclusion: Subaxial cervical spine injuries are complex and a definite treatment algorithm is still a work in progress. However, early surgical decompression and stabilization lead to good neurological outcome in the majority of cases.

Predictors of Failure of Nonoperative Management Following Subaxial Spine Trauma and Creation of Modified Subaxial Injury Classification System

Subaxial cervical spine injuries may be treated with either nonoperative stabilization or surgical fixation. The subaxial injury classification (SLIC) provides 1 method for suggesting the degree of necessity for surgery. In the current study, we examined if the SLIC score, or other preoperative metrics, can predict failure of nonoperative management. We performed a retrospective chart review to identify patients who presented with acute, nonpenetrating, subaxial cervical spine injury within our health system between 2007 and 2016. Patient demographics, medical comorbidities, injuries, and treatments were collected. Logistic regression analysis was used to determine potential predictors of failure of nonoperative management. During the study period, 40 patients met the inclusion criteria. A small subset of patients failed nonoperative management (n= 5, 12.5%). The mean SLIC score was 3.9 ± 1.9; however, 14 (35%) patients had scores >4. Neither total SLIC score (P= 0.68) nor SLIC subscores (morphology [P= 0.96], discoligamentous complex [P= 0.83], neurologic status [P= 0.60]) predicted failure of nonoperative treatment. Time to evaluation/treatment did predict failure of nonoperative management. Evaluation within 8 hours of injury was a negative predictor of failure (odds ratio= 0.03, P= 0.001) and evaluation 24 hours or more after injury was a positive predictor of failure (odds ratio= 66.00, P < 0.001). We created a modified SLIC score on the basis of these findings, which significantly predicted failure of nonoperative management (P= 0.044). Management of subaxial spine injuries is complex. In our cohort, SLIC scoring did not adequately predict odds of failure of nonoperative management. Time to evaluation, however, did. We created a modified SLIC score that significantly predicted failure of nonoperative management.

Functional Outcomes of Subaxial Spine Injuries Managed With 2-Level Anterior Cervical Corpectomy and Fusion: A Prospective Study

ObjectiveTo evaluate the results of operative management of subaxial spine injuries managed with 2-level anterior cervical corpectomy and fusion with a cervical locking plate and autologous bone–filled titanium mesh cage. MethodsThis study included 23 patients with a subaxial spine injury who matched the inclusion criteria, underwent 2-level anterior cervical corpectomy and fusion at our institution between 2013 and 2016, and were followed up for neurological recovery, axial pain, fusion, pseudarthrosis, and implant failure. ResultsAccording to Allen and Ferguson classification, there were 9 cases of distractive extension; 4 of compressive extension; 3 each of compressive flexion, vertical compression, and distractive flexion; and 1 of lateral flexion. Sixteen patients had a score of 6 on the Subaxial Injury Classification system, and the rest had a score of more than 6. The mean follow-up period was 19 months (range, 12–48 months). Neurological recovery was observed in most of the patients (78.21%). All patients experienced relief of axial pain. None of the patients received a blood transfusion. Twenty-one patients (91.3%) showed solid fusion and 2 (8.69%) showed possible pseudarthrosis, with no complications related to the cage or plate. ConclusionTwo-level anterior cervical corpectomy and fusion, along with stabilization with a cervical locking plate and autologous bone graft-filled titanium mesh cage, can be considered a feasible and safe method for treating specific subaxial spine injuries, with the benefits of high primary stability, anatomical reduction, and direct decompression of the spinal cord.

Short-Term Outcome in Subaxial Spine Injury Patients Operated on in a Resource-Limited Setting, Addis Ababa, Ethiopia.

Subaxial spinal injury surgery is expensive, and its significance is uncertain because of limited rehabilitation and postoperative care. To assess complications and outcome in patients surgically treated for subaxial spinal injuries in 2 hospitals in Addis Ababa, Ethiopia. Retrospective study, conducted among 85 patients operated on for subaxial spine injury from January 2013 to August 2016. Data were collected from medical charts. Descriptive statistics and binary logistic regression were used for data analysis. A total of 85 patients were included, and 20 patients were not followed up. The mean age was 33 years (standard deviation ± 12.03 years), and the mean time from injury to surgery was 10 days. The rates of surgical mortality and reoperation were 7.05% and 3.5%, respectively. Deaths occurred in 13 of 16 patients (81.1%) with American Spine Injury Association (ASIA) scores of A and in 3 of 16 patients (18.9%) with ASIA scores of B. The complication rate in patients with a preoperative ASIA score of A was 17/24 (70.8%). The study showed that 55 of 65 patients who were followed up (84.6%; 95% confidence interval [CI]: 75.4, 92.3) experienced improvement. According to the patients' follow-up ASIA scores, 47 (72.3%; 95% CI: 61.5, 83.1) were functional. Sphincter tone before operation (adjusted odds ratio 142.82; 95% CI: 9.973, 204.090) was significantly associated with follow-up ASIA score. Patients with complete cervical injuries had high rates of mortality and morbidity, indicating that it might be better not to operate on these patients in resource-limited settings. There is a moderate recovery rate in patients with incomplete SCI despite a lack of adequate rehabilitation facilities.

Congenital subaxial cervical subluxation presenting as a bilateral Erb’s palsy: surgical management, rehabilitation, and outcome

Subaxial spine injuries during infancy are uncommon. We present the case of an infant referred to our brachial plexus clinic with proximal weakness of both arms noted immediately following a complicated breech delivery. Nerve conduction studies were consistent with bilateral proximal upper plexus injury; however, radiological evaluation revealed a C4-C5 subluxation and MRI features of bilateral C5 root avulsions. He was immobilized in a cervical-body orthosis and underwent open reduction and posterior C4-C5-C6 fixation at 10weeks age using luque rods, sublaminar wires, and rib graft. The spine was immobilized in a custom molded cervicothoracic brace for a total of 3months, and a home exercise program prescribed. Follow-up radiographic evaluation showed good posterior bony fusion by 2months but persistent bilateral proximal upper limb weakness with reduced compound motor action potential (CMAP) amplitudes of the axillary and musculocutaneous nerves. Bilateral supraclavicular exploration and C5 root neurotization using the ipsilateral C7 nerve roots were performed at 7months of age. Voluntary biceps activity followed by voluntary external rotation with gravity eliminated was noted within the next 2-3months. He progressed to develop near normal motor control of bilateral upper limbs within 1year. We wish to report this rare entity and our favorable outcome using a strategy of early spinal stabilization and neurotization repair to restore function following proximal nerve root injury.

MDCT of acute subaxial cervical spine trauma: a mechanism-based approach

Injuries to the spinal column are common and road traffic accidents are the commonest cause. Subaxial cervical spine (C3–C7) trauma encompasses a wide spectrum of osseous and ligamentous injuries, in addition to being frequently associated with neurological injury. Multidetector computed tomography (MDCT) is routinely performed to evaluate acute cervical spine trauma, very often as first-line imaging. MDCT provides an insight into the injury morphology, which in turn reflects the mechanics of injury. This article will review the fundamental biomechanical forces underlying the common subaxial spine injuries and resultant injury patterns or “fingerprints” on MDCT. This systematic and focused analysis enables a more accurate and rapid interpretation of cervical spine CT examinations. Mechanical considerations are important in most clinical and surgical decisions to adequately realign the spine, to prevent neurological deterioration and to facilitate appropriate stabilisation. This review will emphasise the variables on CT that affect the surgical management, as well as imaging “pearls” in differentiating “look-alike” lesions with different surgical implications. It will also enable the radiologist in writing clinically relevant CT reports of cervical spine trauma. Teaching Points • Vertebral bodies and disc bear the axial compression forces, while the ligaments bear the distraction forces.• Compressive forces result in fracture and distractive forces result in ligamentous disruption.• Bilateral facet dislocation is the most severe injury of the flexion-distraction spectrum.• Biomechanics-based CT reading will help to rapidly and accurately identify the entire spectrum of injury.• This approach also helps to differentiate look-alike injuries with different clinical implications.